Summary MBBS Obstetrics and Gynaecology All in One
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Course
MBBS
Institution
National University Of Singapore
A guide to success in MBBS study!
Self-written notes based on lecture notes and Uptodate.
The notes cover all materials medical student need to know about obstetrics and gynaecology before they graduate. Detailed coverage on common O&G diseases (signs and symptoms, investigations, treatment) with...
MISCARRIAGE 100
TERMINATION OF PREGNANCY (TOP) 112
ECTOPIC PREGNANCY 120
Chapter 4: Antenatal care
ANTENATAL CARE 128
THALASSEMIA 135
RH(D) SCREENING AND ANTI-D PROPHYLAXIS 150
DOWN SYNDROME 155
RUBELLA INFECTION 172
GROUP B STREPTOCOCCUS (GBS) INFECTION 178
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,Chapter 5: Perinatal/ Intrapartum care
STAGES OF LABOUR AND DELIVERY 182
INDUCTION OF LABOUR 198
ANALGESICS IN LABOUR 203
METHODS OF DELIVERY 206
SHOULDER DYSTOCIA 211
CARDIOTOCOGRAPHY (CTG) 214
TOCOLYTICS AND CORTICOSTEROIDS 218
ENDOMETRIAL HYPERPLASIA 334
ENDOMETRIAL CANCER 340
OVARIAN CANCER 347
CERVICAL CANCER 365
VAGINAL CANCER 387
VULVAR CANCER 391
GESTATIONAL TROPHOBLASTIC DISEASE (GTD) 395
GESTATIONAL TROPHOBLASTIC NEOPLASIA (GTN) 402
Chapter 9: Urogynecology
PELVIC ORGAN PROLAPSE 410
URINARY INCONTINENCE 425
Chapter 10: Reproductive medicine
BIRTH CONTROL 440
INFERTILITY AND ART 458
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, Physiology of pregnancy and minor ailments
I. Physiological adaptation of different system
1. Respiratory system
Anatomical changes
• Lifting of rib cage with upward flaring of the ribs
• Elevation of diaphragm
o Due to presence of fetus
o Reduced diaphragmatic excursion in late pregnancy
o Respiratory movement is maintained by increased thoracic movement
• Clinical relevance
o Mother may experience dyspnea
Physiological changes
• ↑ TV
• ↓ Functional residual capacity (FRC)
o Due to decrease in expiratory reserve volume (ERC) and residual volume (RC))
• Compensated respiratory alkalosis
o Due to increased PaO2 and decreased PaCO2 level
↑ Maternal PaO2
• ↑ Minute ventilation
o ↑ TV with RR remains essentially unchanged)
• Functions
o Extra cardiac, renal and respiratory work
o Uterine and breast development of mother
o Metabolism of feto-placental unit
↓ Maternal pCO2
• Alveolar CO2 decreases due to increased respiratory rate
• Fetus relies on mother to excrete CO2 through the placenta
• Allow more efficiency placental transfer of CO2 from fetus
• Clinical relevance
o Mother may experience dyspnea, nausea and dizziness
2. Cardiovascular system
↑ Cardiac output (50% from baseline)
• ↑ HR and SV
o Increases during the 1st trimester, reaches maximal at 20 – 24 weeks and plateau
during 3rd trimester
o Increased in CO is initially due to rise in SV but the increase is maintained later in
pregnancy by rise in HR when SV starts to fall during 3rd trimester
• ↑ Cardiac size
• Normal S3 gallop
• Ejection systolic murmur
o Detected from 2nd trimester due to hyperdynamic circulation
↓ Diastolic BP
• ↓ Total peripheral resistance (TPR)
o Increased progesterone production leads to vasodilation
o Lowest in 2nd trimester and gradually rise in 3rd trimester to pre-pregnant level at
term
o Increase in pulse pressure due to an unchanged systolic BP accompanied by a
decrease in diastolic BP
• Clinical relevance
o Raise clinical suspicion of pre-eclampsia if BP rises in 2nd trimester
o More common for gestational hypertension and pre-eclampsia to be diagnosed in
3rd trimester
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,3. Gastrointestinal system
↑ Intra-gastric pressure
• Due to growing fetus
↓ Gastric secretion
↓ Stomach and intestinal motility
• ↑ Gut transit time and thus water absorption from gut
• Clinical relevance
o Pregnant woman may suffer from constipation and GERD and thus heartburn is
common during pregnancy
Liver function test (LFT)
• ↑ ALP since it is produced in placenta
• Clinical relevance
o Interpret LFT from pregnancy woman with caution
4. Urological system
Anatomical changes
• Increased in kidney length
• Marked dilatation of calyces, renal pelvis and ureters in most pregnant women due to
hormonal effect by progesterone and pressure effect by uterine compression
• Clinical relevance
o Physiological hydronephrosis and hydroureters during pregnancy
↑ Glomerular filtration rate (GFR)
• ↑ Effective renal plasma flow (ERPF)
• ↓ Plasma creatinine and urea level
Glycosuria
• ↑ Excretion of glucose across glomerulus
• ↓ Reabsorption of glucose by kidney
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,5. Hematological system
↑ Plasma and blood volume
• Due to increased volume of circulation for fetus and prepare blood loss during delivery
• Clinical relevance
o Expansion in plasma volume is relatively static in pre-eclampsia
↑ Red cell mass
• Expansion of plasma volume is much greater than that of the increase in red cell mass
leading to physiological or dilutional anemia
• Greatest disproportion between rates at which plasma and RBC are added to maternal
circulation occurs in late 2nd to early 3rd trimester and the lowest Hb is at 28 – 36 weeks
• Cutoff for anemia in pregnancy
o 1st trimester: Hb < 11.0 g/dL
o 2nd trimester: Hb < 10.5 g/dL
o 3rd trimester: Hb < 11.0 g/dL
↓ Hb, hematocrit and red cell count
• Hemodilution effect
• Clinical relevance
o Monitor Hb level at booking visit and repeat in 28 – 32 weeks of pregnancy to
note for anemia
o ↑ Hematocrit in pre-eclampsia due to hemoconcentration
↑ WBC
• Increase in neutrophils count to prevent mother and fetus from infection
• Prepare mother for delivery
↓ Platelet count
• Hemodilution effect
• Platelet count decreases but remain in normal pre-pregnant range in the vast majority of
pregnancy and will return to baseline level several weeks post-partum
• Clinical relevance
o Gestational thrombocytopenia occurs in 8 – 10% of woman and is a diagnosis of
exclusion
↑ Pro-coagulatory factors
• ↑ Factors II, VII, VIII, X, XII, XIII, fibrinogen (Factor I) and VWF
• ↓ Anti-thrombin III and Protein S which are inhibitors of coagulation
• Reduced fibrinolysis due to increasing activity of fibrinolytic inhibitors
• Pregnancy is a pro-coagulatory state which prepare the mother for increased blood loss
during delivery
• Clinical relevance
o Assess possibility of venous thromboembolism if other risk factors such as
prolonged bed rest are present which may require thrombo-prophylaxis
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,6. Endocrine system
Glucose metabolism
• Insulin resistance mediated by placental secretion of diabetogenic hormones including
o Human placental lactogen (human chorionic somatomammotropin (hCS)
o Progesterone
o Growth hormone
o Corticotropin-releasing hormone (CRH)
o Prolactin
• Action of diabetogenic hormones are counterbalanced by an increase in insulin
concentration which reaches almost twice of pre-pregnant levels
• Clinical relevance
o Majority of women manage to maintain BG within normal limits but those fail to
do so will lead to gestational diabetes (GDM)
Thyroid gland
• Human chorionic gonadotropin (hCG) produced from the placenta structurally mimics
TSH which stimulates secretion of thyroxine from thyroid glands
o Homology between β-subunit of hCG and TSH
o HyphCG concentration rises soon after fertilization and peak at 10 – 12 weeks of
gestation after which the level declines
• Total T4 increases as the level of thyroxin-binding globulin (TBG) increases due to
estrogen stimulating effect on liver production of binding proteins
o TBG excess results in high serum total T4 and total T3 concentrations but not high
serum fT4 or fT3 concentrations
• Clinical relevance: hCG-mediated hyperthyroidism
o High hCG level during early pregnancy may lead to transient ↓ TSH and ↑ fT4
resulting in subclinical or rarely overt hyperthyroidism
Gestational transient thyrotoxicosis (GTT)
Multiple pregnancy
Hyperemesis gravidarum (higher hCG level with more thyroid-
stimulating activity)
Gestational trophoblastic disease (GTD) (hydatidiform mole/ molar
pregnancy)
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,II. Minor ailments in pregnancy
1. Hyperemesis gravidarum/ Nausea and vomiting (Morning sickness)
General features
• Nausea and vomiting are common in 1st trimester and occurs till 12 weeks of gestation
• Affects 70% of pregnant woman
• Hyperemesis gravidarum
o Excessive or intractable vomiting to the extent of dehydration, electrolyte
imbalance, acid-base imbalance, weight loss for 5%, ketosis or acetonuria
o Related to the production of hCG which stimulates the chemoreceptors in
hypothalamus and the risk is higher in
Multiple pregnancy
Gestational trophoblastic disease (GTD)
Hyperthyroidism
Urinary tract infections (UTI)
Diagnosis
• CBC with differentials
• RFT
o Assess degree of dehydration
• LFT
• TFT
o Up to 70% of patients have suppressed TSH or elevated fT4
o Not required routinely if patient does not have thyroid symptoms
• MSU for microscopy and culture with sensitivity testing
o Rule out urinary traction infection
• Pelvic USG
o Rule out multiple pregnancy and GTD
• hCG level is NOT useful
Complications
• Hyponatremia and hypokalemia
• Mallory-Weiss tear
• Wernicke’s encephalopathy
Management
• Dietary modifications (↓ Protein ↓ Fat ↑ Carbohydrates)
o Small frequent meals with fluid taken in between
o Avoid greasy and highly spiced foods
o Vitamin B1 (thiamine) supplements for Wernicke’s encephalopathy
o Avoid iron supplements to prevent GI disturbances
• Monitoring of patient
o Intake and output (IO) chart
o Daily body weight monitoring
o BP and pulse monitoring
o Urine ketones
• IV fluid and electrolyte replacement
o K supplements
• Antiemetics
o Metoclopramide
o Dimenhydrinate (H1-receptor antagonist)
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,2. Heartburn
General features
• Burning sensation felt behind sternum due to acid reflux into esophagus
• Affects 50% of pregnant woman
Pathophysiology
• ↑ Intra-gastric pressure and progesterone relaxes smooth muscles which reduces strength
of lower esophageal sphincter (LES)
• Flattening of diaphragm distorts shape of stomach which decreases the angle at the
gastro-jejunal junction
Treatment
• Antacids
Prevention
• Small frequent meals with low spices
• Avoid late meals
• Avoid food such as chocolate, coffee and alcohol
o Decreases sphincter pressure
• Sleeping in a more upright position by using additional pillow
3. Constipation
General features
• Can lead to development of hemorrhoids
Pathophysiology
• ↓ Stomach and intestinal motility due to high level of progesterone
o ↑ Gut transit time and thus water absorption from gut
• Intake of oral iron supplements
Treatment
• Lactulose
o Not absorbed by gut and absorb water into gut by osmosis
Prevention
• Adequate fluid intake
• Dietary fiber intake
• Maintain regular bowel habits
4. Urinary frequency
General features
• Affects woman in the 1st and 3rd trimester
o 1st trimester: Uterus is still in pelvis and compresses on bladder
o 2nd trimester: Mother is relieved from minor ailments
o 3rd trimester: Contraction of presenting part of baby
• Urinary tract infection (UTI) has to be excluded when there is also urgency and dysuria
Pathophysiology
• Pressure from growing uterus on bladder
• ↓ Tubular reabsorption and ↑ excretion of Na+ and water
o Increases need to pass urine especially at nighttime
Prevention
• Fluid restriction in evening and increase fluid intake during the day
o Decreases nocturia
• Limit intake of caffeine which are natural diuretics
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, 5. Backache
General features
• Affects 50% of pregnancy women
Pathophysiology
• Relaxation of pelvic ligaments by progesterone and relaxin
• Exaggerated lumbar lordosis causing strain on back muscle
• Demineralization of bone
Prevention
• Sit with support of back and thigh
• Stand with abdomen and buttocks tucked in
• Wear low heel shoes
o Maintain good body posture
• Sleep on good mattress
o Ensure equal pressure on all body parts
• Careful in postural changes to avoid strain on back muscles
• Avoid lifting heavy objects
6. Leg cramps
General features
• Common during the 3rd trimester
• Tend to occur in bed and may awaken the woman
Pathophysiology
• ↓ Ionized Ca2+
• ↑ PO43-
Treatment
• Calcium gluconate
o Calcium salts that are free of phosphates
Prevention
• ↓ Milk and processed food intake (PO43-)
• Perform stretching exercise before bed
7. Varicosities
General features
• Includes varicose veins, hemorrhoids and vulvar varicosities
Pathophysiology
• Progesterone-induced venodilatation due to relaxation of smooth muscle of veins
• Obstruction of venous return and pelvic congestion due to enlarged uterus
• Increasing constipation (for hemorrhoids)
Prevention
• Varicose veins
o Avoid prolonged standing
o Exercising of leg muscles
o Elevation of legs
o Apply pressure stockings
• Vulvar varicosities
o Sanitary pad or panty girdle for support
• Hemorrhoids
o Prevent and treatment of constipation
o Hydrocortisone acetate (Anusol suppositories)
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