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Contents

Section I

History taking and examination
Part I History taking.
Part II General Examination.
Part III Local abdominal examination.

Section II

Clinical cases Pg no.
Anemia in pregnancy 1
Pregnancy induced hypertension 18
Heart disease in pregnancy/Diabetes 37
Previous LSCS 56
Fibroid 68
Dysfunctional uterine bleeding 85
Uterine prolapse 101

Section III

Practical spotters 115
Female pelvis
Fetal skull
Specimens




















SECTION 1

HISTORY TAKING AND EXAMINATION













































PART I


HISTORY TAKING

It is a known fact that a thorough history taking is of outmost help for both the diagnosis and the
management of the obstetric case. The various items to be considered in this history taking
are:
1. Personal history.
2. Menstrual history.
3. Obstetric hi story.
4. History of previous operations.
5. History of previous disease.
6. Family history.
7. Complaint and history of the present condition

HISTORY TAKING
Personal and Past History

Personal History:
I. Name and address.
2. Age.
3. Marital state.
4. Occupation.
5. Name, Age, Occupation of the husband

Menstrual History
1. Age of menarche.
2. Rhythm.
3. Duration &amount.
4. Dysmenorrhoea.
5. Last menstrual period (Nature &
date).

Obstetric History
1. Number of previous pregnancies.
2. Course of previous pregnancies.
3. Nature of previous deliveries.
4. Nature of previous abortions.
5. Puerperium and type of feeding

Previous Operations:
1. Gynecological.
2. Surgical."Non gynecological"
Family History
Diabetes. Hypertension. Syphilis. Tuberculosis. Fibromyoma Multiple pregnancy Diseases of
husband and his family.

Complaint and Present History
Symptoms of Pregnancy
1. Amenorrhea.
2. Morning sickness.
3. Urinary symptoms.
4. Breast symptoms.
5. Psychogenic.
6. General.
7. Abd. enlargement.
8. Quickening.
9. Lightening.

Symptoms of Pathological Pregnancy
1. Vomiting. 2. Pain. 3. Bleeding.
4. Oedema. 5. Toxemia.


Symptoms of Onset and Progress of Labor:
1. Onset
a. The show. b. Labor pains.
2. Condition of the bag of membranes.
3. Nature of uterine contractions.
4. Associated complications
a. General. b. Impending & Actual rupture uterus.
Function of Various Systems
1. Gastro-intestinal. 2. Urinary tract. 3. Sleep.
Associated Diseases with the Pregnant State.

PERSONAL HISTORY AND PAST HISTORY
PERSONAL HISTORY

The personal history entails asking the patient about her name, address, age, marital state and
occupation.
Name and Address.
The patient's name in particular, do assure the patient and help her to relax. Particularly when
the patient is being examined for the first time. The patient's name and address are also of
help in the filing system,, and for contacting the patient whenever considered necessary.
Age.
Asking the patient about her age, may cause her some embarrassment, and it may be difficult to
get the exact age in many cases. To attain this, one can resort to indirect evidence to calculate the
age as for example the age at marriage and the duration of marriage, the age of an elderly son or
the appearance of grey hair. The importance of the age lies in the facts that:
(a) It does influence the course and the management of the obstetric case.
(b) Certain diseases are more liable to develop at certain age groups.

An obstetric problem due to:

(a) The fetus being very valuable as the chances of further pregnancies are rather limited.
(b) The patient is more liable to complications during pregnancy, labor and the puerperium and
these are:

During pregnancy:
i. Abortion.
it. Premature labor.
iii.. Abnormal presentations.
iv. Toxemia of pregnancy.
v. Placenta praevia.
vi. Accidental hemorrhage.

During labor :
i. Premature onset of labor.
ii. Premature rupture of the membranes.
iii. Abnormal presentations.
iv. Inefficient uterine action.
v. Prolonged labor.
vi. Lacerations of the cervix, vagina and perineum.
vii. Post-partum hemorrhage.
viii. Adherent placenta.
ix. Higher rate of operative interference particularly C.S.
x. Higher rate of still births.

During the puerperium:
i. Puerperal infections.
ii. Failure of lactation.
iii. Femoral thrombosis.

c)Being elderly, she is mire liable to get certain complications of her advanced age group such as:
i. Essential hypertension.
ii. Heart disease.
iii. Fibromyoma of the uterus.
iv. Other tumours in the genital tract.

Marital State.
The patient must be asked about:
The number, the duration and the off-springs of the previous marriages, if any
The present marital status and whether she is widowed, divorced or subject of an illegal
pregnancy.
The duration of the present marriage, with special consideration to the number of living
children resulting from this marriage.
The husband's name, age, occupation and diseases if any.

All, these factors do reflect on the social state, the mode of living and on the psyche of the
patient; and these in turn influence the course of pregnancy and labor materially.

Occupation.
The number of employed women is increasing very rapidly and consequently a big number of
pregnant women are encountered nowadays employed in various occupations. Some of these
occupations do reflect on the health of the female in general, and on the pregnant state in
particular. Thus women employed in printing jobs are occasionally exposed to lead vapor, which
causes chronic lead poisoning, leading later on to repeated abortions. In women employed in
radiological departments, or working near-by other radio-active sources; the growing ovum in the
uterus may be subjected to the dangerous effects of radiological emissions. Again, pregnant nurses
are subjected to various infectious diseases, and these may have a deleterious effect on the
pregnancy and its outcome. thyroid dysfunctions.
iii. Chronic ill-health, general diseases and endemic diseases.Such causes of delayed menarche may
influence the course of pregnancy and labor, resulting in one or more of the following complications:
i. Delayed onset of pregnancy, i.e., pregnancy after a long period of sterility.
ii. Abortion.
iii. Premature labor.
iv. Abnormal presentations.
v. Abnormal uterine action.

2. Rhythm of the Menstrual Cycle.
In the majority of women, the rhythm is a regular one, the flow recurring every 3-5 weeks. Again,
the rhythm may be a regular one, but the periods recurring every 8-12 weeks or more.

3. Duration and Amount of Blood Loss.
Normally these show wide variation from one patient to another, and so what is considered as
normal for one patient, may be too much for the second and too little for the third. What is
important here, as well as in the previous item, i.e., the rhythm - is the change that takes place in
the same patient. Such a change may be the result of the development of a local disease in the
uterus as fibromyoma, or of a general disease as anemia, and such diseases are known to influence
the course of pregnancy, labor, and the puerperium.

4. Associated Pain or Dysmenorrhoea.
Though no cause for this pain is found in some patients, yet in a good number of cases, some local
lesions are found which account for the dysmenorrhoea, such as displacement of the

MENSTRUAL HISTORY

I. Age of Menarche.
This is defined as the age at the onset of the first menstrual flow. Normally it varies between 11
years and 14 years in our country. Delayed onset of the menstruation may be due to:
i. Genital hypoplasia and/or congenital anomalies of the uterus.
ii. Endocrinological disturbances such as pituitary or uterus particularly retroversion flexion,
uterine hypoplasia, fibromyoma, or ovarian tumours. In addition to the above, the amount of
dysmenorrhoea gives an idea about the pain threshold of the patient, thus the lower the pain
threshold the greater the amount of pain (dysmenorrhoea)."" Low pain threshold in the patient may
manifest itself during labor as exaggerated suffering, nervousness and irritability"". These in turn
predispose to colicky uterus and cervical spasm.

5. Date and Nature of the Last Menstrual Period.
This date is of great importance as it helps in calculating the duration of pregnancy and the
expected date of delivery. Thus knowing the first day of the last menstrual period, we add 7 to the
days and 9 to the months, and the resulting date will be the expected date of delivery - within two
weeks before or two weeks after.

Being so important, the last menstrual period must be scrutinized carefully, to know whether it was
normal in amount, duration, nature of blood loss and whether it was at the expected time or not.
This is done to exclude the possibility of an irregular period being considered as an attack of
threatened abortion, or on the contrary, an attack of threatened abortion taking place during the
present pregnancy and considered as the last menstrual period, and thus causing wrong calculation.

OBSTETRIC HISTORY
In the history of previous pregnancies and labors a good record about what to expect in the course
of the present one. In taking the obstetric history, the examiner must lay particular stress on the
following:
1. The number of previous pregnancies.
2. The course of previous pregnancies.
3. The nature of previous deliveries.
4. The nature of previous abortions.


I. Number of Previous Pregnancies.
Pregnancy, labor and lactation, do throw a big strain on the vital organs: such as the liver, kidneys,
heart or supra renal glands; and also. On the nutritional stores and the metabolic functions of the
body. Hence repeated successive pregnancies are often associated with more complications than a
corresponding or even a larger number of pregnancies but spread over a longer period. Thus, it is
the duty of the attendant, to ask not only about the number of the previous pregnancies, but also
about the intervals in between these pregnancies.

It is generally agreed that the second delivery is usually much easier than the first, the third
easier than the second, and the fourth is the easiest of all. From the fifth delivery onwards
greater difficulty and more complications are to be expected. Hence the terms "grand multipara"
or the "dangerous multipara" have been applied to describe those pregnant patients with five
previous deliveries or more. Such cases are more liable to certain complications during pregnancy,
labor and the puerperium:
During pregnancy
i. Abortion.
ii. Toxemia of pregnancy,
iii. Hypertension with pregnancy.
iv. Osteomalacia.
v. Pendulous abdomen.
vi. Nutritional deficiencies.
vii. Abnormal presentations.
viii. Accidental hemorrhage.
ix. Placenta previa.
x. Premature labor and post-maturity.

During labor
i. Difficult labor.
ii. Abnormal uterine action.
iii. Rupture uterus.
iv. Post-partum hemorrhage.
v. Adherent placenta.

During puerperium
i. Puerperal infection.
ii. Uterine displacements.

In describing the number of previous pregnancies, two terms are used frequently and these are:

Para : This describes the number of previous deliveries the patient had had. Thus a third para is a
patient who had been delivered three times before, while a primipara is a patient who had been
delivered once before.

Gravida : This describes the number of previous pregnancies the patient had had, irrespective of
their mode of termination "Whether in abortion or labor. The present pregnancy is included "the
numerical description of gravidity. Thus a fourth gravida is a patient who was pregnant three times
before and is now pregnant for the fourth time. Parity and gravidity are used simultaneously. So a
"fourth gravida, second para, pregnant patient" is that one who had been delivered twice before,
who aborted once, and who is now pregnant for the fourth time.

2.Course of Previous Pregnancies.
The obstetric history must include a good study -of the course of the previous pregnancies, and
whether this was smooth and uneventful, or was complicated with excessive vomiting, bleeding,
toxemia, heart lesions, kidney lesions or other systems

In addition, the attendant must study the late of the previous pregnancies, i.e., whether these
pregnancies ended in:

- Abortion (miscarriage),
- Premature labor
- Delivery at full term,
- Post maturity,

3. Nature of the Previous Deliveries.
Patients with history of dystocia (difficult labor) need special handling as many of the causes of
dystocia are permanent ones, and hence the difficulty will be encountered every time the patient
goes into labor. Such permanent causes are either local cause as contracted pelvis, congenital
anomalies of the uterus,
Pendulous abdomen, fibromyoma ... etc. or general causes such as heart disease, lung disease,
diabetes or hypertension.

On the other hand, the history of one or more normal deliveries before, does not exclude the
possibility of difficulty arising in the present one. This is due to the facts that:
(a)Certain complications may arise for the first time in any pregnancy such as placenta previa,
accidental hemorrhage, toxemia of pregnancy, polyhydramnios, multiple pregnancy and abnormal
presentations.
(b)Multiparity specifically predisposes to certain complications such as pendulous abdomen and its
accompanying abnormal presentations, osteomalacia and the osteomalacic contracted pelvis, or
cicatricial contraction of the vagina or cervix.

While taking the history of the previous deliveries, the attendant must carefully study the
duration of labor, the time of rupture of membranes, the mode of termination of labor, the
behaviour of the fetus and the infant during and after labor, the nature of the previous
puerperium.

1. Duration of labor
The normal duration varies between 6-24 hours. Marked shortening of the duration, from few
minutes up to one hour is indicative of "precipitate labor". On the other hand, marked prolongation
of the course of labor is indicative of some fault in the passage, the passenger or the powers which
again may recur in the following deliveries.

2. Time of rupture of the membranes
These usually rupture at the beginning of the second stage of labor When the os is fully dilated.

3.Mode of termination of labor
(a) Expulsion of the fetus may have been completed spontaneously or needed operative
interference such as forceps, vacuum extractor, breech extraction, version, upper or lower
segment Caesarean section or a destructive operation on the fetus.
(b) Expulsion of the placenta also may have been completed normally, or was complicated
hemorrhage or retained placenta necessitating manual removal.

4-Behaviour of the fetus and the infant after labor:
a) Behaviour of the fetus after birth:
i. Cried immediately or needed resuscitation. Again, the color of the fetus and the presence of any
birth injuries or congenital abnormalities should be taken into consideration.
ii. In cases of still born fetus (fetus born dead), the attendant must ask whether it was macerated
or fresh,
iii. The birth weight of the fetus or infant, and if not available, the approximate size must be asked
about. Here it must be remembered, that a patient who gave birth easily to a small fetus, may
encounter great difficulty, or even complete obstruction, in the following labor with a normal or an
over sized fetus.

(b) Behaviour of the infant.
i. The development of jaundice, its time of appearance, its degree and the course taken by the
disease, in the early neonatal period.
ii. The number, age and sex of the living children the patient had.
iii. In case she had lost any child, the age and if possible the cause of death must be asked about.

5. Nature of the previous Puerperium:
The duration of stay in bed, the mode of feeding the infants (breast fed or artificial), the
occurrence of complications such as hemorrhage, fever, femoral thrombosis, breast infections or
urinary tract infections.

6. Obstetric Operations:
The history of previous obstetric operations is of great significance on account of two main facts:

i. The indication of the obstetric operation may be a permanent one and hence interference will be
needed in every succeeding labor, as in cases of contracted pelvis or heart disease.
ii. The influence of the obstetric operation on the genital tract in general and on the uterine muscle
in particular; and the ability of such a muscle to stand the strain of the following pregnancies and
labors.

For the proper understanding of the significance of the previous
obstetric operations on the uterine muscle following have to be considered:
(A) Following Caesarean section.
(B) Following traumatic laceration of the uterine muscle.
(C) Following traumatic laceration of the cervix, vagina and vulva.

(A) Following Caesarean section : Some time ago, it was stated that "Once Caesarean, always
Caesarean". Nowadays, this statement does not hold any longer, and too many patients are allowed
to undergo vaginal delivery following Caesarean section. The decision of' the mode of delivery in
subjects with a history of previous Caesarean section is governed by
(a) The indication of the previous operation, and whether it is a permanent one such as contracted
pelvis or a transient one as placenta previa.
(b) The type of the previous Caesarean section and whether it was a lower segment or an upper
segment one; the former being much more favorable if vaginal delivery is avafavorable The time
since the previous operation and the following pregnancy. The longer that time, the greater is the
chance of vaginal delivery, owing to the better healing of the uterine scar.
(c) The nature of the puerperium following the operation whether hectic and stormy indicating an
unhealthy scar, or smooth and afebrile indicating proper healing.
(d) The examination of the patient, laying particular stress on the scar in the abdominal wall, the
size and presentation of the fetus, the size of the pelvis and the soft tissues of the birth canal.
If the decision then is in favor of allowing vaginal delivery, the patient must be put under the
closest observation during pregnancy and labor, not only those immediately following the
Caesarean section, but in every pregnancy and labor that follow later. This is to be expected, as it
is a known fact that ruptures of the uterus following Caesarean section may not only take place in
the first succeeding pregnancy, but in later ones also.((ONCE C.S ALWAYS HOSPITALISED
DELIVARY))

(B) Following traumatic lacerations : Extensive laceration of the uterine muscle and/or deep
cervical tears extending into the lower uterine segment, are occasionally inflicted during the course
of various obstetric operations as failed and difficult forceps, destructive operations on the fetus,
intra-uterine manipulations particularly internal version and manual removal of the placenta.
Such lacerations may be detected at the time of the operation and repaired immediately, and the
patient instructed against further pregnancy if possible. In case such a patient becomes pregnant,
Caesarean section will clearly be the line of choice for delivery.

(C)Following lacerations of cervix, vagina and vulva. These lacerations commonly heal spontaneously
without any effect the course of the following pregnancy and labor. Occasionally however,
extensive fibrosis takes place, rendering another vaginal delivery almost impossible.

4. Nature of the Previous Abortions.
1. The number of abortions.
2. The cause of the abortion.
3. The mode of completion of the abortion.
4. The duration of pregnancy in each abortion.
5. The nature of the puerperium following these abortions.

1. The number of abortions
One must ask about the succession of abortions. The occurrence of three successive spontaneous
abortions in the same patient is rather important as this will group her as a case of habitual
abortion. In fact as the number of successive abortions in the same patient increases, her chance
of getting a pregnancy reaching full term diminishes.

2. The cause of the abortion
3. Mode of completion of the abortion
The abortion may have ended spontaneously, completed medically or completed surgically. The
latter, that is surgical completion, entails special risks of injury and laceration to the uterine
muscle, and this may seriously reflect on the course of the present pregnancy or labor.

4. Duration of pregnancy in each abortion
A careful study of this duration is sometimes of great help in the diagnosis of the cause of the
abortion As:
- Abortion in the first few weeks is usually due to a defective germplasm.
- Abortion resulting from retroversion flexion of the gravid uterus takes place between the 12th
and the 16th week.
- Abortion due to cervical incompetence is commonly encountered between 16th. and the 26th week.
- Uterine hypoplasia causes repeated abortions in a rising schedule.
- In the cases of Rh incompatibility, Thus, after one or two normal deliveries, the patient gives
birth to an infant showing severe jaundice at, or shortly after birth (icterus gravis neonatorum).
The next delivery may be a still born fetus at, or near term; to be followed later by a variable
number of abortions. The cause of this pattern of abortions is said to be that with every
successive pregnancy, there is a progressive increase in the level of antibodies in the patient's
blood and thus affecting the fetus at earlier dates
- In cases of syphilis, on the other hand, there is no specific pattern in the deliveries or the
abortions and thus the patient may give a history of several abortions of variable duration
intermingled with deliveries of normal infants.


HISTORY OF PREVIOUS OPERATIONS
Any operation performed on the patient may have its bearing on the course of pregnancy and labor;

Gynecologic Operations :

As these operations are performed on the genital tract, they can, materially reflect on the course
of pregnancy and labor.

1. Cauterisation of the cervix : it may lead to excessive fibrosis or scarring in the cervix organic
cervical rigidity soft tissue obstruction to delivery.

2. Dilatation of the cervix : This is occasionally complicated by cervical tears and lacerations of the
sphincter of the internal os. These complications sometimes become manifested later as cervical
incompetence and repeated abortions during pregnancy.

3. Curettage : When vigorously and/or carelessly performed, it may lead to laceration of the
uterine muscle, thus predisposing to spontaneous rupture uterus during pregnancy and labor.

4. Plastic gynecologic operations as the repair of prolapse, vesicovaginal fistula, recto-vaginal
fistula and complete perineal tear it is advisable to perform Caesarean section on every patient
as the method of delivery after successful repair of these lesions.

5. Abdominal hysterotomy, myomectomy and other operations in which the uterine muscle is cut :
As expected, the scar left in the uterine wall following these operations may be the cause of
serious trouble during pregnancy and labor, such as spontaneous rupture uterus, adherent placenta
at the site of the scar, or repeated abortions.

6. Transperitoneal gynecologic operations : These operations may be followed by adhesions causing
fixation of the uterus in abnormal positions, and resulting later on in: (i) uterine obliquity with its
sequela of malpresentation
(ii) fixed retroversion flexion with its serious sequelae during pregnancy and labor.

Surgical Operations:
1. Abdominal and pelvic operations with their sequelae of adhesions, uterine obliquity...
2. Operations on the spine, the pelvic bones or the lower limbs, as their indications and sequelae
may reflect on the size, the form and the obliquity of the pelvis.

HISTORY OF PREVIOUS DISEASE
Kidney disease:
Here it may be mentioned that a patient, who had had an acute nephritis that passed into the
chronic state and leading an almost normal life, may under the influence of pregnancy to an acute
exacerbation and/or a super-added toxemia. In fact, these cases of chronic nephritis need the
outmost care during pregnancy as there is an old saying that ((such patient will loose the baby in
her first Pregnancy, loose her sight in the second and loose her kidney in the third)). Other
diseases of the urinary tract as pyelitis or cystitis should be carefully noticed.

Heart disease:
Any patient who gives a history of heart disease, must be specifically asked about the history of
heart failure and whether this took place away from pregnancy; during previous pregnancies; or
even at an earlier time during the present one. As the earlier the heart failure takes place during
pregnancy, the more serious is the case.

Diabetes mellitus: both the mother and the fetus may be very serious.

Effects of Pregnancy on diabetes:
- During the first three months, there is no change.
- During the rest of pregnancy, there is a progressive increase in the requirements till full term.
However, in some cases, the insulin requirements diminish during the last three months of
pregnancy.
-During labor, there is a fall in the requirements.
-After labor, there is a marked- diminution of the requirements for several weeks.

Effects of diabetes on pregnancy

Effects of diabetes on labor
i. Difficult labor and inertia.
ii. Post-partum hemorrhage.
ill. Intra natal death of the fetus.
iv. Ketosis and diabetic coma.

Effects of diabetes on puerperium:
I. Liability to puerperal sepsis. ii. Diabetic coma.

Effects of diabetes on the offspring:
i. Repeated intra-uterine death of the fetus (10%-30%).
ii. Intra-natal death of the fetus.
iii. Neonatal death of the fetus.
iv. Oversized fetus (Macrosomia). (fetus born at full term with a post-mature size "oversized" and
a premature behavior "fragile")
v. Hyperglycemia of the foetal blood.
vi. Congenital anomalies of the fetus, such as hydrocephalus, imperforate anus, congenital heart
lesions.
vii. Abnormal presentations of the fetus, with their sequelae of difficult labor and traumatic
injuries of the fetus.

Hypertension : The history of hypertension in the patient, before pregnancy, the attendant must
try to get the duration and the degree of the elevated blood pressure before the present
pregnancy.

Pulmonary tuberculosis : the added strain of pregnancy, labor and lactation, can easily turn the
balance against the patient.

Syphilis : less frequently encountered nowadays, as a cause of repeated abortions, intra-uterine
death of the fetus, still births, neonatal death of the infant and syphilitic children.

Rheumatic fever, chorea, tonsillitis and scarlet fever : exacerbated during pregnancy.

Malaria : exacerbations during pregnancy

Appendicitis: Previous attacks of appendicitis should be carefully noticed as, they are liable to
recurrence during pregnancy, labor or the puerperium.

Mental diseases : exacerbation

Rickets and osteomalacia : These sometimes leave their mark on the pelvic bones, and hence cause
difficulty and multiple complications during labor.

Accidents and severe infection of the bones and joints of the pelvis, lower limbs or spine :
These may leave their mark on the pelvic bones particularly if inflicted or caught during childhood,
when the bones were still developing.

FAMILY HISTORY
Some of the hereditary or familial conditions that are transmitted to the patient.
-The most important amongst these are:
1 Diabetes Mellitus.
2 Essential Hypertension.
3 Syphilis.
4 Tuberculosis.
5 Multiple Pregnancies. particularly important in cases of multiple pregnancy, syphilis, diabetes
mellitus and mental diseases. In fact in the last two conditions, i.e., mental disease and diabetes, if
both parents are subject of the same disease, the chance of the off-spring inheriting the disease
rises so much that such cases indicate a therapeutic abortion.
-History of consanguinity
-History of any congenital anomalies
-History of similar conditions among family members


COMPLAINT AND HISTORY OF THE PRESENT
CONDITION
Such a thorough questionnaire about the symptomatology helps in the following conditions:
1. The diagnosis of pregnancy and its duration.
2. The diagnosis of pathological pregnancy.
3. The diagnosis of the onset and progress of labor.
4. The study of the function of the various systems in the body, such as the bowel action,
micturition, and sleep.
5. The diagnosis of any associated disease.

SYMPTOMATOLOGY OF PREGNANCY

1. Amenorrhea : This is the earliest and most outstanding symptom of pregnancy. between puberty
and the menopause, should be considered as due to(pregnancy till otherwise proved)

-On the other hand, the amenorrhea of pregnancy may be superimposed on amenorrhea from other
causes whether physiological or pathological.

-It is helpful for the determination of the duration of pregnancy, the expected date of delivery
and the diagnosis of postmaturity.

2. Morning sickness and vomiting of pregnancy : It starts as early as the sixth week, and
disappears spontaneously by the end of the third month.
Closely related to the vomiting, there are few symptoms that may be complained of during
pregnancy and these are : (a) Belching. (b) Retching. (c) Heart burn. (d) Eructation (e) Ptyalism.
These symptoms however, may not disappear at the end of the third month, but may persist
throughout the whole course of pregnancy.

3. Frequency of micturition and bladder irritability : These are met with in the early weeks of
pregnancy when it is due to the pelvic congestion and the exaggerated anteflexion of the uterus
taking place at this time, causing compression of the bladder and hence its irritability . As the
patient approaches full term, these symptoms occur again, but they are then due to descent of the
presenting part in the pelvis.

4. Symptoms in the breasts : Various symptoms in these appear progressively. The earliest are
pain, a sense of fullness, enlargement and warmth; and these may appear even before the date of
the first missed period. Later on, blue veins appear under the skin and pigmentation of the areola
takes place. Later still, the secondary areola shows.

5. Psychogenic symptoms : Longing, i.e., the strong desire for special types of food, changes in the
mood with excessive irritability, unexplained dislikes for certain smells, foods, places or even
persons.

6. General symptoms : lassitude, easy fatigability, giddiness, occasional vertigo, spells of fainting,
tendency to sleep, heaviness in the pelvis and the appearance of varicose veins in the legs.

7. Abdominal enlargement : This symptom becomes manifest from the third month onwards. due to
the increase in the size of the uterus, deposition of fat in the omentum and the subcutaneous
tissues of the abdominal wall, and the gaseous distension of the bowels (flatulence).

8. Quickening: This is one of the most important symptoms of pregnancy. The date of its onset
offers a great help in calculating the duration of pregnancy, in cases where there is difficulty in
getting the exact date of the last menstrual period. felt around the 18th-20th week in the
primigravida, multipara from the 16th to the 18th week of pregnancy. Excessive foetal movements
and deficient foetal movements are among the common complaints encountered in obstetrics. In
some cases of intra-uterine death of the fetus, cessation of foetal movements may be the first
symptom that directs the patient's attention to the accident.

9. Lightening : This is one of the important symptoms met with very late in pregnancy. It is not so
valuable for the diagnosis of pregnancy;. However, it's significant in denoting that the patient is
approaching labor. It is manifested by the patient feeling a certain amount of descent of the
uterus with a change in the shape of her abdomen "coming clown of the abdomen". Accompanying
this, there is relief of the upper abdominal symptoms and the appearance of some pelvic symptoms.

SYMPTOMS OF PATHOLOGICAL PREGNANCY!!!!!

"Vomiting"

vomiting is normally encountered in a big number of patients in early pregnancy, yet occasionally
this vomiting is so excessive or persistent that it affects the general health deleteriously condition
known as "hyperemesis gravidarum or toxic vomiting" of pregnancy. In such cases the patient does
not only vomit in the morning, but goes on vomiting all day long, and not only after meals, but may
vomit even without taking any meal.

In cases of excessive vomiting, though no manifest cause may be discovered, one of the following
conditions is found:
1. Multiple pregnancies.
2. Vesicular mole or hydatidiform mole.
3. Polyhydramnios.

Vomiting taking place late in pregnancy is occasionally the result of severe toxemia of pregnancy.
Other causes of this associated vomiting are:
1. Gastro-intestinal disease such as peptic ulcer, gastro-enteritis or intestinal obstruction.
2. Indiscretion of diet.
3. Pyelitis and pyelonephritis.
4. Red degeneration of a fibromyoma.
5. Twisted small ovarian tumours.
6. Cerebral tumours.

"Pain"
Pain, is one of the commonest complaints met with in obstetric practice. the time of onset of pain,
its duration, its recurrence, its site, its radiation, its nature whether colicky, throbbing, stitching,
aching, burning; its severity, its effects, its initiating or aggravating factors and any accompanying
manifestation.

"Pain in Normal Pregnancy":
As expected, pain in normal pregnancy is minimal. The common causes of this pain are:

1. Stretch of one or the other round ligament, causing stitching pain in one or both sides of the
lower abdomen. This pain is characteristically relieved when the patient lies on the affected side.
2. Near full term, at the site of the foetal head, the patient experiences some form of aching pain
or a sense of a lump there. This point is helpful in the diagnosis of the site of the head of the
fetus.
3. Backache at various sites is commonly complained of during pregnancy. It may have its origin in
the muscles of the back, the spine or the sacro-iliac joints. In the former two sites, it is due to the
compensatory lordosis imposed on the patient particularly during the last month of pregnancy. In
the latter site, it is due to the vascularity and softening taking place in the sacro-iliac joints and
ligaments preparatory to delivery.
4. Pain in the subcostal margin is encountered in some patients near the end of pregnancy. It-is due
to the stretch of the abdominal muscles attached there, by the enlarging uterus and its forward
fall.
5. Normally uterine contractions during pregnancy are painless, but as the patient approaches
term, she may get bouts of painful contractions that cease after some time. These are encountered
during the last month, particularly during the last few days, and are known as "doloris presagientis",
and may be the cause of a false alarm (false onset of labor).
6. Cramp-like pain in the skeletal muscles is commonly encountered during pregnancy particularly in
muscles of the calf, muscles of the thigh and the abdominal muscles. It is said to be due to calcium
or vitamin D deficiency. It has also been ascribed to sodium chloride deficiency.
7. Foetal movements in general are not painful. At their onset, they are accompanied with a
peculiar sense of slight fear, but later on they are rather pleasurable. Towards the end of
pregnancy, they may be so strong and cause the patient some discomfort.

"Pain in Abnormal Pregnancy":

1)Pain arising from the Uterus:
1. Dull aching pain. This results from rapid and/or over distension of the uterus as in cases of
vesicular mole, polyhydramnios, multiple pregnancy or accidental hemorrhage.
2. Severe stitching pain. This is encountered in cases of a degenerated fibromyoma in the wall of
the uterus, in cases of perforating vesicular mole, in cases of accidental hemorrhage with intra-
mural bleeding (uterine apoplexy or Couvelaire uterus).
3. Colicky pain. lower abdomen and back. It is caused by uterine contractions when the uterus, for
one reason or the other, tries to expel its contents.

2)Pain arising from the Fallopian Tube:
This is encountered in cases of ectopic tubal pregnancy. The growing ovum in the tube will distend
it far beyond its capacity, and during this time the patient will complain of mild colicky pain with a
persistent dull ache on one side of the lower abdomen. Thus the patient may get:
1. Severe colicky pain on one side of the lower abdomen or the other, when the tube tries to expel
the ovum out.
2. Severe lancinating pain, due to perforation of the tubal wall.
3. Severe stitching lower abdominal pain, due to the escape of blood into the peritoneal cavity
4. Sudden severe diffuse abdominal pain with profound collapse, in fulminating cases of tubal
rupture with diffuse intraperitoneal hemorrhage. In such cases, the pain may be referred to the
epigastrium.
5. Severe heaviness in the lower abdomen and back with pain at defecation, micturition, due to
"pelvic hematocele".

Pain arising from the Ovaries:
1. Hemorrhage in the corpus luteum of pregnancy. This may give the same types of pain as that
encountered in ectopic pregnancy,
2. Ectopic ovarian pregnancy. This gives almost exactly the same nature and extent of pain as that
encountered in ectopic tubal pregnancy with the exception of the colicky pain.
3. Rapid enlargement of the ovaries with the formation of multiple theca lutein cysts in cases of
vesicular mole, This gives a dull aching pain
4. Accompanying ovarian tumours.

Pain from the Vagina and Vulva:
Subclinical pain manifested as soreness and/or pruritis. pregnancy predisposes these parts to
special parasitic and fungus infections, i.e., trichomonas vaginalis and Monilia.

Pain from the Rectum and Anal Canal:
1. In the presence of pelvic hematocele, a severe lancinating pain in the rectum is complained of.
This pain is especially exaggerated during the passage of stools or flatus. Occasionally it is
encountered as a sense of heaviness in the rectum,
2. In cases of retroverted gravid uterus, the pressure on the rectum gives rise to an aching pain
lower down with dyschezia.
3. In cases of tumours complicating pregnancy and becoming incarcerated in the pelvis, the patient
gets the same types of pain as those described above.
4. The development of piles During pregnancy, these piles may undergo certain complications such
as infection, prolapse, irreducibility or strangulation. Luckily however, most of these cases of piles
improve or may disappear completely some time after labor.

Pain in the Puerperium.
1. After pains : These are caused by severe uterine contractions during the puerperium, and may be
very distressing. They are due to the presence of some remnants in the uterus as pieces of
membranes or placenta, or a blood clots but may also be encountered even when there is nothing in
the uterus. They are
characteristically ""augmented or only manifested when the patient is lactating the infant, and this
point helps to differentiate them from other causes of pain in the puerperium"".
2. Concealed hemorrhage in the uterus : This gives rise colicky.
3. Puerperal infection: The severest pain in these cases is encountered with infection of the
parametrium (parametritis).
4. Inversion of the uterus :
5. Complications in associated lesions : Fibromyoma and ovarian tumours

Pain from Associated Lesions:
1. Pain from the alimentary tract as in cases of appendicitis, cholecystitis or intestinal obstruction.
2. Pain from the urinary tract as in cases of pyelitis, cystitis, or
urinary calculi.

Bleeding
Normally, a pregnant patient should not bleed from the uterus during pregnancy, except perhaps
for a minimal even microscopical amount during the embedding of the ovum (Hartman sign).

Bleeding taking place before the 28th week of pregnancy.
In addition to the nature of the blood passed, one must ask about its amount, the duration of blood
loss, the passage of clots. vesicles or pieces of tissue in it, the frequency and recurrence of blood
loss and any predisposing or initiating factor for the blood loss (as sexual intercourse, muscular
exertion, psychic or physical trauma, medications taken or local interferences).

Bleeding taking place from the 28th week onwards.
Surface bleeding or Incidental bleeding.
Bleeding during labor.
This must be given special consideration in the history taking, owing to its serious significance in
many cases. The causes of such bleeding are
i. An exaggeration of the normal "show"
ii. Antepartum hemorrhage
iii. Surface bleeding or incidental bleeding. Here it must be remembered that in the primigravida,
during labor, the passage of the foetal head through the vagina, may cause extensive vaginal
lacerations leading to a considerable amount of bleeding.
iv. Rupture of a vasa previa
v. Laceration or rupture of the uterus.

On the other hand, this bleeding during labor may represent an actual postpartum hemorrhage.

Bleeding during the puerperium.
Normally there is a slight amount of blood lost during the early days of the puerperium which is
mixed with the lochia. In some patients, however, this blood loss is excessive and endangers the
patient's life, a condition known as "secondary ,post-Partum hemorrhage". The causes of this
condition are :
i. Subinvolution of the uterus resulting from retained products, puerperal infections and/or
retroversion flexion.
ii. Separation of a slough from the uterine wall, cervix, vagina or vulva.
iii. Inversion of the uterus.
iv. Pedunculated submucous fibromyoma or other fibromyoma
v. Associated lesions in the genital tract, particularly surface lesions, such as carcinoma of the
cervix or
vaginal ulcers.
vi. General diseases of the mother such as congestive heart failure, hypertension or blood
dyscrasias.

Oedema
Oedema is very commonly encountered during pregnancy. sub-clinical oedema can be detected by
asking the patient about:
1. Sense of tightness in the hands and small joints of the fingers, sense of fullness and heaviness in
the upper limbs and lower limbs with tingling sensation, and puffiness of the eyelids.
These symptoms arc most manifest on arising from bed in the morning, but will disappear later on
during the day owing to the muscular contractions improving the circulation in these areas and
removing the excessive amount of fluid from the tissues.
2. Growing tightness of the wedding ring around the finger.
3. Bigger size of shoes needed.
4. Excessive increase in weight.
Once oedema becomes manifest, it is always complained of by the patient. In such cases, one must
ask about the time of' its onset, whether it is persistent or variable from time to tune, whether it
is stationary or progressive, and whether it is related to ingestion of salty food.

Causes of oedema during pregnancy.
1. Toxemia of pregnancy :
2. Hypostatic oedema : This is due to compression of the veins of the lower limbs by the growing
uterus. As expected, this appears in the second half of pregnancy and near full term, weight of the
uterus are big enough to exert such compression.
3. Retention of sodium in the body : This is perhaps the commonest cause of oedema during
pregnancy. Owing to the hormonal changes taking place, particularly the hyperactivity of the
suprarenals, such oedema may take at any time during pregnancy,
4. Varicose veins of the lower limbs
5. Nutritional oedema: Though this is rarely encountered nowadays, yet occasionally it may be seen
during pregnancy as a result of excessive vomiting in the early months
6. Associated conditions : chronic nephritis oedema, cardiac oedema and allergic oedema. local
causes of oedema as venous thrombosis, obstruction of lymphatics or inflammatory lesions.

SYMPTOMS OF THE ONSET AND PROGRESS
OF LABOUR
When the patient is encountered during labor, in addition to, the foregoing questionnaire, she must
be asked about:
1. The symptoms and time of onset of labor.
2. The condition and the time of rupture of membranes.
3. The nature of uterine contractions.
4. Any associated complication.

Symptoms and time of onset of labor.
The symptoms of onset of labor are the passage of the show, and the appearance of regular painful
uterine contractions.
The show : This is the passage per vagina of blood stained mucus. The mucus passed comes from
the cervical plug and the abundant secretion of mucus from the cervical glands, while the bleeding
is due to the separation of the lower part of the bag of membranes from the lower uterine segment
and to the shedding of a part of the lining mucosa of the cervical canal. Appearance of painful
uterine contractions : With the onset of labor, the painless uterine contractions of pregnancy will
change their character, strength, frequency and rhythm; turning into labor pains. For the
differentiation between these two types of contractions, the symptoms as well as the local findings
are important

The time of onset of labor should be carefully noticed to judge the progress and duration of labor.
The normal duration of labor in the primigravida it varies between 12-24 hours, while in the
multipara it varies between 6-12 hours. Prolongation of labor beyond 24 hours is considered
abnormal and a cause for such a prolongation must be looked for. Again, in asking about the time of
onset of labor, care must be taken not to mistake the premonitory uterine contractions for the
actual onset of labor.

Condition and time of rupture of membranes.
The time of rupture of the membranes should be noticed and correlated to the findings during the
examination. However, helpful, is not conclusive, as she may mistake voiding of urine, the passage of
excessive vaginal discharge or a leak from the hind waters for actual rupture of the bag of
membranes.

The nature of uterine contractions.
As uterine contractions are essential for the termination of labor, the attendant must ask about
their frequency, strength, the site where they are maximally felt, and any accompanying feeling
such as bearing down.

Associated complications.
the symptoms of obstructed labor, the symptoms of impending rupture of the uterus, and the
symptoms of actual rupture of the uterus.

Symptoms of obstructed labor and/or impending rupture uterus:
1. Prolonged labor.
2. Symptoms of maternal exhaustion such as irritability, nervousness, twisting in bed and vomiting.
3. Severe agonizing abdominal pain is felt, even in between the uterine contractions, over the
markedly stretched lower uterine segment in cases of excessive retraction, or all over the uterus
in cases of general tonic contraction.
4. Rapid recurrence of strong painful uterine contractions which may even assume a tetanic form.
Inspite of these, the patient feels that there is no progress of labor.
5. Urinary symptoms such as retention of urine, dysuria, oliguria or the passage of smoky urine.

Symptoms of actual rupture of the uterus:
1. Acute agonizing abdominal pain, with a sense of something giving way in the abdomen.
2. Sudden cessation of the uterine contractions.
3. Cessation of the foetal movements, though this usually takes. place some time earlier.
4. Change in the configuration of the abdomen may be noticed by some patients.
5. Appearance of symptoms of hemorrhage and shock, such as loss of conscious, fainting, severe
lassitude, irritability, and air-hunger.
6. Appearance of a variable amount of external vaginal bleeding..
7. If the patient tries to pass urine, nothing comes down or only few drops of blood. This is
particularly the case if the bladder is involved in the tear.

The symptoms described above, are those of rupture of the uterus
taking place late in labor and spontaneously. On the other hand, in cases of traumatic rupture,
symptoms may be completely missing at the onset, as the rupture then usually takes place during
the course of some operative interference, while the patient is under anesthesia.


FUNCTION OF THE VARIOUS SYSTEMS

Gastro-intestinal Tract:
Symptoms referable to the gastro-intestinal tract are commonly encountered during pregnancy and
labor. Some of these as nausea and vomiting.

Flatulence and Constipation :
These two are commonly encountered:
-During pregnancy and labor, owing to the hypotonia or atony of the muscle wall of the intestine,
resulting from the action of a special hormone.
Diarrhoea : Whenever encountered during pregnancy, it should be treated promptly owing to its
deleterious effects, such as abortion from reflex irritation of the uterus, nutritional deficiency or
dehydration.
Heart burn and epigastric discomfort : due to the atony described above, but may also result
from the diminished, rather than the increased, secretion of hydrochloric acid, i.e. anacidity or
hypo-acidity of the stomach.
Ptyalism : Excessive salivation may occasionally be the main complaint of the patient during
pregnancy. The exact cause of this is unknown, though it is sometimes attributed to neurosis,
toxemia of pregnancy or local lesion in the mouth such as dental caries.

Urinary Tract:

Effects of pregnancy and labor on the urinary tract:
1. Frequency of micturition.
2. Dysuria due to compression of the urethra by the presenting part.
3. Dilatation of the ureter with its sequelae of urinary stasis and urinary infections.

4. Retention of urine which arises from:
(a) Incarcerated retroverted gravid uterus.
(b) Ectopic pregnancy with the formation of a pelvic hematocele or a secondary abdominal
pregnancy.
(c) Incarcerated pelvic tumours as fibromyoma or ovarian tumours with pregnancy.
(d) During labor with the pulling upwards of the lower uterine segment stretching the urethra, and
the presenting part coming down and compressing it.
(e) Following labor with lacerations in the perineum and around the urethra causing severe pain and
reflex retention of urine.
(f) The anxiety of pregnancy and/or labor.

5. Serious bladder, urethral or ureteral injuries sometimes follow difficult labor, obstetric
operations, rupture uterus or even spontaneous delivery.
(a) Injuries to the supporting structures leading to descent of the bladder" cystocele", of the
urethra " urethrocele" or of both "cysto-urethrocele".
(b) Injury to the musculature around the neck of the bladder and the urethra, leading to "Stress
incontinence or sphincter incontinence. Difficulty in starting the act of micturition. Dribbling of
urine following micturition.
(c) Fistulous communication into" Bladder:
Vesico-vaginal fistula.
Vesico-cervical fistula.
Vesico-uterine fistula.
Vesico-abdominal fistula.
Vesico-intestinal fistula.
Ureter:
Uretero-vaginal fistula.
Uretero-cervical fistula.
Uretero-abdominal fistula.
Uretero-urethral fistula
Urethro-vaginal fistula.

Influence of the urinary tract on pregnancy and labor
1. Infections in the urinary tract predispose the patient to a greater incidence of toxemia of
pregnancy.
2. During labor a full bladder is a notorious cause of inertia and post-partum hemorrhage; while in
the puerperium it predisposes to retroversion of the uterus.
3. Urinary infections are amongst the common causes of puerperal pyrexia.

"Sleep"
The pregnant patient needs at least 8 hours of sleep every day. Insomnia, however, is not an
uncommon complaint in obstetrics. The cause of this may be excessive quickening, respiratory
distress or pain anywhere in the body, In cases of insomnia with no apparent cause, the attendant
must think of toxemia and/or an impending attack of mania as the possible cause. Again it must be
remembered that insomnia may be one of the early manifestations of "osteomalacia'



PART II

GENERAL EXAMINATION

General condition & configuration.
1. Gait. 2. Height
3. Build. 4. Pendulous abdomen.
5. Weight. 6. General condition.
7. Pulse. 8. Temperature.
9. Blood pressure.

The head &neck.
l. Scalp. 2. Skin of face.
3. Ears. 4. Eyes & brows.
5. Nose. 6. Mouth.
7. Scars. 8. Thyroid gland.
9. Blood vessels. 9. Lymph nodes.

The breasts.
1. Signs of pregnancy:
(a) Enlargement (b) Nodularity
(c) Vascularity (d) Pigmentation & areolae
(e) Montgomery's follicles (f) Secretion.
2. Readiness for lactation.
3. Infection.
4. Lumps & associated lesions

Thoracic cage.
Form, shape and configuration

The lungs.
1. Associated diseases. 2. Effects of pregnancy.

The heart.
1. Associated diseases. 2. Effects of pregnancy.

Upper limbs.
1- Configuration. 2- Hair distribution.
3- Nutritional deficiencies. 4- Oedema.
5- Specific lesions. 6- Muscular development.

Lower limbs.
1- Configuration. 2- Hair distribution
3-Nutritional deficiencies. 4- Varicose veins.
5- Oedema.

The back.
1-Spine. 2- Sacro-iliac joints.
3- Muscles of back. 4- Costo-renal angles


GENERAL CONDITION AND CONFIGURATION
The general examination starts from the moment the patient Walks into the consultation
office,

GAIT
As the patient approaches term, the enlarged heavy uterus falls Forward, and she
compensates for this by lordosis of the spine, With the resultant characteristic waddling gait
of the pregnant Patient near term.
A limping gait must be noticed as it sometimes denotes an Accompanying abnormal pelvis such
as obliquely contracted pelvis or spondylolisthetic pelvis.

HEIGHT
The patient's height is the direct result of the development of the osseous system (skeleton).
Hence short stunted patients invariably have small pelvis, yet the reverse does not hold true,
that is to say, a tall patient does not exclude the presence of pelvic contraction.

BUILD
The build of the patient depends on hereditary, developmental, endocrinological, constitutional
and pathological factors. The case of a kyphotic patient particularly if The kyphosis is in the
lower dorsal or lumbar spine, which results in the typical kyphotic pelvis. Another good
example is the short patient (Dystocia Dystrophia syndrome).The salient features of this
conditions or Dystocia Dyspituitarism is:
Delayed onset of puberty, irregular scanty flow of menstruation, dysmenorrhoea and a
long period of primary sterility before the onset of pregnancy.
The patient is short and stocky, the neck is thick, and the chest is broad and short,
the long bones of the limbs are short, and the wrists and ankles are heavy.
Excessive fat deposition on the abdomen hips and legs with a tendency to hirsutism.
The vagina is short and rigid, and the uterus is small.
The pelvic bones are heavy and masculine and the pelvic cavity is small with an android
tendency (funnel pelvis).
During pregnancy, there is great liability to abortion, excessive gain in weight, toxemia
of pregnancy and eclampsia, abnormal presentations particularly occipito posterior,
delayed
engagement of the head and post-maturity.
During labor, there is tendency to premature rupture of the membranes, colicky
uterus and excessively painful uterine contractions, prolonged labor, cervical tears and
lacerations of the
soft parts of the birth canal.
Spontaneous delivery is uncommon, and thus forceps delivery and Caesarean section is
frequent.
The still birth rate is high and the liability to puerperal infection is great.

PENDULOUS ABDOMEN
Pendulous abdomen is best detected with the patient standing. specially in multipara
Pendulous abdomen can be the cause or the result, of any abnormal presentation. In
fact, one would be correct in mentioning pendulous abdomen in the aitiology of any
abnormal presentation, whether it is occipito-posterior, brow, face, breech, shoulder,
cord or complex presentation.
Another point to remember about pendulous abdomen, is that whenever it is
encountered in a primigravida, the possibility of contracted pelvis is very great.

WEIGHT OF THE PATIENT
Weighing the patient must constitute a part of the regular examination during every antenatal
visit. The average gain in weight during the whole period of gestation is about 11-12 kgms. This
is due to the growth of the fetus (3.25 kgms.), the placenta (0.5kg), the liquor amnii (0.7-1
kg.), increased weight of the uterus (1.0 kgm.); in addition to the increased blood volume,
development of the breasts and increased deposition of fat in the subcutaneous tissues. This
gain in weight is more marked during the second half of pregnancy (9 kgms) than during the
first half (3 kgms.). In fact, during the first month Excessive gain in the body weight, much
beyond the average, particularly during the last trimester of pregnancy, calls for special
attention, as it is generally the result of excessive fluid retention in the body. Impending
toxemia of pregnancy, especially when the excessive gain in weight takes place suddenly
(within 1-2 weeks).

GENERAL CONDITION
As the history is being taken, the examiner can get an idea about the general condition of the
patient.

PULSE
On holding the patient's hand to count the pulse, it is always advisable to wait for a while
before starting the count. This allays the patient's anxiety and hence more accurate count of
the pulse rate is obtained. during the last weeks of pregnancy, owing to the hemodynamic
changes in the circulation and the enlarged uterus pushing and displacing the heart slightly
upwards, a slight increase in the pulse rate,

Obstetric causes of raised pulse rate:

"In early pregnancy"
1. Internal hemorrhage as in ectopic pregnancy.
2. External hemorrhage as in inevitable or incomplete abortion.
3. Acute hydramnios.
4. Vesicular mole.
5. Incarcerated retroverted gravid uterus.
6. Hyperemesis gravidarum. Here the pulse rate gives some help as to the prognosis of the
case, and It is stated that in such cases a progressive rise in the pulse rate, or a pulse rate
persistently above 100 beats per minute, is an indication for termination of pregnancy. Again,
the high pulse rate in these cases, helps to differentiate them from cases of cerebral
tumours which may cause incessant vomiting, but with lowering of the pulse rate.

"In late pregnancy"
1. Antepartum hemorrhage.
2. Toxemia of pregnancy.
3. Polyhydramnios.
4. Multiple pregnancies.

During labor
1. Maternal distress or exhaustion.
2. Obstructed labor.
3. Abnormal uterine action.
4. Hemorrhage, either anteparturm or else.
5. Intra-uterine infection.
6. Rupture uterus.
7. Obstetric shock.
8. Post-partum hemorrhage, either the third stage hemorrhage or true post-partum
hemorrhage.

During the puerperium
1. Puerperal infection.
2. Urinary tract infection.
3. Breast infection.
4. Venous thrombosis of the femoral vein, pelvic veins or the veins in the calf muscles. This
causes a persistent high pulse rate, with a low grade temperature, during the second
puerperal week.
5. Secondary post-partum hemorrhage.
6. Subinvolution of the uterus.
7. Subacute and chronic inversion of the uterus.

Non obstetric causes of raised pulse rate.

In the genital tract
Fibromyoma, undergoing degenerations
Ovarian tumours undergoing complications.
Outside the genital tract
Heart diseases.
Lung diseases.
Endocrinal diseases such as diabetes and thyrotoxicosis.
Infectious fevers.
Nutritional deficiencies, including osteomalacia.
Kidney diseases.


TEMPERATURE
Normal pregnancy, labor and puerperium do not cause any material change in the body
temperature. However, during the fourth or fifth day of the puerperium a mild transient rise
of the temperature for a few hours only, may accompany the milk engorgement of the breasts.
Again, during the first few hours following a prolonged labor, slight pyrexia may be
encountered and is ascribed to the muscular exercise of labor. A subnormal temperature
during pregnancy, and resulting from the pregnant state does occur sometimes in cases of
internal or external hemorrhage. On the other hand a high temperature may indicate a super-
added infection in the uterus as in cases of trials at criminal abortion. Again, it is occasionally,
the result of excessive dehydration in hyperemesis gravidarum, and in such cases it is stated
that a temperature persistently above 38C. Is an indication for termination of pregnancy.

During labor, regular recording of the patient's temperature is essential. A raised
temperature then, may either indicate the onset of maternal distress or may be the result of
intra-uterine infection.
An elevated temperature in the puerperium, as it may be the result of puerperal infection.

Puerperal Pyrexia : This is defined as "a rise of the temperature to 38 C. or over, maintained
for 24 hours or recurring during that period; in the first twenty one days after confinement
or abortion".
Puerperal Sepsis or Puerperal Infection : This describes those cases of puerperal pyrexia in
whom the cause of the pyrexia is a genital tract infection. Infectious fever, it was found that
sonic of the specific fevers caused by virus infections - as measles, german measles and
chicken pox when caught early in pregnancy, may cause intrauterine death of the ovum or its
mutilation resulting in various types of congenital abnormalities

BLOOD PRESSURE
An accurate record of the bleed pressure in the pregnant woman must be taken. It is also of
advantage, if possible, to get a record of the blood pressure of the patient before the onset
of the present pregnancy.

Effect of normal pregnancy on the blood pressure.
Normal pregnancy sometimes causes slight lowering of the blood pressure. This lowering of
the blood pressure explains the attacks of giddiness, the lassitude and the frequent spell of
fainting .
The causes of this lowered blood pressure are:
1 Imposed rest on the patient.
2. Arterio-venous shunt in the placental circulation.
3.Dilatation of the arterioles under the influence of relaxin.
4. Certain hypotensive substances produced by the fetus. Effects of pathological pregnancy
and laboron, the blood pressure.

Pathological pregnancy and labor may affect the blood pressure,. Causing either its lowering or
its elevation.
Obstetric causes of lowered blood pressure.
1. Internal hemorrhage
2. External bleeding as in cases of abortion, hydatidiform mole, antepartum hemorrhage and
postpartum hemorrhage
3. Excessive vomiting of pregnancy,
4. Acute yellow atrophy of the liver.
5. Obstetric shock or surgical shock accompanying major obstetric accidents.

Causes of elevated blood pressure during pregnancy.
1. A very important group of diseases met with in the second half of pregnancy, during labor
or in the early days of the puerperium; and known as "toxemia of pregnancy" or the "pre-
eclampsia- eclampsia" syndrome.
2. Essential hypertension with pregnancy.
3. Chronic nephritis with pregnancy.
4. Thyrotoxicosis, or pheochromocytoma of the suprarenal gland.
5. Labile hypertension. anxious and neurotic patients during the examination.

The level of the blood pressure. there have been much discussion about the upper - most limit
of normality of the blood pressure. Some authors consider any rise above 120/80 as an
elevated blood pressure, while others take this limit as 140/190.

1. Early appearance of toxemia of pregnancy "In the first half of
pregnancy" as in cases of :
a. Hydatidiform mole.
b. Polyhydramnios.
c. Multiple pregnancy.
d. Toxemia complicating essential hypertension.

Frequency of measuring the blood pressure.
As expected, this will be governed by the nature of the case. In normal pregnancy
The blood pressure is recorded during the regular antenatal visits which are:
Once every month, during the first twenty eight weeks. 50
Once every fifteen days from the 28th week till the 26th week.
Once every week. during the last four weeks of pregnancy.

In pathological Pregnancy:
Much more frequent recordings of the blood pressure arc needed, as for example:
In bleeding patients, it is measured every 1/4 to 1/2 hour.
In shocked patients, it is measured even 1/4 to 2 hours.
In eclamptic patients, it is measured. Every 2 hours or less.
In severe pre-eclampsia, it is measured every 4 to 8 hours
In hyperemesis gravidarum, it is measured every 6 to 12 hours.
In mild pre-eclampsia, it is measured every 1 to 3 days.



EXAMINATION OF THE HEAD, NECK, CHEST,
LIMBS, AND BACK

HAIR OF THE SCALP
Falling of the hair of the scalp during pregnancy or lactation. Hence a look at the scalp for
seborrhea or manifest skin lesions, do benefit much from the big doses of vitamins, minerals
and calcium given for the management of the pregnant state.

SKIN OF THE FACE
-The dry, dehydrated skin in cases of dehydration. The malar flush in cases of mitral stenosis,
the general puffins in cases of salt and fluid retention and the yellowish in cases of jaundice.
- the skin of the face shows certain signs of great obstetrical significance As:

It occasionally shows one of' the early signs of pregnancy, that is, brown pigmentation
on the maxillae and bridge of the nose, simulating a butterfly appearance and is known
as chloasma this pigmentation disappears after labor, Again, the skin of the face
occasionally shows a tendency to male distribution of hair or excessive hirsutism.
Though this is difficult to detect in the majority of cases owing to the make-up, yet a
careful scrutiny of the hair follicles will give an idea about the hair.

Distribution, 'The significance of this is that a patient with a male distribution of hair
is more liable to have a male type of pelvis, the so--called android pelvis, which can
cause trouble during labor.

Acne of the skin of the face sometimes makes its first appearance during pregnancy,
but in these cases it usually disappears after labor. On the other hand, some patients
suffering from acne find that it improves or even completely disappears during
pregnancy.

THE EARS
Difficulty in hearing is occasionally found during pregnancy. The most salient causes of this
are
1 . Accumulation of wax in the external ear,
2. Accompanying congestion in the mucous membrane of the pharynx encroaching on the
calibre of the Eustachian tubes.
3. Oto-sclerosis which occasionally comprises one of the serious complications of pregnancy.
patient should be referred to the specialist.

THE EYEBROWS
Falling of the hair on the outer third of the eyebrow is one of the recognized signs of
hypothyroidism. However, this sign is commonly masked by the make-up of the patient.

THE EYES
Eyelids.
This oedema can be detected from the puffiness of the eyelids. Such a sign,. however, may be
transient, showing only in the morning when the patient is awaked, but as she moves about,
repeated blinking and the movements of the face muscles, restore the excessive fluid back
into the circulation_ Still, even in such cases, if the patient is asked to smile, the wrinkles
which normally appear at the outer angles of the eyelids, do not show in these cases.
Conjunctiva.
This is examined for:
1. Manifestations of deficiencies such as iron deficiency where it is pale, or vitamin A
deficiency appearing as xerotic patches near the outer canthus. The presence of such
manifestations of nutritional deficiency calls for prompt treatment as they seriously affect
the course of pregnancy and labor.
2. Manifestations of diseases. Particularly important in this respect are jaundice and
hemorrhage under the conjunctiva.
a) jaundice, in the early months of pregnancy in cases of severe hyperemesis gravidarum, and
in the later months in cases of acute yellow atrophy.
b) Hemorrhage under the conjunctiva. This is encountered in some cases of hypertensive
diseases of pregnancy complicated by accidental hemorrhage.
Pupils
The presence of an Argyll-Robertson pupil can be of help in the diagnosis of the cause of
repeated abortions or still-births(Syphilis).
Signs of Thyrotoxicosis in the Eyes.
These must be looked for, whenever the patient's complaint and/or look, point to the
possibility of its presence.
Fundus Oculi.
The examination of the fundus of the eyes must constitute a part of the general examination
of every patient suffering from hyperemesis gravidarum or from hypertensive diseases of
pregnancy. Hyperemesis gravidarum: They show as a picture of optic neuritis. These changes
are ascribed to vitamin B, and or vitamin C deficiency. It must be remembered that the
appearance of any fundal change in cases of hyperemesis calls for immediate termination of
pregnancy. Hypertensive diseases of pregnancy: the changes in the fundus oculi depend on the
duration and the severity of the disease, picture of arteriosclerotic or albuminuric retinitis.
It is commonly said that through the fundus oculi, one can have a direct look at the changes
taking place in the arterioles all over the body in these cases.

THE NOSE
-A septic focus there, may play an etiological part in some obstetric complications such as
puerperal sepsis.
-The presence of a sunken bridge of the nose directs the attention to the possibility of
congenital syphilis being the cause.

There is a certain inter-relation between the endometrium and the mucous membrane lining
the nose, the nasopharynx and the throat. Thus, during pregnancy, there is a manifest
congestion of the mucous membrane lining these parts which may cause some change in the
tone of the voice and extent - why opera singers refrain from performing during pregnancy.
suffer from severe allergic rhinitis and/or laryngitis which persist during the whole course of
pregnancy.


THE MOUTH
Lips.
The lips are examined for manifestations of nutritional deficiency such as anemia, cheilosis
and rhagades at the outer angles of the mouth; for excessive dryness and in cases of severe
dehydration.
Gums.
The gums must be examined to find out if there is oedema, swelling, bleeding. The presence of
"elides gravidarum" or hypertrophy gingivitis should also be noticed. and disappears after
labor.
Tonsils.
The tonsils have to be thoroughly examined for any enlargement, congestion or infection,
whether acute or chronic. The role of infected tonsils in the causation of puerperal sepsis.
Again, infection in the tonsils or the throat plays an important part in the etiology of some
diseases associated with pregnancy such as heart disease, or kidney disease.

THE NECK
Thyroid Gland.
-This should be examined for scars of previous operations, enlargement or any nodularity. In
normal pregnancy there is some visual and palpable enlargement of the thyroid gland
described as the physiological enlargement of pregnancy.
-Thus, hypothyroidism whether post-operative or spontaneous, may be a factor in the etiology
of abortion, premature labor or toxemia of pregnancy. Again, pregnancy is known to aggravate
the hypothyroidism. On the other hand, hyperthyroidism could be responsible for abortion,
premature labor, heart failure during pregnancy or labor and post-partum hemorrhage.
Blood Vessels.
Dilated veins, venous pulsations and arterial pulsations must be looked for, as they may give an
idea about the cardiovascular state of the patient. Owing to the changes in the dynamics of
the circulation during pregnancy, it is not uncommon to get suprasternal pulsations Enlarged
Lymph Nodes and Scars. The presence of enlarged lymph nodes and/or scars in the neck, calls
for a careful scrutiny of the history.

THE BREASTS
Thorough examination of the breasts in obstetrics is essential. In doing so, the examiner
should look for:
1. The signs of pregnancy in the breasts.
2. The readiness of the breasts for lactation.
3. The presence of infection particularly during the puerperium.
4. The presence of a lump or any other associated lesions.

Signs of Pregnancy in the Breasts.
i. Vascularity and hyperactivity : The breasts become larger, warmer, tense, knotty and
tender, with the appearance of superficial veins under the skin. In some patients a lobule of
the gland appears on the anterior fold of the axilla. This however is mainly encountered in the
puerperium with the milk engorgement (axillary lobule).
ii. Nipple and Areola: "primary areola"
iii. Secondary areola : This appears around the 16th week of pregnancy, as a spider like or a
mesh work form of pigmentation, around the primary areola.
iv. Montgomery's Follicles (glandular tubercles) : These usually appear by the 12th to the 16th
week of pregnancy as small nodules on the primary areola. They are commonly described as
due to modified enlarged - sebaceous glands, but recently they are believed to be due to
distended peripheral lactiferous ducts.
v. Secretion : One of the earliest signs of pregnancy in the breasts is the appearance of a
clear serous secretion. Milk engorgement is occasionally encountered during the second half
of pregnancy, in which cases it denotes a serious occurrence,
i.e., the intra-uterine death of the fetus; a sign known as "MonteeDu Lait"

Reading of the Breasts for lactation
Presence of Infection Particularly in the Puerperium .Clinically infection in the breast is mainly
manifested in the following clinical pictures:
i. Infected abrasion or fissure in the nipple.
ii.Subcuticular abscess.
iii. Parenchymatous mastitis. In this condition the infection is localised to one lobule of the
breast.
iv. Diffuse interstitial mastitis. Here the infection is diffuse all over the substance of the
breast.
Presence of a Lump or Other Associated Lesions. In fact, the presence of a carcinoma in the
breast by itself indicates the termination of pregnancy. Again, a certain type of breast
carcinoma its first appearance during lactation, and hence termed "lactation carcinoma". This
is a very active encephaloid carcinoma, occurring in young patients and simulating a mammary
abscess.

THE THORACIC CAGE
The form, shape and configuration of the thoracic cage should be carefully studied. The most
evident example of this is an old attack of rackets which may leave its imprint on the thoracic
cage in the form of a pigeon shaped chest, and on the pelvis as a flat rachitic or a generally
contracted rachitic pelvis.
Towards the end of pregnancy, a certain degree of flaring out of the subcostal margin takes
place due to the enlargement of the uterus and its falling forwards, and this sometimes
causes distressing pain at the costal margin.

THE LUNGS
Effects of Pregnancy on the Lungs.
i. Dysfunctional : In almost every pregnancy, as the patient approaches term, there are some
respiratory symptoms such as dyspnoea, shortness of' breath, respiratory oppression, sense
of choking or suffocation and occasional orthopnea. Such subjective symptoms are caused by
the compression of the lungs by the enlarging uterus.
ii. Pathological : collapse, pneumonia, lung abscess, pulmonary embolism or spontaneous
pneumothorax. may be met with as complications in certain obstetrical accidents such as
eclampsia, excessive hard straining during labor, puerperal sepsis, puerperal femoral or deep
pelvic veins thrombosis.

THE HEART
Normal pregnancy throws a great strain on the heart owing to the increased blood volume
(hydremia of pregnancy), the increase in the vascular bed, the arteriovenous shunt (placental
circulation) and the displacement of the heart upwards and outwards by the enlarging uterus.
Though the normal heart bears well this added strain, so that a patient can gave birth to 10 or
15 children without the heart suffering any damage, yet a diseased heart may easily succumb
even during the early months of the first pregnancy (ride infra). Pathological pregnancy
throws a greater; strain on the heart. Thus, in toxemia of pregnancy, there is the added work
to compensate for the accompanying hypertension; Associated Lesions in the Heart. Organic
heart diseases are encountered in about 2% of pregnant patients. The main pathological
lesions met with are:
a) Myocardial disease such as auricular fibrillation, and paroxysmal tachycardia.
(b) Valvular disease
(c)Hypertensive heart disease.
Assessment of the functional capacity of the heart.
Grade I. Patients with heart disease, who can carry out physical activity without limitation.
Grade II. Patients with heart disease which limits their activity on ordinary exertion, as for
example, hurrying up the stairs.
Grade III. Patients with heart disease which severely limits their activity, e.g., they get
dyspnea on walking on the flat.
Grade IV. Patients with heart disease who are unable to carry out any physical activity
without discomfort. These patients usually show symptoms and signs of cardiac insufficiency
at rest.

Assessment of the degree of heart failure.
Slight: Here there are symptoms such as shortness of breath, palpitation, and occasional
precordial pain on exertion.
Moderate: Here the symptoms appear on walking on the flat. In addition, there may be slight
tachycardia at rest and few basal crepitations in the lungs.
Severe: Here the symptoms are present at rest, with orthopnoea, cyanosis, oedema,
tachycardia, hepatic enlargement and albuminuria.
Extreme: Here in addition to the above, there is effusion in the serous cavities, huge liver
and tic-tac rhythm of the heart.

Heart failure may be encountered at any time during pregnancy or labor:
1. During the 13th week of pregnancy, when the hydremia is at its maximum (increased blood
volume).
2. During the second stage of labor, owing to the straining effort needed for the expulsion of
the fetus.
3. During the third stage of labor, owing to the extensive changes in the vascular bed
resulting from :
(a) Sudden relief of intra abdominal pressure.
(b) The cessation of the placental circulation so that a big amount of the blood is drawn back
into the maternal circulation.
4. During the puerperium, owing to the super-added risk of subacute bacterial endocarditis
taking place particularly around the fourth day of the puerperium.

UPPER LIMBS
The upper limbs should be examined for:
1. Length and form of the limb bones which, being a part of the skeleton, can give an idea
about the bony pelvis.
2. Hair distribution as excessive hirsutism denotes an android tendency.
3. Manifestations of nutritional deficiency such as :
(a) Pellagra, showing in its early stages as erythema, desquamation and exfoliation, later on as
pigmentation and thickening of the dermis, and finally atrophy supervenes, the skin becoming
wrinkled, inelastic and thinned. These changes are seen on the back of the hands, wrists and
forearm, and on the back of the elbow joint.
(b) Minerals and vitamin deficiency can be detected from the paleness of the nail beds and
the brittleness of the nails.
4. Oedema which shows as tightness of the wedding ring around the finger, and inelasticity of
the bulk of the muscles with a sense of fullness.
5. Specific lesions such as enlarged epitrochlear glands in cases of syphilis or clubbing of the
fingers in cases of chronic infections.
6. Muscular development, as excessive muscularity indicates an android tendency and a great
liability to toxemia of pregnancy.

LOWER LIMBS
The lower limbs arc to be examined for :
1. General configuration and bony diseases, such as short bones, bow-legs, knocked knees,
saber tibia (syphilitic), clubbed feet, evidence of old fractures. Here it must be remembered
that lesions of the bones or joints of the lower limbs may reflect directly on the size and the
shape of the pelvis, particularly if these lesions took place during infancy or childhood.
2. Hair distribution and muscularity, the significance of which was described before.
3. Manifestations of nutritional deficiency, such as pellagra rash, tender calf, nutritional
oedema or hypocalcemia.
4. Varicose veins such varicosity usually regresses alter labor, yet the regression is not always
complete, Still, this is augmented during pregnancy by :
(a) Increased vascularity of the pelvic vessels and their tributaries.
(b) Pressure of the enlarging uterus on the main venous trunks of the lower limbs.
c) The effect of certain hormone (relaxin) acting directly on the wall of the vein, leading to
its dilatation even very early in pregnancy.
5. Oedema.. When the oedema is extensive, it is detected even by inspection as peau d'orange.
Once oedema is found, its level and extent (by measuring the girth of the limb) must be
determined repeatedly to judge the progress of the case. Again, the attendant must examine
both limbs and the amount of oedema noticed and compared on both sides.

The BACK
During such, an examination, more stress must be laid on the spine, the sacro-iliac joints, the
muscles of the back and the costo-renal angles.
The Spine.
1. Lumbar kyphosis leads to kyphotic pelvis.
2. Scoliosis may result in, or be the result of, obliquely contracted pelvis.
3. Spondylolisthesis or falling forward of the last lumbar vertebra in front of the promontory
of the sacrum, Dads to marked contraction of the pelvic inlet (Spondylolisthetic pelvis).
4. High assimilation (i.e., sacralization of the last lumbar vertebra) and low assimilation (i.e.,
lumbarization of the first piece of the sacrum), lead to changes in the obliquity of the pelvic
inlet with their sequelae.

The Sacro--iliac Joints.
During pregnancy, as a result of the general pelvic congestion and under the effect of the
various pregnancy hormones, the supporting ligaments of these joints become softened and
thus may partly give way, leading to persistent low backache over the joints which becomes
more manifest following exertion. Again, these joints are subjected to a big strain during the
passage of a big head of the fetus, and this explains some cases of low backache following
difficult or prolonged labor. Following the operations of symphysiotomy and pubiotomy, sacro-
iliac sprain is quite a common sequela. The Muscles of the Back. Pain and tenderness in the
muscles of the back are common Findings during pregnancy, particularly in patients with
pendulous abdomen, multiple pregnancy, polyhydramnios; and those suffering from nutritional
deficiency particularly calcium deficiency. Such pain sometimes persists during the
puerperium and even for a long time after labor.

The Costo--renal Angle.
The significance of pain, tenderness or swelling in this area in denoting a possible renal
affection and the importance of such affection have already been described.
PART III


LOCAL ABDOMINAL EXAMINATION

INSPECTION

1- Hair distribution. 2- Pigmentation.
3- Scar of previous operations. 4- Oedema.
5- Movements. 6- Abdominal enlargement

PALPATION
General palpation.
1. Palpation of the uterus.
2. Palpation of swellings beside the uterus.
3. Palpation of other abdominal organs

Palpation near full term.
1- Level of fundus 2- Fundal grip.
3- Lateral grip. 4- Pelvic grip
5- Pawlick grip. 6- Combined grip
7- Anterior shoulder. 8- Deep pelvic palpation

Palpation during labor.
1- As near full term 2- Uterine action.
3- Progress of labor. 4- Abnormalities.

Palpation after labor.
Palpation during the puerperium.
1- Involution. 2- Puerperal sepsis.
3- Associated lesions.

PERCUSSION & AUSCULTATION
Percussion.
1 Level of fundus 2- Pseudocyesis.
3-Liver dullness. 4- Shifting dullness
Auscultation
1 Foetal heart sounds. 2- uterine souffl
3- funic souffl 4- maternal pulsations

5- fibrillary twitches 6- peristaltic movements
7- foetal movements 8- vagitus uterinus





INSPECTION
The main items to look for when inspecting the abdomen of a
pregnant patient arc the following:
I. Hair distribution.
II. Pigmentation.
III. Scars of previous operations.
IV. Oedema.
V. Movements.
VI. Abdominal enlargement.

HAIR DISTRIBUTION
Three main types of hair distribution on the abdominal wall may be met with, and these are:
a)Female distribution : Here the pubic hair ends in a transverse line above the mons veneris
(b) Male distribution : In this type the pubic hair tapers towards the umbilicus. A patient with
such a male distribution of hair is more liable to have a male type of pelvis, and is frequently the
subject of toxemia of pregnancy
(c)Excessive generalized hirsutism on the whole skin of the abdomen

PIGMENTATION
Pigmentation of pregnancy in general, is more marked in the brunette than in the blonde patients,
1. Linea nigra: This is a dark brown pigmentation along the midline of the abdomen, extending
from the xiphi-sternum to the symphysis pubis and passing through the umbilicus. It is diagnostic
only in the primigravida, as in the multipara, the pigmentation of the first pregnancy may never
disappear.

2. Striae gravidarum: These are depressed pink or brown streaks which vary in length and width.
particularly its lower part below the umbilicus, on the buttocks, upper part of the thighs and the
breasts. After labor, they become pale or silvery white and are then termed striae albicantes or
striae album. In multipara, during pregnancy, both forms are seen on the skin of the abdomen: the
striae albicantes (striae album) of the previous ones. The striae gravidarum are the result of
tearing of the elastic fibres of the dermis under the effect of abdominal distension and the
increased deposition of the subcutaneous fat.

Besides pregnancy, striae are occasionally seen in some diseases such as Cushing syndrome, or
excessive obesity of whatever cause.

The clinical significance of striae gravidarum is that they indicate the elasticity index of the
tissues of the patient. Thus, the more the striae, the less the elasticity of the tissues, and
hence, the greater the liability to perineal tears and vaginal lacerations during labor.

3. Generalized pigmentation of the skin of the abdomen, similar to the chloasma utrinum seen on
the skin of the face

4. Pigmentation around the umbilicus: Occasionally a peculiar play of colors from brown to green
to yellow, is seen around the umbilicus in cases of internal intraperitoneal hemorrhage, such as
that following ruptured ectopic pregnancy (Cullen's sign). It is more frequently encountered in
cases with umbilical hernia, and is believed to be due to the imbibing of the blood by the
peritoneum. addition to the pregnancy pigmentation described above, various types of
pigmentation are occasionally seen due to associated lesions such as birth marks, accessory
nipples skin rashes, drug eruptions, various skin diseases or Addisons disease.

SCAR OF PREVIOUS OPERATION

The site, the length, the width and the nature of the scar must be carefully studied. The
significance of these seats in denoting previous operations and the influence of such operations
on the course of pregnancy and labor have been discussed before.

OEDEMA

Oedema in the abdominal wall manifests itself either as depressions and markings at the sites of
constrictions in the clothes, or as "Peau d'orange" of the skin, particularly in the lower part of
the abdominal wall. discussed before. It must be remembered that the appearance of oedema in
the abdominal wall denotes a severe degree of fluid retention necessitating prompt treatment.

MOVEMENTS

Movements of Pregnancy and Labor.

(A) Foetal movements.

When these are seen, felt or heard by the examiner, they are considered as one of the sure signs
of pregnancy. Such movements start from the 16th to the 18th week of pregnancy. From the
24th week onwards, they can be seen by the attendant. Compression of the foetal head by the
examiner, is usually effective in eliciting these movements. obstetric importance as:

1. They constitute one of the sure signs of pregnancy.
2. They indicate that the fetus is alive.
3. Then position in patients near full term,
4. The presence of' excessive foetal movements points to one of the following condition:
a)Nutritional or vitamin deficiency.
b)Multiple pregnancy.
c)Intra-uterine asphyxia of the fetus.
d)Uterine contractions.

Though these are present from the early weeks, yet they cannot be seen except when the patient
is well advanced in pregnancy and the uterus is high up in the abdomen (24th week or later).
During these contractions, the contour of the abdomen changes as the uterus moves forwards
with every contraction.
During labor, these contractions change into labor pains, and the forward movement of the uterus
becomes more manifest. This forward movement of the uterus is ascribed to the contractions of
the round ligaments and is intended to bring the long axis of the fetus in line with the longitudinal
axis of the pelvic inlet.

Associated movements.

(A) Respiratory movements

Abdominal respiratory movements can be easily seen in early pregnancy. As the patient
approaches term, and with the progressive enlargement of the uterus, the nature of the
respiratory movements changes into a thoracic one, Marked limitation of the abdominal
respiratory movements is seen in cases of acute abdomen or pelvic peritonitis of whatever origin
it may be. The obstetrical causes of this are
1. Disturbed ectopic pregnancy.
2. Perforating vesicular mole.
3. Acute polyhydramnios.
4. Traumatic perforation of the uterus.
5. Torsion of the uterus and accidental hemorrhage.
6. Rupture uterus.
7. Intra-uterine infection and puerperal sepsis.
8. Complications in tumours associated with pregnancy such as fibromyoma and ovarian tumours.

(B) Transmitted pulsations

These are occasionally seen. in the abdomen in thin patients, in neurotic patients, and in some
cases of cardiovascular disease such as aneurysm of the abdominal aorta, heart failure or
tricuspid valve disease.

(C) Intestinal movements (Peristalsis)

These are not seen normally except in thin and emaciated patients. Their presence to a marked
degree indicates a mechanical obstruction in some part of the alimentary tract, such as pyrolic
stenosis or chronic intestinal obstruction.

(D) twitches in the muscles of the abdominal wall

The clinical significance of associated movements in general and of muscular and peristaltic
movements in particular, is that they are occasionally mistaken by the patient and even by the
attendant for foetal movements.

ABDOMINAL ENLARGEMENT

This is one of the signs of pregnancy. As expected, the degree of enlargement will depend on the
duration of the pregnancy.
This shape is best arrived at by inspecting two lines
(1) A median vertical one passing from the symphysis pubis to the umbilicus and thence to the
xiphisternum.
(2) A transverse trans-umbilical one, passing from one flank to the other

The first of these lines (the vertical), is inspected from the side of the bed, while the second is
inspected from the top or the foot of the bed. As to the position of the patient, she should be
centralised in the bed, with her shoulders slightly raised, and her legs extended. The inter-
relation between these two lines, as well as the bulges or the depressions along them must be
carefully noticed.

The Inter-relation Between the Two Lines.

Normally the vertical line is longer than the transverse one. In some cases, however, the
transverse line may approach or even exceed the vertical one, as in the following conditions

1. Transverse lie of the Fetus. 2. Multiple pregnancies.
3. Polyhydramnios. 4. Fibromyoma or ovarian tumours with pregnancy.
5. Associated conditions causing transverse abdominal enlargement such as ascites, splenomegaly
or hydronephrosis.

The Contour Along the Vertical Line.

-This may be altered by changes in the position of the fetus, full bladder, fibromyoma of the
uterine muscle, pathological retraction ring, polyhydramnios or by lesions of the anterior
abdominal wall.

-Fibromyoma of the anterior wall of the uterus alter the shape of the vertical line according to
their number, size, site and bulge.

-Pathological retraction ring or Bandl's ring. This is a serious condition encountered in cases of
obstructed labor. As the uterus tries to expel the fetus past the obstruction, the retracting
upper uterine segment becomes much shorter and thicker, while the stretchable lower uterine
segment becomes longer and thinner. This pathological exaggeration of the normal retraction,
manifests itself as a constriction at the junction of the upper and lower segments which
progressively raises up in. the abdomen. Thus, it will be visible during inspection also

-depression across the anterior abdominal wall and so along the vertical line The seriousness of
this condition is that it denotes an impending rupture of the uterus.

-Excessive distension of the uterus, as in cases of multiple pregnancy, hydrocephalus or
polyhydramnios; causes a great abdominal bulge, and hence results in marked exaggeration of the
convexity along the vertical line

The Contour Along the Transverse Trans-umbilical Line.

In the majority of patients, this shows a slightly greater bulge on one side or the other, generally
on the right side. That is to be expected, as the uterus is not exactly a central organ, but is
slightly deviated as well as rotated to the right.

However, an exaggerated bulge to one side or the other, is of great obstetrical significance. Such
an exaggerated bulge may be due to
1. Exaggerated uterine obliquity. This is a common cause of abnormal presentations.
2. Oblique lie or transverse lie of the fetus.
3. Some cases of breech presentation, as the head in the fundus usually lies to one side of the
midline.
4. Associated lesions such as fibromyoma, ovarian tumours, enlarged spleen or distended colon.

This irregular contour is encountered in the following conditions
1- Congenital anomalies of the uterus.
2-Advanced ectopic pregnancy.
3- Rupture uterus with escape of the fetus into the peritoneal cavity.
4- Fibromyoma and ovarian tumours associated with pregnancy.
5- Other abdominal tumours associated with pregnancy such as splenomegaly or kidney tumours.

The sites of hernial orifices for the presence of any hernia. In some cases, it is also advisable to
inspect the abdomen with the patient standing.
This is particularly helpful for the diagnosis of pendulous abdomen and for the detection of
shelving of the uterus. Shelving of the uterus : This describes a peculiar change that takes place
in the configuration of abdomen with the onset of lightening

GENERAL PALPATION
The general rules which are essential to get the maximum information. These are:

1. Palpation must be carried out with gentleness and care. Cold hands in winter days, sweating wet
hands in summer and rough manipulations, are very distressing to the patient. These may lead to
contraction of the abdominal muscles and occasionally to reflex uterine contraction. Such
conditions render the palpation difficult,
2. The patient must be in a relaxed position with the head raised slightly on a, pillow. The
temperature of the room must he appropriate and only the parts to be palpated are uncovered.
3. The examination is usually carried out from the left side of the patient.
4. The palpating hands should be flat on the abdomen, with no space between the palm and the
abdominal wall. Palpation with the whole of the hand elicits no pain, awhile palpation. with the
finger tips causes pain leading .
5. If during palpation, the uterus or the abdominal muscles contract, the hands must be kept still
on the abdomen, till the contraction is over, is not recommended, as this may excite another.
contraction every time the hands are put on the abdomen.

The technique of abdominal palpation is carried out along the
following lines:
(a) Superficial abdominal palpation.
(b) Palpation of the uterus and its contents.
(c) Palpation of swellings beside the uterus.
(d) Palpation of the other abdominal organs.

SUPERFICIAL ABDOMINAL PALPATION
Position of the patient : The patient lying on her back, with the, shoulders slightly raised on a
pillow, the knees slightly flexed and wide apart.
Position of the examiner : Standing on the right side of the patient facing her.
The technique of the examination : The examiner applies his hands gently to the abdomen and
slides them from one quadrant to another in a systematic way, to cover all the area of the
abdomen.

Superficial abdominal palpation is specifically intended for the following:
1. To gain the confidence of the patient and give her the impression that the manipulations are
not going to elicit any pain. This point is rather important with a nervous and irritable patient,
which is not uncommon during the first obstetrical examination.
2. To detect areas of superficial tenderness, so that they may be left to the very end in doing
deeper palpation, and then palpated with great gentleness to minimize the patients sufferings.
3. To get an idea about the contour of the abdominal swelling or swellings.

PALPATION OF THE UTERUS AND ITS CONTENTS
When palpation is carried out after the seventh month, a full report about the fetus must be included.

GENERAL PALPATION OF THE UTERUS
Site of the Uterus.
Early in pregnancy, the uterus is encountered as a central mass in the lower abdomen. As it grows,
it encroaches more and more on the upper part of the abdomen, and in the majority of cases will
show some deviation and rotation to the right. Marked deviation of the uterus to one side or the
other may result from :
(1) Laxity of the uterus due to multiparity.
(2) Adhesions pulling it to one side.
(3) A push from the other side by an ovarian tumour, a fibromyoma, distended sigmoid colon or
other abdominal tumours.

Size of the Uterus.
Proper determination of the size of the uterus is of great importance for the diagnosis of the
presence of pregnancy, the duration of pregnancy, pathological pregnancy and abnormal
puerperium.

-At the 12th week of pregnancy, the uterus is felt just at the upper border of the symphysis
pubis, and from this time onwards, its size is measured by its height above the symphysis pubis
Thus:
-At the 16th week : its fundus is felt at the junction of the lower 1/3 with the upper 2/3 of the
line joining the symphysis pubis to the umbilicus.
-At the l0th week : it is felt at the junction of the lower 2/3 with the upper 1/3 of the line
mentioned above.
-At the 24th week : it reaches the level of the umbilicus.
-At the 28th week : it reaches the junction of the lower 1 /3 with the upper 2/3 of the line
joining the umbilicus to the xiphisternum.
-At the 32nd week : it reaches the junction of the lower 2/3 with the upper 11/3 of this line.
-At the 36th week : it reaches up to the xiphi-sternum.
-At the 4oth week : i.e., full term, it conies down almost to, or a little above, its previous level at
the 32nd week.

GENERAL PALPATION

Causes of the uterus being larger than the expected size
1. Mistaken dates, i.e., the patient giving wrong information about the date of the last menstrual
period.
2. An attack of bleeding
3. Vesicular or hydatidiform mole. This is a pathological condition in which the chorion (coverings
of the ovum), grows very rapidly and extensively. The rate of growth of the pathological chorion,
being much higher than the normal rate of growth of the fetus, results in the uterus becoming
much larger than expected in the majority of cases.
4. Polyhydramnios or an excessive amount of the liquor amnion accumulating in the uterus.
5. Multiple pregnancies
6. Big sized fetus as in cases of diabetes.
7. Certain congenital anomalies of the fetus as hydrocephalus, or foetal ascites.
8. Accidental antepartum hemorrhage (concealed or mixed variety)
9. Uterine fibromyoma associated with pregnancy.
10. During the puerperium from delayed involution

Causes of the uterus being smaller than the expected size
1. Mistaken dates.
2. A menstrual flow or two which were irregular, and considered by the patient as attacks of
threatened abortion.
3. Pregnancy following a period of amenorrhea of whatever cause.
4. Intra-uterine death of the fetus. '
5. Rarely in some cases of vesicular mole.
6. Small sized fetus as in cases of chronic nephritis, severe anemia
7. Deficient amount of liquor amnii, i.e. oligohydramnios.
8. During early pregnancy in cases of uterine hypoplasia.
9. During the early days of the puerperium, occasionally the uterus could not be felt per abdomen.
This may be due to rapid involution

Contour or Shape of the Uterus.
The pyriform non-pregnant uterus becomes globular by the eighth week of pregnancy. However,
by the sixteenth week it is pyriform again, and this shape is preserved till term.

Abnormality in the shape of the uterus may be encountered in the following conditions
1. Polyhydramnios, in which cases the shape is more or less spherical due to over distension of the
uterus.
2. Vesicular mole in which cases also the uterus is spherical, and for the same reason as described
above.
3. Abnormal presentations causing excessive distension of one part of the uterus or another, as
for example, cases of shoulder presentation.
4. Uterine fibromyoma causing excessive bulge on the uterine wall.
5. Congenital anomalies of the uterus, particularly duplications resulting in arcuate uterus or
other abnormal shapes.
6. During the third stage of labor, blood may accumulate in one cornua of the uterus giving a
characteristic bulge on one side or the other.
7. In early pregnancy, when the ovum is occupying only one part of the uterus, the shape may be
an irregular one owing to a greater bulge on that side occupied by the ovum. However, this can
only be detected during vaginal examination . Again, at such an early time a localised contraction
in an area of the uterine muscle may give an irregularity simulating a fibromyoma (phantom tumour
of the uterus).

Consistency of the Uterus.
In early pregnancy, the uterus is markedly softened. By the sixteenth week it becomes more or
less elastic, and this consistency is kept for some time. Late in pregnancy, as the fetus fills the
major part of the uterine cavity, the consistency will vary from one part to another. Thus it may
be hard when a bony part of the fetus is felt, firm where another part of the fetus is felt.
However, owing to the presence of uterine contractions during pregnancy, the uterus may feel
uniformly quite firm or even hard when it is examined during a contraction. Feeling these hard
uterine contractions constitutes one of the signs of pregnancy and is known as "Braxton _Hick's"
sign of pregnancy.

Abnormal consistency of the uterus may be felt in pathological pregnancy:
1. In cases of vesicular mole, the uterus has a characteristic doughy consistency. In some of
these cases however, the uterus is felt to be hard on account of a super-added accidental
hemorrhage on top of the mole.
2. In cases of polyhydramnios, the uterus feels very tense and cystic. In such cases one can easily
elicit a transmitted thrill. On the other hand, in cases of oligohydramnios the uterus is firm or
even hard.
3. In cases of concealed accidental hemorrhage, the bent-in blood may give the uterus a very
hard consistency.
4. Fibromyoma of the pregnant uterus sometimes present as multiple firm or hard nodules on the
surface of the uterus.
5. In cases of general tonic contraction of the uterus, one may feel it very firm or even hard.
6. Occasionally a characteristic cystic feeling of the uterus is encountered in cases of cystic
anomalies of the fetus such as foetal ascites, polycystic kidneys, atresia of the foetal urethra
with over distended urinary bladder.
7. In cases of intra-uterine death of the fetus, a good amount of the liquor amnii is absorbed,
which combined with the loss of the foetal tone, give a peculiar doughy consistency to the uterus.

Tenderness on the Uterus.
None or only trivial tenderness is encountered on the uterus in normal pregnancy. the stretch in
the round ligaments which elicits some pain, In fact, the most tender part of the uterus in
normal pregnancy is that part where the foetal head lies, and this point may be of great help in
the diagnosis of the position of the head. causes of tender uterus with pregnancy :
1. Vesicular mole.
2. Accidental hemorrhage.
3. Degenerated fibromyoma and particularly red degeneration.
4. Polyhydramnios.
5. Torsion of the uterus.
6. Ectopic intra-uterine pregnancy.
7. Intra-uterine infection.
8. Excessive retraction of the lower uterine segment in labor.
9. Colicky uterus.
10. Localised tonic contraction of the uterus (contraction ring).
11. General tonic contraction of the uterus.
12. Rupture uterus.

Mobility of the Uterus.
Owing to the marked vascularity and softening that take plane in the supporting structures of the
uterus during pregnancy, one may be able to move it from one side to the other, and to a less
extent upwards and downwards. This uterine mobility can also be detected during vaginal
examination, and forms the basis of "Piskacek's sign" of pregnancy

External Ballottement.
This is one of the signs of pregnancy, and can be detected from the 18th week onwards. It
depends on the presence of a firm object (fetus), floating in a fluid medium (liquor). To elicit it,
the patient lies on her side and two hands of the examiner are placed by the sides of the uterus.
The lower hand is then dipped sharply upwards, when a firm object is felt to recede from this
hand and impinges, on the other.

PALPATION OF SWELLINGS BESIDE THE UTERUS
Occasionally during palpation, masses are felt beside the uterus and closely related to it:
1. A full urinary bladder (retention of urine).
2. Fibromyoma.
3. Ovarian tumours.
4. Pelvic hematocele.
5. Advanced ectopic pregnancy.
6. Non-pregnant horn of a bicornuate uterus.

The Full Bladder.
Obstetrical significance of full bladder.
(a) Simulate and may be mistaken for an ovarian cyst.
(b) Mask the underlying structures, rendering palpation of the uterus quite difficult. This is
particularly the case during the puerperium.
(c) Inhibit the uterine contractions during labor, causing inertia, retained placenta and post-
partum hemorrhage.
(d) Push the uterus backwards during the puerperium, thus predisposing to retroversion flexion
of the uterus.

Fibromyoma with Pregnancy.
The importance of this tumour lies in the following facts
(a) It may completely mask the underlying pregnancy.
(b) It is affected by pregnancy, labor and the puerperium.
(c) It affects the course of pregnancy, labor and the puerperium.

Effects of pregnancy on fibromyoma.
1. Enlargement
2. Softening.
3. Flattening.
4. Degeneration, particularly red degeneration.
5. Torsion.
6. Incarceration.

Effects of labor on fibromyoma.
1. Traumatisation.
2. Hemorrhage within the tumour.
3. Red degeneration.
4. Torsion.
5. Incarceration.
6. Tumour drawn upwards from the pelvis.

Effects of puerperium on fibromyoma.
1. Infection.
2. Torsion.
3.Extrusion of sub-mucous or interstitial herniation of fibromyomatous polyp.

Effects of fibromyoma on pregnancy.
1. Abortion and premature labor.
2. Premature rupture of the membranes.
3. Pressure symptoms.
4. Abnormal presentations.
5. Placenta praevia.
6. Torsion of the uterus with accidental

Effects of fibromyoma on labor.
1. Premature labor, and premature rupture of membranes.
2. Abnormal presentation, with delay of the engagement of the presenting part.
3. Inertia.
4. Non dilatation of the cervix.
5. Mechanical obstruction to the passage of the fetus.
6. Adherent placenta and postpartum hemorrhage.

Effects of fibromyoma on the puerperiunr.
1. Infection
2. Inversion of the, uterus.
3. Sub-involution of the uterus.
4. Secondary postpartum hemorrhage.
5. Retrovcrsion flexion of the uterus.

Ovarian Tumours:
obstetrical significance of these tumours lies in the following facts
1. They mask the underlying pregnancy and'or may be mistaken for polyhdramnios, hydatidiform
mole, uterine firbromyomata, full bladder or hydronephrosis.
2. They are affected by pregnancy, labor and the puerperium.
3. They affect the course of pregnancy, labor and the puerperium.

Effects of pregnancy on ovarian tumours.
1 . Torsion. This takes place in 12% of cases, which is about double the incidence of torsion in the
non pregnant patients (6%).
2. Suppuration.
3. Incarceration (uncommon during pregnancy).
4. Rapid growth of the tumour (doubted and uncommon).
5. Rupture (uncommon apart from torsion).
6. Hemorrhage (uncommon apart from torsion).
7. Adhesions between the cyst and the surrounding structures.

Effects of labor on ovarian tumours.
1. Traumatisation.
2. Hemorrhage within the cyst.
3. Rupture.
4. Incarceration.
5. Torsion.
6. Infection.

Effects of puerperium on ovarian tumours.
1. Torsion. This takes place in about 24%/, of cases, is double its rate during pregnancy.
2. Rupture.
3. Hemorrhage.
4. Suppuration.
5. Rapid growth of the tumour.

Effects of ovarian tumours on pregnancy.
1. Abortion.
2. Premature labor.
3. Obliquity of the uterus and abnormal presentations.
4. Pressure symptoms.

Effects of ovarian tumours on labor.
1. Premature onset of labor.
2. Delay in the engagement of the presenting part.
3. Difficult labor due to abnormal presentation.
4. Obstructed labor, in cases where the tumour lies below the presenting part of the fetus.

Effects of ovarian tumours on the puerperium.
1. Increased risk of sepsis.
2. Acute abdomen due to complications in the tumour.

Pelvic Hematocele.
This is met with in cases of disturbed ectopic pregnancy. by a pelvic hematocele has the following
characteristics:
1. Site : Central swelling in the lower abdomen, arising from the pelvis and bulging downwards in
the posterior vaginal fornix and backwards into the rectum.
2. Size : Variable.
3. Mobility : Fixed.
4. Tenderness : Present all over the tumour, and particularly in Douglas pouch, during vaginal or
rectal examination.
5. Consistency : Variable, being firm in certain areas, or cystic and soft in other areas.
Advanced Ectopic Pregnancy.

In these cases the empty uterus is enlarged, but its size is far less than what is expected. with
the following characteristics
1. Site : An abdominal or abdomino-pelvic mass, not exactly central in the abdomen, but taking an
excentric and unusual position, to one side or the other.
2. Size : Variable, depending on the duration of pregnancy.
3. Contour : Rather irregular.
4. Tenderness : Of variable degree all over the mass.
5. Consistency : Variable. Foetal parts however are felt with greater ease, as the pregnancy sac is
usually thinner than the wall of the pregnant uterus. Occasionally foetal parts are difficult to
identify on account of the tenderness.
6. Mobility : Pregnancy sac is more fixed than the pregnant uterus.
7. The fetus within the sac : Abnormal presentation is the rule, and congenital anomalies are
frequent.



Non-pregnant Horn of a Bicornuate Uterus.
In cases of congenital mal-formations of the uterus with duplication, pregnancy may take place in
one horn while the other horn remains empty. This empty horn presents as a mass with the
following characteristics:
1. Site : Lower abdomen and arising from the pelvis.
2. Size : Variable.
3. Contour : Rounded and regular, bulging from the wall of the uterus and simulating a
fibromyoma.
4. Tenderness : Absent.
5. Consistency : Relatively firm.
6. Mobility : Fixed to the uterus and moves only with it.

Obstetrical significance of the non-pregnant horn
1. Predisposes to abortion, premature labor and abnormal uterine action. This is due to the
underlying factor, i.e., the abnormal development of the uterus as a whole.
2. Leads to abnormal presentations of the fetus.
3. Constitutes a form of soft tissue obstruction during labor.
4. May be mistaken for fibromyoma, ectopic pregnancy, retroverted gravid uterus or an ovarian
tumour with pregnancy.

PALPATION OF THE OTHER ABDOMINAL ORGANS

1. Liver and gall-bladder.
2. Spleen.
3. Kidneys and costo-renal angles.
4. McBurney's point.
5. Sites of hernia.

Liver and Gall-bladder.
Normal pregnancy throws a definite strain on the liver, yet a healthy liver can easily cope with
such a strain, and does not show any pathological change. Some abnormal pregnancies, on the
other hand, inflict serious liver damage as in cases of hyperemesis gravidarum, acute and
subacute yellow atrophy, and severe cases of toxemia of pregnancy. Again, the liver also may be
affected by associated diseases,
As to the gall-bladder, it is a known fact that pregnancy and its accompanying intestinal and
biliary stasis, flatulence, constipation and hypercholesterolemia, sometimes predispose to
cholecystitis and to the formation of gall-stones.

Spleen.
Huge enlargement of the spleen, as encountered in cases of endemic hepatosplenomegaly,
sometimes causes exaggerated obliquity of the uterus with its sequelae of mal presentations.

Kidneys.
The effects of pregnancy and labor on the urinary tract, and the effects of urinary tract
diseases on the course of pregnancy and labor, have been described before. Here, it suffices to
mention that the examination of the obstetric case during pregnancy or the puerperium is never
complete, unless the loins aie palpated and the costo-renal angles and the suprapubic legion are
examined for any tenderness or masses there.

Mc Burney`s Point.
Palpation of McBurney's point and, in fact, thorough examination of the patient fur an acute or
chronic appendicitis, must be performed in every patient complaining of lower abdominal pain or
vomiting during pregnancy.

Sites of Hernia

The common sites to be examined for hernia arc
1 . The umbilicus and along the linca alba.
2. The inguinal canal.
3. The femoral canal.


PALPATION NEAR FULL TERM, DURING LABOUR
AND IN THE PUERPERIUM

When palpation is carried out, at or after, the 28th week of pregnancy, the examiner must lay
particular stress on the palpation of the fetus in utero,

PALPATION OF THE UTERUS AFTER THE 28th WEEK
OF PREGNANCY

This palpation is of great help to determine the following
1. The size of the uterus, the size of the fetus and the duration of pregnancy.
2. The lie of the fetus
3. The attitude of the fetus
4. The presentation of the fetus
5. The position of the fetus
6. The degree of descent of the presenting part in the pelvis
7. The inter-relation between the size of the fetus (specifically the foetal head) and the pelvis,
and whether they are proportionate or disproportionate.

Determination of the "Level" of the Fundus Uteri.
The examiner stands on the right side of the patient, facing her head. Any exaggerated obliquity
of the uterus is corrected with the left hand, to bring the fundus to the midline. The ulnar
border
of the right hand is thrust under the xiphi-sternum and moved downwards till the fundus of the
uterus is reached under the palmer surface of the hand . This point, that is the highest level of
the fundus in the midline is marked, and its relation to the: distance between the umbilicus and
the xiphi-sternum is noticed.


"The Fundal Grip".
The aim of this grip is to determine the nature of that part of the fetus occupying the fundus of
the uterus. Whether to start by this grip or by the pelvic grips, is a matter of the examiner's
choice. However, as the hands of the examiner have been on the fundus to determine its level, he
may as well, proceed with the fundal grip

Position of the patient and examiner : The same as that for the determination of the level of the
fundus.
Technique : The two hands of the examiner are placed on the fundus of the uterus If the fundus
is markedly deviated to one side, it should be either brought to the midline, or the examiner's
hands should go to where it lies. By gentle manipulations, the hands Advocates of starting with
the pelvic grip state that as in the majority of cases (96%), the head is lower down, and as the
head is more easy to diagnose as a head than the breech to diagnose as a breech, therefore they
start lower down to get a rapid clue to the diagnosis. at the fundus should notice the exact
characteristics and nature of that part of the fetus lying there, namely : Its contour, whether
regular or irregular; its consistency, whether film or hard; its size, and this is to be compared to
the size of that part of the fetus lying lowermost; the way it joins the rest of the body of the
fetus, and whether there is a sulcus separating them or not; its mobility and whether it could be
moved independently of the trunk of the fetus or not (ballottement vide infra). Such a thorough
study of that part of the fetus occupying the fundus is essential to differentiate between the
characteristics of the breech which is encountered there in 96% of cases and the characteristics
of the head, which is met with there in 3.5% of cases only.

"The Lateral or Umbilical Grip".
This grip is intended to palpate the front and the sides of the uterus and their contents. It helps
to locate the back of the fetus in the majority of cases.
Position of the patient : The same as that for the fundal grip.
Position of the examiner : On the right side of the patient, facing her head or her feet.
There are two methods for performing this grip:-

The first method, and the one recommended, is to place one hand flat on one side of the
abdomen to fix the uterus, while the other hand on the other side, proceeds to palpate that part
of the fetus lying underneath Finishing with palpation on one side, the same procedure is carried
out on the other side with the other hand.

In the second method:- the two hands arc laid flat, side by side, on either side of the midline at
the level of the umbilicus, and. The structures underlying each hand are palpated in succession.
The two hands are then moved sideways to corresponding areas and palpation is performed again;
and so on till both sides of the uterus are completely palpated..
By these method palpation is performed, the data obtained help to diagnose the position of the
back and the limbs of the fetus. Thus the back is felt as a smooth object with uniform
resistance, extending along a considerable part of the uterus, over which the fingers pass without
interruption. The limbs, on the other hand, are felt as small knobs or irregularities which could be
easily displaced and which may occasionally undergo a spontaneous movement. Again, the side of
the uterus where the limbs lie, gives an impression of apparent "emptiness'' owing to the greater
amount of liquor intervening between the hand and the concave ventral side of the fetus
(resulting from its flexed attitude). Occasionally the resistance of the back is not very manifest.
In such cases it is advisable to apply sonic fundal pressure while doing the lateral grip. As a result
of this pressure, the back of the fetus becomes more convex and nearer to the examining hand
and hence more manifest as a back, while the side of the lambs appeals more empty. This sign, i.e.,
increased flexion of the back on applying fundal pressure, is also of help to differentiate between
the complete breech and breech with extended legs, being present in the former and absent in
the latter. In some cases, when the back of the fetus lies posterioriy, lateral palpation shows the
presence of small knobs on either side of the midline; the resistance of the back being absent or
felt as a ridge, far away from the middle line, on one side or the other, depending en the degree
of the posteriority of the back. This degree of posteriority is best determined by location of the
anterior shoulder of the fetus and estimating its distance from the midline.
In doing lateral palpation -- as the back of the fetus is followed downwards--one must notice the
way in which it passes into the lower pole of the fetus, as this helps to differentiate between
breech, face and occiput presentations. Thus, in breech presentation the resistance of the back
is felt to pass smoothly into the back of the breech, while in occiput presentation a slight groove
can be felt between the lower part of the back and the bulk of the occiput. On the other hand, in
cases of face presentation (head extended as the resistance of the back is followed downwards,
it is found to recede from the examining hand and a deep groove can he felt between its lower
end and the bulk produced by the extended head

In some patients, as lateral palpation is performed, uniform resistance is encountered on both
sides of the midline. The causes of this are:
1. Irritable patient contracting her abdominal muscles and masking the underlying structures.
2. Irritable uterus contracting underneath the examining hands and masking the underlying
structures.
3. Some cases of twin pregnancy with the back of each fetus to one side
4. Cases of, polyhydramnios, where the tense uterus may give the sense of uniform resistance on
both' sides.
.5. The presence of a flattened fibromyoma of the uterus on one side, with they back of the
fetus on the other side.
6. Cases of concealed accidental hemorrhage where a part, or the whole uterus may be stony
hard.
7. Cases of intra-uterine death of the fetus.

The Pelvic Grips.

These grips are intended to palpate that part of the fetus lying in the lower uterine segment or
in the pelvic inlet.

Such grips are helpful to diagnose the following:
1. The nature of that part of the fetus lying lowermost (presenting part), and whether it is the
head, the breech or the shoulder.
2. The relationship between the presenting part and the pelvic inlet, and whether this presenting
part is floating, fixed or engaged_ in the pelvic inlet.
3. The attitude of the head in cephalic presentation, whether it is flexed, deflexed or extended..
4. Certain specific conditions, such as hydrocephalus, placenta praevia, and emptiness of the lower
uterine segment above the pelvic inlet
Clinically two pelvic grips are described. Unfortunately there is no uniformity of opinion as to the
numerical order of these - two grips.

The First Pelvic Grip.

The position of the patient is the same as for the other obstetric grips. The examiner stands on
the right side of the patient facing her feet.
The hands are placed flat on both sides of the lower abdomen with the tip of the middle finger a
little above the mid-inguinal point. The palms of the hands should be directed inwards and
backwards, in order to get the presenting part of the fetus in between the two hands. Direct
backward pressure by the hands is wrong, as this causes the presenting part to lie between the
hands anterior and the posterior abdominal wall of the patient posteriorly; and hence very little
data can be obtained. the sinciput -- in which cases the sinciput is out of reach and in its place
the hand feels the hoof shaped bony prominence of the chin
- the head is completely extended, i.e., face presentation. In between these two extreme
degrees, intermediate presentations arc encountered as the head passes from complete flexion
to complete extension and these are: - flexed vertex commonly encountered in occipito-
posterior.
- Brow presentation.
- incompletely extended face.

The pelvic grip described above may be slightly modified to palpate, and even to determine the
position of the head which is deeply engaged in the pelvis, and this will be discussed later as deep
pelvic palpation

The Pawlick Grip.
This grip is particularly useful when the presenting part of the fetus is wholly or partly above the
pelvic inlet. Busy obstetricians usually resort to it as a method of rapid diagnosis of
the presenting part. The position of the patient is the same as for the other grips, but with the
flexed knees wide apart. The examiner stands on the right side of the patient facing her face.
The right fore-arm of the examiner is placed between the abducted thighs of the patient, and
more or less in line with the abdominal wall. The right hand is placed on the lower abdomen with
the palm on the symphysis pubis, the abducted thumb on the right side of the lower abdominal
wall, the fingers outstretched on the opposite side : and then grasping what lies underneath. It is
advisable to use the whole hand and to leave no space between it and the abdominal wall, as this
causes the minimal possible pain to the patient. The left hand must be placed on the abdomen
higher up to feel the trunk of the fetus. Unfortunately the use of this left hand is not stressed
in most descriptions of the Pawlick grip, though its use is essential. By this left hand, one can
determine whether the movements applied to the lower pole of the fetus by the right hand are
imparted to the trunk or not The right hand grasping that part of the fetus lying above or at the
pelvic brim should notice its size, contour, consistency and whether it can be moved independently
of the trunk or not. In the majority of cases (96%), the head lies lower down and is easily
differentiated from the breech by its characteristics As the head is traced upwards with this
grip, it is felt to recede; and the hand ultimately grasps the groove of the neck between the head
and the shoulders. Again, in head presentations, the Pawlick grip helps also to determine the
position of the occiput and the sinciput, and hence the degree of flexion or extension of the
head.

In cases of occipito-posterior position of the vertex, the small anterior sincipital end. of the
head may recede from the grasp of the hand, closely simulating a breech with extended legs. On
the other hand, cases of breech with extended legs, occasionally simulate very much the occipito-
posterior positions of the head in the Pawlick grip, and radiography may be resorted to for the
correct diagnosis of such cases.

As the two pelvic grips are performed certain specific conditions are occasionally met with and
these deserve special mention:
1. Emptiness of the lower segment or apparent absence of the presenting part of the fetus: This
is encountered in cases of polyhydramnios, fibromyoma of the lower uterine segment, shoulder
presentation and in some cases of placenta previa.
2. Hydrocephalus: In such cases, the examining hands encounter a huge tense swelling occupying
the lower segment and distending it. Occasionally a special crackling sensation is encountered
under the fingers. Though this sensation may also be encountered over the head in some cases of
intra-uterine death of the fetus, yet the marked difference in the size of the head helps to
differentiate between the two conditions.
3. Placenta previa: If the placenta is situated on the lateral wall in the lower segment, a sense of
a wet sponge is sometimes felt intervening between the examining hand and the presenting part
Of the fetus. Also, in some of these cases, apparent emptiness of the lower segment may be
encountered
4. Deeply engaged head in cases is-here the head is deeply engaged in the pelvis, the pelvic grips
grasp the shoulders of the fetus, lying at or just above the pelvic brim, and these may closely
simulate the breech of the fetus. This is due to the fact that most of the characters of the
breech can be simulated by the shoulders the shoulders have the following characteristics:
(a) Larger than the breech.
(b) Too many small parts are felt near-by, due to the presence of the arms and hands.
(c) Variable in consistency, but generally elastic and compressible.
(d) Could not be moved independent of the trunk, (.e. it does not ballot.
e) Not tender.
In such cases, however, the diagnosis can he easily clinched by
(a) History of lightening.
(b) Absence of the head from the fundus.
(c) Deep pelvic palpation.
(d) Vaginal or rectal examination, revealing the deeply engaged head in the pelvic cavity.

While performing palpation of the fetus in utero the examiner sometimes finds it advisable to
vary the technique, or to extend it in one way or the other, to get _6arther data about the case.
The most important special palpatory techniques arc : The combined grip, the location of the
anterior shoulder and the deep pelvic palpation

Deep Pelvic Palpation.

When the presenting part is deeply engaged in the pelvis, the classical pelvic grips described
before will fail to reach it. In such cases, deep pelvic palpation is the method of choice by which
the nature, the attitude and the position of the presenting part can be determined. To minimize
the pain elicited by this palpation, and to get the maximum relaxation of the abdominal muscles,
the patient is asked to take a deep breath and then perform a prolonged expiration, and just at
the very end of this prolonged expiration, deep palpation is performed.
Determination of the position of the occiput in vertex presentation with the head engaged : The
examiner facing the patient's feet, places his hands on both sides of the middle line
symmetrically above the symphysis pubis. Either the index finger alone or the whole finger tips
are then pressed backwards and. downwards in the fore-pelvis (anterior part of' the pelvis). On
one side, the finger (or fingers) will encounter no resistance and will go deeper, while on the
other, greater resistance will prevent the finger or fingers) .

Knowing the side of the back of the fetus before-hand (and hence the side of the occiput), the
position of the occiput whether anterior or posterior can be easily determined.. Thus, if the back
is on the right side and the fingers on the right side showed the forepelvis to be empty, then the
occiput must be in a posterior position; while if the fingers on this right side encounter
resistance and cannot be passed in the pelvis, then the occiput must be in an anterior position

PALPATION OF THE UTERUS DURING LABOUR
In addition to the above data, described in the previous pages.
palpation during labor gives valuable information a s regards:
1.Uterine action.
2. Progress of labor.
3. Presence of abnormalities and complications.
4. During the third stage of labor.

Uterine Action

Progress of Labor

Progress of labor is determined during palpation by noticing the following:

1. Descent of the presenting part as judged by the Pawlick grip, the pelvic grip and the deep
pelvic palpation.
2. Descent of the anterior shoulder
3. Peculiar change in the character of labor pains denoting the onset of the second stage of labor,
when they become bearing down pains, due to the accompanying reflex contractions of the
voluntary expulsive muscles of the patient.

Presence of Abnormalities and Complications

The main abnormalities or complications that are detected by palpation of the uterus during labor
are:

1. Abnormal uterine action.
A) Co-ordinate :
i. Over action
a) Precipitate labor.
b) Pathological retraction ring.

ii. Under action

a) Primary uterine inertia (hypotonic inertia).
b) Secondary uterine inertia (uterine exhaustion)

B) In coordinate :
a) Colicky uterus (hypertonic inertia).
b) Contraction ring.
c) General tonic contraction of the uterus.
d) False onset of labor

2. Rupture uterus.

3. Concealed and mixed. accidental hemorrhage.

The above abnormalities will now be described seriatim.

Precipitate labor : This is rarely seen by the attendant as the patient in the majority of cases,
will be delivered before his arrival. In such cases, uterine contractions are very powerful and
follow each other in rapid succession, so that the whole course of labor may terminate within few
minutes.

Pathological retraction ring : This is encountered in cases of obstructed labor where the uterine
contractions, though very powerful and frequent, are unable to overcome the obstruction.
Hence the retracting upper segment becomes much shorter and thicker than normal, while the
stretched lower segment becomes much longer and thinner. As a result of this abnormally
exaggerated retraction, the boundary line between the two segments of the uterus becomes very
manifest and may be seen or felt abdominally a, the pathological retraction ring or "Bandl's ring".

Abdominal palpation in these cases will reveal the following

1. Strong uterine contractions, Marked tenderness on the thinned, stretched lower uterine
segment.
3. Manifest depression between the upper and the lower uterine segments, demarcating the site
of the pathological retraction ring(Bandl's ring).
4. Difficulty in differentiating and palpating the, foetal parts.
5. Deficient amount of liquor amnii within the uterus.
6. Occasionally the cause of the obstruction may be detected, such as a shoulder presentation or
a hydrocephaly head of the fetus.

The importance of the above condition, i.e., pathological retraction ring is that it is a precursor of
rupture uterus.

Primary uterine inertia or Hypotonic inertia.

In this condition, the patient does not feel much pain during the contractions, and. the labor may
be very prolonged. Abdominal palpation in such cases reveals that the uterine contractions are:
1. Infrequent
2. Weak.
3. Of weak amplitude.
4. Short duration.
5. Irregular in rhythm.
6. No tenderness felt on the uterus in between the contractions.

Secondary uterine inertia or uterine exhaustion.

In this condition, uterine contractions are quite efficient at the start, being strong regular and
frequent. After some time and owing to the presence of an obstruction to the passage of the
child or else, the uterus becomes exhausted and the uterine contractions become infrequent,
irregular, weak; and ultimately they cease completely. This condition is very serious as it
predisposes to post-partum hemorrhage, obstetric shock and even to the death of the mother.
The uterus in such cases is in need of rest and not of stimulants. It is always advisable to refrain
from termination of labor in these cases until the uterus regains its activity.

Colicky uterus This is a clinical entity including different types of in coordinate uterine action and
these are

1. Hypertonic inertia.
2. Hypertonic lower uterine segment.
3. Spasmodic rigidity of the cervix.
4. Asymmetrical uterine action.

The main characteristic of these types is the disturbed polarity of the uterus with a disturbance
or reversal of the "fundal dominance" The uterine tone is elevated, but the uterine contractions
vary in their strength, frequency and periodicity, though occasionally they are quite strong. In
contrast to the hypotonic inertia, the patient experiences severe pain during the contraction. At
the same time, she feels that these contractions are ineffective. During palpation, the uterus is
tender and the patient resents any examination. The presenting part remains high and there is
little or no taking up of the cervix.

Contraction ring or Constriction ring. This is a localised spasmodic contraction in the muscle wall
of the uterus. It can take place during the first, second or the third stage of labor. It is usually
found around a depression of the fetus, such as the neck, though occasionally it is found below
the fetus or the placenta.
Its commonest site is at the junction of the upper and the lower segments of the uterus, i.e., at
the site of the physiological retraction ring. Clinically, the uterine contractions are colicky and
inefficient; but sometimes they are quite strong. There is slow dilatation of the cervix, delay in
descent of the presenting part and prolongation of labor. Characteristically, the patient feels
continuous pain, and tenderness can be elicited at the site of the ring in the hypogastrium. This
pain and tenderness become much severer when the uterus contracts. The fetal parts arc easily
felt and the condition of the fetus is usually good. Though the ring is sometimes described as
palpable per abdomen, vet this is not universally accepted. The diagnosis of this condition is only
clinched by the vaginal examination as will be described later.

-"Fundal pressure test" : The fundal pressure during the uterine contraction causes greater
amount of descent of the presenting part of the fetus, than when the pressure is applied in
between The contractions. In the presence of contraction ring, the results obtained with the
fundal pressure are reversed, i.e., fundal pressure during the uterine contraction causes smaller
amount of descent of the presenting part than when pressure is applied in between the
contractions. This is due to the contraction ring holding the fetus tightly during the contraction
and preventing its descent. Contraction ring must not be confused with the pathological
retraction ring described before. The accompanying table , helps in the differentiation between
the two conditions General tonic contraction of the uterus. Here, the upper and the lower uterine
segments pass into a state of tonic spasm which is more or less continuous. This results in the
uterus holding the fetus rather than trying to expel it; a condition sometimes described as
"active retention of the fetus". This condition is a very serious one as it is a precursor of rupture
uterus. Abdominal palpation in these cases of general tonic contraction reveals the following:

1 . The uterus is smaller than normal, owing to the drainage of the liquor amnii.
2. General tenderness all over the uterus.
4. The foetal parts are difficult to be defined
5. Occasionally, the cause of the abnormal uterine behaviour may be found, such as a contracted
pelvis or an abnormal presentation.

False onset of labor . This is commonly encountered in patients near or at full term. It presents
as bouts of painful uterine contractions, occasionally accompanied with passage of some blood Pier
vagina and thus closely simulating the actual onset of labor. Though the uterine contractions in
these cases are painful, yet they lack the other characteristics of labor pains, and are akin to the
uterine contractions of pregnancy. It is particularly important to differentiate this condition
from the first stage of labor, or else the case will be diagnosed as severe inertia and unnecessary
interferences will be resorted to.

Rupture Uterus : This is one of the. most serious complications encountered during labor. In the
impending stage of rupture uterus, palpation reveals the following findings
1. Rapidly recurring vigorous uterine contractions, with short or no period of relaxation in
between.
2.Markedly stretched, thinned and very tender lower uterine segment.
3. Occasionally a manifest depression between the upper and the lower segments demarcating the
site of the pathological retraction ring below, at or even above the umbilicus.
4. Difficulty in differentiating the foetal parts. rupture occurs, a marked change in the picture
takes place, palpation will then reveal the following
1 Sudden cessation of the uterine contractions.
2. Generalized abdominal tenderness.
3. Change in the contour of the abdominal enlargement, as a part or the whole fetus escapes
through the rent in the uterine wall.
4.Occasionally the empty uterus is felt separately as a firm mass in the lower abdomen.
If the fetus escapes into the peritoneal cavity, the foetal pails will be very easily felt as if under
the skin of the abdomen.

Concealed Accidental Hemorrhage : In this condition, the pent up blood inside the uterus, gives
the following characteristic local findings in the uterus during palpation :
1. The uterus is larger than the expected size and the level of the fundus rises gradually.
2. The uterus is hard or very firm, with minimal or no contraction at all.
3. The uterus is very tender and there may be accompanying rigidity of the abdominal muscles.
4. Occasionally an abnormal bulge is felt in the uterus, corresponding to the site of the retro--
placental hacmatoma .
5. Foetal parts are not easily defined.

Palpation During the Third Stage of Labor
Once the fetus is expelled, the abdomen must be thoroughly palpated. The object of this
palpation is manifold, and the attendant must specifically look for the following
1. The presence of a second fetus.
2. Signs of separation of the placenta.
3. Concealed third stage hemorrhage.

The Presence of a second fetus.
Occasionally there are some cases in whom the presence of a second fetus was not diagnosed or
even suspected. Hence immediate examination of the abdomen after the expulsion of the fetus,
will be of great help for the diagnosis of -the presence of a second fetus in these cases. If so
found, its position and presentation must be assured and any necessary correction or else the
attendant will be faced with serious complications laser on, if the second fetus is presenting
abnormally.

Signs of placental separation.
On abdominal palpation during the, third stage of labor, the following signs denoting separation of
the placenta are found:
1. The fundus of the uterus rises in the abdomen.
2. The uterus becomes harder in consistency.
3. The uterus changes from a discoid to a globular contour, even in between the uterine
contractions.
4. Bulging in the hypogastrium, due to the placenta distending the lower uterine segment.
5. Pressure in the hypogastrium, elevating the fundus of the uterus, does not cause retraction on
the umbilical cord, but on the contrary may cause its lengthening.
6. Pressure on the fund-us causes some lengthening of the cord outside the vagina, and this
lengthening persists after the pressure on the fundus is relieved.
While the placenta is still attached, compressing the fundus between the thumb and fingers, will
cause a transmitted impulse in the umbilical cord. outside the vagina, which can be easily
detected. This transmitted impulse disappears as the placenta separates and passes into the
lower segment.
ii. The patient may get a bearing down feeling, contracting her abdominal muscles, as the
separated placenta comes down and distends the vagina.
Other helpful signs of placental separation are detected vaginally as lengthening of the cord and
the passage of a certain amount of blood).
To detect the above signs, the hand is applied to the fundus of the uterus during the third stage
of labor, either continuously or intermittently. A word of caution must be mentioned concerning
this palpating hand. It should be applied only "to detect" what is "taking place" in the uterus.
Playing around with this hand as occasionally happens with beginners may irritate the uterus and
result in the notorious condition known as "student's placenta".
In such cases, there is partial separation of the placenta with excessive third stage hemorrhage,
hour glass contraction of the uterus, and a great tendency

Determination of the Rate of Involution.
Immediately following labor, the uterus reaches up to the level of the umbilicus. At the end. of
the first week of the puerperium, it is felt midway between the umbilicus and the symphysis
pubis.
By the end of the second week, the fundus of the uterus can be palpated just at, or a little
behind, the upper border of the symphysis pubis .
The determination of the rate o involution is carried out by the daily observations of the level
of the fundus uteri early in the puerperium. Occasionally however, the level of the fundus is
found to be higher or lower than expected.

Causes of higher level of the fundus than expected:

I . Full bladder or loaded rectum.
2. Retained products of conception, such as pieces of placenta, membranes and or blood clots.
3. Delayed involution of the uterus resulting from non-lactating the infant, infections, or retained
products.
4. Puerperal sepsis and its occasional rare manifestations such as
Lochiometra (accumulation of lochia in the uterus).
Pyometra (accumulation of pus in the uterus).
Physometra (accumulation of gas in the uterus).
5. Uterine fibromyoma.
6. Hematometra : This is very rarely encountered following elective Caesarean section, when the
operation is done prior to the onset of labor, and at a time when the cervix is completely closed.
In the majority of such cases, the cervix dilates in time to allow the drainage of the blood,
escaping in the uterus. Occasionally non dilatation of the cervix or an adherent piece of the
membranes at the internal os, leads to the accumulation of blood in the uterus.


Causes of lower level of the fundus than expected
1. Rapid involution of the uterus.
2. Prolapse or descent of the uterus. 3. Retroversion flexion of the uterus.
4. Inversion of the uterus.
5. Full bladder or gaseous distension of the intestines masking the uterus.

Diagnosis of Puerperal Sepsis.
For the diagnosis of puerperal sepsis, a thorough complete general, local abdominal and internal
examination is essential.
The main local abdominal findings in these cases are
I. Rigidity of the abdominal muscles. This may be localised to the hypogastrium or generalized all
over the abdomen, according to whether the infection is limited to the pelvis or had extended to
the general peritoneal cavity. However, rigidity in general is not very marked. early in the
puerperium, owing to the marked stretch of the abdominal muscles by the preceding pregnancy,
2. Size of the uterus. Not uncommonly the uterus is larger than expected due to the sub-
involution. Occasionally, however, it may be difficult to determine the size of the uterus on
account of
the rigidity of the abdominal muscles and the accompanying gaseous distension.
3. Consistency of the uterus. The uterus is usually softish or cystic, and lacks the characteristic
firm consistency of the puerperal uterus.
4. Tenderness. 'The extent and the site of tenderness vary according to the type and localization
of' the infection. Thus when the infection is limited to the uterus, the tenderness is encountered
in the hypogastrium and its extent is usually variable. In cases of parametritis (infection of the
parametrium), the tenderness is usually very severe and is encountered in one or the other iliac.
fossa. Again severe tenderness is met with in cases of pelvic peritonitis.
5. Masses. These may he felt to one side, behind or in front of the uterus in cases of
parametritis and in some cases of pelvic peritonitis.

PERCUSSION AND AUSCULTATION


PERCUSSION

Determination of the level of the fundus uteri.
Though this is better determined by palpation, yet in some cases, percussion gives more definite
data about the level of the fundus uteri. Thus percussion is more helpful in patients with
excessive fat deposition in the abdominal wall and in cases of excessive flatulence or gaseous
distension of the abdomen during pregnancy or prolonged labor.




Diagnosis of pseudocyesis.
This is a peculiar condition which is encountered in patients who are very desirous to have a child
(or very afraid to be pregnant), particularly those patients approaching the menopause. These
patients believe that they are pregnant though in fact they have not.
Actually many' of the symptom) and signs of pregnancy; are mimicked in this condition thus:
(a) The amenorrhea or the oligomenorrhea of the approaching menopause is considered by the
patient as the amenorrhea of pregnancy. This amenorrhea may be due to psychogenic or organic
causes as well. Again, the passage of small amounts of blood is considered by the patient and even
by the attendant as attacks of threatened abortion.
(b) Morning sickness, nausea, vomiting and longing appear due to the disturbed psychological state
of the patient.
(c) The fibrillar twitches in the abdominal muscles and the movements of gases in the intestines
are mistaken by the patient for foetal movements.
(d) Progressive abdominal enlargement takes place. This is due to the increased deposition offal in
the abdomen, particularly in the sub-umbilical region, the excessive Gaseous distension of the
bowels1 n addition to the tonic contraction of the diaphragm (psychic) which results in forward
bulge of the abdominal wall.
(e) Some of these patients may even undergo a spurious labor at the end of the nine months
(severe uterine contractions taking place, with the passage of a small amount of blood vaginally).

Determination of the liver dullness.
The liver is, not uncommonly, affected by pathological pregnancy or diseases associated with
pregnancy . Hence, percussion may be performed to detect whether the 'liver is normal, ptosed,
enlarged or small (liver atrophy).

Detection of free fluid in the peritoneal cavity.
This fluid may be the result of conditions associated with1 pregnancy such as endemic hepato--
splenomegaly with ascites, congestive heart failure, twisted or ruptured ovarian tumours.

Obstetric causes of intraperitoneal hemorrhage
a) Disturbed ectopic pregnancy.
b) Perforation of the uterus during criminal or therapeutic abortion.
(c) Rupture of the uterus during pregnancy or labor.
(d) Perforating vesicular mole.
(e) Occasionally in severe cases of accidental hemorrhage, though in the majority of these cases
the fluid is sero--sanguinous and its amount is usually not enough to be detected clinically.
f) A group of rare causes such as rupture of a vein on the surface of a fibromyoma, rupture
aneurysm of the splenic artery or of the abdominal aorta, perforated peptic ulcer or other similar
surgical accidents associated with pregnancy.

Again, in some cases of puerperal sepsis resulting in general peritonitis, free fluid is found in the
abdomen. In such cases the fluid, as expected, is pus.

AUSCULTATION

Pinards foetal stethoscope For auscultation to be successful and efficient, when using this
stethoscope, the following rules must be adhered to
1. The examiner must be at ease during the examination and in a position which gives him easy
access to the area he is auscultation. Awkward position of the examiner with twists in the neck or
the trunk, interferes with the acuity of hearing.
2. The stethoscope must be fixed in position either with one hand or with the pressure exerted
by the head of the examiner.
3. Whenever one. fide of the uterus is auscultate, counter-- pressure must be applied to the
opposite side, or else the stethoscope will push the uterus and the fetus away, causing difficulty'
in hearing.
4. The stethoscope must be perpendicular to the area where auscultation is being done. Again, it
must exert equal pressure along the circumference of its abdominal end. This proper application
of the stethoscope is essential, or else the external adventitious sounds near-by will be heard
superimposed on the foetal heart sounds and masking them.
5. The examiner must not he satisfied with hearing the foetal heart sounds in one area. The whole
uterus must be auscultate systematically as there may be another fetus or another area where
the foetal heart sounds are better heard.

-Auscultation of the abdomen is essentially performed to detect the foetal heart sounds. These
are heard as a tic-tac rhythmic soft sound, simulating the sound of a watch. However, during
auscultation,
-other sounds may be heard beside the foetal heart sounds and these are
1. Uterine souffle.
2. Funic souffle.
3. Transmitted maternal pulsations.
4. Fibrillary twitches in the abdominal wall.
5. Foetal movements.
6. Peristaltic movements.
7. Vagitus uterinus.

The Position of the Fetus.
In the flexed attitude of the fetus, the foetal heart sounds arc best heard over the back of the
left scapula, while in the extended attitude they arc best heard over the front of the chest.
Hence, the area of maximum intensity of the foetal heart sounds varies with the changes in the
presentation and the position of the fetus.




In vortex presentations .

* In the first position, i.e., the left occipito anterior position (L.O.A.), the foetal heart sounds are
best heard mid way along the line joining the umbilicus to the left anterior superior iliac spine.
* In the second position, i.e., the right occipito anterior position (R.O.A), they are best heard on
the corresponding point on the right side, or a little medial to it. In fact, in some of these cases
* In the third position, i.e., the right occipito posterior (R.O.P.), they arc best heard a little above
and lateral to their site in the second position. The upwards deviation of the site of the foetal
heart sounds in these cases is due to the deflexed attitude of the fetus and to the non-
engagement of the head. The extent of the lateral deviation depends on the degree of the
posteriority of the back, and so indicates the degree of posteriority of the occiput.

In the fourth position, i.e., the left occipito posterior (L.O.P.), the foetal heart sounds are heard
with some difficulty above and lateral to their site in the first position. In some of these cases
however, it may be quite difficult or even impossible to hear them. This is due to the fact that
the back of the left scapula ver which the foetal heart sounds are heard, is far away from the
anterior abdominal wall.
In general, in posterior positions of the occiput, the foetal heart sounds may be heard over the
front of the chest of the fetus rather than on its back. This is due to the deflexed attitude of
the fetus commonly encountered in these cases. Consequently, in such cases the foetal heart
sounds are heard on the opposite side of the back of the fetus, i.e., somewhere near the middle
line of the abdomen.

In breech presentations
In the first position, i.e., left sacro anterior (L.S.A.), the foetal heart sounds are heard
best to the left side of the middle line, at or above the level of the umbilicus.
In the second position, i.e., the right sacro anterior (R.S.A.), they are heard at the
corresponding point on the right side.
In the third position, i.e., the right sacro posterior (R.S.P.), they are indistinctly audible,
well to the right side, at or above the level of the umbilicus.
In the fourth position, i.e., the left sacro posterior (L.S.P.), they may be heard at the
corresponding point to the above, on the left side. breech presentations. denotes that the
sounds are indistinct, lower shaded areas are the sites in. frank breech).

As was mentioned before with the vertex, it may be quite difficult to hear the foetal heart
sounds, in the third and more so in the fourth position, and for the same reasons mentioned
before.

In breech with extended legs.
Owing to the small size of the breech, it may easily come down in the pelvis, resulting in the
descent of the site of maximal intensity of the foetal heart sounds. In such cases, they are
heard at the same points as those of the corresponding vertex presentations.

In face presentations
Owing to the extended attitude of the fetus, the heart sounds are best heard over the front of
the chest of the fetus, which is thrust forwards against the anterior abdominal wall of the
mother in mento anterior positions. In such cases, if the abdominal wall is thin, the foetal heart
beats may be even seen or felt.

Site of the foetal heart sounds in face presentations. Denotes that the sounds are:
In the first position, i.e., the right mento posterior (R.M.P. )

In the second position, i.e., the left mento posterior (L.M.P.), the front of the chest of the fetus
is directed backwards, while the upper part of the back is separated from the abdominal wall by
the bulk of the extended head and the gap above it Hence the foetal heart sounds may be
difficult to hear, or heard indistinctly somewhere on either side of the umbilicus or below it.

In the third position, i.e., the left mento anterior (L.M.A.),

In the fourth position, i.e., the right mento anterior (R.M.A.), the foetal heart sounds are best
heard a little above the midpoint of the line joining the umbilicus to the corresponding anterior
superior iliac spine.

In transverse or shoulder presentations:

The foetal heart sounds are usually, but not invariably, heard at or a little below the umbilicus on
one side of the middle line. The site of the foetal heart sounds in these cases however, is not of
much help in the diagnosis of this presentation.

Heart sounds may not be heard ill the following conditions
(a) Hurried inefficient examination.
(b) Some abnormal positions of the fetus as left occipito- posterior position, right sacro
posterior position, mento-posterior position, and some cases of transverse lie.
(c) Auscultation during uterine contraction which obscures the foetal heart sounds.
(d) Tumours of the uterus or the admiral wall masking the foetal heart sounds.
(e) Presence of an excessive amount of liquor amnii.
(f) Presence of other sounds that mask the foetal heart sounds.

UTERINE SOUFFLE

This is a soft, blowing, systolic murmur which is synchronous with the maternal pulse. It is
produced by the flow of blood in the markedly - enlarged uterine arteries. It is heard best on the
lateral border of the uterus lower down, more on the left than on the right side, owing to the
slight uterine twist (to the right) bringing the left border nearer to the anterior abdominal wall
Sometimes it is quite loud and is heard all over the anterior surface of the uterus masking the
foetal heart sounds. It is first heard round about the 24th week of pregnancy, and is considered
as one of the signs of pregnancy at this time. Occasionally, however, it is heard in cases of huge
fibromyoma. It is differentiated from the foetal heart sounds by its character, its site, and by
being synchronous with the maternal pulse.

FUNIC SOUFFLE
The funic or umbilical souffle is a soft, faint, rapid, blowing murmur which is synchronous with the
foetal heart sounds. It is produced by the flow of blood in the umbilical vessels. It is only heard
when a loop of the cord is caught either between the stethoscope and a hard part of the fetus or
between the trunk of the fetus and a limb. Though it is considered as one of the sure signs of
pregnancy, yet it is of no practical value as it is seldom detected. It is differentiated from the
foetal heart sounds by its character and by its disappearance when the fetus is manipulated.

TRANSMITTED MATERNAL PULSATIONS

Transmitted maternal pulsations from the aorta, big vessels, congested liver or vascular
abdominal tumours are not uncommonly heard when the abdomen is auscultate. These transmitted
pulsations are to be differentiated from the foetal heart sounds by the following:
1. Being synchronous with the pulse of the mother.
2. Being heard over a wide area of the abdomen with almost equal intensity, and at sites where
the foetal heart sounds could not be heard, as for example, away from the uterus.
3. Being of a different character.
4. The foetal heart sounds become slower when the foetal head is compressed by the hand or
during a uterine contraction, while these transmitted pulsations do not become slower and may
even become more rapid on account of the pain felt by the patient.
5. The rate of the foetal heart sounds is generally much higher than that of the transmitted
pulsations (maternal pulse rate). However,. in cases of shock and/or hemorrhage the maternal
pulse rate rises to, or even exceeds the rate of the foetal heart sounds.

FIBRILLARY TWITCHES

The fibrillary twitches in the muscles of the abdominal wall some times simulate closely the
foetal heart sounds in character and in rate,_ They are not uncommonly heard in nervous
patients, in cases of pseudocyesis, in patients approaching the menopause and in certain_ diseases
of the nervous system. They arc differentiated from the foetal heart sounds by being transient,
and heard only for a few seconds.

FOFTAL MOVEMENTS

In addition to being seen or felt by the examiner, the foetal movements are not uncommonly
heard during auscultation. They give a characteristic sharp compound sound which can be easily
detected. The significance of these sounds is that they give a sure evidence of pregnancy and of
viability of the fetus, in those cases where the foetal parts and/or hearing the foetal heart
sounds are difficult to determine, such as in cases of polyhydramnios.

PERISTALTIC MOVEMENTS

Peristaltic movements and the passage of gases and or fluid through the intestines, can be easily
heard when auscultation the abdomen. These sounds, being of a totally different nature, are
easily differentiated from the foetal heart sounds. However, if the peristaltic movements are
excessive, they mask the underlying foetal heart sounds, rendering their auscultation rather
difficult.

VAGITUS UTERINUS

Vagitus uterinus or intra-uterine foetal cry is very rarely heard when the abdomen is auscultate.
It is met with in those cases where air is introduced in the amniotic cavity, a., in cases of
premature rupture of the membranes and or intra-uterine manipulations such as bipolar or
internal version. The asphyxiated fetus in utero in these cases, may inspire the air and hence the
intra-uterine cry is produced.

1 Abhishek .V


CASE OF ANAEMIA IN PREGNANCY
NAME Vasanthamma
HUSBANDS NAME Bailanjappa
AGE 30 years AGE 35 years
ADDRESS Nelamangala OCCUPATION Coolie
OCCUPATION Housewife INCOME Rs. 3300/month (PCIRs. 750)
RELIGION Hindu SE STATUS Upper Lower class
Comes with 8 months of amenorrhea
PRESENTING COMPLAINS Easy fatigability since 2 months
HISTORY OF PRESENTING COMPLAINTS:
Patient presents with 8 months of amenorrhea with easy fatigability since 2 months.
Previously, the patient was able to do her household work, but for the past 2 months, she
gets tired even with minimal work. On walking about 50 m, patient complains of fatigability,
giddiness, blurring of vision which is relived on rest.
No history of increased bleeding during menses prior to pregnancy.
No history of exertional dyspnea, palpitation, PND, pedal edema or giddiness.
No history of bleeding or leak PV.
No history of bleeding PR or melena.
No history of passing worms in the stools.
No history of fever with chills and burning micturition.
No history of cough with expectoration, hemoptysis, evening rise of temperature or contact
with a known case of tuberculosis.
No history of drug intake (anti-malarial drugs or aspirin).
No history of any yellowish discoloration of skin and sclera.
Not a known diabetic or hypertensive.
OBSTETRIC HISTORY:
Married Life 13 years
Obstetric index G
3
P
2
L
2
A
0


2 Abhishek .V
No. DELIVERY BABY AT BIRTH PRESENT
AGE
COMMENTS
G
1
FTND,
Government
Hospital
Cried soon after
birth, Male, 3.2 kg,
Breast fed 3 years
12 years Post partum period
normal
Baby booked & immunized
Had 3 ANC visits + TT +
IFA
G
2
FTND,
Government
Hospital
Baby cried soon after
birth, Female, 3 kg,
Breast fed 2
years
10 years Post partum period
Normal
Booked & Immunized
Had 3 ANC visits + TT +
IFA

PRESENT PREGNANCY
T
1
No history of nausea, vomiting or weakness.
No urinary symptoms
No drug intake
No history of craving for abnormal food (pica)
T
2
Quickening in 5
th
month
1
st
ANC visit 20 weeks, given TT & IFA tablets
T
3

Fetal movements present
No leak or bleed PV
CONTRACEPTIVE HISTORY:
No history of using any contraceptive methods.
MENSTRUAL HISTORY:
Age of Menarche 13 years
Past Cycles Regular 30 days cycles with flow lasting 5 days, normal quantity, no pain or passing of
clots.
LMP 02/11/2006
EDD 09/07/2007

3 Abhishek .V
FAMILY HISTORY:
No history of congenital anomalies or twinning.
PAST HISTORTY:
No history of Tuberculosis, Epilepsy, Asthma.
No history suggestive of any cardiac ailments.
No history of previous surgeries, blood transfusions.
PERSONAL HISTORY:
Diet Mixed
Appetite Good
Sleep Sound
Bowel & Bladder Regular
Habits Nil
DIET HISTORY:
Consumes 2100 kcal/day
Required 2400 kcal/day
Deficit 300 kcal/day
GENERAL PHYSICAL EXAMINATION:
Mother is a 30 year old female, moderately built and nourished, conscious, alert & cooperative.
Pulse 84/min, regular, good volume
BP 110/68 mm of Hg
RR 14/min, regular
Temperature Afebrile
Pallor Present
Icterus Absent
Cyanosis Absent
Clubbing Absent
Clubbing Absent
Edema Absent
Lymphadenopathy Absent
Thyroid Normal
Breasts Normal
Spine Normal
4 Abhishek .V
Height 146 cm
Weight 56 kg
BMI 26.27

SYSTEMIC EXAMINATION:
CVS S
1
S
2
heard, No murmurs.
RS NVBS heard no basal crepitation.
CNS NAD.
PA Organomegaly could not be made out due to enlarged uterus
OBSTETRIC EXAMINATION:
INSPECTION:
Abdomen is uniformly distended, globular in shape
Umbilicus everted
Flanks do not appear to be full
Stria gravidarum and linea nigra present
No scars or sinuses
PALPATION:
Abdominal circumference 76 cm
Symphysio-fundal height 28 cm (corresponds to 32 weeks)
FUNDAL GRIP Soft, broad & non-ballotable, suggestive of Breech
LATERAL GRIP
Knob like structures on the right side suggestive of limb buds
Uniform resistance on the left side suggestive of spine
1
ST
PELVIC GRIP Smooth, hard, ballotable mass suggestive of head
2
ND
PELVIC GRIP Fingers converge, not engaged.
Uterus is relaxed
Fetal age = 28*8/7 = 32 weeks
Fetal weight = (28-12)*155 = 2480 gm
AUSCULTATION:
Fetal Heart sounds heard along the left spino-umbilical line
142/min, regular, rhythmic

5 Abhishek .V
DIAGNOSIS:
30 years old 3
rd
gravid with 32 weeks of gestation, moderate anemia probably Iron
deficiency, not in labor with no clinical signs of failure.


DISCUSSION
ANEMIA Decrease in the oxygen carrying capacity of the blood due to the decrease in the total
circulating RBC or Hb or both for that particular age, sex & physiological state.
Taylor and associates (1982) reported that hemoglobin levels at term averaged 12.7 g/dL among
women who took supplemental iron compared with 11.2 g/dL for women who did not. Bodnar and
associates (2001)studied a cohort of 59,248 pregnancies and found a prevalence of 27 percent for
postpartum anemia.
CLASSIFICATION (BASED ON ETIOLOGY)
1. Physiological
2. Pathological
a. Nutritional Deficiency of Fe, Folate, Vit. B
12
, Protein deficiency, Dimorphic Anemia.
b. Hemorrhagic
i. Acute Bleeding, APH
ii. Chronic Hookworm infestation (loss of 0.05ml/day), Piles
c. Hemolytic Sickle Cell Anemia
d. Hemoglobinopathies
e. Aplastic Anemia Radiation, drugs, etc.
f. Anemia of Infections Malaria, Kala azar
g. Anemia of Chronic diseases

GRADING OF ANEMIA
MILD MODERATE SEVERE
WHO 9 11 gm/dl 7.1 9 gm/dl 7 gm/dl
INDIA 8 10 gm/dl 6.5 8 gm/dl 6.5 gm/dl

6 Abhishek .V

As per WHO anemia in pregnancy is < 11 gm% in T
1
& T
2

< 10.5 gm% in T
3


Diagnostic criteria for anemia cut off levels of Hb (WHO)
Infants 6-12 mo and children 1-
2yrs
Adolescent girls
Pregnant women
Lactating women
Women in reproductive age
group
Adult men
<11gm%
<12gm%
<11gm%
<12gm%
<12gm%
<13gm%

ICMR grades of anemia in pregnancy
Mild anemia
Moderate anemia
Sever anemia
Very severe anemia
10-10.9 gm%
7-9.9 gm%
6.9-4 gm%
<4 gm%

INVESTIGATIONS
AIM
To confirm the presence of anemia
To know the
o Degree
o Type
o Cause

1. BLOOD FOR Hb% ESTIMATION
7 Abhishek .V
a. Sahlis Acid Hematin Method
i. Capillary blood from left hand ring finger, dont squeeze
ii. Spirit used not betadine as latter doesnt vaporize & dilutes the blood giving
wrong results
iii. 20 cc Tube dilute with 0.2 ml N/10 HCl 10 min & then match the color
b. Other methods
i. Tallquists (using blotting paper) used in rural areas
ii. Cyanmethemoglobin method
iii. CuSO
4
method
iv. Alkaline hematin method
2. URINE FOR
a. ALBUMIN
i. Heat coagulation
ii. Hellers Test
iii. Esbachs Test
b. SUGAR
i. Benedicts Test 5 ml Benedicts reagent heat to remove impurities add
urine & heat compare
c. MICROSCOPY If pyuria, send for Culture & Sensitivity
CAUSES OF ANEMIA IN UTI
Progesterone relaxation of urethral muscle retrograde flow anemia
Infection causes decreased Fe absorption
Ascending pyelitis pyelonephritis
Toxins released lysis of RBCs.
3. Peripheral Smear
a. Iron deficiency Microcytic hypochromic anemia with anisocytosis, target cells/
b. B
12
/Folate deficiency Macrocytic normochromic anemia with megaloblast, Howell
Jolly bodies (disfigured RBCs)
c. Dimorphic Anemia Fe & Folate deficiency
d. Malaria/Kala azar (with Leishmans stain) Haemo-parasites
e. Hemolytic Sickle shaped RBC, Increased Reticulocyte count
f. Anemia of chronic diseases & hemorrhage Normocytic normochromic
4. BLOOD INDICIES

INDEX NORMAL Fe
deficiency
B
12
/Folate
deficiency
MCV 75 100
g
<75 g

MCH 27 32 pg <25 pg Normal
MCHC 28 32 % <30%

8 Abhishek .V

5. HEMATOCRIT VALUE
Normal female 35 45%
Pregnancy 30 37%
Anemia in Pregnancy <30%
6. STOOL FOR OVA, CYST & OCCULT BLOOD
a. Hookworm ova
b. Giardia Lamblia
c. Ascariasis bile stained
d. Occult blood Benzidine test
Treat the anemia 1
st
because, if anti-helminthic drugs are given 1
st
, the parasites are
killed and retained for a longer time, the raw area left longer which further bleeds
(healing in anemia) aggravating anemia
7. IRON PROFILE
NORMAL Fe deficiency
Serum Fe 60 120 g/dl < 30 g/dl
TIBC 300 350
g/dl
>400 g/dl
Serum
ferritin
15 200 g/dl <15 g/dl
% saturation 20 45% <10%
8. BONE MARROW BIOPSY in case of
a. Refractory anemia
b. Aplastic anemia

Levels less than 15 u g/L confirm iron-deficiency anemia (Centers for Disease Control and
Prevention, 1989) cutoff point of 30 u g/L has an 85-percent positive and a 90-percent negative
predictive value.

Free erythrocyte protoporphyrin (FEP) is not routinely carried out. The latest investigation is
transferrin receptor level it is increased early on case of iron deficiency and is more sensitive than
ferritin.
MANAGEMENT
PREVENTIVE MEASURES:
1. Food/salt fortification with Iron (Jaggery). Wheat flour is fortified with 30-36mg iron/Kg
2. Screening of adolescent girls & give Fe supplementation.
9 Abhishek .V
3. Control & treatment of malaria( prophylaxis weekly 2 tab of chloroquine 300mg are given in
2
nd
trimester onwards in endemic areas, UTI, hookworm infestation( albendazole 400mg
stat or mebendazole 100mg bid for three days), piles.
4. Maintain minimum 2 years gap between successive pregnancies.
5. Change in food habits i.e. avoiding tea coffee for at least 2 hours after meals
THERAPEUTIC MEASURES:
1. ORAL IRON
a. Prophylactic
i. T
1
not given as
It may be teratogenic.
Aggravates morning sickness.
Hemodilution occurs only after 20
th
week.
ii. T
2
onwards 100 tablets of FeSO
4
200 mg 60 mg elemental Fe, 500 g Folic
Acid
Prevents progression of latent anemia to overt anemia.
Meets increased requirements of Fe during pregnancy.
Bioavailability of Fe during pregnancy is 20% - thus only 12 mg of iron
is absorbed.
iii. If the mother has normal Hb%, then need for prophylaxis is determined on
basis of Serum Ferritin levels
If normal, then the dose is given.
If it is less, then full dose is given.
b. Therapeutic when Iron deficiency is confirmed.
i. Start with 1 tablet/day 3 tablets/day (to prevent gastric
irritation).
ii. Take immediately after meal to reduce gastric irritation though should be
ideally consumed hour before meal.
iii. To check compliance
Ask for blackening of stools.
Ask for gastric symptoms.
Ask to show empty packets.
iv. Preparations
Ferrous ascorbate (best, Vitamin C increases absorption).
Ferrous sulphate Cheapest and widely used (FEROSOLATE).
Ferrous fumarate Commercial preparation.

10 Abhishek .V
New gastric delivery system (GDS) contains ferrous sulphate in a gel forming polymer
matrix so tab floats in stomach for 5 -12 hrs releasing slowly it has better absorption and
lower side effects.

Latest preparations
Carbonyl iron: prepared by thermal decomposition of iron pentacarbonyl it has no side
effects as by ionic forms.

IPC complex it is ferric hydroxide polymaltose complex it is non ionic so it does not stain
teeth no metallic taste no interaction with drugs or foods.

c. Side Effects Nausea, Vomiting, Staining of teeth, Constipation.
2. PARENTERAL IRON
a. Indications
i. Intolerance/non-compliance to oral iron.
ii. Poor absorption (achlorhydria).
iii. Moderate to severe anemia >32 weeks, <36 weeks.
iv. No response to oral therapy after 4 wks in confirmed iron deficiency anemia
case.
b. Preparations
i. Iron dextran (IMFERON 100 mg in 1 ampoule) IM or IV.
ii. Iron sorbitol citrate (JECTOFER 75 mg) only IM excreted by kidney (thus
avoid in renal disease).
iii. Iron sucrose
(Deep IM upper outer quadrant of gluteal region Z technique)
iv. Formula
0.3 weight (lb) (100-Hb%) + 50% dose for stores
(1 amp 2 ml & 1 ml 50 mg elemental Iron)
4.4 weight (kg) (14 Hb%) + 500 mg for pregnancy
[Suspend Oral Fe <24 hours before injection to avoid reaction]
0.66 x %def of Hb x wt in Kg=mg of iron taking 14.5g HB as 100%
Or approx 25mg x % deficit of Hb=mg of iron
v. TDI Total Dose of Iron IV Fe for cases of painful IM injection (1 sitting).
It takes 4 9 weeks for Hb% to increase, 8 10 drops/min over 6 hours after
test dose.
vi. Side effects it is painful discoloration of skin injection abscess and reported
cases of sarcoma
3. BLOOD TRANSFUSION
a. Indications
i. Severe anemia <7 gm%
11 Abhishek .V
ii. >36 weeks when no time to act.
iii. Severe anemia due to acute hemorrhage.
iv. Thalassemia.
b. 1 unit increases Hb% by 1 gm%. (maximum 1 unit/day)
c. Reactions
i. Immune Anaphylaxis, Acute/delayed hemolysis.
ii. Non-immune Infections, Hypothermia, citrate toxicity, DIC.
(Obstetric problem patient goes into labor)
SIGNS OF IMPROVEMENT
1. Sense of well being with an increased appetite
a. Due to release of endorphins in brain
b. Phagocytic activity of neutrophils require peroxidase enzyme which requires Fe for
catalysis.
c. Increased Oxygen carrying capacity shifts anaerobic to aerobic respiration.
2. Hb% increases (rate of 0.7 mg/100 ml/week).
3. Reticulocyte Count Increases (stained with cresyl blue).
INDICATIONS FOR GIVING FeSO
4
TABLETS AS SUGGESTED BY THE WHO:
1. Pregnancy.
2. 1
st
6 months after Delivery.
3. After inserting Copper T.
4. After Tubectomy.
NOTE:
1. Why is it called Physiological Anemia?
a. Occurs in every woman.
b. Cant prevent even with Iron supplementation.

EFFECT OF ANEMIA ON PREGNANCY
Mother:
Pregnancy
Cardiac failure at 30-34 weeks
Increased susceptibility to infections
Preterm labor 3 times risk
Preeclampsia may be related to malnutrition

Labor
Uterine inertia
12 Abhishek .V
PPH even moderate blood loss dangerous
Cardiac failure
Shock

Puerperium
Cardiac failure
Puerperal sepsis
Subinvolution
Failing lactation
Chronic illness ,back ache

Fetus and neonate
Prematurity
IUGR 3 times more risk
Increased perinatal mortality
Decreased iron stores in neonate note that the Hb level in neonate is not altered by
anemic status of mother.

2. Management is based on severity of anemia and duration of pregnancy.
a. Mild Fe supplementation.
b. Moderate (7-9 mg)
i. If delivery is within the next 4 weeks Blood Transfusion.
ii. If delivery is not within the next 4 weeks Fe Supplementation.
c. Severe Blood Transfusion.
3. Obstetric Management when patient is in labor
a. Not in failure.
b. In failure Take Physicians help.
4. Hb% estimation in pregnancy
a. 1
st
ANC visit.
b. 28
th
week.
c. 36
th
week.
5. Raise in Hb%
a. Oral Fe 0.7 g/dl/week.
b. Parenteral 0.7 1 g/dl/week.
6. Situations in Obstetrics where we get Pulmonary Edema
a. Anemia.
b. PIH.
c. Any Cardiac disease.
d. Tocolytic use.
7. Obstetric Management
13 Abhishek .V
a. 1
st
Stage
i. Monitor Pulse, BP, RS, CVS, fluids, start a wide bore IV line and draw blood
for investigations.
ii. Strict asepsis, IV started.
iii. Left lateral position or propped up if in failure.
iv. Keep Oxygen ready.
v. Monitor uterine contractions.
vi. Monitor fetus and mother + partogram.
b. 2
nd
Stage
i. Cut short the 2
nd
Stage.
ii. IV Methergine (CI if in failure).
c. 3
rd
Stage
i. Clamping the cord
1. Not in failure early clamping.
2. In failure Late clamping.
ii. Replenish blood loss by transfusion if severe anemia.
iii. Active Management.
iv. Episiotomy suture.
d. Puerperium
i. Continue Parenteral Antibiotics for 2-3 days/
ii. Early ambulation (DVT).
iii. Discharge by 7 days.
8. Test dose for
a. IM Few drops of deep IM, wait for a fem minutes, if no reaction, then full dose is
given.
b. IV Take 0.5 ml in a 5 ml syringe, pass into the vein and pull 5 ml blood and inject
the same into vein and look for reaction.
9. Blood Loss with Worm Infestation per day
a. Necator americans 0.05 ml
b. Ankylostoma duodenale 0.20 ml
Fe REQUIREMENT DURING PREGNANCY:
1. Expansion of RBC 400 mg(450)
2. Fetus & placenta 300 mg(270)
3. Basal losses 200 mg(170)
4. iron in placenta and cord90mg
Total 900 mg ~ 1 gm + 300 mg lost during delivery.
Avg requirement 4mg/day throughout pregnancy2.5mg/day upto 20wks
5.5mg/day in 20-32wks
6-8mg/day 32wks onwards
14 Abhishek .V

Food factors influencing the absorption of iron
Inhibitors Enhancers
Phyates In cereals
Tannins in tea and polyphenols in coffee
Oxalates in vegetables
Phosphates in egg yolk
proteins
drugs like alphadopa levodopa ciprofloxacin
cimetidine.
Ascorbic acid
Organic acids like citric acid lactic acid
Sprouted and fermented food
Meat and fish


FOLIC ACID DEFICIENCY ANEMIA
Pure folic acid deficiency anemia is hardly 3-4% but commonly associated with iron
deficiency in 40%cases causing dimorphic anemia.
FA absorption or metabolism may be impaired by drugs like oral contraceptives
pyrimethamine primidone phenytoin barbiturates and Cotrim oxazole.

Recommended daily allowance
Non
pregnant
pregnancy lactation
Iron 15mg 30mg 15mg
FA 180ug 400ug 280ug
Vit B 12 2.0ug 2.2ug 2.6ug

Diagnosis
Apart from anemia hematocrit <32% MCV >100u3 MCHC 30-36% plasma folate
<3ng/ml
RBC folate <80ug/ml
Note: FIGLU excretion test diagnostic of folate deficiency is not useful in pregnancy
because there is increased utilization of Histidine by fetus as pregnancy advances.
Earliest morphological change is hypersegmentation of neutrophils
15 Abhishek .V
The fetus and placenta extract folate from maternal circulation so effectively that the fetus is
not anemic despite severe maternal anemia. There have been instances in which newborn
hemoglobin levels were 18 g/dL or more, whereas maternal values were as low as 3.6 g/dL
Effect on pregnancy
FA deficiency causes abruptio placenta, spontaneous abortion, IUGR. Open neural tube defects e.g.
anencephaly spin bifida. But fetus is not anemic it extracts folic acid from maternal blood.


MEGALOBLASTIC ANEMIA
For diagnosis of megaloblastic anemia at least 2 of the following feature must be present in the
films of buffy coat layer
>4% neutrophils must have >5 lobes
Presence of orthochromic macrocyte dia>12um
Nucleated RBCs are found
Howell jolly bodies
Macropolycyte
Causes partial or total gastric resection Crohn disease, ileal resection, and bacterial overgrowth
in the small bowel.

Addisonian pernicious anemia is rare in pregnancy due to 1. Patients are usually
infertile 2. Occurs above 40 years of age 3. Uncommon in India

HEMOGLOBINOPATHIES
Alpha thalassemia
Silent carrier state no clinical effect on pregnancy
Thalassemia minor mild anemia well tolerated pregnancy oral iron and folic acid given
parenteral iron contra indicated. Diagnosis by low MCV MCH but normal serum iron
and ferritin levels Hb A2 <3.5% on electrophoresis.
Hb H disease moderate to severe chronic anemia in adult 5-30% Hb is Hb H though
stable oxidative stress precipitates hemolysis. Blood transfusion is required during
pregnancy.
Thalassemia major Hb Barts high affinity for O2 so does not deliver oxygen to fetus
so fetus develops hypoxia and hydrops (nonimmune) and dies in utero so pregnancy
rarely occurs. Mother can develop severe preeclampsia if fetus has thalassemia
major.




16 Abhishek .V
Beta thalassemia
Major pregnancy very rare due to multisystem involvement if pregnancy occurs MTP
is strongly indicated
Minor asymptomatic Hb A2 >3.5% by Hb electrophoresis confirms beta thalassemia
however concomitant iron deficiency anemia in our country decreases Hb A2 so
diagnosis difficult.

SICKLE CELL ANEMIA
Sickle cell trait: no effect on pregnancy mild anemia double risk for UTI but
incidence of malaria less. Counselling mother if husband also has sickle cell trait.
Sickle cell anemia: chronic anemia exists many types of 1 crisis pain crisis 2 aplastic
crisis( more during pregnancy due to bacterial or viral infection 3 hemolytic crisis 4
splenic sequestration crisis 5 megaloblastic crisis ( more in pregnancy due to folic
acid deficiency)
As many as 40 percent of patients suffer from acute chest syndrome, which is characterized by
pleuritic chest pain, fever, cough, lung infiltrates, and hypoxia.The spectrum of pathology includes
infection, infarction, pulmonary sequestration, and fat embolization from bone marrow (Fig. 51-3).
Recurrent episodes may lead to restrictive chronic lung disease associated with arteriolar
vasculopathy. Pregnant women with sickle-cell anemia usually have some degree of cardiac
dysfunction from ventricular hypertrophy


Effect of sickle cell anemia on pregnancy
Maternal
Severe anemia due to extra burden of pregnancy on chronic anemic state.
Sickling crisis increased
Preeclampsia increased by 15% due to placental ischemia and endothelial injury due
to sickling.
Infections pyelonephritis pulmonary infections and puerperal sepsis.
Maternal mortality increases by 25 %

Perinatal
Abortion
Prematurity
IUGR due to poor placental perfusion.
Still birth

Perinatal mortality increased by 7 times
17 Abhishek .V

Note:
Folic acid 5mg is given to all but iron is given only if iron deficiency is confirmed
Intrapartum management same as for cardiac patients
Contraception
Oral pills contraindicated due to thromboembolic risk
IUCD contraindicated due to infections
Barrier methods preferred
Hypertonic saline not be used for MTP if required instead emcrdil or prostaglandins
should be used.
Drugs which increase fetal Hb are used like hydroxyurea Butyrates recombinant
erythropoietin.
Pregnancy-Induced Hemolytic Anemia. Unexplained hemolytic anemia during pregnancy is a rare
but distinct entity in which severe hemolysis develops early in pregnancy and resolves within
months after delivery. There is no evidence of an immune mechanism or for any intraerythrocytic
or extra erythrocytic defects. Because the fetus-infant also may demonstrate transient hemolysis,
an immunological cause is suspected. Maternal corticosteroid treatment usually is effective. We
have observed one woman with recurrent hemolysis during several pregnancies, and in each
instance, intense severe hemolytic anemia was controlled by prednisone given until delivery.

Some drugs stimulate gamma-chain synthesis and thus hemoglobin F, which inhibits polymerization
of hemoglobin S and resultant sickling. Regimens of hydroxyurea along with either 5-azacytidine or
recombinant erythropoietin increase fetal hemoglobin production with fewer clinical sickling
episodes. Hydroxyurea also reduces sickle erythrocyte adherence to endothelium. Experience with
hydroxyurea in pregnancy is limited, but it is teratogenic in animals. Another cancer drug,
decitabine, has been used in patients who are unresponsive to hydroxyurea

The Bernard-Soulier syndrome is characterized by lack of platelet membrane glycoprotein
(GPIb/IX), which causes severe dysfunction. Maternal antibodies against fetal GPIb/IX antigen
can cause isoimmune fetal thrombocytopenia.




18 Abhishek .V
CASE OF PREGNANCY INDUCED HYPERTENSION
Name Narayanamma Husbands Name Chandrababu
Age 20 years Age 25 years
OCCUPATION House wife Occupation Driver
Address Dairy Circle Income Rs.1700/person/month
RELIGION - Hindu SE Status Upper Middle Class
Date of Admission 10/07/07 Date Of Examination 12/07/07
Comes with 8 months of amenorrhea.
Generalized edema since 10 days.
HISTORY OF PRESENTING COMPLAINTS:
Patient is a gravid 2 presents with generalized edema since 10 days, insidious in onset,
initially noticed in the lower limbs which have gradually progressed to involve the upper
limbs and face. It is present throughout the day (no diurnal variation), not relieved by
overnight rest nor by limb elevation in the morning.
No history of headache, blurring of vision or syncopal attacks(CNS with visual symptoms)
No history of reduced urine output, hematuria. (Renal symptoms)
No history of chest pain, palpitations or breathlessness on exertion or history suggestive of
cardiac failure.(Cardiac symptoms)
No history of epigastric pain, nausea, vomiting. (GI symptoms)
No history of DM or HTN.
No history of jaundice, ascites before 20 weeks of gestation. (Hepatic)
OBSTETRIC HISTORY:
Married Life 2 years (non consanguineous marriage)
Obstetric index G
2
P
0
A
1

PREVIOUS PREGNANCY
G
1
:
Painless spontaneous abortion at 6
th
month following bleeding PV. Patient had gone for 4
ANC visits, 2 scans, booked and immunized.
No history of excessive vomiting. (Rule out H. mole)
No history of HTN during pregnancy.


19 Abhishek .V
PRESENT PREGNANCY
T
1

Morning sickness for 2 months present.
Increased frequency of micturition present.
No history of easy fatigability.
No history of discharge or bleed PV.
No history of drug intake or radiation exposure.
No history of Pica.
T
2

Quickening at 5
th
month.
No history of headache, blurred vision or sudden increase in weight.
Booked and immunized 3 ANC visits, 2 TT, 100 IFA, and Scan done at 20
th
week.
T
3

Fetal movements present.
No history of bleeding or discharge PV.
No history of pain abdomen.
Generalized edema present.
Last abortion 1 year back.
MENSTRUAL HISTORY:
Age of Menarche 16 years
Past Cycles Regular, 30 day cycle, and 4 days flow, no pain or passage of clots.
LMP 03/11/06
EDD 10/08/07
No history of any contraceptives used.
FAMILY HISTORY: No history of DM, HTN, asthma, twinning in family. No history of PIH in
mother or sister.
PAST HISTORTY:
Medical No history suggestive of DM/HTN. No history of TB, epilepsy or asthma.
Surgical No history of blood transfusions or any previous surgical procedures.


20 Abhishek .V
PERSONAL HISTORY:
Diet Mixed
Appetite Good
Sleep Sound
Bowel & Bladder Regular
Habits Nil
GENERAL PHYSICAL EXAMINATION:
Mother is a young lady, moderately built and nourished, conscious, alert & cooperative; well
oriented to time, place and person.
Pulse 86/min, regular, good volume
BP 146/92 mm of Hg
RR 18/min, regular
Temperature Afebrile
Pallor Present
Icterus Absent
Cyanosis Absent
Clubbing Absent
Clubbing Absent
Edema Present, Pitting in nature
Lymphadenopathy Absent
Thyroid Normal
Breasts Normal
Spine Normal
Gait Normal
Height 160 cm
Weight 70 kg

SYSTEMIC EXAMINATION:
CVS S
1
S
2
heard, No murmurs.
RS NVBS heard no basal crepitation.
CNS Knee jerk present. Sensory, motor and cranial nerves normal.
PA Organomegaly could not be made out due to enlarged uterus
21 Abhishek .V
OBSTETRIC EXAMINATION:
INSPECTION:
Abdomen uniformly distended.
Flanks not full.
Umbilicus everted.
Striae gravidarum, albicans & linea nigra present.
No scars over abdomen, no dilated veins.
Hernial orifices normal.
PALPATION: (Patient examined in supine position with legs semi flexed).
Fundal height corresponds to 32 weeks gestation.
SFH is 28 cm, abdominal circumference 85 cm.
Fundal grip Smooth, broad irregular structure suggestive of breech.
Lateral Grip
o Right Knob like structures suggestive of Limb buds.
o Left Uniform curved resistance suggestive of spine.
1
st
Pelvic Grip Smooth, round, hard ballotable mass (not engaged) suggestive of head felt
at lower pole

AUSCULTATION:
FSH heard along the left spinoumbilical line, mid point.
Rate 146/min, regular.
DIAGNOSIS:
20 year old 2
nd
gravid with 32 weeks gestation, single live fetus with cephalic presentation
with head not engaged and not in labor, with Grade IV (pre-eclampsia on treatment) PIH
complicating her pregnancy.




22 Abhishek .V
DISCUSSION
The classification of hypertensive disorders complicating pregnancy by the Working Group of
the NHBPEP (2000)

1. Gestational hypertension (formerly pregnancy-induced hypertension that included transient
hypertension)
BP>140/90 mm Hg or greater for the first time during pregnancy
proteinuria is not identified.
Gestational hypertension is also called transient hypertension if preeclampsia does
not develop and the blood pressure has returned to normal by 12 weeks' postpartum.
2. Preeclampsia.
BP> 140/90mm Hg after 20 wk gestation
Significant proteinuria is defined by 24-hour urinary protein exceeding 300 mg per
24 hours, or persistent 30 mg/dL (1+ dipstick) in random urine samples.

Mild preeclampsia
HTN >140/90 to <160/110
Proteinuria >300mg/24hrs
Pathological edema
Severe preeclampsia
HTN >160/110 mm Hg
Proteinuria >5g/24hrs
Oliguria <400ml/24hrs
Epigastric pain or Rt hypochondriac
pain
Cerebral or visual symptoms
Thrombocytopenia <1,00,000/mm3
Increased liver function tests
Pulmonary edema
Hyperuricemia and increased serum
creatinine
Fetal growth restriction

3. Eclampsia.
convulsions in a woman with preeclampsia that cannot be attributed to other causes
4. Preeclampsia superimposed on chronic hypertension.
23 Abhishek .V
New onset proteinuria >300mg/24hrs in women with chronic HTN
Sudden increase in blood pressure or proteinuria or platelet count <1,00,000/mm3 in
women with HTN and proteinuria before 20wks.

5. Chronic hypertension.
Hypertension (140/90 mm Hg or greater) is documented antecedent to pregnancy.
Hypertension (140/90 mm Hg or greater) is detected before 20 weeks, unless there
is gestational trophoblastic disease.
3. Hypertension persists long after delivery

Risk factors for preeclampsia
Genetic factors
Family h/o preeclampsia
Obstetric factors
Primigravida
Previous h/o preeclampsia
New paternity
Multiple pregnancy
Hydrops fetalis with large
placenta
Molar pregnancy
Poor placentation
Placental ischemia
Medical factors
Diabetes
Chronic HTN
Renal diseases
Sickle cell disease
Anti phospholipid
antibody
Protein C S factor V
leiden deficiency
Etiology
1. Abnormal trophoblastic invasion of uterine vessels.
In normal implantation, the uterine spiral arteries undergo extensive remodeling as they are
invaded by endovascular trophoblasts. In preeclampsia, however, there is incomplete
trophoblastic invasion. In this case, decidual vessels, but not myometrial
Vessels become lined with endovascular trophoblasts. Preeclamptic changes included
proliferation of myointimal cells, and medial necrosis. They found that lipid accumulates
first in myointimal cells and then in macrophages. such lipid-laden cells and associated
findings have been termed atherosis . Typically, the vessels affected by atherosis develop
aneurysmal dilatation and are frequently found in association with spiral arterioles that have
failed to undergo normal adaptation

2. Immunological intolerance between maternal and fetoplacental tissues.
24 Abhishek .V
The risk of preeclampsia is appreciably enhanced in circumstances where formation of
blocking antibodies to placental antigenic sites might be impaired. This may arise in
situations in which effective immunization by a previous pregnancy is lacking, as in first
pregnancies; or in which the number of antigenic sites provided by the placenta is unusually
great compared with the amount of antibody, as with multiple fetuses. Beginning in the early
second trimester, women destined to develop preeclampsia have a significantly lower
proportion of helper T cells (Th1) compared with that of women who remain normotensive.
This Th1/Th2 imbalance, with Th2 dominance, may be mediated by adenosine, which is found
in higher serum levels in preeclamptic. In women with anticardiolipin antibodies, placental
abnormalities and preeclampsia develop more commonly antibodies associated with beta 2-
glycoprotein I appear most relevant. Immune complexes and anti-endothelial cell antibodies
may also be involved

3. Maternal maladaptation to cardiovascular or inflammatory changes of normal
pregnancy.
Cytokines such as tumor necrosis factor-alpha (TNF-alpha) and the interleukins may
contribute to the oxidative stress associated with preeclampsia.
Oxidative stress is characterized by reactive oxygen species and free radicals that lead to
formation of self-propagating lipid peroxides. These in turn generate highly toxic radicals
that injure endothelial cells, modify their nitric oxide production, and interfere with
prostaglandin balance.
4. Dietary deficiencies. Supplementation with various elements such as zinc, calcium, and
magnesium to prevent preeclampsia
5. Genetic influences. Angiotensinogen gene variant T235 higher incidence preeclampsia
and fetal growth restriction. Some of the inherited thrombophilias predispose some women
to preeclampsia Polymorphisms of the genes for TNF, lymphotoxin-alpha , and interleukin-
1beta have been implicated.

PATHOGENESIS OF PIH:
NORMAL PREGNANCY BP is regulated by the following factors:
Angiotensinase from placenta destroys angiotensin Vasodilatation.
Vascular synthesis of PGI
2
and EDRF Vasodilatation.
Increased VEGF.
Decreased TXA
2
and Endothelin 1.
All the above factors maintain BP on lower side during normal pregnancy. When
there is imbalance between vasodilator and vasoconstrictor mechanisms, PIH
results.
25 Abhishek .V
In preeclampsia,
Decreased PGI
2
+ increased TXA
2
Vasoconstriction.
Increased vascular sensitivity of endothelium to angiotensin II
Vasoconstriction.
Decreased activity of angiotensinase increased angiotensin II
Vasoconstriction.
Decreased NO &increased endothelin 1 Vasoconstriction.
VEGF is increased in serum from women with preeclampsia but its
bioavailability is decreased. In preeclampsia, the gene for soluble fms-like
tyrosine kinase 1 (sFlt1) is up regulated, and serum levels are increased for up
to 48 hours after delivery. Because sFlt1 antagonizes VEGF and PlGF by
binding them and decreasing their unbound serum levels, their effects are
lost and there is endothelial dysfunction
Activated WBCs cytokines, IL, TNF

endothelial injury.
Abnormal lipid metabolism oxidative stress endothelial injury.
In normal pregnancy, 1, 2 and 3 villi are present in placenta which invade the tunica
media of uterine arteries by the tertiary villi and reduce sensitivity of vessels to
circulatory catecholamines and angiotensin II.
In abnormal placentation, seen in patients of PIH, failure of 2
nd
wave of endovascular
trophoblastic inversion (tertiary villi) which usually occurs around 16
th
24
th
week
does not occur. This causes increased sensitivity of the vessels to catecholamines
and hence HTN.

Symptoms
CNS: headache, mental confusion drowsiness dizziness
GIT: epigastric pain due to edema and subcapsular hemorrhage stretching Glissons
capsule
Visual: blurred vision, scotoma, blindness
Renal: oliguria, hematuria, anuria
Pulmonary dyspnea due to cardiogenic and non cardiogenic pulmonary edema.



26 Abhishek .V
Signs
Abnormal weight gain more than 1kg/wk or 3kg/mo
Hypertension
Edema on non dependant parts
Hyperreflexia and clonus ( considered serious if more than 6 beats)
Eye changes retinal artery spasm retinal hemorrhages papilledema RD
Abdominal examination hepatic enlargement tenderness ascites.
Predictive tests
Elevated second trimester BP MAP>90mm Hg
Angiotensin infusion test +ve is <8ng/kg/min required to raise diastolic BP by 20mm
Hg
Supine pressor or roll over test (Gaints test) done 28-32wks >20mm change in
diastolic pressure on lying on left lateral position +ve( positive predictive value 33%)
Hand grip test isometric contraction raises diastolic BP by 20 mm +ve
Uric Acid. Elevated serum uric acid levels due to decreased renal urate excretion are
frequently found in women with preeclampsia. plasma uric acid values exceeding 5.9
mg/dL at 24 weeks had a positive predictive value for preeclampsia of 33 percent.
Fibronectin. Endothelial cell activation likely is the cause of elevated serum cellular
fibronectin levels in some women with preeclampsia positive predictive value 29%
negative predictive value 98%
Coagulation Activation Fibrinolytic activity is normally decreased in pregnancy due to
increased plasminogen activator inhibitors (PAI) 1 and 2. In preeclampsia, PAI-1 is
increased relative to PAI-2 because of endothelial cell dysfunction the PAI-1: PAI-2
ratio to be predictive of preeclampsia in high-risk women.
Oxidative Stress. Increased levels of lipid peroxides, coupled with decreased
activity of antioxidants in women with pre eclampsia malondialdehyde is a marker of
lipid peroxidation. Other markers are a variety of pro-oxidants or potentiator of
pro-oxidants, including iron, transferrin, and ferritin; blood lipids, including
triglycerides, free fatty acids, and lipoproteins; and antioxidants, including ascorbic
acid and vitamin E.
Fetal DNA. Identification of fetal DNA in maternal serum may be predictive of
preeclampsia.
Hypocalciuria <12mg/dl
Atrial natriuretic peptide increased
Maternal serum AFP if raised > 3 times
Microalbuminuria >11ug/ml is suggestive.
Urinary kallikrein- creatinine ratio <170 predicts PIH
27 Abhishek .V
Doppler ultrasound abnormal waveform in second trimester presence of diastolic
notch predicts PIH increased S/D ratio and resistance >.58 in uterine artery is
suggested.


PIH profile (Investigations):
Biochemical
Urine proteinuria, sugar and microscopy.
Blood Hb%, grouping and cross matching, platelet count and peripheral
smear.
Serum Uric acid, proteins.
LFT AST, ALT, Alkaline phosphatase, LDH.
FBS/PPS.
RFT Blood urea and serum creatinine.
Fundoscopy.
Antenatal Fetal monitoring:
USG.
NST.
Modified BPP.
Before termination, to assess lung maturity,
LS ration
AM-I
FUNDOSCOPIC CHANGES:
Grade I Mild attenuation of retinal arterioles.
Grade
II
Moderate to severe attenuation of retinal arterioles, AV
kinking at right angles.
Grade
III
Copper wiring and flame shaped hemorrhage.
Grade
IV
Grade II changes + Silver wiring and papilledema.
.
REASONS TO DO FUNDOSCOPY:
To differentiate chronic HTN and acute HTN.
Grade II and above terminate pregnancy.
Only place to see severity of HTN.


28 Abhishek .V
MANAGEMENT OF A CASE OF PIH:
Irrespective of the type (mild or severe) advice
Complete bed rest.
Sedation.
4
th
hourly BP recording and daily weight check with urinary proteins.
INVESTIGATIONS:
Routine
Blood Complete hemogram, grouping, Peripheral smear, Rh, VDRL,
HIV, etc.
Urine albumin (if >2+, terminate pregnancy), sugar microscopy.
RFT (Urea, creatinine, uric acid).
LFT Bilirubin (indirect), Protein, SGOT, SGPT, LDH, Prothrombin time.
Fundoscopy Grades I & II are mild while Grades III & IV are severe.
USG and NST AFI and IUGR.
LABEL THE PATIENT AS MILD OR SEVERE PIH:
Mild PIH
Baby mature Terminate pregnancy.
Baby immature pull on till maturity and constant monitoring.
Severe PIH
Do all investigations.
See gestation
o >36 weeks terminate pregnancy.
o 32 36 weeks benefit of doubt, give steroid treatment and then
MTP.
Anti-hypertensive therapy.
If BP still <170/120 mm of HG, terminate pregnancy.
[Maintain diastolic BP >90 mm of Hg to avoid uteroplacental
insufficiency]

Anti hypertensive therapy in pregnancy
Role of antihypertensives in mild preeclampsia
Role is controversial
Mostly used when diastolic BP>100mm and systolic >160mm Hg
Main objective is to reduce risk of severe hypertension and cerebral hemorrhage if
MAP>150 cerebral auto regulation is lost.
Antihypertensives may help prolong pregnancy but the disease process is not
modified.
29 Abhishek .V
Overzealous correction of hypertension may lead to further reduction in
uteroplacental flow and IUGR.

Common hypertensives used in mild-moderate PIH
Alpha methyl dopa Central acting s/e postural hypotension depression hemolytic
anemia
Nifedipine Ca++ blocker Headache flushing palpitations
Hydralazine Peripheral
vasodilator
Headache flushing tachycardia lupus
Labetalol Combined alpha
and beta blocker
Postural hypotension tremulousness c/I
asthmatics
Atenolol Beta blocker Bradycardia hypotension hypoglycemia fatigue
IUGR so avoided.
Congenital defects produced by ACE inhibitors
Bony malformations
Persistent PDA
Respiratory distress syndrome
Neonatal death
Limb contracture
Pulmonary hypoplasia
Prolonged neonatal hypotension

In pregnancy antihypertensive
Avoided Safe
Diuretics
ACE inhibitors
Losartan
Reserpine
Nonselective beta blockers
Sodium nitroprusside
Hydralazine
Methyldopa
Dihydropyridine CCBs to be
discontinued before labor as they
weaken contractions
Cardioselective beta blockers
atenolol pindolol acebutolol
Prazosin and clonidine if postural
hypotension can be avoided

IMMINENT SIGNS OF SEVERE PIH:
Headache, blurring of vision, epigastric pain.
BP >160/120 mm of Hg.
Fundal height doesnt correspond to gestational weeks.
30 Abhishek .V
Proteinuria > 5g/dl.
Creatinine > 1 g.
Uric acid > 4.5
COMPLICATIONS OF PIH:
Eclampsia.
Intracranial hemorrhages (do CAT scan and localize site of lesion and give
appropriate therapy).
Pulmonary edema (Furosemide 40mg with propped up position + 100% oxygen).
Renal failure (give furosemide, then dialysis).
HELLP Syndrome.
Ocular manifestations.
Shock.
Incidence of eclampsia highest in antepartum period 50% fits in 3
rd
trimester 50% if
fits in 1
st
trimester suspect H. Mole. Intrapartum 30% post partum 20 % intercurrent
conscious after recovery from convulsions and pregnancy continues beyond 48hrs upto
7-10 days.
MANAGEMENT OF ECLAMPSIA:
Hospitalize the patient.
Basic principles of ABC.
Put patient in railed cots and raise foot end.
See for airway, put tongue depressor and remove secretions.
Start IV line with 18G needle on 20% dextrose or mannitol (not 0.9% saline).
Start on Magnesium sulfate regimen (1 amp = 2 ml = 1 gm MgSO
4
):
Regimen PRITCHARD REGIMEN ZUSPAN (IV) REGIMEN
Loading
dose

20 ml of 20% MgSO
4
solution slow IV
+
10 gm MgSO
4
5gm each buttock IM
4-6gm MgSO
4
IV initially in
20% solution given slowly
over 15-20 minutes.
31 Abhishek .V
Maintenance
dose

5 gm MgSO
4
every 4
th
hourly into
alternate buttocks.
Only if
a. Knee jerk present
b. Respiratory rate > 14/min
c. Urine output >30 ml/hr
If any 1 also of the above absent, skip
that dose.
Continue for 24 hours after last
convulsion.
In between 2gm IV MgSO
4
or
phenobarbitone 60 mg can be given to
control convulsions but never diazepam.
1 gm/hr in 5% dextrose IV.


Important points about MgSO
4
Regimen:
Mechanism of action:
Acts at the neuromuscular junction and reduces the neuromuscular
irritability.
Reduces Acetyl choline release from the nerve endings.
Reduces motor end plate sensitivity to Acetyl choline.
Blocks Ca
2+
channels in synaptic bulb no influx.
Latest theory acts on the NMDA receptors of neurons in brain and
reduces their excitability.
Vasodilation increases cerebral uterine and renal flow.
Therapeutic levels achieved with 14 g loading dose = 47 mEq/dl
Knee jerk lost at 9 12 mEq/dl.
Respiratory arrest at 14 18 mEq/dl. (Hence 60 g MgSO
4
required).
Antidote if respiratory arrest occurs Intubate + Calcium gluconate IV (10 ml
10%)
Toxicity sets in early in cases of renal failure.
MgSO
4
is tocolytic may interfere with labor.
Contraindication for use of MgSO
4
Myasthenia gravis.
OTHER REGIMENS:
Mag Pi regimen In case of severe headache, blurred vision, BP > 110 mm of
Hg, reduced urine output, epigastric pain, ascites, IUGR.
[Give only 10 g MgSO
4
IM and induce labor]
Anderson & Sibai regimen 4 gm IV dose followed by 2 gm IV 24 hrs later.
32 Abhishek .V
Menons lytic cocktail regimen 3 drugs Pethidine + Promethazine +
Chlorpromazine.
Leans diazepam regimen 40 mg IV initially followed by 40 mg in 500 ml of
5% dextrose IV infusion.
Phenytoin sodium regimen 10 mg/kg IV initially followed by 5 mg/kg IV 2
hours later. (Requires continuous ECG monitoring for arrhythmias).
Once patients BP has settled, terminate pregnancy (if cervix dilated, use lanoprost
to induce labor or do ARM).
Continue anticonvulsants to prevent post partum eclampsia.
Patient supervised in hospital till all vital parameters are normalized.
In case of status ellipticus, intubation is done and thiopentone sodium given IV and
pregnancy terminated.
CAUSES OF UNCONSCIOUSNESS IN ECLAMPTIC PATIENTS:
Cerebral edema.
Intracranial hemorrhage.
CAUSES OF DEATH IN ECLAMPTIC PATIENTS:
Cerebral hemorrhage
Cardiac failure
Hepatic failure hepato- renal failure
Renal failure
DIC HELLP
Respiratory pneumonia pulmonary embolization Aspiration.
Post partum shock sepsis
ACTION OF CERVIPRIME (Dinoprostone gel PGE
2
0.5 mg):
Causes ripening of cervix.
It brings about inflammatory changes in the capillaries of cervix and increases
capillary permeability.
Neutrophils extravasate and release collagenase and break down collagen fibres
when broken causes dilatation and softening of cervix.
Edema due to fluid extravasation also reduced softens cervix.
Separation of membranes releases PGF
2
brings about uterine contraction
onset of labor.
DIFFERENCE BETWEEN ECLAMPSIA & EPILEPSY:
FEATURE ECLAMPSIA EPILEPSY
BP rise +++ Normal
Proteinuria +++ Normal
Past history - +
Timing T
3
,
intrapartum
Anytime
33 Abhishek .V
Preceding
cry
- Epileptic
cry
CSF Hemorrhagic Normal
CAUSES OF DEATH IN ECLAMPSIA:

MATERNAL DEATH FETAL DEATH
Cardiac failure.
Pneumonia.
Pulmonary edema.
Cerebral hemorrhage.
Anuria, shock, sepsis.
Prematurity.
Intrauterine asphyxia.
Trauma during operative surgery.
Immediately after a convulsion, fetal bradycardia is common due to maternal acidosis and
hypoxia induced by a fit.
ACE inhibitors contra indicated in pregnancy because:
Threat of oligohydramnios due to reduced fetal renal function.
Neonatal renal failure.
Malformations (early pregnancy).
In PIH, lung may mature at 32 weeks due to release of endogenous corticosteroids because
of stress.
INDICATIONS OF DIURETICS IN PIH:
Acute pulmonary edema.
Cerebral edema.
Acute cardiac failure.
Acute renal failure.
Use of Calcium channel blockers in PIH may predispose to PPH due to lack of Calcium.
INDICATIONS FOR ANTEPARTUM TERMINATION (32 38 weeks):
Eclampsia.
Abruptio placenta.
IUD.
Persistent proteinuria.
Oliguria.
Retinopathy.
HELLP syndrome.
Congenital malformations.
No point in asking about history of seizures in history of present pregnancy as pregnancy
would be terminated in such a circumstance.
History of drug intake (those used in VVH)
Methyl dopa (250 mg) yellow coloured tablet.
34 Abhishek .V
Nifedipine (5 mg) orange coloured capsules.
Pulse rate increases by 10 beats/min in pregnancy and further when patient is on nifedipine.
HOW TO PROCEED WITH THE CASE:
I would do the relevant investigations
To assess the damage already caused.
To know the well being of the fetus (antepartum fetal surveillance).
Assess severity of case and put her on anti-hypertensive treatment.
Obstetric management
Continue pregnancy with frequent monitoring.
BP every 4
th
hourly except at night.
Serum creatinine twice weekly.
BPP once a week.
Terminate
Vaginal route.
Caesarian section.
Management of complications if any.
D/D OF ECLAMPSIA:
Epilepsy.
Hysteria.
Encephalitis.
Cerebrovascular accidents.
Cerebral tumours.
MATERNAL COMPLICATIONS AND THEIR TREATMENT:
Eclampsia MgSO
4
regiment.
Hepatic damage/rupture laparotomy and surgery taking help of a
gastroenterologist.
Acute renal failure dialysis for 7-10 days till dieresis occurs.
Cardiac failure and pulmonary edema Frusemide IV 40-60 mg in propped up position.
Aspiration pneumonitis intubation and suction clearance.
Cerebral edema CT scan, then respective treatment with help of neurologist.
HELLP syndrome terminate pregnancy. Other modalities include platelet
transfusion and steroidal therapy.
HELLP SYNDROME:
Hemolysis abnormal peripheral smear with schistocytes.
Elevated liver enzymes LD > 600 IU/l and SGOT > 70 IU/l
Low platelet count - < 100000/cu mm
CLASSIFICATION
I
35 Abhishek .V
Complete all features present.
Incomplete only 1 or 2 features present.
II Mississippi Classification
Grade Platelet count (in platelets/cu mm)
Grade 1 < 50000
Grade 2 50000 100000
Grade 3 100000 150000
SYMPTOMS:
Nausea, vomiting, malaise.
Right upper quadrant pain.

MANAGEMENT OF PRE-ECLAMPSIA IN GENERAL:
BABYS AGE MANAGEMENT
<28 weeks Better terminate.
28 34 weeks
Conservative management so that baby
survives.
>34 weeks Obvious terminate.
Causes of edema in pregnancy
Physiological due to hemodilution, there is decreased oncotic pressure by apparent
hypoproteinuria and pressure of gravid uterus. It is relieved by 12 hours of rest.
Pathological
Toxemias of pregnancy.
Anemia.
CCF, Renal and hepatic causes.
Hypoproteinemia.

Grading of edema
Grade I Confined to ankle not subsiding on
treatment.
Grade
II
Extending up to knee.
Grade
III
Above knee, between pelvis and face.
Grade
IV
Generalized edema with vulval
involvement.
Why to measure BP in the Left lateral tilt and not in right lateral?
Since we usually stand on the right side of the patient, we measure the BP in the right arm.
Hence, if measured in the right lateral tilt, the thoracic cage and sometimes breast may
exert external pressure on the cuff and give false values.
36 Abhishek .V
TESTS FOR PROTEINURIA
QUALITATIVE TESTS:
Sulphosalicylic acid test 3 drops of 20% Sulphosalicylic acid + 1 ml urine in
test tube. +ve if haziness or turbidity seen.
Hellers Test 3ml concentrated Sulfuric acid is layered over 3ml of urine.
+ve if white ring is seen at the junction of the 2 liquids.
SEMI-QUNATITATIVE TESTS:
Heat & Acetic Acid (1%) Coagulation Test Upper part of 3/4
th
test tube of
urine is heated. To the turbidity seen, 3 drops of 1% acetic acid is added and
heated again. If turbidity persists, it indicates presence of proteins. If it
disappears, proteins are absent.
Interpretation:
0 Traces.
1+ Letters of newspaper can be seen
through.
2+ Haziness.
3+ Cant see the letters.
4+ Precipitate.
QUANTITATIVE TESTS:
Esbachs albuminometer Esbachs reagent contains Picric acid and citric acid.
Aufrechts albuminometer












37 Abhishek .V
CASE OF HEART DISEASE IN PREGNANCY 1
NAME Chandrakala HUSBANDS NAME Manjunath
AGE 32 years AGE 35 years
ADDRESS Chikaballapur OCCUPATION Cloth merchant
OCCUPATION Housewife INCOMERs.2000/month (PCIRs. 1000)
RELIGION Hindu SE STATUS Upper Middle Class
DATE OF ADMISSION 12/07/2007 DATE OF EXAMINATION 12/07/2007
Patient comes with 9 months of amenorrhea for safe confinement of delivery.
HISTORY OF PRESENTING COMPLAINTS:
Patient comes with 9 months amenorrhea for safe confinement with a history of cardiac
surgery.
No history of breathlessness on exertion, palpitations, chest pain, PND, orthopnea, edema
of feet.
No history of fleeting joint pains or fever in the childhood and patient not on penidure
prophylaxis.
No history of any congenital heart disease.
No history suggestive of CCF, infective endocarditis in the past or present pregnancy.
OBSTETRIC HISTORY:
Married Life 16 years (non consanguineous marriage)
Obstetric index G
3
P
1
L
1
A
1

PREVIOUS PREGNANCY:
G
1
FTND, Government Hospital, Now 11 years, Cried soon after birth, Weighed 3 kg, Post partum
period normal, Booked and immunized, 3 ANC visits, 2TT & 100 IFA received.
G
2
Aborted at 1 months gestation (MTP).

PRESENT PREGNANCY:
T
1

History of nausea and vomiting.
No history of urinary symptoms.
No history of drug intake or radiation exposure.
No history of pica.
T
2

Quickening at 18
th
week.
38 Abhishek .V
No history of headache or blurring of vision or edema.
Patient was booked and immunized 4 ANC checkups, 2 TT & 100 IFA.
T
3

Increased frequency of micturition present.
Fetal movements present.
Uneventful.
MENSTRUAL HISTORY:
Age of Menarche 15 years
Past Cycles Regular, 30 day cycle, and 3 days flow, no pain or passage of clots.
LMP 15/10/06
EDD 22/07/07
No history of any contraceptives used.
FAMILY HISTORY: No history of DM, HTN. No history of any congenital heart disease among
relatives.
PAST HISTORTY:
Patient underwent a cardiac surgery 2 years back when she developed sudden onset of
breathlessness though she was on medical treatment for some cardiac ailment for 5 years.
Her previous reports revealed that she was diagnosed to have VSD. She underwent the
operation in a government hospital in Putbarti.
No history of any post-op complications.
No history suggestive of DM or HTN.
No history of TB, epilepsy or asthma.
PERSONAL HISTORY:
Diet Mixed
Appetite Good
Sleep Sound
Bowel & Bladder Regular
Habits Nil
GENERAL PHYSICAL EXAMINATION:
Mother is a young lady, moderately built and nourished, conscious, alert & cooperative; well
oriented to time, place and person.
Pulse 90/min, regular, good volume, normal character, all PP felt, JVP normal.
BP 130/70 mm of Hg
39 Abhishek .V
RR 18/min, regular, TA
Temperature Afebrile
Pallor Absent
Icterus Absent
Cyanosis Absent
Clubbing Absent
Clubbing Absent
Edema Absent
Lymphadenopathy Absent
Thyroid Normal
Breasts Normal
Spine Normal
Gait Normal
Height 160 cm
Weight 60 kg
SYSTEMIC EXAMINATION:
CARDIO-VASCULAR SYSTEM:
INSPECTION
No precordial bulge.
Apical impulse left 4
th
inter-costal space, 2 cm lateral to Mid-clavicular line.
No other abnormal pulsations.
A linear scar seen over the mid-sternum 15 cm 2 cm.
No dilated veins over the chest wall.
PALPATION
Inspectory findings were confirmed.
Apex beat left 4
th
inter-costal space, 2 cm lateral to Mid-clavicular line.
No parasternal heave.
No thrill felt.
No abnormal pulsations.


40 Abhishek .V
AUSCULTATION
Aortic area
Pulmonary
area
Mitral area
Tricuspid area
S
1
S
2
heard no
murmurs.

RS NVBS heard no basal crepitation.
CNS NAD.
PA Organomegaly could not be made out due to enlarged uterus
OBSTETRIC EXAMINATION:
INSPECTION:
Abdomen is distended, flanks are full.
Umbilicus normal.
Striae gravidarum, albicans & linea nigra present.
No dilated veins or scars or sinuses.
Hernial orifices normal.
PALPATION: (Patient examined in supine position with legs semi flexed).
Fundal height corresponds to 32 weeks with flanks full corresponding to 40 weeks of
gestation.
Shelving Sign positive.
Symphysis fundal height is 30 cm.
Fundal grip Broad, soft, non-ballotable, relatively large irregular structure suggestive of
breech.
Lateral Grip
o Right Knob like structures suggestive of Limb buds.
o Left Uniform curved resistance suggestive of spine.
1
st
Pelvic Grip Smooth, hard ballotable mass relatively small felt suggestive of head.
Abdominal girth 104 cm.
Weight of fetus (Johnsons formula) 2800 gm.
Age of fetus (Mc Donalds formula) 40 weeks.
AUSCULTATION:
FSH heard along the left spinoumbilical line, mid point.
41 Abhishek .V
Rate 140/min, regular.
DIAGNOSIS:
32 year old 3
rd
gravid with full term pregnancy with cephalic presentation, not in labor with a
previous history of cardiac surgery.





DISCUSSION:
Look for the following Pulse, BP, anemia, weight gain, JVP, RR, cyanosis and thyroid, pedal
edema.
Management of pregnancy with heart disease based on
a. Grading of heart disease
b. Gestational Age
c. Risk factors for heart failure
i. Anemia
ii. Infections
iii. Hypertension
iv. Previous heart failure
v. Thyrotoxicosis
vi. Cardiac arrhythmias LVH
vii. Multiple pregnancy
viii. Stress
ix. Advanced age
d. Complications of heart disease
i. Cardiac failure
ii. Arrhythmia
iii. Pulmonary edema.
iv. Pulmonary embolization
v. SABE
vi. Rupture of aortic aneurysm
42 Abhishek .V
Grade I
Grade
II
Treatment on OPD basis (admit 2 weeks before EDD or 36 weeks if signs of
failure ve).
Grade
III
Grade
IV
Admit the patient soon after pregnancy is diagnosed.

Antepartum management
Adequate rest at home.
Avoid excess weight gain and restrict salt intake.
Prevention of anemia and infections.
Early detection and treatment of above and PIH.
Complete cardiology workup.
For Grade I & II during ANC visits,
History and symptoms.
Examination anemia, pallor, pedal edema, pulse, BP, PA and CVS examination.
Look for weight gain, Hb%, Urine, USG, ECG & ECHO.
Admit around 36 weeks.
For Grade III & IV,
During ANC Visits (T
1
),
o Tell her about the outcome of complications (if patient wants
termination, do MTP provided patient is in good condition, but if in
failure, treat first and only then do MTP).
o Around 14-16 weeks, look for any correctable pathology like MS, and
then do valvotomy.
o Admit the patient till they become Grade I or II.
Complete bed rest.
Sedation (anxiolytic).
Continuous monitoring (look for precipitating factors).
Treat cardiac failure.
o During 1
st
stage of labor,
Patient in propped up position (avoid supine position) or left
lateral position.
Oxygen is given as required.
Adequate sedation (Pethidine 75-100 mg IM)
Fluid restriction. Not more than 75ml/hr
Prophylactic antibiotics.
Nutrition is maintained (restrict IV fluids).
43 Abhishek .V
Pulse, BP, Respiration monitored every 30 minutes and look for
signs of failure.
Pain relief (using epidural analgesia only).
Patient should be allowed to go into spontaneous labor if
required vaginal PGE2 may be done ( induction safe in heart
diseases)
Only heart disease where vaginal delivery contraindicated is
aortic coarctation.
o During 2
nd
stage of labor,
Lithotomy position with propped up posture.
Outlet forceps ore ventouse should be used to shorten the 2
nd

stage.
Liberal episiotomy.
Restrict fluids.
40mg iv furosemide given to divert some of the excess blood
added from contracting uterus.
o During 3
rd
stage of labor,
Oxytocin or PGs can be given (Methergine Contraindicated) for
PPH.
Active management of 3
rd
stage withheld.
o During Post-partum period,
Careful observation for heart failure.
Continue antibiotics.
Keep in labor ward for at least 48 hours.
Contraception
No IUCD (risk of infection)
Barrier method or husband vasectomy.
Low dose OCPs (20 g ethynlestradiol)
Laparoscopic sterilization may cause cardiac
embarrassment and hence open procedure at 1 wk using
LA through abdominal route using minilap technique.
Prophylactics in patients with prosthetic heart valves during pregnancy:
Heparin upto 12-14 weeks gestation (5000 IU IM daily)
Warfarin 12 weeks to 34 weeks
Heparin 34 weeks onwards (because heparin is short acting and hence action can be
terminated in case of uncontrolled vaginal bleeding during labor.
No surgery done in 1
st
trimester because:
Abortion in 1
st
trimester usually occurs due to genetic abnormalities and hence rules
out if abortion occurs spontaneously.
Avoid anesthesia.
44 Abhishek .V
Surgery may disturb the prostaglandin production which is occurring outside the uterus in T
1
and
lead on to abortion.



CASE OF HEART DISEASE IN PREGNANCY 2
NAME Farida Taj HUSBANDS NAME Rehman
AGE 25 years AGE 30 years
ADDRESS Chikaballapur OCCUPATION Plastic Items retailer
OCCUPATION Worker in Agarbatti factory INCOMERs.3000/month (PCIRs. 1500)
RELIGION Hindu SE STATUS Upper Middle Class
DATE OF ADMISSION 08/11/2007 DATE OF EXAMINATION 21/11/2007
Patient comes with 9 months of amenorrhea
PRESENTING COMPLAINTS:
Pain abdomen 13 days.
Swelling of both lower limbs 13 days.
Chest pain and breathlessness 8 days.
HISTORY OF PRESENTING COMPLAINTS:
Patient gives history of pain abdomen for the past 13 days, over the lower part of the
abdomen, moderate intensity, intermittent in nature, each episode lasting about 2 hours and
approximately 2-3 episodes per day, relived on medication.
Patient also complaints of swelling of both the lower limbs since 13 days, insidious in onset,
initially present over the feet and has gradually progressed to the knee, present throughout
the day, increases on walking and relived on taking rest. No diurnal variation. No history of
distention of abdomen or puffiness of face.
Patient also gives a history of chest pain since last 8 days, sudden in onset, over the
retrosternal region, progressive, constricting type, non-radiation, moderate severity,
aggravated on exertion and relieved on rest. It is associated with breathlessness, insidious
in onset, progressive in nature, initially patient was able to do her routine activities but now
she is not able to walk a few meters. It is relieved on rest.
History of palpitations present.
No history of bleeding or discharge per vagina.
No history of orthopnea, PND.
No history suggestive of CCF, Infective endocarditis.
45 Abhishek .V
No history of fever.
No history suggestive of thyroid disease.
Not a known case of DM or HTN.
OBSTETRIC HISTORY:
Married Life 1 years (non consanguineous marriage)
Obstetric index G
1
P
0
L
0
A
0

PRESENT PREGNANCY:
T
1

History of nausea and vomiting.
History of urinary symptoms present.
No history of drug intake or radiation exposure.
No history of pica Booked and Immunized.
T
2

Quickening at 5
th
month.
No history of headache or blurring of vision or edema.
T
3

Fetal movements present.
Developed swelling of lower limbs, chest pain and breathlessness as mentioned previously.
MENSTRUAL HISTORY:
Age of Menarche 15 years
Past Cycles Regular, 30 day cycle, and 3 days flow, no pain or passage of clots.
LMP 03/03/07
EDD 10/12/07
No history of any contraceptives used.
FAMILY HISTORY: No history of DM, HTN. No history of any congenital heart disease among
relatives.
PAST HISTORTY:
No history of fleeting joint pains or fever in the childhood and patient not on penidure
prophylaxis.
No history suggestive of any other congenital heart disease.
No history of heart surgery.
46 Abhishek .V
No history suggestive of DM or HTN.
No history of TB, epilepsy or asthma.
No history of previous hospitalization or treatment for heart ailments.
PERSONAL HISTORY:
Diet Mixed
Appetite Good
Sleep Sound
Bowel & Bladder Regular
Habits Nil
GENERAL PHYSICAL EXAMINATION:
Mother is a young lady, moderately built and nourished, conscious, alert & cooperative; well
oriented to time, place and person.
Pulse 99/min, regular, good volume, normal character, all PP felt, JVP raised (6 cm).
BP 126/90 mm of Hg in left upper limb in supine position.
RR 18/min, regular, TA
Temperature Afebrile
Pallor Absent
Icterus Absent
Cyanosis Absent
Clubbing Absent
Clubbing Absent
Edema Absent
Lymphadenopathy Absent
Thyroid Normal
Breasts Normal
Spine Normal
Gait Normal
Height 160 cm
Weight 60 kg


47 Abhishek .V
SYSTEMIC EXAMINATION:
CARDIO-VASCULAR SYSTEM:
INSPECTION
No precordial bulge.
Apical impulse left 4
th
inter-costal space, 2 cm lateral to Mid-clavicular line.
No other abnormal pulsations.
No dilated veins over the chest wall, no scars.
PALPATION
Inspectory findings were confirmed.
Apex beat left 4
th
inter-costal space, 2 cm lateral to Mid-clavicular line.
Parasternal heave present.
No thrill felt.
No abnormal pulsations.
AUSCULTATION
Aortic area S
1
S
2
heard, No
murmurs
Pulmonary
area
ESM present
Mitral area MDM present
Tricuspid area S
1
S
2
heard, No
murmurs

RS NVBS heard no basal crepitation.
CNS NAD.
PA Organomegaly could not be made out due to enlarged uterus
OBSTETRIC EXAMINATION:
INSPECTION:
Abdomen is distended, flanks are full.
Umbilicus normal.
Striae gravidarum, albicans & linea nigra present.
No dilated veins or scars or sinuses.
Hernial orifices normal.
48 Abhishek .V
PAPLATION: (Patient examined in supine position with legs semi flexed).
Fundal height corresponds to 32 weeks with flanks full corresponding to 40 weeks of
gestation.
Shelving Sign positive.
Symphysis fundal height is 30 cm.
Fundal grip Broad, soft, non-ballotable, relatively large irregular structure suggestive of
breech.
Lateral Grip
o Right Knob like structures suggestive of Limb buds.
o Left Uniform curved resistance suggestive of spine.
1
st
Pelvic Grip Smooth, hard ballotable mass relatively small felt suggestive of head.
Abdominal girth 105 cm.
Weight of fetus (Johnsons formula) 2800 gm.
Age of fetus (Mc Donalds formula) 40 weeks.
No signs suggestive of free fluid in abdomen.
AUSCULTATION:
FSH heard along the left spinoumbilical line, mid point.
Rate 140/min, regular.
DIAGNOSIS:
25 year old primi with full term pregnancy with cephalic presentation not in labor with cardiac
disease (Valvular lesion).








49 Abhishek .V
Discussion
CVS changes during normal pregnancy which mimic heart disease
Collapsing pulse due to wide pulse pressure
Increased heart rate and ectopics.
JVP waves are more prominent
Heart size increases
Apex beat displaced upward and laterally
S1 loud and there may be third heart sound
Ejection systolic murmurs (grade 2 and 3) may be heard over precordium in 90% women.
Venous hums and mamillary souffle over breast.
Peripheral edema very common
ECG shows left axis deviation and mild ST elevation
Clinical indicators for heart diseases in pregnancy
Symptoms Clinical findings
Severe progressive dyspnea
Progressive orthopnea
PND
Hemoptysis
Syncope on exertion
Chest pain related to effort
Sustained palpitations
Cyanosis
Clubbing of fingers
Persistent neck vein distension
Systolic murmur > grade 3
Diastolic murmur
Persistent split of S2

Contraindications for pregnancy
Absolute
Eisenmengers syndrome
Primary pulmonary hypertension
Uncorrected severe coarctation
Marfans with aortic involvement
Severe MS with complications
Relative
Grade III and IV
Grade I and II with previous h/o failure
50 Abhishek .V
Group I minimum risk
Mortality 0-1%
Group II
Mortality 5-15%
Group III
Mortality 25-50%
ASD, VSD ,PDA ,Teratology
of fallot (corrected),
pulmonary and tricuspid
disease, bioprosthetic valve,
MS grade 1 and 2(NYHA)
AS, Aortic coarctation
without valvular involvement,
uncorrected Teratology of
fallot ,MS III IV previous
MI, Marfans with normal
aorta, MS with AF artificial
valve.
Eisenmengers syndrome,
Primary pulmonary
hypertension, aortic
coarctation with valvular
involvement, Marfans with
aortic involvement.


In developing countries and in India Most common cardiac disease is rheumatic followed by
congenital most common rheumatic valvular lesion is MS 80%
In developed countries Most common cardiac disease congenital heart disease most common lesion
is ASD.
Predictors of cardiac complications in pregnancy
Prior heart failure TIA arrhythmia or stroke
Base line NYHA class III or greater or cyanosis
Left side heart obstruction defined as Mitral valve area <2cm aortic valve <1.5cm or peak
left ventricular outflow tract gradient >30mm Hg by echocardiogram
Ejection fraction <40%

In general regurgitant lesion do well in pregnancy unlike stenotic lesions which worsen AS
>MS >TS
Cardiac surgery should be postponed until after delivery but if required may be done at second
trimester indications for surgery failure of medical treatment for heart failure, recurrent
pulmonary edema. Surgery of choice in MS balloon valvuloplasty or valve replacement indication
for replacement when combined stenosis and regurgitation are present or when mitral valve
echo score is > 8


51 Abhishek .V
DIABETES
More than half of women with gestational diabetes ultimately develop overt diabetes in the ensuing
20 years, and there is mounting evidence for long-range complications that include obesity and
diabetes in their offspring.
There is extensive evidence that insulin and the insulin-like growth factors I (IGF-I) and II (IGF-
II) play a role in the regulation of fetal growth Insulin is secreted by fetal pancreatic beta -cells
primarily during the second half of gestation and is believed to stimulate somatic growth and
adiposity. These growth factors, which structurally are proinsulin-like Other factors implicated in
macrosomia include epidermal growth factor and leptin.
Pederson hypothesis maternal hyperglycemia fetal hyperglycemiafetal
hyperinsulinemiaexcess fetal growth and adipose deposition macrosomia.

In pregnant mother with diabetes oral hypoglycemics are switched over to insulin
Insulin does not cross over placenta
Insulin requirement increase in pregnancy cannot be met by oral hypoglycemics
oral hypoglycemics have teratogenic effects especially ear deformities
Oral hypoglycemics cause severe fetal hyperinsulinemia and neonatal hypoglycemia.
Oral hypoglycemics aggravate neonatal hyperbilirubinemia by competing for albumin binding
site.

Class of diabetes
Class I A
Non insulin dependant low
risk gestational diabetes


Class I B
Non insulin dependant high
Fetal surveillance

Risk of fetal distress low so
no Req for surveillance
before 40wks


Should begin by 34 wks NST
done weekly/biweekly other
methods biophysical profile
Obstetric management

Allow for spontaneous labor
if at 40 wks fetal and
cervical condition good
continue for 1 more wk but
have to deliver at 41wk

Delivery at 38-40wks
previous still birth induce at
52 Abhishek .V
risk gestational diabetes
h/o still birth ,h/o neonatal
death, h/o fetal macrosomia
obesity HTN, development
of polyhydramnios,
preeclampsia, inadequate
control by diet alone.

Class II A
Insulin dependant stable
diabetes


Class II B
insulin dependant unstable
diabetes
contraction stress test.





Req fetal surveillance in last
6-10 wks weekly
CST/biophysical score NST


Req fetal surveillance in last
6-10 wks weekly
CST/biophysical score NST
38wks






Can be carried to term but
best to deliver at 38-39wks


Should be delivered as soon
as fetal lung maturity is
attained L/S ratio >2.4 and
appearance of phosphatidyl
glycerol

Fetal malformation risk detected at 4-6 wk after conception by Hb A1c
Maternal HbA1c levels
<7.9
8.9-9.9
>=10
Malformation %
3.2
8.1
23.5

Once the risk of congenital malformation is known following monitoring have to be done
8-10wks ultrasound
10-12wks CVS examination
15-20wks MSAFP
53 Abhishek .V
16wk triple test
14-16 wks amniocentesis
18-20wks cordocentesis
18-20wks detailed second ultrasound
16-20wks fetoscopy
24-26wks fetal echocardiogram

Common anomalies in infants of diabetic mothers
Anencephaly > spina bifida > TGV > VSD
TGV>VSD>coarctation of aorta >ASD
Congenital defect which is specific to diabetes caudal regression syndrome/ sacral agenesis
1.3/1000 diabetic pregnancy

Effect of diabetes on
Fetus Neonate
Abortion
Congenital malformations
IUGR
Prematurity
Macrosomia
Unexplained fetal deaths
Shoulder dystocia
RDS
Hypoglycemia
Hypocalcemia
Hypomagnesemia
Polycythemia
Hyperbilirubinemia
Hyperviscosity syndrome
Hypertrophic cardiomyopathy
Birth trauma erb and Klumpke paralysis

54 Abhishek .V
After birth if baby in diabetic mother has respiratory difficulties if term baby it is transient
tachypnea of newborn due to delayed clearance of lung fluid.. If it is preterm baby it is RDS
though diabetes delays lung maturity it is gestational age and not diabetes that is the main
factor for causing respiratory distress.
Use of IV beta adrenergic drugs to stop preterm labor is contraindicated in diabetic mother drug
of choice for initial tocolysis in diabetic mother Mg SO4 once the contractions have subsided
maintained on oral nifedipine.
GTT American diabetes association 100g glucose used WHO 75g..
Tests for assessment of lung maturity
1. L/S ratio at 34 wks should be greater than 2 it is not a good indicator for pulmonary
immaturity when L/S <2.3 only 54% develop HMD high false predictive value disadvantage as
in pregnancies where early delivery is desirable may be prolonged unnecessary also false
values due to contamination by blood /meconium.
2. Phosphatidyl glycerol best marker in diabetes appears at 36wks no false values with blood
meconium.
3. Dipalmitoylphosphatidyl choline definitive for lung maturity
4. Shake test or bubble test/ Clements test amniotic fluid + 96% ethanol shake 15 sec observe
for bubbles after 15 min
5. Foam stability index
6. Amniotic fluid opacity at 650mu >.15/ml pulmonary maturity.
7. Phosphatidyl choline > 500ng/ml pulmonary maturity.
8. Fluorescence polarization >55mg surfactant/ gm of albumin
9. lamellar body > 30,000/ul
10. orange color cells desquamated fetal cells obtained from amniotic fluid centrifuge attained
with 0.1% Nile blue sulphate presence of orange cells > 50% pulmonary maturity.

Somogyi phenomenon: nocturnal hypoglycemia followed by an exaggerated counter response
producing elevated fasting blood sugar levels the treatment is to reduce rather than increase dose
of insulin mid night symptoms of hypoglycemia confirms the diagnosis.
55 Abhishek .V
Dawn phenomenon: high fasting blood sugar levels in absence of nocturnal hypoglycemia treatment
is to increase the dose of insulin at bed time.


























56 Abhishek .V
CASE OF PREVIOUS LSCS
NAME Anita HUSBANDS NAME Venkatesh
AGE 23 years AGE 24 years
ADDRESS Atmajyothinagar, Kengeri OCCUPATION Painter
OCCUPATION Maid servant INCOME Rs. 2600/month (PCIRs. 850)
RELIGION Hindu SE STATUS Lower Middle Class
DATE OF ADMISSION 09/07/2007 DATE OF EXAMINATION 10/07/2007
Patient comes with 9 months of amenorrhea for safe confinement of delivery.
HISTORY OF PRESENTING COMPLAINTS:
Patient comes with 9 months amenorrhea with a history of previous LSCS and was admitted
for safe confinement. Patient had been here for regular ANC checkup on 27/07/2007 and
was asked to get admitted as her EDD as per scan was 10/07/2007.
Patient complaints of backache since today morning in the lower mid-back, non-radiating and
not associated with pain abdomen.
Patient gives history of white discharge since 1 week, non-foul smelling, not associated with
fever or itching.
No history of leak PV or bleeding PV(scar dehiscence, APM, PROM)
No history of supra-pubic pain or bulging. (scar dehiscence, APM, PROM)
No history of hematuria.
No history of any change in bladder habits.
Fetal movements are well perceived.
No history of Diabetes mellitus or Hypertension.
OBSTETRIC HISTORY:
Married Life 4 years (non consanguineous marriage)
Obstetric index G
2
P
1
L
1
A
0

PREVIOUS PREGNANCY:
T
1

History of increased vomiting present.
History of easy fatigability.
No history of urinary symptoms.
No history of drug intake or radiation exposure.
No history of pica.
T
2

Quickening at 20
th
week.
57 Abhishek .V
History of generalized edema present.
No history of headache or blurring of vision.
Patient was booked and immunized 6 ANC checkups, 2 USG scans, 2 TT & 100 IFA.
T
3

Fetal movements present.
Uneventful.
Delivered by Lower Segment Caesarean Section probably due to obstructed labor or non-
progression of labor.
Patient was initially put n trial of labor by administering injections, but since labor pains
were not adequate, she was posted for emergency LSCS, after infusing 1 unit of blood.
Outcome was a live male fetus, 3.7 kg at birth, was booked and immunized and exclusively
breast fed for 1 year.
Mother had no fever or wound discharge in the post-op period.
Sutures were removed on the 7
th
day but had to stay in the hospital for 16 days as the baby
had jaundice.
Last C/S 3 years back (April 25
th
, 2004)
PRESENT PREGNANCY: T
1
, T
2
and T
3
uneventful.
MENSTRUAL HISTORY:
Age of Menarche 12 years
Past Cycles Regular, 50-70day cycle, and 8-9 days flow, no pain or passage of clots.
LMP 01/11/06
EDD 08/08/07
No history of any contraceptives used.
FAMILY HISTORY: No history of DM, HTN.
PAST HISTORTY:
Medical No history suggestive of DM/HTN. No history of TB, epilepsy or asthma.
Surgical No history of blood transfusions or any previous surgical procedures.
PERSONAL HISTORY:
Diet Mixed
Appetite Good
Sleep Sound
Bowel & Bladder Regular
Habits Nil
58 Abhishek .V
GENERAL PHYSICAL EXAMINATION:
Mother is a young lady, moderately built and nourished, conscious, alert & cooperative; well
oriented to time, place and person.
Pulse 78/min, regular, good volume
BP 116/82 mm of Hg
RR 18/min, regular
Temperature Afebrile
Pallor Present
Icterus Absent
Cyanosis Absent
Clubbing Absent
Clubbing Absent
Edema Absent
Lymphadenopathy Absent
Thyroid Normal
Breasts Normal
Spine Normal
Gait Normal
Height 158 cm
Weight 51 kg

SYSTEMIC EXAMINATION:
CVS S
1
S
2
heard, No murmurs.
RS NVBS heard no basal crepitation.
CNS NAD.
PA Organomegaly could not be made out due to enlarged uterus
OBSTETRIC EXAMINATION:
INSPECTION:
Distended and flanks are full.
Umbilicus normal.
Striae gravidarum, albicans & linea nigra present.
No dilated veins.
Hernial orifices normal.
59 Abhishek .V
A vertical right paramedian incision, 14 cm long is seen in the infra-umbilical region, healed
by primary intention no hypertrophy or keloid formation, no supra-pubic bulge.
PALPATION: (Patient examined in supine position with legs semi flexed).
Fundal height corresponds to 32 weeks with flanks full corresponding to 40 weeks of
gestation.
SFH is 32cm.
Fundal grip Broad, soft irregular structure suggestive of breech.
Lateral Grip
o Right Knob like structures suggestive of Limb buds.
o Left Uniform curved resistance suggestive of spine.
1
st
Pelvic Grip Smooth, hard ballotable mass.
2
nd
Pelvic Grip Fingers diverge.
Abdominal girth 95 cm.
Weight of the fetus (Johnsons formula) = 3260 gm.
Age of fetus (Mc Donalds formula) = 40 weeks.
Palpation of scar reveals no tenderness.
No supra-pubic bulge felt.
AUSCULTATION:
FSH heard along the left spinoumbilical line, mid point.
Rate 140/min, regular.
DIAGNOSIS:
23 year old 2
nd
gravid with full term pregnancy, not in labor with previous LSCS.








60 Abhishek .V

DISCUSSION
CAESAREAN SECTION definition Surgical extraction of the baby after the period of viability
through the abdomen from an intact uterus.
- If ruptured, then it is LAPROTOMY AND EXTRACTION.
- Before period of viability HYSTEROTOMY
WHO states that no region in world is justified in having a cesarean rate greater than 10-15%.
India rate is 8-20% in our hospital 15-20%.
Causes for increased incidence of primary C.S
Increase in number of repeat cesarean as many obstetricians are unwilling to give trial
vaginal delivery in case of previous CS of fear of rupture.
Decreasing skill and experience of vaginal instrumental delivery prefer CS to difficult
vaginal delivery.
Increased cases of failed induction. Induction rate has doubled in last decade. Few of them
will fail and end up in CS
Uses of modern gadgets like electronic fetal monitoring which over diagnose the causes of
fetal distress.
More and more breech presentation particularly after Hannahs multicentric term breech
trial recommended CS for all breech presentation
With better neonatal facilities more premature and IUGR babies are saved these are
better delivered by CS.
Increase number of precious pregnancy i.e. conceived after infertility treatment or ART
and more cases of elderly primigravida/late marriages.
To avoid litigation for alleged neglect in vaginal delivery
Failures to progress of labor with lack of patience in patient her relatives and also in
obstetrician this becomes a ready indication for LSCS.
Past Obstetric history is most crucial part in a case of previous LSCS.
Patient was on course of normal labor with saline drip and was taken to C/S suggests
patient not progressing in labor, even induction has failed and hence taken for C/S (Non-
recurrent cause)
61 Abhishek .V
Full term pregnancy; patient after examination taken for elective C/S without TOL
suggests
CPD (Recurrent Cause)
Malpresentation (Non-recurrent cause)
Hence we can know if the C/S was elective or emergency.
Scar in
Emergency LSCS
Cervix would be dilated, incision on lower uterus
Many referrals or repeated pelvic examinations increase the chances of
puerperal sepsis wound heals by secondary intention and hence weak scar.
Elective LSCS
Cervix usually not dilated incision higher up, difficult technically.

Age of Scar date of C/S to present pregnancy. Scar >3 years is ideal. At least 18 months
gap between 2 pregnancies to give VBAC-TOL.
Ask if she has had a successful vaginal delivery ever before, this rules out CPD.
Ask for symptoms of wound infection in the post-op period (fever, foul smelling lochia or
wound discharge) infection delays wound healing and when wound healing takes by
secondary intention, scar is definitely weaker than which healed by primary intention.

Benefits of vaginal delivery over repeat LSCS
Shorter hospital stay
Early ambulation and resumption of work
Economical
Less chances of bleeding
No contamination of peritoneal cavity
No pulmonary and wound complications
Damage to bowel bladder ureter and major vessels avoided
Psychological satisfaction in few communities vaginal delivery is a sign of female
competence
Scar related remote complication avoided and subsequent obstetric care improves.
Selection Criteria for VBAC-TOL:
Previous Lower segment uterine scar (previous classical C/S is an absolute indication
for repeat C/S).
Pelvis adequate for fetus.
62 Abhishek .V
Non recurrent cause for previous LSCS.
Average sized baby no macrosomia.
Previous scar healed by primary intention.
Gap between present pregnancy and previous LSCS >3 years (minimum 18 months).
Normal presentation.
No added problems to mother PIH, CHF, GDM.
Placenta normally situated.
Absence of any pathology in baby e.g. IUGR distress, Monster baby scar
rupture.
Commitment on side of mother for vaginal delivery (IMP).
Availability of resources anesthesia, blood transfusion and OT for emergency
laparotomy in case of scar rupture and continued labor monitoring possible.
As per recommendations of American academy of family physicians
Positive factors for success of VBAC
Maternal age <40
Adequate pelvis
Prior vaginal delivery
Presence of spontaneous labor
Non recurrent indication
Negative factors decreased success of VBAC
Increased number of prior CS
Gestational age > 40 wks
Birth weight >4kg
Previous CS requiring induction or augmentation
Success rate of VBAC
Overall 60-80%
Previous indication breech upto 85%
Previous indication CPD or Dystocia 50-70%
Contraindications for VBAC-TOL:
Previous classical or inverted T shaped uterine scar.
2 or more previous LSCS.
63 Abhishek .V
Pelvis contracted or suspected CPD.
Presence of complication of pregnancy.
VBAC after previous CS is a relative contraindication as the scar would have
stretched during trial.
Line of management to give VBAC-TOL:
After regular antenatal supervision, I would admit the patient at 38 weeks and
confirm, see the integrity and rule out contraindications for VBAC.
During labor, active management and continuous monitoring of both fetus and mother
is mandatory and at least suspicion of complications like scar rupture, immediate
emergency laparotomy is the rule.
In the 1
st
stage of labor,
I will put an IV cannula using a wide bore 18G needle because if scar ruptures
hypokalemia causes veins to collapse, making them inaccessible. Wide bore is
for blood transfusion.
Start on 10 RL to maintain adequate hydration during labor.
Monitor both mother and fetus.
Mother
o Pulse Tachycardia is one of the earliest sign of scar rupture.
It occurs due to reflex sympathetic discharge resulting from
peritoneal irritation due to bleeding.
o BP
o Hydration
o Intensity of uterine contractions.
Fetus FHS every 15 minutes which reduce or disappear in cases of
fetal distress or Scar rupture.
In the 2
nd
stage of labor,
Must be cut short.
Use prophylactic forceps or ventouse to deliver head and delivery of trunk
between contractions manually to prevent prolongation.
Give liberal episiotomy if required.
In the 3
rd
stage of labor,
Though incidence of placental retention is more, I will wait for separation and
later deliver it by Modified Brandt Andrews Method. [Manual separation is
contraindicated in Rh ve pregnancy and anemia but such cases not chosen for
VBAC-TOL].
To prevent PPH, oxytocin can be given IV. [Usually given after delivery of
shoulder in routine cases but here delivery is done in uterine relaxation, hence
oxytocin not given early]
In the 4
th
stage of labor,
64 Abhishek .V
Episiotomy wound sutured.
Careful monitoring for 6 hours essential.
Patient shifted to ward only after she passes urine.
In post-natal period,
Prophylactic antibiotics for 5 days.
Watch for progressive uterine involution.
Fe and Ca supplementation for 6 months.
Advice sterilization for 3
rd
time C/S.

CLINICAL FEATURES OF SCAR RUPTURE
SYMPTOMS
Supra-pubic pain dull aching which persists in between contractions.
Slight vaginal discharge fresh blood ominous sign of scar dehiscence. [D/D
excess show, however it is mixed with mucoid material].
Bladder tenesmus.
SIGNS
Unexplained tachycardia.
Falling BP.
Fetal distress (abnormal FHS).
Tenderness over uterine scar.
Failure of progression of labor.
Bulging of supra-pubic area.
Patient suddenly becomes silent.
Presenting part recedes back.
Hematuria.
Scar rupture incidence previous 1 LSCS 1% ( .3-1.7%) previous 2 LSCS 3.7% previous
classical CS 12%
REASONS OF STRONG SCAR IN LSCS:
Upper segment contracts and relaxes intermittently during puerperium, while lower
segment is at rest. Thus absence of rest to the tissues and loosening of stitches
leads to improper healing and weak scar.
Due to thick edges in upper segment, exact apposition and adequate suturing nor
possible.
65 Abhishek .V
Small pockets of blood left behind in thick edges lead to improper healing and weak
scar. The pockets of blood are replaced by fibrous tissue.
More chances of placenta implanted on the scar inn next pregnancy and weakening
due to trophoblastic penetration or amniotic sac herniation.
Stretching occurs along the line of scar in future pregnancy rather than
perpendicular as occurs in classical scar.
Can rupture only during labor, classical may rupture during pregnancy or labor.
To test the strength and integrity of scar in non-pregnant state,
Hysterosalpingography Inject radio-opaque dye and take X ray in supero-inferior
and lateral views and assess how much scar has given way.
Problems in repeat C/S
Adhesions bladder, bowel, omentum.
Incision of skin done on either side of previous scar.
If uterine scar had healed by secondary intention or its baby is big, uterine incision
is taken by side of scar.
U/S in T
3
in LSCS
Important because incidence of placenta previa increases in previous LSCS patients
and can cause massive bleeding in placenta previa caeseria (i.e. placenta implanted
over the scar).
Fetal maturity can be assessed.
Integrity of the scar.
In VBAC, D/D for signs of placental separation are
For supra-pubic bulge hematoma following scar rupture.
For gush of blood PV scar rupture.
Recurrent indications for C/S contracted pelvis.
Non-recurrent indications for C/S PIH, GDM, cord prolapse, PROM, Malpresentation, fetal
distress.
SCAR RUPTURE & DEHISCENCE
Theoretical definition (asymptomatic thinning, peritoneum intact, no hemorrhage)
Dehiscence Amniotic sac should be intact.
Incomplete rupture visceral peritoneum intact.
Complete rupture all broken.
Practically,
Dehiscence disruption of part of scar and not entire length. Fetal
membranes intact.
Scar rupture Disruption of entire length of scar.
ADVANTAGES OF:
ELECTIVE C/S
66 Abhishek .V
Resources available (well planned).
Reduced chances of infections.
Reduced chances of aspiration (nil orally).
Mother mentally prepared.
EMERGENCY C/S
Fetal maturity is confirmed (baby can survive outside)
Less bleeding and approximation is good (because lower segment is well
formed).
Less chance of scar rupture in future.
Recurrent absolute indication for C/S
Contracted pelvis.
Vaginal atresia.
Pelvic tumours.
Advance Ca cervix.
SIGNS OF:
SCAR DEHISCENCE:
Pulse rate increased.
Scar tenderness over uterus.
FHS variation.
Fresh bleeding per vagina.
Mild vaginal discharge.
SCAR RUPTURE:
Signs of hypotension.
Altered contour of uterus.
FHS +/- with tachycardia.
Hematuria.
Receding of presenting part.
Patient suddenly becomes silent.
Causes of hematuria in scar rupture:
Extension of scar into the bladder wall.
Prolonged pressure on the bladder edema of bladder mucosa rupture of
capillaries of submucosa
Closure of uterus during C/S operation:
Closed in 2 layers
1
st
layer for hemostasis for deep uterine muscles with Chromic catgut No. 2
2
nd
layer superficial uterine muscles.
3
rd
layer closure of UV fold not to be done because healing is by amoeboid
movement of mesothelium and if we suture it, it gets necrosed and then heals,
so post-op pain increases.
67 Abhishek .V
After this, leave parietal peritoneum without closing and even the abdominal muscles
(or just approximate).
Then suture rectus sheet with Vicryl or Prolene.
Skin closure.
In history, IMPORTANT points to be asked:
When the patient got admitted for previous C/S as emergency case or elective.
What stage of labor C/S was done.
History of blood transfusion (PPH, Placenta previa) 5-10% chances of recurrence.
Duration between previous and this pregnancy (minimum 18 months but ideal 3 years).
Any MTP in between previous and this pregnancy (curettage can cause placenta
previa and complicate C/S).
Post-operative hospital stay.


















68 Abhishek .V
CASE OF FIBROID UTERUS
NAME Mangala HUSBANDS NAME Chandru
AGE 30 years AGE 34 years
ADDRESS Dasarahalli OCCUPATION Clerk in private factory
OCCUPATION House wife INCOME Rs. 2000/month/person
RELIGION Hindu SE STATUS Lower middle class
DATE OF ADMISSION 20/07/07 DATE OF EXAMINATION 23/07/07
PRESENTING COMPLAINS
Excessive bleeding per vagina during menses 4 months
Mass per abdomen 1 month
HISTORY OF PRESENTING COMPLAINTS:
Patient was apparently normal 4 months back when she developed increased bleeding during
menstruation lasting for 12-15 days during 30 day cycle, she changes 5-6 pads/day as
against 1-2 pads/day earlier. Flow is associated with passage of clots.
Patient also complains of associated pain in the lower abdomen, starts with the onset of
menstruation and increased on subsequent days. The pain is dull aching and in nature,
present continuously and often associated with cramps. No radiation, relieved on taking
medication.
Patient noticed a mass in her lower abdomen in the mid-region, insidious in onset, non-
progressive, not associated with pain. No history of change in size of the mass.
No history of white discharge per vagina with fever.
No history of fatigue, weakness, breathlessness, palpitation or pedal edema.
No history of increased frequency of micturition, incontinence or constipation.
No history of dyspareunia.
No history of breast discomfort.
No history of evening rise of temperature, cough with expectoration or hemoptysis.
No history suggestive of thyroid dysfunction or use of anti-thyroid drugs.
No history of any bleeding disorders.
No history of IUCD implantation.
No history of mass protruding out of vagina.
MENSTRUAL HISTORY:
Age of Menarche 14 years
Past Cycles Regular 30 days cycles with 4 days flow.
Present Cycles 12-15 days flow for every 30 days cycle, 5-6pads/day associated with pain and
passage of clots.
LMP 05/07/07
69 Abhishek .V
OBSTETRIC HISTORY:
Married Life 15 years
Obstetric index P
2
L
2

G
1
Full term home delivery, male baby cried immediately after birth, 3kg at birth, booked &
immunized, breast fed for 6 months, now 14 years old.
G
2
Full term home delivery, female baby cried soon after birth, 2.8 kg, booked & immunized,
breast fed for 8 months, now 12 years old.
FAMILY HISTORY: Nothing significant.
PAST HISTORTY:
No history of Tuberculosis, Epilepsy, Asthma.
No history suggestive of any cardiac ailments.
No history of previous surgeries, blood transfusions.
PERSONAL HISTORY:
Diet Mixed
Appetite Good
Sleep Sound
Bowel & Bladder Regular
Habits Nil
GENERAL PHYSICAL EXAMINATION:
Patient is middle aged lady, moderately built and nourished, conscious, alert & cooperative.
Pulse 80/min, regular, good volume
BP 110/70 mm of Hg
RR 18/min, regular
Temperature Afebrile
Pallor Absent
Icterus Absent
Cyanosis Absent
Clubbing Absent
Clubbing Absent
Edema Absent
Lymphadenopathy Absent
70 Abhishek .V
Thyroid Normal
Breasts Normal
Spine Normal
Height 155 cm
Weight 55 kg

SYSTEMIC EXAMINATION:
CVS S
1
S
2
heard, No murmurs.
RS NVBS heard no basal crepitation.
CNS NAD.
PER ABDOMINAL EXAMINATION
INSPECTION:
Shape of abdomen normal
Umbilicus appears normal
Corresponding quadrants move equally with respiration.
No dilated veins, scars or sinuses.
Striae albicans present.
No visible pulsations or peristalsis.
Hernia orifices normal
PALPATION:
No tenderness over the
Single globular mass felt in the hypogastric region, 46 cm extending 4 cm above the pubic
symphysis.
Lower border not made out, superior and lateral borders are well defined appears to be
arising from the pelvis.
Surface is smooth, firm in consistency.
Mobile horizontally but vertical mobility is restricted.
On asking her to raise the legs, the mass becomes prominent (intra-abdominal)
No organomegaly.
PERCUSSION:
Dull not over the mass.
Tympanic note elsewhere.
No evidence of free fluid in the abdomen.
71 Abhishek .V
AUSCULTATION:
Bowel sounds heard.
[I would like to do per speculum, per vaginal and bimanual examination to confirm any diagnosis)
DIAGNOSIS:
Fibroid uterus (corresponding to 16 weeks gravid uterus)
DIFFERENTIAL DIAGNOSIS Ovarian tumour or dermoid.



















72 Abhishek .V
DISCUSSION
DEFINITION: it is a benign neoplasm of the female, derived from the smooth muscle nests;
either from vessel wall or uterine musculature.
ETIOLOGY:
Estrogen, GH and placental lactogen are important for its growth.
Fibroid have Chromosomal abnormalities translocation b/w chr 12 &14 trisomy 12, rearrangement
of short arm of chr 6, rearrangement in long arm of chr 19, deletion of chr 3 and deletion of chr 7.
IMPORTANT TO NOTE:
1. Rare before puberty and regresses after menopause.
2. New myoma occurs rarely past menopause.
3. Increases in size during pregnancy and OCP use.
4. Contains more estrogen receptors than surrounding myometrium.
5. Progesterone/GNRH shrinks the tumour.
RISK FACTORS FOR FIBROID:
Increased risk Decreased risk
Age 35-45 years.
Nulliparous or low parity
Obesity
Early menarche <10 years
Strong family history
DM HTN

Exercise
Increased parity
High intake green vegetables
Progesterone only contraceptives
Cigarette smoking

CLASSIFICATION:
1. UTERINE
a. Body of Uterus
i. Submucous
Sessile
Pedunculated
73 Abhishek .V
ii. Intramural (interstitial)
iii. Subserous
Sessile
Pedunculated
b. Cervix (1-2%)
i. Supravaginal
ii. Vaginal
2. EXTRAUTERINE
a. Round ligament
b. Broad ligament
c. Uterosacral ligament
d. Vagina
e. Vulva
3. UNUSUAL FORMS
a. Intravenous leiomyomatosis
b. Disseminated intraperitoneal leiomyomatosis
c. Parasitic/wandering fibroid
d. Pseudo cervical fibroid
e. False broad ligament fibroid
ANATOMY:
GROSS
Well circumscribed with a pseudo capsule.
Firm in consistency.
Cut surface pinkish white with whorled appearance.
(degeneration starts from centre, calcification from periphery)
Pathological variants of leiomyoma microscopic variants mitotically active myoma cellular
myoma bizarre myoma lipoleiomyoma. Intravenous leiomyomatosis.. LPD leiomyomatosis
peritonealis dissemination.. Leiomyosarcoma.
MICROSCOPY Muscle cell bundles separated by fibrous strands.
SECONDARY CHANGES:
Atrophy: Menopause reduced vascularity shrinks and central cystic, fatty degeneration
Calcareous degeneration deposition of PO
4
and carbamates of lime in periphery when whole
of fibroid calcific WOMB STONE
Red degeneration during pregnancy, becomes tense & tender with pain abdomen and fever.
Differential Diagnosis:
o Appendicitis
o Twisted ovarian cyst
74 Abhishek .V
o Pyelitis
o Acute hemorrhage
Sarcomatous changes (<0.5%) most common in intramural and submucous tumors begins
from centre
COMPLICATIONS:
1. Capsular hemorrhage (rupture of surface)
2. Inversion of uterus
3. Torsion
4. Infection
5. Endometrial Ca (3%)
SYMPTOMS:
1. Abnormal Uterine bleeding due to
a. Increased surface of endometrium
b. Interference with contraction
c. Venous obstruction causing congestion
d. Endometrium improper maturation, improper ripening & shedding
e. Increased vascularity
f. Hyper estrogenic state
2. Dysmenorrhea congestive and spasmodic type
3. Pain usually does not cause pain except in torsion, hemorrhage, red degeneration, infection.
Associated endometriosis ,malignancy, extruded from body as polyp.
4. Pressure symptoms
a. Bladder increased frequency, retention.
b. Ureter hydroureter, hydronephrosis
c. Bowel constipation, tenesmus
d. Pelvic veins edema legs
5. Lump in the abdomen
6. Vaginal discharge
7. Infertility associated with PID, endometriosis, distortion of uterine cavity, etc.
8. Recurrent pregnancy loss especially in submucosal myoma





75 Abhishek .V
SIGNS
G/E Anemic (in OBG, even look for vaginal pallor) polycythemia is seen in broad ligament fibroids.
P/A Palpable mass if >12 weeks size, suprapubic, midline swelling, firm, nodular, well defined,
arising from pelvis, mobile side to side, non-tender, dull on percussion.
P/V Transmitted movements present, i.e. cervix moves when fibroid is moved, uterus not
separately felt, enlarged, nodular, notch not felt.
N.B. - 50% of fibroid patients are asymptomatic.
20% of women >20 years have fibroid.
40% of women >40 years have fibroid.
DIFFERENTIAL DIAGNOSIS:
1. Full bladder cystic with ill defined border, reduces after voiding.
2. Pregnancy signs of pregnancy, soft cervix, HCG +ve, USG confirmatory.
3. Adenomyosis does not go beyond 14 weeks, soft, tender, uniform with well defined
margins.
4. Ovarian tumours no menorrhagia, pain present, mass felt separately from uterus, no
transmitted movements.
5. Endometriosis uterus normal in size and adherent to the pelvic mass.
6. Tubo-ovarian mass felt in fornices, separately from uterus, no menorrhagia.
7. Ectopic pregnancy history is different, USG confirmatory.
8. Hematometra history is different, USG confirmatory.
9. Bicornuate uterus history is different, USG confirmatory.
10. Chronic inversion of uterus, pelvic kidney, appendicular mass.
11. Ca endometrium, vulva, cervix Age, multiparity, early age of marriage, intermenstrual
bleeding, P/S ulceration, cauliflower like growth, do pap smear to confirm.
INVESTIGATIONS:
1. ROUTINE:
a. Blood Hb%, grouping, Bt, CT, Rh status, Sugar
b. Urine routine examination
c. Serum urea, creatinine
d. Chest X ray & ECG for general fitness
2. SPECIFIC:
a. Hb%, blood grouping
b. USG
c. Hysterosalpingography
d. Hysteroscopy
76 Abhishek .V
e. DIC
f. D-scopy
g. MRI
h. IVP intravenous pyelography.
MANAGEMENT
GENERAL LINES
Correct anemia with hematinic, good nutrition.
Improve general condition of patient if to be taken for surgery.
EXPECTANT:
When patient is asymptomatic, near menopause, less than 12 weeks; do regular pelvic examination
and USG at regular intervals and put on treatment if size >12 weeks or symptomatic.
INDICATIONS FOR SURGERY AT 1
ST
VISIT EVEN IF ASYMPTOMATIC
Fibroid larger than 12-14 wks pregnancy
Rapidly growing fibroids
Subserous and pedunculated fibroids prone for torsion
If it is likely to complicate in future pregnancy
If there is a doubt about its nature
Unexplained infertility or repeated abortions
Uncertain diagnosis

GENERAL INDICATIONS FOR TREATMENT (INCLUDING SURGERY):
1. Infertility due to corneal fibroid, etc.
2. Symptomatic fibroid
3. Pressure symptoms present
4. Rapid growth (implies Ca)
5. When nature of tumour cant be assessed.
MEDICAL:
Indications for therapy
To treat anemia and recover Hb before surgery
To reduce size of large fibroid to facilitate surgery
Treatment of women approaching menopause to avoid surgery
In women with medical contraindications to surgery or those postponing surgery
77 Abhishek .V
For preserving fertility in women with large myoma before conservative surgery like
myomectomy.

For decreasing blood loss during surgery
Code: For Minor go to Gynec OPD
Anti Fibrinolytic, Mifepristone, Gn RH agonist, OCP, Progesterone & Danazol
For decreasing size of tumor
Code: Go 2 Gynec MD
Gn RH agonist, Gn RH antagonist, Mifepristone & danazol.

1. PROGESTERONES: Norethisterone acetate or MPA 5-10 mg (day 5-25) controls
menorrhagia.
2. ANTIPROGESTERONE Mifepristone (RU 486) 50mg/day 3 months causes amenorrhea
and shrinkage of fibroid and androgenic effect.
3. ANDROGENS: i. Danazol 400 mg/day for 4 months reduces size of tumour, reduces blood
loss; Side effects Hirsutism. Ii. Gestrinone antiestrogenic and anti progesterone 2.5- 5 mg
2-3 times /wk for 3-6 months lesser side effects than danazol.
4. Gn RH AGONISTS: most commonly used for 1. Preoperative 2. Definitive treatment for
small fibroids 3. When associated endometriosis 4. To reduce the size of cornual fibroid to
restore patency of fallopian tube. Triptorelin 3.75mg( Decapeptyl) Leuprolidine depot
3.75mg i/m monthly for 3mo Goserelin ( Zoladex) 3.6 mg sc monthly for 3 mo Nafarelin IM
causes sustained pituitary down regulation and suppression of ovarian function.
Advantages:
Decreases size of myoma by 20-80%
Decreases uterine volume
Decreases bleeding and amenorrhea
Possibility for autologous blood transfusion
Converts abdominal hysterectomy to vaginal hysterectomy or LAVH
Converts hysterectomy to myomectomy
Pfannenstiel incision possible instead of vertical incision

Disadvantages
High cost
Prolonged use hyp oestrogenic side effects osteoporosis
Rarely increased bleeding due to degeneration requiring emergency surgery.
Estrogen progesterone give back may be necessary newer drugs for add back
therapy tibolone and alendronate.

5. Gn RH ANTAGONISTS: Cetrorelix 60mg i/m repeated after 3-4wks suppresses pituitary
and ovaries directly.
78 Abhishek .V
6. ORAL CONTRACEPTIVE PILLS reduce size.
7. SERMs (Selective Estrogen Receptor Modulators)
8. SPRMs (Selective Progesterone Receptor Modulators)
9. PROGESTERONE IUCD Mirena used for 6-18 mo reduces size
10. AROMATASE INHIBITORS
SURGERY:
MYOMECTOMY, UTERINE ARTERY EMBOLIZATION, LAPROSCOPIC MYOLISIS,
GENE THERAPY (conservative) or HYSTERECTOMY (radical)
1. MYOMECTOMY it is the enucleation of the myoma(s) from the uterus leaving behind a
potentially functioning organ capable of future reproduction.
Indications:
a. Infertile patients
b. Patients who wish to preserve reproductive/menstrual function.
Contraindications broad ligament fibroid as many large vessels are in surrounding region.
Multiple small fibroids scattered throughout the uterus.
Pre-requisites:
a. Hb level to be restored.
b. Blood arranged for surgery.
c. Other causes of infertility ruled out in infertile patients.
d. Consent for hysterectomy under grave circumstances.
e. Diagnostic DSC to exclude endometrial Ca.
Measures to control blood loss during myomectomy:
a. Pre-operative treatment with Gn Rh analogues reduced vascularity as well as size.
b. Use of victor bonneys clamp to reduce uterine artery blood blow.
c. Use of vasoconstrictor agents (vasopressin on inversion line)
d. Hypotension.
Steps of operation (abdominal myomectomy):
a. Patient is anesthetized spinal, placed supine, part is painted and draped.
b. Incision single midline incision or Pfannenstiel incision.
c. Abdomen opened in layers and hemostasis achieved.
d. Uterus incision single midline incision on anterior wall of uterus and lateral fibroids
removed by tunneling to avoid scars.
e. Incision deepened through myometrium and pseudo capsule till myoma is reached.
f. Myoma is grasped and dissected in the plane between myoma and capsule.
g. Myoma is enucleated from its bed.
h. Myoma bed (clear space) is obliterate by
Interrupted mattress sutures or
79 Abhishek .V
Figure of 8 sutures or
Tire stitch
i. Bleeding controlled.
j. Precautions to prevent adhesions, newer adhesion barriers like intercede (oxidized
regenerated cellulose) and Gortex used.
k. Francis Hutchins used medical tourniquet i.e. 20 units Pitressin in 60 ml saline. 5-10 ml
injected bilaterally at cornual and isthmic area
l. Abdomen closed in layers.
Complications:
a. Immediate
i. Primary Hemorrhage
ii. Injury to bladder and ureter, fallopian tube.
b. Early post-op
i. Reactionary hemorrhage
ii. Secondary hemorrhage
iii. Paralytic ileus, infection.
c. Remote Adhesions, recurrence, scar rupture, etc.
Other types
a. Vaginal Myomectomy Submucous fibroid polyp.
b. Hysteroscopic myomectomy submucous myoma less than 4X4cm
c. Laparoscopic myomectomy pedunculated, subserous upto 10 cm diameter for cutting
and coagulation spoon electrode and bipolar electrode used with current 20 to 150
watt.
d. Bonneys Hood Operation In case of posterior upper segment or fundal fibroid,
transverse incision made posterior to tubal insertion and after enucleation, the
capsule sewn over the anterior wall.
e. Uterine artery embolization using polyvinyl alcohol.

Results of myomectomy
Pregnancy rate following myomectomy 40%
Abortion rate if women conceive 25%
Recurrence rate 5-10%
Persisting menorrhagia 1-5%
20-25% women after myomectomy require hysterectomy

2. HYSTERECTOMY It is an operative procedure to remove uterus either through an
abdominal or vaginal route.

Types (depending on extent of removal of uterus and adjoining structures)
80 Abhishek .V
a. Total hysterectomy removal of entire uterus including cervix.
b. Sub-total hysterectomy removal of body of uterus leaving behind the cervix.
c. Pan hysterectomy Total hysterectomy + B/L salphingo-oopherectomy.
d. Extended hysterectomy Pan hysterectomy + removal of upper cull of vagina
e. Radical hysterectomy Removal of uterus, tubes, ovaries on both sides + upper 1/3
rd
of
vagina + parametrium + draining Lymph nodes.
Wertheims
Meiges
f. Ultra radical hysterectomy radical hysterectomy + removal of bladder and or rectum.
Indication in India:
a. Genital prolapse
b. Fibroids
c. Adenomyosis
d. DUB
e. Ca cervix/endometrium
VAGINAL HYSTERECTOMY:
1. Mayo wards (with pelvic floor repair)
2. Haneys (no pelvic floor repair)

Advantages Disadvantages
1. No scar, no adhesions
2. Faster recovery, faster ambulation
3. Less pain, less bleeding
4. Less hospital stay, no stitch
removal
5. No incisional hernia
6. Lesser chances of bowel/bladder
injury
7. Lesser complications
1. Uterus size >14-16 weeks, cant
be done
2. Abdomen cant be explored
3. LNs cant be removed
4. B/L S-O is not possible







81 Abhishek .V
ABDOMINAL HYSTERECTOMY:
Indications:
Gynecological Obstetric
1. Genital prolapse
2. Fibroids, Tubo-ovarian mass
3. Adenomyosis & endometriosis
4. DUB
5. Neoplastic
a. Ca cervix
b. Ca endometrium
c. Ca ovary
d. Ca fallopian tube
e. Choriocarcinoma
6. Pyometra, PID, genital TB
7. Chronic inversion of uterus
8. Pelvic congestion syndrome
1. Uterine tear/rupture
2. Accidental hemorrhage
3. Placenta accrete
4. PPH (last resort)
5. Septic foci following MTP
6. Uterine inversion
7. Ectopic pregnancy
8. As a method of permanent
sterilization

Steps of Total Abdominal Hysterectomy:
1. Patient anesthetized spinal or GA, supine, parts painted and draped (Trendelenburg
position).
2. Pfannenstiel incision or infraumbilical paramedian or median incision.
3. Abdomen opened in layers
4. Uterus opened, Doyens retractor placed in position.
5. Traction to uterus given by vulsellum or long artery forceps on either side of uterine
cornu and uterus pulled to one side while clamps are placed in contralateral side
a. If ovaries to be retained paired clamps placed near cornu of uterus to include
FP, mesosalpinx and ovarian ligament.
b. If ovaries to be removed clamps placed in infundibulopelvic ligament.
And the cut in between clamps and replaced by Tran fixation sutures.
6. Paired clamps placed over round ligament, cut replaced by sutures (CC-1)
7. Similarly broad ligament and round ligament are clamped and cut off on either side.
8. Loose peritoneum of UV fold is cut and extended from one divided round ligament to the
other and bladder pushed down and cut.
9. Paired clamps placed on parametrium, containing ascending branch of uterine artery
close to the level of internal os. Tissues in between cut and replaced sutures.
10. Uterus pulled forwards to make uterosacral ligament prominent. Clamps placed over the
US ligament as close to the cervix, cut, and replaced by sutures.
11. Clamps placed close to cervix on Mackenrodts ligaments containing descending cervical
artery, cut and replaced by sutures. Similar steps on other side.
82 Abhishek .V
12. Vault of vagina opened of cervico-vaginal junction and the lateral vaginal angles closed by
Tran fixation sutures. Vault closed by continuous locking sutures.
13. Uterus removed out. Abdominal packs removed. Peritoneal toileting done.
14. Abdomen closed in layers.
Complications:
1. Immediate
a. Hemorrhage
b. Injury to bladder, ureter or bowel
c. Anesthetic hazards
2. Post-op
a. Shock
b. Urine retention, cystitis
c. Urinary incontinence
d. DVT & PE
3. Remote
a. Vault granulation
b. Vault prolapse
c. Incisional hernia
Red degeneration/carneous degeneration
Mostly during mid pregnancy
Aseptic condition
Presenting features acute abdominal pain vomiting malaise fever moderate leucocytosis and
raised ESR
Fibroid becomes soft necrotic homogenous. Stained salmon pink. Fishy odour due to
secondary infection by coliform organism. Thrombosis of vessels subacute necrosis of
myoma due to aseptic infarction.
Management conservatively, bed rest, analgesics, sedatives.
Myomectomy should never be done during cesarean section as vascularity of fibroid is
maximum during pregnancy



83 Abhishek .V
Submucous Intramural Subserous
Can cause abortions
Often associated with
heavy menstrual bleeding
menorrhagia and anemia
Inflammatory change
+ve
Malignant change ++
Metrorrhagia can occur
due to ulceration
Inversion in fundal sub
mucous fibroid.
Most common type
May cause 1
st
trimester
abortion abruptio placentae
obstructed labor preterm
labor.
Uterine inertia
Associated with menorrhagia
Malignant change most
common in intramural type
Do not cause abortions
Presents on surface of
uterus
Pressure effects on
rectum/ureter
Pedunculated and serous
usually does not cause
anemia but torsion can occur
Fibrous/calcific/hyaline
change
Pseudo Meigs syndrome

Embolotherapy
Uterine artery embolization done using polyvinyl alcohol or gel foam
Shrinks fibroid by 40-50%
Results lowered fertility rate, risk of placental insufficiency, uterine rupture in subsequent
pregnancy because of interference of blood supply and necrosis of leiomyoma.
Post op complications pain fever pulmonary embolization complete amenorrhea.
Most common type of fibroid
To start all fibroids are
Most common fibroid for
malignant change
Most common fibroid causing
urine retention
Torsion is most common in
Fibroid causing pseudo Meigs
syndrome
Most common symptom of fibroid
Intramural
Intramural
Intramural

Anterior cervical and central fibroid

Pedunculated or subserous fibroid
Subserous fibroid

Menorrhagia
Fundal fibroid
84 Abhishek .V
Inversion is seen in
Most common symptom of fundal
fibroid
Fibroid with maximum symptoms
Wandering or parasitic fibroid
Lantern dome of St Paul
Most common fibroid to undergo
calcerous degeneration
Pseudo cervical polyp
Menorrhagia


Submucosal
Subserous
Cervical fibroid
Subserous

Fibroid polyp


















85 Abhishek .V
CASE OF DYSFUNCTIONAL UTERINE BLEEDING
NAME Sameedha HUSBANDS NAME Javed Sharieff
AGE 33 years AGE 35 years
ADDRESS Magadi Road OCCUPATION Factory worker
OCCUPATION Worker in beedi factory INCOME Rs. 425/month/person
RELIGION Muslim SE STATUS Upper Lower class
DATE OF ADMISSION 14/06/07 DATE OF EXAMINATION 26/06/07
PRESENTING COMPLAINT Prolonged & excessive bleeding per vagina during menses since 6
months
HISTORY OF PRESENTING COMPLAINTS:
Patient was apparently normal 1 month back when she developed prolonged and excessive
bleeding lasting about 15 days. The bleeding was excessive compared to her previous cycles,
previously used to change 1-2 pads/day but this time 4-5pads/day. Patient noticed passage
of clots for the 1
st
8 days.
No history of pain during bleeding (anovulatory cycles, endometriosis)
No history of missed periods prior to this episode. (metropathia hemorrhagica)
No history of white discharge PV, pain, fever or pain during coitus. (PID)
Patient does not complain of any mass per abdomen. (Fibroid Uterus)
No history suggestive of TB.
No history of use of IUCD or OCP.
No history suggestive of any bleeding disorders.
Patient underwent laparoscopic tubectomy 8 years back. (post ligation syndrome)
No history of fatigue, breathlessness or giddiness. (anemia)
No history of intake of any drugs other than eltoxin. (secondary to drugs)
MENSTRUAL HISTORY:
Age of Menarche 11 years
Past Cycles Regular 30 days cycles with 5 days flow, no pain or passage of clots.
LMP 24/05/06
OBSTETRIC HISTORY:
Married Life 15 years
Obstetric index P
4
L
4

1
st
child 14 years male FTND, booked & immunized
2
nd
child 13 years male FTND, booked & immunized
3
rd
child 10 years female FTND, booked & immunized
86 Abhishek .V
4
th
child 10 years male FTND, booked & immunized
Underwent laparoscopic tubectomy 8 years back.
No OCP intake.
No history of abortions
Last delivery 8 years back.
FAMILY HISTORY:
No history of bleeding disorders among other family members.
No history of exposure to TB.
No history of cervical Ca among mother or sister.
PAST HISTORTY:
No history of Tuberculosis, Epilepsy, Asthma.
No history suggestive of any cardiac ailments.
Patient underwent thyroidectomy 6 years back for complaint of enlarged thyroid.
PERSONAL HISTORY:
Diet Mixed
Appetite Good
Sleep Sound
Bowel & Bladder Regular
Habits Nil
GENERAL PHYSICAL EXAMINATION:
Patient is 33 years old lady, moderately built and nourished, conscious, alert & cooperative, sitting
comfortably on bed.
Pulse 90/min, regular, good volume
BP 130/100 mm of Hg
RR 16/min, regular
Temperature Afebrile
Pallor Present
Icterus Absent
Cyanosis Absent
Clubbing Absent
Clubbing Absent
Edema Absent
Lymphadenopathy Absent
87 Abhishek .V
Thyroid Scar over thyroid region present, no palpable gland
Breasts Normal
Spine Normal
SYSTEMIC EXAMINATION:
CVS S
1
S
2
heard, No murmurs.
RS NVBS heard no basal crepitation.
CNS NAD.
PER ABDOMINAL EXAMINATION
INSPECTION:
Shape of abdomen normal
Umbilicus appears normal
Corresponding quadrants move equally with respiration.
No visible mass, dilated veins, scars or sinuses.
Stretch marks present.
No visible pulsations or peristalsis.
Hernia orifices normal
PALPATION:
No local rise of temperature, no tenderness.
No organomegaly.
No palpable mass P/A.
PERCUSSION:
Tympanic note elsewhere.
No evidence of free fluid in the abdomen.
AUSCULTATION:
Bowel sounds heard.
[I would like to do per speculum, per vaginal and bimanual examination to confirm my diagnosis)
PROVISIONAL DIAGNOSIS:
Premenopausal dysfunctional uterine bleeding.


88 Abhishek .V
DISCUSSION
DEFINITION A state of abnormal uterine bleeding without any clinically detectable organic
pelvic pathology.
It is a diagnosis of exclusion, i.e. abnormal uterine bleeding which is not attributable to any of the
following known causes:
1. Pregnancy related complications abortion, ectopic pregnancy.
2. Tumours of uterus
a. Benign Cervical polyp, endometrial polyp, fibroids
b. Malignant ca cervix, Ca endometrium, Ca fallopian tube.
c. Others endometriosis, adenomyosis.
3. Infections PID, cervicitis, endometritis
4. Intrauterine foreign body IUD
5. Systemic diseases
a. Hepatic reduced coagulation factors, reduced metabolism of sex steroids.
b. Renal reduced excretion of estrogens.
6. Blood disorders
a. Platelet disorders ITP, TTP.
b. Clotting factor disorders, leukemias, ets.
7. Iatrogenic exogenous hormones, anticoagulants.
8. Endocrinal disorders Thyroid disorders, adrenal disorders.
CLASSIFICATION OF DUB:
ANOVULATORY (80%) OVULATORY (20%)
1. Threshold bleeding of puberty
2. Metropathia hemorrhagica
3. Premenopausal DUB
1. Irregular ripening
2. Irregular shedding
3. IUCD insertion
4. Following sterilization operation

PATHOLOGY:
1. ANOVULATORY BLEEDING:
Unopposed estrogen and lack of progesterone
Excess endometrial growth highly vascular and fragile
When estrogen withdrawal occurs, there is threshold bleeding with asynchronous
endometrial shedding.
Due to lack of progesterone reduced ratio of PGF
2
:PGE
2
heavy bleeding
2. OVULATORY BLEEDING:
a. Irregular endometrial ripening
89 Abhishek .V
Inadequate corpus luteum function inadequate progesterone secretion
C/F Premenstrual spotting/brownish discharge
b. Irregular endometrial shedding (Halbans disease)
Persistent corpus luteal function irregular desquamation of endometrium
Persistent LH secretion continued progesterone secretion No FSH
inadequate estrogen secretion Failure of endometrial regeneration
c. Metropathia hemorrhagica excessive menses for long intervals associated with
anovulatory cycles and cystic endometrial hyperplasia
Type I 8-10 weeks amenorrhea continued bleeding for weeks
Type II Previous cycles normal continued bleeding at next cycle
Type II Previous menorrhagia continued bleeding
Important features
i. Parity not related to incidence
j. Age 40-45 years
k. Bleeding not severe but prolonged
l. Painless bleeding
m. Thickening of endometrium + cystic ovary + myohyperplasia of myometrium
Differential Diagnosis Ectopic Pregnancy, Abortion.
PATTERNS OF ABNORMAL UTERINE BLEEDING: Normal menstrual cycle 21-35d with 2-6 d of
flow and average blood loss 20-60 mean loss 35ml mean duration of menses 4.7d
Oligomenorrhea Uterine bleeding occurring at intervals > 35 days
Polymenorrhea Uterine bleeding occurring at interval < 21 days
Amenorrhea No bleeding for > 6 months
Menorrhagia Prolonged or excessive uterine bleeding at regular intervals
Metrorrhagia Uterine bleeding at irregular intervals superimposed on normal cyclical
bleeding
Menometrorrhagia Prolonged or excessive uterine bleeding occurring at intervals.
Hypomenorrhea Decreased uterine bleeding at regular intervals
Hypermenorrhea Increased uterine bleeding at regular intervals
Intermenstrual bleeding (spotting) Uterine bleeding of variable amounts occurring
between regular menstrual periods
Menorrhea (normal menstruation) Regular cyclic uterine blood flow lasting 2-5 days with an
interval of 21-35 days and blood loss of 30-60 ml.



90 Abhishek .V
INVESTIGATIONS:
PUBERTAL AGE GROUP
Hb%, CBC, TC, DC, Platelets.
Coagulation profile CT, BT, PT, APTT
Pregnancy test
Thyroid function test
Abdominal USG (specific) to rule out tumour, uterine anomalies, polyps, etc.
Chest X ray & sputum for TB
CXR cardiomegaly & ECG
Last resort Diagnostic D&C
REPRODUCTIVE AGE GROUP
Hb%, CBC, TC, DC, Platelets.
Pregnancy test
Thyroid profile
USG abdomen, TVS, TPS
Diagnostic D&C (in premenstrual period) to differentiate clot and endometrium, put
it on a gauge. If it dissolves clot, does not dissolve endometrium.
[Curative D&C diseased endometrium gets curetted and the spiral arteries which
are sources of bleeding are curetted, ends undergo vasospasm stops bleeding]
Hysteroscopy (if available)
Colpohysteromicroscopy (comes in contact with endometrium)
Endometrial sampling has to be done in females
At risk of endometrial polyps
At risk of endometrial hyperplasia or carcinoma
With anovulatory bleeding and 35-40 yrs age
With anovulatory bleeding and obesity no age constraint
H/O prolonged anovulation

PERIMENOPAUSAL AGE GROUP
Hb%, BT, CT
Urine for sugar, albumin, microscopy
Pap smear
USG
D&C
Hysteroscopy
LFT, RFT, TSH
Hysteroscopic biopsy
OTHER SPECIAL METHODS
91 Abhishek .V
HSSG Hystero Saline Sonography done when polyp cant be made out. Here saline
is injected into uterine cavity after passing Foleys catheter and then USG done.
CAUSES OF MENORRHAGIA:
1. PREPUBERTAL AGE GROUP Foreign bodies, Action of maternal hormones in infants
2. PUBERTAL AGE GROUPS Anovulatory cycles due to incomplete development of HPO axis
3. REPRODUCTIVE AGE GROUP
a. Local Inflammations, genital TB, Polyps (cervical), Gonorrhea and other STDs
chlamydia can cause irregular bleeding and post coital bleeding
b. Uterine Fibroids, adenomyosis, Polyps (endometrial), IUCD
c. Adnexal Salpingo-oophoritis, PID, Gonorrhea, PCOD, Chocolate cyst, Endometriosis,
Ovarian cyst/cystic ovary
d. Endocrine: HPO Axis disturbance , hypothyroidism, hyper prolactin emia, premature
ovarian failure.
e. Neoplastic : endometrial hyperplasia, cervical neoplasia vaginal neoplasia.
4. PERIMENOPAUSAL AGE GROUP
5. MENOPAUSAL AGE GROUP
6. POST MENOPAUSAL BLEEDING
a. Exogenous estrogen HRT 30%
b. Atrophic endometritis/ vaginitis 30%
c. Endometrial/ cervical polyp 10%
d. Endometrial hyperplasia 5%
e. Endometrial cancer 15%
f. Cervical cancer
g. Ovarian cancer
h. Urethral caruncle

Post menopausal HRT
26% increase in breast cancer
29% increase in CHD
41%increase in stroke
33% decrease in hip fracture
37% decrease in colon cancer
Raloxifene SERM decreases osteoporosis no effect in fact has side effect of hot flushes.
Tibolone decreases hot flushes.
Isoflavones present in soya contains phytoestrogen, genistein, diadzein it reduces symptoms
of menopause when given in doses of 45-60mg/day without the typical side effects of
HRT
Causes of acyclic bleeding
DUB usually during adolescence following
92 Abhishek .V
child birth preceding menopause
Submucosal fibroid
Uterine polyp
Carcinoma cervix and endometrial
carcinoma
Causes of contact bleeding
Carcinoma cervix
Mucosal polyp of cervix
Vascular ectopy or cervix during
pregnancy or pill users
Causes of intermenstrual bleeding
Urethral caruncle
Ovular bleeding
Breakthrough bleeding in pill users
IUCD in utero
Decubitus ulcer

Endometrial pattern in DUB
Normal secretory endometrium 60 %
Hyperplastic endometrium 30%
Irregular ripening irregular shedding atrophic pattern 10%
ASSESSMENT OF AMOUNT OF BLEEDING:
PBAC Scoring System (Pictorial blood loss assessment chart)
PADS (per day) CLOTS
Type Scoring Type Scoring
Lightly soiled
(spotting)
Moderate soiled (half
pad)
Saturated with blood
(full
1 pt
5 pts
20 pts
Small (1p coin)
Large (50p
coin)
1 pt
5 pts


DIFFERENTIAL DIAGNOSIS:
93 Abhishek .V
1. Chronic PID
2. Tubo-ovarian mass
3. Fibroid
4. Ovarian mass
5. Endometrial polyps
6. Hormone secreting tumour of ovary
RULE OUT:
1. Adenomyosis
2. Adrenal tumours (HTN + mass P/A)
3. Thyroid disorders
4. Ca cervix

ROLE OF D&C:
Only controls the present episode of bleeding
Does not remove the etiology (since basal layer is untouched)
A experienced gynecologist can remove up to 60% of endometrium
Do not administer hormones prior to D&C to avoid misinterpretation of Histopathological
report.


ITP and Von-Willebrands disease present late in life.
Granulosa cell tumour can present as
Puberty menorrhagia (1
st
and 2
nd
decade)
Post-menopausal bleeding
Post-menopausal bleeding also called as flash on pan due to heavy bleeding suddenly after
menopause has attained.
Importance of BREAST EXAMINATION in case of DUB:
Any pathology secondary to the effect of estrogen (estrogen excess causing DUB)
Hyperprolactinemia + menorrhagia in hypothyroidism
Thickness of endometrium double layer thickness is taken in sagittal view
Proliferative phase 4-6mm
Ovulatory phase 6-10 mm
Secretory phase 10-12 mm
Post-menses phase 1-2mm
In case Genital TB is suspected, then,
Send the sample for MPR in normal saline and not formalin
AFB staining & C&S to be done
94 Abhishek .V
Animal inoculation
PCR (latest)
Ask pathologist to prepare medium for growth
LJ medium
Dorsets egg medium
Bactec media
What type of progesterone to use for each purpose
Hemostasis norethisterone acetate
Regularize the cycle with control of HPO axis MPA
Contraception Levonorgestrel IUCD
Mirena Levonorgestrel intrauterine system (ideal for peri-menopausal women)
DUB is usually painless, if there is pain, think of
Spasmodic dysmenorrheal
Congestive dysmenorrheal
Dyspareunia
PID
Bleeding from estrogen withdrawal more profuse than bleeding from progesterone
withdrawal
Absence of progesterone causes low level of PGF
2

Absence of progesterone hence no interstitial edema of endometrium, its
proliferation, more rigid and bleeds profusely.
Action of Prostaglandin
PROSTAGLANDIN MYOMETRIUM VESSELS
PGE
2
Contraction Vasodilatation
PGF
2
Contraction Vasoconstriction
PGI
2
Relaxation Vasoconstriction
Anemia can be a cause as well as effect of DUB
Due to lack of clotting factors and serum proteins
Effect of anemia on endocrine organs

MEDICAL LINE OF MANAGEENT OF DUB:
1. Medroxyprogesterone acetate (MPA) 5
th
-21
st
day or 11
th
-25
th
day for 3-6 cycles [10 mg
TID] only to control bleeding
2. Norethisterone
3. Clomiphene citrate 150 mg OD 5
th
-9
th
day to induce ovulation if she wants to conceive
4. Combined OCPs for conception
5. Gn RH analogues 3-6 mg (1 injection every month) precocious puberty
6. Antifibrinolytic Tranexamic acid
95 Abhishek .V
7. NSAIDS Ibuprofen, Mephenesin acid 500 mg TID
8. Ethamsylate
9. Danazol 200-400 mg (SE Hirsutism, weight gain, anemia)
10. Duphaston dehydro androstenedione
METHOD OF CHOICE IN TREATMENT OF DUB:
AGE D&C +
HYSTEROSCOPY
MEDICAL LINE SURGICAL
(HYSTERECTOMY/ABLATION)
Adolescent age
group
Only for refractory
cases
1
st
choice always Never
Reproductive age
group
1
st
choice always Always (as per HP
report)
Rarely
Per-menopausal age
group
Mandatory For a short time
(palliative phase)
1
st
choice always

MEDICAL MANAGEMENT OF DUB
A. GENERAL
a. Rest
b. Reassurance
c. Anemia correction
B. HORMONAL
ESTROGEN conjugate Equine estrogen
PROGESTERONE
1. MPA
2. Norethisterone
COMBINED - Ethinyl estradiol 0.25 mg + Progesterone 10 mg
ANDROGENS
1. Danazol
2. Gn RH analogues
C. NON-HORMONAL
NSAIDS Mefenamic acid 500 mg TID
Antifibrinolytic Tranexamic acid
Ethamsylate
Clomiphene citrate 150 mg OD 5
th
-9
th
day








96 Abhishek .V
Mild bleeding Moderate bleeding Acute severe bleeding
Hematinic
Reassurance
Hormone therapy low
dose OCPs or cyclic
MPA 5-10mg/d for
10-13 d
Combined monophasic OCP
every 6hrs for 4-7d and
then stop withdrawal
bleeding low dose OCP for
3-6 cycles
Admit patient
Stabilize vitals
Conjugate estrogen
25-40mg iv every
6hrs
Once bleeding stops
MPA 10mg for 10d
If above regimen not
effective assess the
patient for any local
cause USG done to
rule out fibroid
endometrial
hyperplasia or clots if
clots detected D&C



Management of polymenorrhea/DUB
In young women of reproductive age group not desiring pregnancy
Polymenorrhea DUB
Cyclic combined OCP from day 5 to day 25
for 3 cycles
Cyclic progesterone DMPA or
norethisterone from day 5 to day 25 for 3
cycles
In women desiring pregnancy
Polymenorrhea DUB
Dydrogesterone from 15
th
to 25
th
day of
cycle
Clomiphene citrate

CLASSIFICATION OF ENDOMETRIAL HYPERPLASIA: (% - ending in Ca)
1. Simple
a. Without atypia 1%
b. With atypia 7-9%
2. Complex
a. Without atypia 3%
b. With atypia 27-29%
SURGERIES FOR DUB:
1. Hysterectomy
2. Endometrial ablation (TCRE Transcervical Resection of Endometrium0
3. B/L oophorectomy surgical or radiotherapy
4. Uterine artery embolism
97 Abhishek .V
ASSOCIATION BETWEEN DUB & THYROID DISORDERS:
1. HYPERTHYROIDISM
Excess T
3
/T
4
has a suppressive effect on pituitary thyrotrope and due to molecular
mimicry there can be suppression of gonadotroph altered FSH & LH levels.
Excess T
3
/T
4
binding to albumin competes with estrogen binding increased free
estrogen levels DUB
2. HYPOTHYROIDISM
Antigenic mimicry between TSH & FSH
Increased deposition of hyaline material in myometrium interferes with contraction excess
bleeding.


PRIMARY AMENORRHEA
Primary amenorrhea is condition when a female has not attained menarche by ae of 14 in the
absence of growth or development of secondary sexual characteristics.
Or
No menarche by age of 16 regardless of the presence of normal growth and development of
secondary sexual characters.
Requirements for a female to menstruate normally
Intact outflow tract which connects uterus to outside and a normally developed uterus
Proper quantity and sequence of steroid hormones from ovary
Maturation of follicular apparatus guided by gonadotrophins FSH and LH
Secretion of these hormones in turn dependent on Gn Rh from hypothalamus
Primary amenorrhea
Compartment I
Disorder of outflow tract/uterus

Mllerian anomalies- Mayer Rokitansky
Kuster Hauser syndrome (2
nd
most common
cause for primary amenorrhea) androgen
insensitivity( testicular feminization)
Compartment II
Disorders of ovary
Gonadal dysgenesis ( MC cause for primary
amenorrhea) ,turner syndrome 45XO, pure
gonadal dysgenesis 46XX, Swyers syndrome
46XY, savage syndrome resistant ovary
98 Abhishek .V
syndrome.
Compartment III
Disorders of anterior pituitary
Neoplasia, craniopharyngioma/prolactinoma
hypopitutary states Simmonds disease
Chiari Frommel syndrome Forbes Albright
syndrome.
Compartment IV
Disorders of CNS
Kallmann syndrome adrenal hypoplasia
Prader Willi syndrome, Frhlichs syndrome
septo optic dysplasia, Laurence moon Biedl
syndrome.

Mllerian agenesis is associated with skeletal and renal abnormalities in 30% cases Rx Frank
technique or reconstruction of vagina by Mc Indoe operation or Willams vaginoplasty.
Sheehans syndrome
It is a syndrome which results from ischemic necrosis of anterior pituitary due to spasm in
arterioles occurring at time of sever hemorrhage or shock complicating childbirth.
When 75% anterior pituitary destroyed Sheehans if 95% destroyed Simmonds syndrome.
Hormones affected in order of frequency GH, FSH, LH, TSH & ACTH
Symptoms: failure to lactation after delivery, secondary amenorrhea, loss of libido and sensitivity
to cold.
Signs: absence of axillary sweating , loss of axillary and pubic hair, anemia, decreased skin
pigmentation, weakness lethargy, hypothermia, hypoglycemia decreased insulin tolerance,
hypothyroidism, all genital organs show atrophy uterus smaller than post menopausal women, ovary
retain their ova till menopause.
Lab investigations: decrease in FSH, LH, TSH, ACTH, oestrogen urinary 17 keto steroids.

Amenorrhea + galactorrhea +raised prolactin
Pituitary adenoma/ prolactinoma
Microadenoma <1 cm dia, F:M 20:1, 5% progress to macroadenoma, 30 % spontaneous regression
Macroadenoma >1 cm dia F:M 1:1 prolactin level >100ug/ml
99 Abhishek .V
Presentation women: galactorrhea, amenorrhea, infertility Men; impotence loss of libido infertility.

Kallmann syndrome
Defective hypothalamic Gn Rh secretion + anosmia due to olfactory bulb agenesis also may be
associated with optic atrophy nerve deafness renal anomalies color blindness cleft palate
cryptorchism
Presentation males delayed puberty micropenis anosmia females primary amenorrhea failure of
secondary sexual characters anosmia
Premature menopause incidence 1% population causes ovarian dysgenesis 30% Chromosomal
abnormalities 10-20% autoimmune 30-60% other Tb radiation Chemo ovarian failure after
hysterectomy. FSH >40mIU/ml and estrogen <20pg/ml
Cls of endometrial hyperplasia
Type Progression to cancer%
Simple (cystic without atypia)
Complex ( adenomatous without atypia)
Atypia
Simple ( cystic)
Complex( adenomatous)
1
3

8
29

Progressive secondary amenorrhea is feature of psychosomatic disorder
Metrorrhagia associated with DUB, submucosal fibroid, uterine polyp, endometrial Ca, Ca
cervix
Pain of endometriosis not related to depth of invasion according to Novak 22 e
Post tubal surgery for tubal diseases success rate 3-5% monthly fecundability whereas IVF
15-20%
Anti semen antibodies are IgM, IgG, IgA.. IgG found in cervical mucous and semen IgA
cervical mucous and seminal plasma IgM exclusively in serum.
Miller Kuzrok test sperm penetration in cervical mucus <3cm in 30min abnormal.
100 Abhishek .V
Sperm bank liq N2, I2 propanediol, glycerol ,dimethyl sulphoxide with sucrose used for
sperm preservation.
Insler scoring system for cervical mucous properties considered spinnbarkeit, ferning,
viscosity, cellularity max score 15 <10 abnormal.






















101 Abhishek .V

CASE OF UTERINE PROLAPSE
NAME Shivamma HUSBANDS NAME Rajanna
AGE 65 years AGE 70 years
ADDRESS Aravahalli OCCUPATION Coolie
OCCUPATION Coolie INCOME Rs. 1000/person/mth
MARITAL STATUS - Married SE STATUS Upper Lower class
PRESENTING COMPLAINT Mass per vagina since 6 months.
HISTORY OF PRESENTING COMPLAINT:
Patient was apparently normal 6 months back when she initially noticed a mass protruding
from the vagina while voiding urine, insidious in onset, initially the size of a lemon which has
gradually progressed to attain the present size. The mass used to come out on straining and
coughing and reduces on lying down.
Patient gives history of lifting heavy weights.
No history of backache.
No history of any discharge (white discharge, foul smelling, blood stained) per vagina or
bleeding per vagina.
No history of increased frequency, retention or difficulty in passing urine.
No history of burning micturition or itching over the genital region.
No history of ulceration over the mass or bleeding.
No history of chronic constipation or cough.
No history of abdominal distention or mass per abdomen.
MENSTRUAL HISTORY:
Age of Menarche 15 years
Past Cycles Regular, 30 days cycle, flow lasting 4-5 days, normal amount, no history of pain during
menses or passing clots or inter-menstrual bleeding.
Attained menopause 14 years back.
OBSTETRIC HISTORY:
Married Life 35 years
Obstetric index P
2
L
2

1
st
child Male, FTD, booked and immunized, home delivery, conducted by an untrained dai.
2
nd
child Female, FTND, booked and immunized, hospital delivery.
Patient conceived 5 years after marriage and the 2
nd
child was 2 years after the 1
st
pregnancy. No
102 Abhishek .V
history of prolonged delivery, difficulty in removing placenta or big baby. Underwent tubectomy
(BAT) after the 2
nd
child, no history of contraceptive usage. Last delivery 28 years back.
PAST HISTORTY:
No history of Tuberculosis, Epilepsy, Asthma.
No history suggestive of any cardiac ailments.
No history of previous surgeries, blood transfusions.
FAMILY HISTORY:
No history of similar complaints among mother or sister. (especially in cases of nulliparous
prolapsed)
PERSONAL HISTORY:
Diet Mixed
Appetite Good
Sleep Sound
Bowel & Bladder Regular
Habits Nil
GENERAL PHYSICAL EXAMINATION:
Patient is an elderly lady, moderately built and nourished, conscious, alert & cooperative.
Pulse 72/min, regular, good volume
BP 110/70 mm of Hg
RR 18/min, regular
Temperature Afebrile
Pallor Present
Icterus Absent
Cyanosis Absent
Clubbing Absent
Clubbing Absent
Edema Absent
Lymphadenopathy Absent
Thyroid Normal
Breasts Normal
Spine Normal
Gait Normal
103 Abhishek .V
Height 155 cm
Weight 55 kg
BMI 23
SYSTEMIC EXAMINATION:
CVS S
1
S
2
heard, No murmurs.
RS NVBS heard no basal crepitation.
CNS NAD.

PER ABDOMEN EXAMINATION
INSPECTION
- Shape of abdomen normal.
- Umbilicus normal.
- Corresponding quadrants move equally with respiration.
- No scars or sinuses.
- Hernia orifices normal.
PALPATION No mass felt per abdomen, no organomegaly.
PERCUSSION No signs of free fluid in the abdomen.
AUSCULTATION Bowel sounds heard.
[I would like to do a PS/PV examination to complete the examination]
DIFFERENTIAL DIAGNOSIS:
1. Prolapsed of the Uterus. (in this case the only diagnosis)
2. Cervical polyp/Fibroid polyp. (ruled out)
3. Bartholins cyst or any other cyst. (ruled out)
4. Ca cervix. (ruled out)
5. Inversion of uterus. (ruled out)
6. Congenital elongation of cervix. (ruled out)






104 Abhishek .V


DISCUSSION
DEFINITION
It is a condition of descent of uterus and vagina from their normal anatomical position either
partially or completely.
CLASSIFICATION
1. Vaginal Prolapse
a. Anterior vaginal wall
i. Upper 2/3
rd
Cystocele.
ii. Lower 1/3
rd
Urethrocele.
b. Posterior vaginal wall
i. Upper 1/3
rd
Enterocele.
ii. Middle 1/3
rd
Rectocele.
iii. Lower 1/3
rd
Lax perineum.
2. Uterine prolapse Shaws classification(OLD)
a. 1 - descent of cervix into the vagina
b. 2 - descent of cervix upto the introitus
c. 3 - decent of cervix outside the introitus
d. Procidentia entire uterus outside the introitus.

Latest classification
Uterine prolapse Vaginal prolapse
1 descent of uterus but cervix remains
within the introitus
2 descent to extent that the cervix
projects through the vulva when woman
is standing or straining
3 complete procidentia
Anterior
compartment
Cystocele
Urethrocele
Middle
compartment
Enterocele
and massive
eversion
Posterior
compartment
Rectocele and
perineal body
defect


ETIOLOGY
1. Postmenopausal atrophy
a. Withdrawal of estrogen decreased blood supply.
105 Abhishek .V
b. Atrophy and atonicity of the genital supports.
2. Birth trauma
a. Repeated delivery at short intervals.
b. Delivery of big baby.
c. Prolonged bearing down in the 2
nd
stage.
d. Ventouse extraction of fetus before full dilatation of cervix.
e. Credes method to deliver placenta.
f. Premature bearing down before full dilatation of cervix.
g. Episiotomy not given timely.
(All these cause overstretching of pelvic floor muscles atonicity)
h. Pudendal nerve injury during childbirth.
3. Genetic Congenital weakness of pelvic floor muscles.
4. In nulliparous women
a. Spina bifida occulta.
b. Split pelvis.
5. Precipitating factors
Increased intra abdominal pressure chronic cough, chronic constipation,
hard work, lifting heavy weights, obesity, ascites, tumors.
Increased weight of uterus: myohyperplasia fibroids adenomyosis,
subinvolution
Pull from below: myomatous polyp primary cystocele.
6. Surgery
a. Abdominoperineal excision of rectum.
b. Radical vulvectomy.
SYMPTOMS
1. Postural patient complains on something coming down or out per vagina more on standing,
straining on coughing and reduces on lying down.
2. Urinary
a. Imperfect control of micturition lack of support to the sphincter muscles of
urethra)
b. Stress incontinence disappears or it may be a symptom.
c. Frequent micturition due to chronic cystitis or incomplete emptying of bladder.
d. Difficulty in micturition patient may have to push back the cystocele vaginally to
complete evacuation.
3. Rectal difficulty in defecation and constipation (rare).
4. Discharge PV due to chronic inflammation or bleeding of decubitus ulcer.
5. Backache vague mid sacral backache, towards end of the day without local tenderness
(different from orthopedic case).
6. Infertility.
106 Abhishek .V

EXAMINATION
INSPECTION Look for perineal tears.
PALPATION (P/V) Determine tone of muscle and dimension of hiatus urogenitalis. Also look
for stress incontinence.
P/S
Degree of prolapse on straining on coughing or with traction
Vaginal wall prolapse whether cystocele rectocele urethrocele or enterocoele in
uterovaginal the part whose supports are more defective appears first on straining.
Cervix: hypertrophy, cervicitis, decubitus ulcer, supravaginal elongation( supra vaginal
cervix is directly supported by ligaments while portio vaginalis is free in vagina. With
gravity force cervix or vagina descends resistance is offered by supravaginal cervix so it
is elongated.
Vaginal walls- secondary changes there is loss of rugosity it is dry (exposure to air)
edematous keratinized( white) thickened due to chronic irritation pigmentation and
decubitus ulcer may be present due to vascular stasis.
Uterocervical length is increased.
DIFFERENTIAL DIAGNOSIS:
1. UTERINE PROLAPSE
a. Congenital elongation of cervix
i. Fornices are deep.
ii. No accompanying cystocele or rectocele.
iii. Minimal descent on impulse.
iv. P/V examination shows normal position of uterus.
b. Inversion of uterus
i. Endometrial surface exposed.
ii. No dimple of external os.
iii. P/V examination fundus not felt.
iv. Uterine sounding test.
c. Cervical fibroid polyp
i. Non-reducible.
ii. No cough impulse.
d. Ca Cervix
107 Abhishek .V
i. Non-reducible.
ii. Bleeding PV.
e. Congenital elongation of cervix deep fornix which is not reducible.
2. ANTERIOR VAGINAL WALL PROLAPSE
a. Anterior vaginal wall cyst (Gartners cyst)
i. Anterolateral.
ii. Well defined.
iii. Non-reducible.
iv. Smooth surface.
v. Doesnt increase on straining.
vi. USG test.
b. Vulval cyst or tumour.
c. Urethral diverticulum
i. Painful
ii. Pus comes out on compression.
d. POSTERIOR VAGINAL WALL PROLAPSE
i. Any mass or collection in pouch of Douglas.
INVESTIGATIONS:
1. Blood sugar, urea, creatinine.
2. Urine examination and culture.
3. X-ray.
4. ECG.
5. Pap smear.
6. USG (if any pathology found then do IVP).
MANAGEMENT
1. PROPHYLAXIS
a. ANTENATAL Good nutrition, antenatal physiotherapy and exercise.
b. INTRAPARTUM
i. Avoid premature bearing down.
ii. Avoid premature application of forceps.
iii. Give liberal episiotomy when required.
iv. Suture all tears carefully.
v. Avoid prolonged 2
nd
stage.
c. POSTPARTUM
i. Postnatal physiotherapy perineal exercises.
ii. Early ambulation.
iii. Adequate gap between deliveries.
108 Abhishek .V



d. general
limit family size to 1 or 2 children
treat chronic cough constipation
HRT treatment after menopause.
2. NON OPERATIVE TREATMENT
a. PELVIC FLOOR EXERCISE (KEJELS EXERCISE) Voluntarily contracting perineal
muscles as if to step the act of defecation (15-20 times, each lasting about 5
seconds, 3 times a day for 3-6 months).
b. PESSARY Palliative treatment, commonly used is Ring Pessary (latex) which is
available in 3 sizes small, medium and large.
i. Indications
During early pregnancy (T
1
).
During postpartum period (up to 6 months).
Patient not willing for surgery.
Patient not fit for surgery.
ii. Contraindications Infection, complete prolapse, stress incontinence.
iii. Complications Infection, discharge, ulceration, dyspareunia.
[Pessary must be removed, cleaned and re-inserted every 3 months).
3. SURGICAL TREATMENT Surgery is the definitive treatment for prolapse.



FUNCTION TO BE PRESERVED
CHILD
BEARING
MENTRUAL SEXUAL
OPERATION OF CHOICE
Abdominal Sling operation
Fothergills operation
Abdominal Sling operation with Tubal
ligation
Vaginal hysterectomy with PFR
Vaginal hysterectomy with Le-Forts
repair

a. Prolapse of Vagina
i. Cystocele & Urethrocele Anterior colporrhaphy.
ii. Rectocele Posterior colporrhaphy.
iii. Enterocele Culdoplasty, Moschcowitz operation.
b. Vault prolapse
109 Abhishek .V
i. Colposacropexy.
ii. Sacrospinous fixation.
iii. Le-Forts operation.
iv. Shaws operation.

1. ANTERIOR COLPORRHAPHY:
Anterior vaginal wall is cut open by inverted T-incision with transverse incision in
the bladder sulcus and through its mid-point or vertical incision up to urethral
opening.
Flaps are separated and line of cleavage i.e. vesico-vaginal space.
Vesico-cervical ligament is divided and bladder is pushed up with gauze.
Vesico-vaginal fascia is tightened (using delayed absorbable sutures); excess
vagina (redundant vagina) was excised and vaginal wall suture.
(To correct stress incontinence Kellys suture to plicate bladder neck)
Some stuff about genuine stress incontinence
Defined as involuntary loss of urine when intravesical pressure exceeds the maximum urethral
pressure in absence of detrusor activity
Pathogenesis: normal women the bladder neck and proximal urethra are intra abdominal structures
and lie above the pelvic floor in standing position and urethral pressure is more than vesical
pressure.
Any factor which leads to distortion of normal urethro vesical anatomy or decreased urethral
pressure leads to GSI like developmental weakness child birth trauma, pregnancy( due to
progesterone which is a relaxant menopause trauma obesity following surgeries like anterior
colporrhaphy repair of VVF lead to fibrosis of urethra.
Management : conservative pelvic floor exercises
Drugs alpha adrenergic increase tone of urethra and bladder neck imipramine & ephedrine
Surgery
Vaginal operations Abdominal operation Combined abdominal and
vaginal
Kelly s repair anterior
colporrhaphy+ bladder
neck repair
Paceys repair medial
fibres of puborectalis
are apposed in midline
under bladder neck to
elevate it
Marshall Marchetti
Krantz operation
bladder neck and vault
of vagina sutured to
periosteum of pubic
symphysis
Burch colposuspension
bladder neck and vaginal
vault suspended using
Pereyras operation
110 Abhishek .V
iliopectineal ligament.

2. POSTERIOR COLPORRHAPHY/COLPOPERINEORRHAPHY
Two allis forceps applied on the mucocutaneous junction.
Posterior vaginal wall cut transversely between these 2 forceps.
Vertical incision made from apex to the mid point of haez incision.
The 2 triangular flaps are dissected laterally.
Rectocele corrected by suturing pararectal fascia.
Levator ani muscles approximated in the midline.
Cut margins of posterior vaginal wall approximated extending back to the perineal
body and then skin.

3. MOSCHOWITZ OPERATION Abdominal repair of enterocele done by obliterating
the pouch of Douglas.

4. FOTHERGILLS OPERATION/MANCHESTER OPERATION
a. Steps:
Preliminary BSC for easy passage of sutures and to remove the
unhealthy endometrium.
Amputation of cervix.
Plication of Mackenrodts (cardinal) ligaments in front of the cervix using
Fothergills stitch.
Anterior and posterior colporrhaphy (pelvic floor repair).
b. Modifications:
Modified Manchester operation No amputation or low amputation of
cervix done in infertile patients.
Extended Manchester Operation/Shirodkar operation)
No amputation of cervix.
Plication of uterosacral ligament.
Opening of POD and high closure of peritoneum of POD.
Pelvic floor repair not needed.

5. LE-FORTS OPERATION:
a. Indication Very old menopausal patient with advanced prolapse who are
not fit for major surgery under GA.
b. Do Pap smear and pelvic USG to rule out pelvic pathology.
c. Done under local anesthesia or epidural anesthesia.
d. Steps:
111 Abhishek .V
Denudation of rectangular vaginal flap from the anterior and
posterior vaginal wall.
Apposition of the denuded anterior and posterior vaginal walls
by chromic catgut and leaving two small channels on either side for
drainage

6. ABDOMINAL SLING OPERATIONS:
a. Indications Young women suffering from 2 or 3 UV prolapse who wants to
retain childbearing and menstrual functions.
b. TYPES:
ABDOMINOCERVICOPEXY:
Transverse abdominal incision made through skin and fat up to
rectus sheath.
By transverse incisions over the rectus sheath, 2 slings are
elevated from the midline outwards and laterally on either side.
Peritoneum is opened and uterus brought into view.
The medial ends of the fascial strips are brought down between
the leaves of the broad ligament up to the space created in front
of the uterine isthmus.
Then fixed anterior to the cervix with non-absorbable sutures (now
they are replaced by mer silene/nylon tape).
PURANDARES CERVICOPEXY:
Above procedure but the tape/strips are attached posterior on the
cervix close to the attachment of uterosacral ligaments.
Other ends of the tape are brought forward retroperitonealy and
attached to the external oblique aponeurosis.
SHIRODKARS SLING OPERATION - The tape is fixed posteriorly to
the anterior longitudinal ligament in front of sacral promontory and
anteriorly tied to supravaginal cervix on the posterior aspect.
KHANNAS OPERATION It is tied laterally to the periosteum of the
anterior superior iliac spine and other end is fixed posteriorly on
the cervix.

7. VAGINAL HYSTERECTOMY WITH PELVIC FLOOR REPAIR WARD MAYOS
OPERATION.
ADVANTAGES DISADVANTAGES
- Can be done in obese patients.
- Post-op complications are less.
- Less mortality and morbidity,
- Experienced surgeon required.
- Cant remove uterus >12 weeks.

112 Abhishek .V


Steps:
a. A circular incision is made over the cervix below the bladder sulcus and vaginal
mucosa dissected off the cervix all around by cutting the pubovesicocervical
ligament.
b. Pouch of Douglas identified and peritoneum incised.
c. Anteriorly, bladder is pushed up until UV peritoneum is visible and incised and
bladder pushed forwards.
d. 1
st
Clamp Mackenrodts ligament & uterosacral ligament clamped, cut and
pedicles transfixed with chromic catgut No. 1.
e. 2
nd
Clamp Uterine vessels Cut, clamp and ligate.
f. 3
rd
Clamp Upper part of broad ligament, Round Ligament, Fallopian tube,
Ligament of ovary Cut, clamp and ligate.
g. The above steps are done on either side and uterus is removed.
h. The peritoneal cavity is closed with a pure-string suture Extra-peritonization
of stump.
i. Retrospective pedicles are approximated in the centre.
j. Anterior colporrhaphy and posterior colpoperineorrhaphy done.
k. Vaginal packing done.
l. Self-retaining catheter introduced.
NOTES:
1. OTHER CLASSIFICATION OF UTERINE PROLAPSE
a. PEREY MALPAS CLASSIFICATION
i. Congenital
ii. Nulliparous
iii. Anterior Vaginal wall
iv. Posterior Vaginal wall
v. Procidentia
vi. Vault prolapse
vii. Arrested
b. JEFFCOTS CLASSIFICATION:
i. Vaginal
Anterior Wall
Posterior Wall
ii. Uterine
1
2
3
113 Abhishek .V
iii. Vault prolapse
b. POP-Q CLASSIFICATION (pelvic organ prolapse quantification system)

2. DECUBITUS ULCER
a. DIFFERENTIAL DIAGNOSIS:
i. STD
ii. TB ulcer
iii. Malignant ulcers
b. TREATMENT
i. Reduce prolapse
ii. Pessary
iii. Vaginal douche and tamponade with antiseptic solution.
iv. Heals in 7-10 days or suspect TB ulcer.

3. HOW DOES PROLONGATION OF 2
ND
STAGE OF LABOUR PREDISPOSE TO PROLAPSE?
2
nd
stage prolongation blood supply to muscles cut off Ischemia Necrosis Fibrosis
weakens the support.

4. CAUSES OF IRREDUCIBILITY
a. Procidentia
b. Dense adhesions due to infections

5. CAUSE OF SPONTANEOUS REDUCTION OF PROLAPSE WITHOUT TREATMENT (due to
fibrosis)
a. Endometriosis
b. PID
c. Ca cervix

6. PRE-OPERATIVE PREPERATION FOR A CSE OF PROLAPSE
a. Treatment of decubitus ulcer if present (even estrogen creams can be used).
b. Keep the prolapse reduced using tampons.
c. Every morning give vaginal douche using dilute betadine solution (5-10 ml betadine in
warm water)

7. HOW TO MANAGE A 30 YEAR OLD LADY WITH PROLPASE
CONDITION TREATMENT
Pregnant/Just delivered/Not fit for
surgery
Pessary
Nulliparous Abdominal sling
operation
114 Abhishek .V
With ovarian cyst or tumour Hysterectomy with
BSO
With 2 or more children Fothergills operation
8. A UTERINE PROLAPSE can be:
a. General Prolapse due to basic problem in the ligaments (lax ligaments) in post-
menopausal women and in nulliparous women Treatment by Sling operation
b. Uterovaginal Prolapse Ligaments are fine in reproductive age group women
Treatment by Fothergills operation.







.












115 Abhishek .V

OBSTETRICS AND GYNAECOLOGY

INSTRUMENTS

1.Sims speculum [bivalve vaginal]
Two blades- groove in between to allow the secretions to drain

Sims position
Sims VVF repair Sims triad
Sims speculum

Functions: - To retract posterior vaginal wall
Inspection of cervix: bleeding,white discharge,etc
Minor procedures: D&C, cervical cautery, cryosurgery
Fother Gills operation
To demonstrate enterocele (bulge in upper 1/3rd of Vaginal wall)
Cerviprime gel application
After encirclage operation to remove the stitch at 38th wk
To diagnose vesico vaginal fistula

Disadvantages: Anterior vaginal wall retractor is a must
Assistant is required

2.Cuscos self retaining speculum

Functions: Introduce IUD
Taking a Pap smear
For cryo surgery- Damage to anterior and posterior vaginal wall is avoided,
116 Abhishek .V
condom is used to avoid damage to lateral walls
For colposcopic examination

Disadvantages: Cannot see anterior and posterior vaginal walls
Speed is limited
(Adv- Assistant not required)

3.Anterior vaginal wall retractor
Bigger rings with serrations for better grip
May be used as a curette after delivery

4.Vulsellum
Teeth to catch the anterior lip of cervix
For Multiparous cervix
(Tinnalum forceps- one tooth, for nulliparous cervix)
Culdocentesis
Tubal sterilization posterior lip of cervix is caught
Culdoscopy
Pelvic abscess

5.Sinus forceps
Has blunt end
To open the abscess cavity
Does not have catch

6.Uterine sound
117 Abhishek .V
Normal length- 7.5 to 8 cm
Cervical canal- 2.5 cm
Graduated in cm / inches
PV is a must to know if uterus is anteverted or retroverted
Gently passed

De Jakarthas test: without any resistance sound can be passed all around in H.mole
Also called DAcoustas test
Uses:
* Clarks Test endometrial CA, bleeding occurs.
* Fothergills Op to know cervical length.
* To diagnose supravaginal lengthening UV prolapse.
* Missing thread by sounding the uterine cavity
Confirmation is by USG,to know position
* Uterocervical length < 6cms

uterine length = 5 = 1
cervical length x 2 2.5 x 2

If length is more i.e, the ratio is <0.75 the uterus is hypoplastic.

7.Hegars Dilators : 3,4 upto 16, number indicates diameter in mm.
Instrument is held like a pen
Indications -* D & E
* D & C
* cervical stenosis ( only dilatation )
* For diagnosis of cervical incompetence. No.8 can be passed in
premenstrual period since progesterone increases the tone
* Before introduction of IUD
* radioactive therapy
* Pyometra, haematometra
* Spasmodic dysmenorrheal

118 Abhishek .V
Complications:
- neurogenic shock
- introduction
- perforation loss of resistance i.e will be +ve if it occurs
- Injury to bladder n rectum
[gest age + 1 = reqd dilatation]

8.Currette : two ends one sharp n blunt end
Sharp : non pregnant uterus
Blunt : pregnant uterus
Uses : Therapeutic D&C
DUB
To detect CA endometrium ;TB

Medical currettage:- progesterone for 5 days, stop. Pt will have withdrawal bleeding.
Fractional currettage 3 specimens 1 endocervix, 1 endometrium, 1 ectocervix
Follow up in H.mole
* peri menopausal women with bleeding pv
* In a 30yr woman, only D&C for bleeding pv
Complications Ashermans syndrome


9.Sponge holding forceps
Blades are serratious, fenesrated, there is a catch.
Uses : For painting n draping
Cervical encirclage
To put cerviprime gel
To know cervical tear
To remove retained bits of placenta
In myomectomy to compress uterine artery
Infundibulopelvic lig- ovarian artery ( as hemostatic forceps )
To push bladder down
Lower segment bleeding in LSCS
Pregnant cervical lip is held

10.Ovum Holding Forceps
Has smooth ends so injury is less
Uses D & E in molar pregnancy

119 Abhishek .V
11.Endometrial Biopsy Currettage
- To detect ovulation
- No need for dilation and sedation

12.Needle Holder : Small tip, used to hold needle for suturing

13.Towel clips : After draping

14.Straight Artery forceps
Different sizes, to catch bleeding points
Pedicle clamping Kochers forceps
To catch bleeding points
Clamp umbilical cord: Early premature( hyperbilirubinemia)
Rh incompatibility
Cord around neck
Fetal distress
Late Anaemia, 80 100 ml blood retained

15.Episiotomy scissors
Types : Mediolateral ( apposition isnt good, can be extended)
Median (apposition is perfect, cant be extended, less bleeding)
Lateral 15 deg from forchette

16.Metal Catheter
Use- Before surgery in OT to catheterize bladder

17.Malecots catheter ( self retaining, Urology)
Uses- As a drain after laparotomy
Suprapubic cystotomy
Drain pelvic abcess

18.Plain catheter
Uses- Manual removal of placenta
Correct Inversion To catheterize for shorter period
Before delivery

19.Foleys Self Retaining Catheter
120 Abhishek .V
Uses- Draining for longer periods ; only during surgery in abdominal hysterectomy.
When cystocele repair is done, to keep bladder empty 4-5 days.
After removing, ask the pt to void & check for residual urine, if > 50cc then re-
catheterise.
After VVF repair 14 days
Wertheins Hysterectomy 14 days
As a tamponade
Extra amniotic instillation of ethacrydine lactate
10 ml x no.of gestation in wks
After 16 weeks 150cc can be used
For diagnosis of cervical incompetence.
To push the bag of membranes.

20.Smellies perforator Craniotomy scissors
Parts - Tip of blade, shoulder of blade.
* Obstructed labour + dead fetus destructive procedure
* Hydrocephalus + dead fetus craniotomy ( thru bony point )

Empty the bladder, avoid injury to bladder & maternal soft tissue
Fetal skull should be fixed by suprapubic/cruciate incision.

21.Dedes mucus sucker Disposable
Use- Asphyxia neonatorum

22.Wrigleys outlet forceps
Right blade
Left blade
shank
lock
-left blade first
- Cervix fully dilated
- vertex presentation
- bladder empty
- aftercoming head
- membrane
- No CPD

Prophylactic forceps- anemia, cardiac disease
121 Abhishek .V

Indicated forceps- maternal/ fetal distress
One blade may be used as vectis in LSCS

23. Long forceps- high application- Kielland forceps
-ventouse (vacuum)

24. Pinards fetoscope- ear piece





25. MR syringe-
50 cc
Pressure created 60mm Hg
2 valves
Can be done upto 8 wks of pregnancy- manual vacuum aspiration
Can be used for check curettage
Lesser time
Incomplete removal
Misoprostol given for ripening of Cervix+ Atropine is given

26. Babcocks forceps-
Round ligament holding
Fallopian tube- Tubal sterilization
Ureters in Wertheims
Catch hold of appendix
Lymphadenectomy

Modified Pomeroys technique-
Crushing the tube, use non absorbable sutures for tying cut ends separately
122 Abhishek .V
Old Pomeroys- cutting + ligating

27.Contraceptive devices-
1. Condom- Barrier method, easiest, Side effect- allergy to latex
(Pearls index = Total No. of pregnancies/Total months of exposure * 12 *100
Expressed in 100 women-years)
2. Cu T- causes foreign body reaction in uterus, prevents implantation by inhibition of
enzymatic process, causes phagocytosis of sperms and ovum
Procedure of insertion- sound the uterine cavity
- mark the length of the uterine cavity on the Cu T inserting
tube
- insert the appropriate length of tube so as to reach the fundus
- withdraw the tube so as to free the Cu T (Withdrawal method of insertion)
Timing of Cu T insertion- immediate post menstrual period before ovulation occurs
- post abortal - immediately
- post LSCS - after 2-3 months
- post delivery- after 1 month
Contra-indications
- undiagnosed bleeding p/v
- suspected pregnancy
- genital tract malignancy
- abnormalities of genital tract
- PID, backache
- Previous h/o ectopic pregnancy
Side effects
- perforation
- backache
- dysmenorrhea

Mirena- Hormone delivery system

3. OCPs- - start on 5
th
day of cycle
- fixed time, at night
123 Abhishek .V
- Mech of action- suppresses ovulation, makes cervical mucus thick, prevents
implantation by causing endometrial changes, reduces tubal motility (POP)
Non contraceptive uses of OCP-1. Dysmenorrhea 6. Ovarian Ca
2. Menorrhagia 7. Benign breast disease
3. Anemia, Fibroid 8. HRT
4. PID 9. Ectopic pregnancy
5. Endometrial Ca
- When OCPs are taken breast milk quantity is reduced not quality
Centchroman (Saheli)- SERM, Non-hormonal product
Dosage-30mg (1 tab) starting on 1
st
day of menses twice weekly for 3 mths then once a
week thereafter
Injectable preparations- Depo provera- once in 90 days, amenorrhea and infertility may last till 6
mths
Post coital pill
1. OCPs- patient takes 2 tabs(containing 50mcg ethinyl estradiol) within 72 hrs of
coitus and 2 tabs 12 hrs later
2. Levonorgestrel- 1 tab containing 0.75mg LNG within 72 hrs foll by 1 tab 12 hrs later
3. Mifepristone- 10mg single dose
4. IUCDs inserted within 5 days of coitus



MATERNAL PELVIS

4 bones- 2 innominate bones, sacrum and coccyx
4 joints- 2 sacroiliac joints, pubic symphysis, sacrococcygeal joints
Backward displacement of sacrum in lithotomy position
Anatomical postion of pelvis- ASIS and symphysis pubis lie in the same vertical plane
Pelvic inclination- 55 degrees
Sacral angle-95 degrees
High inclination- sacralization(common in anthropoid pelvis)-it causes-
1. Delayed descent
2. Delayed engagement
124 Abhishek .V
3. OP position

It has a brim (inlet), cavity and outlet.
BRIM- diameters AP=11cm
Oblique= 12 cm
Transverse=13cm
Diagonal conjugate (measurable)- 12cm
Obstetric conjugate- 10 cm
True conjugate- 11cm
Greatest pelvic dimensions- at S2,3(12cm)
Least pelvic dimensions-at S5- 1. AP dia= 11.5 cm
2. Transverse(between the 2 ischial spines)= 10.5cm
3. Posterior Sagittal=4.5cm
Pelvic assessment- Patient in Dorsal position
- done preferably at onset of labour or after 38 wks
- patient should empty her bladder
- clinical assessment is either by abdominal or abdomino-pelvic (Munro-
Kerr-Muller technique) methods
- if you cant feel the promontory feel for the sacral curvature foll. By
ischial spines, sacrospinous lig. (2 fingers can be comfortably kept).
Isolated mid pelvic contraction can be present but rare.
Outlet contraction- normal sub pubic angle is >85 degrees and the outlet should
accommodate the fist of the examiner( sub pubic angle is acute in android pelvis)
Contracted pelvis is defined as reduction by >0.5 cm in any diameter of pelvis or if
intertuberous dia is <8cm or if sum of posterior sagittal and AP dia. is <13.5cm


FETAL SKULL(Calvaria) - 2 frontal bones
- 2 parietal bones
- 2 temporal bones
- 1 occipital bone

125 Abhishek .V

Position of fetal head- relation of fetal skull to maternal pelvis

Presentation Denominator
1. Vertex- Occiput
2. Face- Mentum
3. Breech- Sacrum
4. Shoulder- Acromion

Moulding- 0.5 cm- safe degree
Usually parietal bones over-ride the other bones

Caput Succadaneum- Collection of fluid in layers of scalp
Types: Pelvic caput(in CPD) & Cervical caput(undilated cervix)
Usually disappears by 2 hrs.
D/D cephalhematoma

Diameters of fetal skull:
Extent of flexion Engaging diameter Measurement

Full flexion Sub-occipito-bregmatic 9.5cm
Slight deflexion Sub occipito frontal 10.5cm
Deflexed Occipito-frontal 11.5cm
Partial Extension Mento-vertical (brow) 14cm

Bi parietal Diameter = 9.5cm

LOA postion is the commonest because of
1. dextro-rotation of uterus
2. Presence of sigmoid colon in left
3. Placenta attached to posterior uterine wall
126 Abhishek .V
4. Uterus is concave backwards and convex forwards thus accommodating the convex fetal
ovoid of the back anteriorly.

SOME OBSTETRICS/ GYNECOLOGY MNEMONICS
Post-partum examination simplified checklist Forceps: indications for use
BUBBLES:
Breast
Uterus
Bowel
Bladder
Lochia
Episotomy
Surgical site (for Cesarean section)

FORCEPS:
Fully dilated cervix
0 ["Zero"] CPD
Ruptured membranes
Cephalic or at least deliverable presentation/
Contracting uterus
Episiotomy done/ Epidural done
P!ss and S#!t (bladder and bowel empty)

Shoulder dystocia: management Oral contraceptives: side effects
HELPER:
Call for Help
Episiotomy
Legs up [McRoberts position]
Pressure subrapubically [not on fundus]
Enter vagina for shoulder rotation
Reach for posterior shoulder and deliver
posterior shoulder/ Return head into vagina
[Zavanelli maneuver] for C-section/ Rupture
clavicle or pubic symphisis

CONTRACEPTIVES:
Cholestatic jaundice
Oedema (corneal)
Nasal congestion
Thyroid dysfunction
Raised BP
Acne/ Alopecia/ Anaemia
Cerebrovascular disease
Elevated blood sugar
Porphyria/ Pigmentation/ Pancreatitis
Thromboembolism
Intracranial hypertension
Vomiting (progesterone only)
Erythema nodosum/ Extrapyramidal effects
Sensitivity to light


Pelvic Inflammatory Disease (PID):
complications
Postpartum collapse: causes
I FACE PID:
Infertility
Fitz-Hugh-Curitis syndrome
Abscesses
Chronic pelvic pain
Ectopic pregnancy
Peritonitis
Intestinal obstruction
Disseminated: sepsis, endocarditis,
arthritis, meninigitis


HEPARINS:
Hemorrhage
Eclampsia
Pulmonary embolism
Amniotic fluid embolism
Regional anaethetic complications
Infarction (MI)
Neurogenic shock
Septic shock

127 Abhishek .V
Abdominal pain: causes during pregnancy Early cord clamping: indications
LARA CROFT:
Labour
Abruption of placenta
Rupture (eg. ectopic/ uterus)
Abortion
Cholestasis
Rectus sheath haematoma
Ovarian tumour
Fibroids
Torsion of uterus

RAPID CS:
Rh incompatibility
Asphyxia
Premature delivery
Infections
Diabetic mother
CS (caesarian section) previously, so the funda
is RAPID CS


ASHERMAN:
Acquired Anomaly
Secondary to Surgery
Hysterosalpingography confirms diagnosis
Endometrial damage/ Eugonadotropic
Repeated uterine trauma
Missed Menses
Adhesions
Normal estrogen and progesterone

"Chorionic" has 9 letters and Chorionic villus sampling performed at 9 weeks gestation.
"AlphaFetoProtein" has 16 letters and it's measured at 16 weeks gestation.


SPECIMENS
SEE THE CD