What is FARRE

FARRE (Frequently Asked Regularly Repeated Exam Questions) is an innovative exam-

prep tool from PW MedEd. It is your ultimate companion for acing the MBBS Professional
University Exams with confidence and ease.

WHY CHOOSE FARRE?

FARRE brings you a meticulously curated collection of 100 key questions per subject—
sourced from professional exam papers of leading universities across different states.
Aligned with the Competency-Based Medical Education (CBME) curriculum outlined
by the National Medical Commission (NMC), FARRE offers a structured, student-
friendly approach to mastering essential concepts in just one week.

WHY FARRE IS THE BEST MBBS PROF EXAM PREP TOOL?

1. Comprehensive Content for Success
™ 100 critical questions in each subject, focusing on high-yield topics most likely to
appear in exams.

2. Visual Learning with Hand-Drawn Diagrams & Flowcharts

™ Easy-to-understand answers enhanced with diagrams and flowcharts, helping
you replicate information during exams effectively.

3. AETCOM-Compliant and CBME-Aligned

™ Integrated with the latest AETCOM module, providing a well-rounded preparation
strategy.

4. One-Week Study Plan

™ Master essential material in just seven days, helping you manage time efficiently
and boost retention.

5. Simple Language for Quick Grasping

™ Answers are provided in clear and concise language, making complex topics
easier to understand.

Equip yourself with MedEd FARRE and unlock the key to passing your MBBS exams with
ease and confidence.
With FARRE, “Passing Proffs just got easier!”
 Normal Pregnancy
1. What is prenatal testing? Write a note on screening and diagnostic tests and
the role of ultrasound in prenatal testing. (10 Marks)

Answer:

PRENATAL TESTING

Prenatal testing aims at monitoring the mother’s health, detecting potential genetic
or structural abnormalities, and providing an assessment of the fetal health and
development.

SCREENING TESTS

a. First-Trimester Screening
™ Ultrasound for Nuchal Translucency (NT): This measures the thickness of the
fetal neck to screen for chromosomal abnormalities.
™ Maternal Serum Markers: Free b-hCG and PAPP-A, pregnancy-associated plasma
protein A.
™ Purpose: Detects the risks of trisomy 21, 18, 13.
™ Duration: 11–13 weeks

b. Second-Trimester Screening
™ Triple Test: Measures AFP, b-hCG, and estriol levels.
™ Quadruple Test: Adds inhibin-A to the triple test.
™ Purpose: Screens for chromosomal abnormalities and Neural Tube Defects (NTDs).
™ Timing: 15–20 weeks

c. Non-Invasive Prenatal Testing (NIPT)

™ Method: Examines cell-free fetal DNA in maternal blood.
™ Purpose: High sensitivity for trisomy 21, 18, 13.
™ Timing: After 10 weeks

DIAGNOSTIC TESTS

a. Chorionic Villus Sampling (CVS)

™ Procedure: Biopsy of chorionic villi via transabdominal or transcervical route.
™ Purpose: Detects chromosomal and genetic conditions.
 MedEd FARRE: Obstetrics and Gynaecology

™ Timing: 10–13 weeks

™ Risks: Miscarriage (0.2–0.5%)

b. Amniocentesis
™ Procedure: Under ultrasound guidance, aspirates amniotic fluid.
™ Purpose: Diagnosis chromosomal abnormalities, infections, and fetal lung maturity.
™ Timing: 15–20 weeks
™ Risks: Miscarriage (0.1–0.3%)

c. Percutaneous Umbilical Blood Sampling (PUBS)

™ Procedure: Blood sample is drawn from the umbilical vein.
™ Purpose: Infections, anemias, and chromosomal conditions.
™ Timing: After 18 weeks
™ Risks: Increased miscarriage rate (~1–2%)

ULTRASOUND IN PRENATAL TESTING

€ Early Pregnancy Scan (6–10 weeks): confirms gestation, viability, and dating.
€ Anomaly Scan (18–22 weeks): Detects structural abnormalities.
€ Growth Scans: Monitors fetal growth and wellbeing in the third trimester.

Reference: Williams Obstetrics, 26th Edition, Page no. 182.

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 Normal Pregnancy

2. Write a short note on antenatal care under following headings: (10 Marks)

a. Objectives

b. Components

c. Interventions

d. Complications commonly monitored

Answer:

OBJECTIVES OF ANTENATAL CARE

€ Maternal health is promoted.

€ Fetal growth is monitored.

€ Prevention, diagnosis, and management of complications.

€ Education and counseling.

€ Preparation for labor and postnatal care

ELEMENTS OF ANTENATAL CARE

Initial Visit (Booking Visit)

€ Period: Preferably at about 12 weeks of pregnancy

Elements:
€ History:

™ Medical history

™ Obstetric history

™ Menstruation

™ Family history

™ Social history

€ General physical, systemic and obstetric examination

€ Haemoglobin estimation

€ Blood grouping and typing

€ Urinalysis

€ Blood sugar levels

€ HIV test & HBsAg

€ Serum VDRL Syphilis testing

€ Ultrasonography scan to ascertain gestation

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MedEd FARRE: Obstetrics and Gynaecology

Subsequent Visits
€ Every 4 weeks: Up to 28 weeks
€ Every 2 weeks: 28–36 weeks
€ Weekly: After 36 weeks
€ Evaluation in Each Visit:
™ Maternal well-being: Blood pressure, weight, and presence of anemia or edema.
™ Fetal well-being: Symphysis-fundal height, fetal heart rate, fetal movements.
€ Tests: Hemoglobin repetition, glucose tolerance test (if required), and infection testing
according to trimester.

Screening and Diagnostic Tests

€ First Trimester: Nuchal translucency scan, PAPP-A, and b-hCG.
€ Second Trimester: Quadruple test, anomaly scan.
€ Third Trimester: Doppler ultrasound for growth restriction, surveillance if high risk.

INTERVENTIONS IN ANTENATAL CARE

a. Dietary Counseling
™ Well-planned diet with adequate energy, proteins, and microminerals.
™ Preconception folic acid supplementation (400 mcg/day) and iron.

b. Immunization
™ Tetanus and diphtheria (Td): Two doses at least 4 weeks apart if unvaccinated,
or one booster dose if previously vaccinated.

c. Counseling and Education

™ Warning Signs: Bleeding, reduced fetal movements, severe headache, swelling.
™ Birth Preparedness: Plan for place of delivery, skilled attendant, and transport.
™ Lifestyle Advice: Avoid alcohol, smoking, and unnecessary medications.

COMMON COMPLICATIONS MONITORED IN ANC

€ Hypertensive Disorders: Preeclampsia, eclampsia

€ Gestational Diabetes Mellitus (GDM)
€ Preterm Labor: Risk factors and prevention strategies.
€ Fetal Growth Restriction (FGR)

Reference: Williams Obstetrics, 26th Edition, Page no. 854.

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 Normal Pregnancy

3. Write a short note on common maternal adaptations in different systems in

pregnancy. (10 Marks)

Answer:

MATERNAL ADAPTATIONS IN PREGNANCY

Cardiovascular System
1. Increased cardiac output (30-50%)
2. Decreased peripheral vascular resistance
3. Increased blood volume (40-50%)
4. Heart rate increase (10-20 beats/min)

Respiratory System
1. Increased tidal volume (10-20%)
2. Increased minute ventilation (20-30%)
3. Decreased respiratory rate
4. Increased oxygen consumption

Renal System
1. Increased glomerular filtration rate (50-60%)
2. Increased renal plasma flow
3. Glycosuria (Normal during pregnancy)
4. Increased urine production

Gastrointestinal System
1. Delayed gastric emptying
2. Increased gut motility
3. Constipation (Due to progesterone)
4. Nausea and vomiting (During first trimester)

Musculoskeletal System
1. Laxity of pelvic joints
2. Lumbar lordosis
3. Weight gain and postural changes
4. Susceptibility to back pain

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 MedEd FARRE: Obstetrics and Gynaecology

Endocrine System
1. Estrogen and progesterone levels are increased
2. Human chorionic gonadotropin (hCG) is increased
3. Insulin resistance is increased
4. Thyroid hormone levels are increased

Immune System
1. Cell-mediated immunity is suppressed
2. Humoral immunity is enhanced
3. Susceptibility to infections is increased
4. Tolerance to fetal antigens

Nervous System
1. Synaptic plasticity is increased
2. Cognitive function is altered
3. Mood swings and emotional changes
4. Sleep disturbances

Dermatological Changes
1. Melasma (Skin pigmentation)
2. Striae (Stretch marks)
3. Hair growth changes
4. Nail changes

Metabolic Changes
1. Increased glucose production
2. Increased lipid metabolism
3. Increased protein synthesis
4. Weight gain (Average 10-12.5 Kg)
Reference: Williams Obstetrics, 26th Edition, Page no. 907.

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 Disorders in Pregnancy
4. Describe the normal levels of hemoglobin, classification, clinical features,
diagnosis, management and complications of anemia in Pregnancy.

 (10 Marks)

Answer:

ANEMIA IN PREGNANCY

Anemia can be defined as decrease in red blood cell mass or hemoglobin

concentration. Pregnancy results in expansion of blood volume, leading to dilutional
anemia.

Normal Hemoglobin in Pregnancy

€ 1st Trimester: Hemoglobin ≥ 11.0 g/dL
€ 2nd Trimester: Hemoglobin ≥ 10.5 g/dL
€ 3rd Trimester: Hemoglobin ≥ 11.0 g/dL

Anemia is diagnosed if hemoglobin is < 11 g/dL in any of the trimesters.

Classification of Anemia in Pregnancy

1. Iron-Deficiency Anemia (IDA):
™ Commonest cause of anemia in pregnancy, accounting for approximately 75% of
cases.
™ Resulting from inadequate iron intake, impaired absorption, or increased
demand.

Findings:
1. Low hemoglobin/hematocrit
2. Low serum ferritin (Early marker)
3. Low serum iron
4. High Total Iron-Binding Capacity (TIBC)
5. Low transferrin saturation
2. Folate deficiency anemia:
™ Folates increase during pregnancy to support the growth and development of the
fetus.
™ Common in women with poor diets or malabsorption disorders.
 MedEd FARRE: Obstetrics and Gynaecology

Findings:
1. Low hemoglobin
2. Low serum folate
3. Elevated homocysteine
3. Vitamin B12 deficiency anemia:
™ Less frequent than iron or folate deficiency.
™ Associated with vegetarian or vegan diets or malabsorption syndromes.

Findings:
1. Low hemoglobin
2. Low serum B12 levels
3. High Methylmalonic Acid (MMA) levels
4. Anemia of Chronic Disease (ACD):
™ Frequently associated with women who have chronic inflammatory conditions
(Autoimmune diseases).

Findings:
1. Low hemoglobin
2. Normal or elevated ferritin

3. Low transferrin saturation
5. Hemolytic anemia:
™ Occurs in pregnancy associated with various conditions, including hereditary
spherocytosis, G6PD deficiency, or autoimmune hemolysis.

Findings:
1. Low hemoglobin
2. Elevated reticulocyte count
3. Elevated indirect bilirubin and Lactate Dehydrogenase (LDH)
6. Sickle cell anemia:
€ Pregnant patients with sickle cell disease are at increased risk for complications such
as vaso-occlusive crises and preeclampsia.

Findings: Hemoglobin S (HbS) on electrophoresis

Clinical Manifestations of Anemia

€ Fatigue and weakness
€ Pallor, especially in the conjunctiva and mucous membranes

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 Disorders in Pregnancy

€ Shortness of breath or dyspnea on exertion

€ Tachycardia (Compensatory)
€ Dizziness or fainting
€ Pica (Cravings for non-food items like clay or dirt)
€ Decreased exercise tolerance

Diagnosis of Anemia in Pregnancy

€ Complete Blood Count (CBC)
€ Hemoglobin: The main diagnostic parameter
€ Hematocrit: Aids in assessing the degree of anemia
€ Mean Corpuscular Volume (MCV): Can be useful in distinguishing between iron
deficiency anemia (Low MCV) and folate/B12 deficiency anemia (High MCV)
€ Serum Ferritin: It is the gold standard for diagnosing iron deficiency. Low ferritin
is a sensitive marker of iron depletion
€ Reticulocyte Count: May be increased in acute blood loss or hemolysis
€ Serum Iron Studies: Serum iron, ferritin, Total Iron-Binding Capacity (TIBC), and
transferrin saturation
€ Other tests: Serum B12 and Folate levels: To detect deficiencies
€ Hemoglobin electrophoresis: If sickle cell anemia or thalassemia is suspected

Treatment of Anemia in Pregnancy

1. Iron-Deficiency Anemia (IDA):
™ Oral Iron Supplementation: First-line treatment (e.g., Ferrous sulfate 325 mg
daily).
™ Side effects: Constipation, nausea, dark stools.
™ Alternative: Ferrous gluconate or ferrous fumarate if side effects are intolerable.
™ Parenteral Iron: Iron sucrose
™ Monitoring: Hemoglobin levels should correct within 2-3 weeks of iron
supplementation.

2. Folate deficiency anemia:

™ Folic Acid Supplementation: 400-800 mcg/day in all pregnant women; higher
doses of history of neural tube defects.
™ Folic acid 5 mg/day in women with documented folate deficiency or who are at
greater risk, for example, a history of neural tube defects.
™ Folic acid is available in diet as in green leafy vegetables, fortified cereals, legumes,
and citrus fruits.

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 MedEd FARRE: Obstetrics and Gynaecology

3. Vitamin B12 deficiency:

™ B12 Supplementation: Oral or parenteral B12 (Cyanocobalamin).
™ In cases of severe deficiency, parenteral injections of B12 may be necessary initially
at a dose of 1000 mcg weekly.
™ Management of Severe Anemia: Transfusion is considered when hemoglobin
levels decrease below 7 g/dL or if symptoms are more severe such as in heart failure
or hypoxia.

4. Anemia of chronic disease:

™ Iron supplementation is generally not given since their iron stores are usually
elevated or adequate.

Complications of Anemia in Pregnancy

1. Maternal complications:
™ High risk of preterm labor
™ Postpartum hemorrhage resulting from poor oxygenation to tissues
™ Fatigue results in poor quality of life

2. Fetal complications:
™ Low birth weight and intrauterine growth restriction
™ Preterm delivery
™ Higher risks of perinatal morbidity and mortality

Reference: Williams Obstetrics, 26th Edition, Page no. 605.

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 Disorders in Pregnancy

5. Describe diabetes in pregnancy under following headings: (10 Marks)

a. Classification
b. Pathophysiology
c. Screening & Diagnosis
d. Management
e. Maternal and fetal complications

Answer:

DIABETES IN PREGNANCY

Classification
€ Pre-Gestational Diabetes Mellitus (PGDM): Type 1 and Type 2 diabetes diagnosed
before conception.
€ Gestational Diabetes Mellitus (GDM): Glucose intolerance that is identified during
pregnancy.

Pathophysiology
€ Pregnancy leads to insulin resistance due to hormones from the placenta, such as
Human Placental Lactogen (HPL), cortisol, and progesterone.
€ Pre-existing or insufficient response of pancreatic insulin leads to hyperglycemia.

Screening and Diagnosis

Screening for GDM:
€ Universal screening is advocated, especially in high-risk women.
€ Risk factors: Obesity, family history of diabetes, previous macrosomic baby, unexplained
stillbirth, polyhydramnios.

Diagnostic Methods:
€ 1-step Method (WHO): 75g oral glucose tolerance test (OGTT) between 24–28 weeks.

Diagnostic if:
™ Fasting glucose ≥ 92 mg/dL,
™ 1-hour ≥ 180 mg/dL,
™ 2-hour ≥ 153 mg/dL.
€ 2-step Method (IADPSG):

Step 1: 50g glucose challenge test.

Step 2: 100 g OGTT if glucose ≥ 140 mg/dL in step 1.

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MedEd FARRE: Obstetrics and Gynaecology

Complications
Maternal complications:
€ Pregnancy: Pre-eclampsia, polyhydramnios, infections
€ Labour and Delivery: Augmentation of cesarean delivery rate, shoulder dystocia
€ Postpartum: Likelihood of developing Type 2 diabetes later

Fetal complications:
€ During Pregnancy: Congenital anomalies (Cardiac, neural tube defects) in PGDM
€ Miscarriage
€ At Birth: Macrosomia, shoulder dystocia, neonatal hypoglycemia, hyperbilirubinemia.
€ Long-Term: Childhood obesity, Type 2 diabetes.

Management
Preconception Counseling (PGDM):
€ Optimize glycemic control with HbA1c < 6.5%.
€ Review medications (e.g., Stop teratogenic drugs such as ACE inhibitors, statins).
€ Screen for complications (e.g., Retinopathy, nephropathy).

Antenatal management:
€ Diet and Lifestyle Modifications
€ Nutritional advice with calorie restriction and dietetics low in glycemic index.
€ Physical activity according to tolerance.
€ Medical Therapy:
™ Insulin: Preferred in pregnancy; short and intermediate-acting insulin is safe.
™ Oral Hypoglycemics: Metformin and glyburide can be used with proper care.

Fetal monitoring:
€ Serial growth scans every 4 weeks after 28 weeks.
€ AFI for polyhydramnios.
€ Doppler studies if fetal growth restriction is suspected.

Maternal monitoring:
€ Self-monitoring of blood glucose (SMBG):
€ Target levels:
™ Fasting: < 95 mg/dL.
™ 1-hour postprandial: < 140 mg/dL.
™ 2-hour postprandial: < 120 mg/dL.

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 Disorders in Pregnancy

Delivery planning:
€ Well-controlled GDM: 39–40 weeks.
€ Poorly controlled or complications: Consider earlier induction.
€ Mode: Vaginal delivery preferred if no contraindications, but cesarean may be needed
for macrosomia (> 4 kg).
Postpartum care:
€ Screen for persistent diabetes 6–12 weeks postpartum using OGTT.
€ Counseling on lifestyle modification to prevent Type 2 diabetes.
€ Family planning, contraception.

Reference: Williams Obstetrics, 26th Edition, Page no. 183.

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 MedEd FARRE: Obstetrics and Gynaecology

6. Write a note on classification, clinical features, pathophysiology, risk factors,

diagnosis, management and complications of hypertension in pregnancy.

 (10 Marks)

Answer:

HYPERTENSION IN PREGNANCY

Classification of Hypertension in Pregnancy (ACOG 2020)

Chronic hypertension:
€ Diagnosed before 20 weeks of gestation or persists > 12 weeks postpartum.

€ BP ≥ 140/90 mmHg.

Gestational hypertension:
€ Diagnosed after 20 weeks of gestation without proteinuria or end-organ damage.

€ Resolves within 12 weeks postpartum.

Preeclampsia-eclampsia:
€ Preeclampsia: Hypertension after 20 weeks with proteinuria (≥ 300 mg/24 hours)
or end-organ damage.
€ Eclampsia: Preeclampsia with seizures unrelated to other causes.

Chronic hypertension with superimposed preeclampsia:

€ Chronic hypertension with new-onset proteinuria or worsening hypertension/end-
organ dysfunction.

White coat hypertension:

€ Elevated BP in clinical settings but normal outside.

Pathophysiology of Preeclampsia
€ Inadequate remodeling of spiral arteries results in placental ischemia.

€ Anti-angiogenic factors (sFlt-1, endoglin) are released and lead to disruption of

endothelial function.
€ Systemic vasoconstriction, increased vascular permeability, and end-organ damage
follows.

Risk Factors
€ Maternal: Primigravida, advanced maternal age (>35 years), obesity, chronic
hypertension, diabetes, renal disease.
€ Obstetric: Multiple gestations, molar pregnancy, family history of preeclampsia.

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 Disorders in Pregnancy

Clinical Features
€ Chronic Hypertension: Persistence of high BP without systemic involvement.

€ Gestational Hypertension: Asymptomatic elevated BP, monitored for progression to

preeclampsia.
€ Preeclampsia: Hypertension and proteinuria or features of severe disease - Severe
headache, visual disturbances, epigastric pain, thrombocytopenia (< 100,000/μL),
elevated liver enzymes, pulmonary edema, or oliguria.
€ Eclampsia: Generalized tonic-clonic seizures.

Investigations
€ Blood Pressure Monitoring

€ Urine Analysis

€ CBC, Liver Function Tests (LFTs), Renal Function Tests (RFTs), and coagulation profile.

€ Ultrasound for fetal growth, Doppler for uteroplacental perfusion, and amniotic fluid
index.

Management
€ Chronic hypertension:

™ Medications: Methyldopa, labetalol, nifedipine. Avoid ACE inhibitors and ARBs.

™ Monitor for superimposed preeclampsia.

€ Gestational hypertension:

™ Monitor closely for progression to preeclampsia.

™ Antihypertensives for severe hypertension (≥ 160/110 mmHg).

€ Preeclampsia:

a. Mild Preeclampsia:
Š Monitor BP, proteinuria, and fetal well-being.

Š Deliver at 37 weeks if stable.

b. Severe Preeclampsia:
Š Stabilize with antihypertensives: Labetalol, hydralazine, nifedipine.

Š Seizure prophylaxis: Magnesium sulfate (Pritchard or Zuspan regimen).

Š Delivery is definitive treatment, often at ≥ 34 weeks or earlier if unstable.

€ Eclampsia:

™ Acute Management: Secure airway, stop seizures (Magnesium sulfate), control

BP, Immediate delivery.

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 MedEd FARRE: Obstetrics and Gynaecology

Complications
€ Maternal Complications:
™ Eclampsia, HELLP syndrome (Hemolysis, elevated liver enzymes, low platelets),
pulmonary edema, renal failure, stroke
€ Fetal Complications:
™ Fetal Growth Restriction (FGR), preterm delivery, placental abruption, stillbirth

Prevention
€ Low-dose aspirin in high-risk cases
€ Calcium supplementation

Reference: Williams Obstetrics, 26th Edition, Page no. 689.

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 Disorders in Pregnancy

7. Write a short note on routes of transmission, diagnosis and complications of

HIV in pregnancy. (10 Marks)

Answer:

HIV IN PREGNANCY

€ Vertical transmission rate without intervention: 15–45%

€ With effective Antiretroviral Therapy (ART) and prevention: <2%

Routes of Mother-to-Child Transmission

€ In utero (5–10%): Transplacental
€ Intrapartum (10–20%): Exposure to maternal blood and secretions during delivery
€ Postpartum (5–15%): Breastfeeding

Screening and Diagnosis

€ Routine antenatal HIV screening is recommended
€ Screening: ELISA or rapid HIV antibody tests
€ Confirmation: Western blot or HIV RNA PCR
€ Perform CD4 count and viral load for staging and treatment planning

Common Effects of HIV on Pregnancy

€ Maternal: Increased risk of opportunistic infections, preterm labor, and postpartum
complications
€ Fetal: Intrauterine Growth Restriction (IUGR), preterm birth and low birth weight

Complications
€ Maternal: Opportunistic infections, ART toxicity, postpartum hemorrhage
€ Fetal: Preterm birth, IUGR, and perinatal HIV transmission

Reference: Williams Obstetrics, 26th Edition, Page no. 967.

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 MedEd FARRE: Obstetrics and Gynaecology

8. Write a note on the classification of different liver disorders in pregnancy.

 (10 Marks)

Answer:

CLASSIFICATION OF LIVER DISORDERS IN PREGNANCY

Pregnancy-specific liver disorders:

€ Hyperemesis gravidarum
€ Intrahepatic Cholestasis of Pregnancy (ICP)
€ HELLP syndrome (Hemolysis, Elevated Liver Enzymes, Low Platelets)
€ Acute Fatty Liver of Pregnancy (AFLP)

Pre-existing liver conditions:

€ Chronic liver diseases (e.g., Hepatitis B, C, cirrhosis)
€ Autoimmune liver diseases

Other liver disorders:

€ Gallstone disease
€ Drug-induced hepatotoxicity
€ Pregnancy-Specific Liver Disorders

Hyperemesis Gravidarum (HG)

€ Severe nausea and vomiting in early pregnancy leading to dehydration and electrolyte
imbalance.
€ Pathophysiology: Elevated b-hCG and estrogen levels.
€ Liver Involvement: Mild elevation of transaminases related to dehydration.

Management: IV fluids, antiemetics, thiamine supplementation

€ Watch for complications such as Wernicke’s encephalopathy.

Intrahepatic Cholestasis of Pregnancy (ICP)

€ Cholestasis caused by impaired bile flow, often in the third trimester.
€ Clinical Features: Pruritus (Notably on palms and soles), jaundice, raised bile acids.

Diagnosis:
€ Elevated serum bile acids (>10 μmol/L)
€ Raising liver enzymes (ALT, AST)

Complications: Premature labor, meconium-stained liquor, stillbirth

Management:
€ UDCA reduces bile acids
€ Early delivery at 37 weeks

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 Disorders in Pregnancy

HELLP Syndrome
€ Hemolysis, elevated liver enzymes, and thrombocytopenia in preeclampsia with
severe features.

Clinical Features: RUQ tenderness, nausea, vomiting, jaundice.

Diagnosis:
€ Hemolysis: Schistocytes on blood smear.
€ Elevated AST/ALT, low platelets (< 100,000/μL).

Complications: DIC, hepatic rupture.

Management:
€ Immediate delivery if > 34 weeks or maternal deterioration.
€ Supportive care: BP control, seizure prophylaxis, blood products if needed.

Acute Fatty Liver of Pregnancy (AFLP)

€ Microvesicular fatty infiltration of hepatocytes, usually third trimester.

Clinical Features: Nausea, vomiting, jaundice, hypoglycemia, coagulopathy.

Diagnosis:
€ Elevated liver enzymes, bilirubin
€ Hypoglycemia, prolonged INR
€ Imaging (Ultrasound/CT): Liver hypodensity

Complications: DIC, renal failure, maternal and fetal mortality.

Management:
€ Immediate delivery
€ Supportive care: IV fluids, glucose, blood products.

Hepatitis B
€ Transmission is through a vertical route.
€ Antiviral therapy (e.g., Tenofovir) and neonatal immunoprophylaxis (HBIG + vaccine).

Hepatitis C
€ ~5% risk of vertical transmission.

Cirrhosis
€ Can lead to variceal bleeding, hepatic decompensation.
€ Management: Beta-blockers for varices.

Autoimmune Hepatitis
€ Continue immunosuppressive therapy (e.g., Azathioprine).

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 MedEd FARRE: Obstetrics and Gynaecology

Gallstone Disease
€ Occurs due to pregnancy-induced cholestasis.

Clinical features: RUQ pain, nausea, jaundice.

Management: Conservative or laparoscopic cholecystectomy in the second trimester if
needed.

Drug-Induced Hepatotoxicity
€ Monitor hepatotoxicity with antiepileptics and TB drugs.
€ Stop the drug causing hepatotoxicity.

Reference: Williams Obstetrics, 26th Edition, Page no. 295.

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 Disorders in Pregnancy

9. What is Rh Negative Pregnancy? Describe the risk factors, effects, diagnosis

and management of Rh Negative Pregnancy. (10 Marks)

Answer:

Rh NEGATIVE PREGNANCY

An Rh negative pregnancy is defined as a woman with Rh negative blood and her

fetus has Rh positive blood.

Risk Factors for Isoimmunization

€ Fetomaternal Hemorrhage (FMH)

€ Procedures like amniocentesis, Chorionic Villus Sampling (CVS)

€ Trauma: Abdominal trauma or placental abruption

€ Previous Pregnancy: Higher risk, if sensitization occurred earlier

Effects of Isoimmunization

Fetal complications:
€ Hemolysis leads to anemia, jaundice, hepatosplenomegaly

€ Severe cases: Hydrops fetalis, stillbirth

Neonatal complications:
€ Severe hyperbilirubinemia causing kernicterus

€ Anemia (Requiring blood transfusion)

Diagnosis

Maternal testing:
€ Blood group and Rh typing

€ Indirect Coombs Test (ICT): Detects maternal anti-D antibodies

€ Positive test indicates sensitization

€ Antibody titers > 1:16 warrant fetal monitoring

Fetal monitoring:
€ Ultrasound: Signs of hydrops fetalis (Ascites, edema, pleural or pericardial effusion)

€ Middle Cerebral Artery Doppler: Increased peak systolic velocity indicates fetal
anemia
€ Amniocentesis: Determines bilirubin levels in amniotic fluid (Liley’s curve)

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 MedEd FARRE: Obstetrics and Gynaecology

Management of Rh Negative Pregnancy

First antenatal visit:

Determine Rh status of the woman. If Rh negative,
determine Rh status of the husband

Rh negative woman with Rh positive husband

Perform ICT titer

ICT titer <1:16 dilution

ICT titer negative ICT titer: 1:16 dilution or
more

Repeat titer every 2 wk

Repeat titer every 4 wk

Monitor every 2 wk:

Deliver at normal time
Fetal USG (20 wk onwards): MCA-
Give anti-D (300 µg IM) No anti-D prophylaxis needed
PSV and features of hydrops
prophylaxis at 28 to 32 wk

Repeat anti-D (300 µg IM) Features of

within 72 h of birth if MCA-PSV: 1.5 MoM or more hydrops
baby is Rh positive present

Repeat MSA-PSV after one wk

MSA-PSV 1.5 MoM or more

Perform cordocentesis: perform IUT if fetal Hb<10 gm/dL

Repeat IUT after 2 wk and every 3 wk thereafter

Deliver at 35 wk or later

1. Rh negative refers to absence of 'D' antigen.

2. ICT titer for anti-D antibodies. Management of isoimmunization due to nonD- Rh antigen remains similar to that
of D- Rh antigen
3. Once the fetal bone marrow is suppressed by initial IUTs, repeat IUT is generally required every 3 wk
4. Give antenatal steroids if delivery is planned before 35 wk

Reference: Williams Obstetrics, 26th Edition, Page no. 921.

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 Disorders in Pregnancy

10. Write a note on the types of twin pregnancy, diagnosis, complications and
management needed. (10 Marks)

Answer:

TWIN PREGNANCY

Types of Twin Pregnancy

Zygosity:
€ Monozygotic results from division of a single zygote
€ Dizygotic results from fertilization of two different ova
Chorionicity and amnionicity:
€ Dichorionic-Diamniotic (DCDA): Two placentas and two amniotic sacs
€ Monochorionic-Diamniotic (MCDA): One placenta and two amniotic sacs
€ Monochorionic-Monoamniotic (MCMA): One placenta and one amniotic sac
€ Conjoined Twins: Failure of the embryonic disc to fully divide, resulting in physically
attached twins

Diagnosis
€ Ultrasound: In the first trimester
™ Lambda sign: Indicates a DCDA pregnancy
™ T-sign: Indicates a MCDA pregnancy
€ Biochemical Markers:
™ Elevated b-hCG and alpha-fetoprotein levels

Complications
€ Preterm labor and delivery
€ Hyperemesis gravidarum
€ Preeclampsia (2–3 times more common)
€ Gestational diabetes
€ Increased rate of cesarean section
€ Postpartum Hemorrhage (PPH)
€ Prematurity: High incidence of preterm birth (before 37 weeks)
€ Fetal Growth Issues: Intrauterine Growth Restriction (IUGR)
€ Discordant growth (> 20% weight difference)
€ Twin-Twin Transfusion Syndrome (TTTS): Occurs in MCDA twins
€ One twin (Donor) becomes anemic, and the other (Recipient) develops polycythemia.
€ Twin Anemia-Polycythemia Sequence (TAPS): Mild form of TTTS without polyhydramnios
€ Selective IUGR (sIUGR): Unequal placental sharing in MC twins
€ Cord Entanglement: Common in MCMA twins
€ Stillbirth and Neonatal Mortality: Higher risk than singleton pregnancies

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Intrapartum Management
Timing of delivery:
€ DCDA Twins: 37–38 weeks if uncomplicated.
€ MCDA Twins: 36–37 weeks.
€ MCMA Twins: 32–34 weeks following corticosteroids.

Delivery:
€ Vaginal Delivery: If both twins are in cephalic presentation.
€ Cesarean Section: For a non-cephalic first twin, MCMA twins, or other complications
like TTTS.

Reference: Williams Obstetrics, 26th Edition, Page no. 237.

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11. What are the physiological changes in thyroid function during pregnancy.
Describe hypothyroidism and hyperthyroidism in pregnancy.  (10 Marks)

Answer:

PHYSIOLOGICAL CHANGES IN THYROID FUNCTION DURING PREGNANCY

€ hCG: Mimics TSH, mildly increasing free T4 in the first trimester

€ Increased Thyroxine-Binding Globulin
€ Increased Iodine demand

HYPOTHYROIDISM IN PREGNANCY

a. Causes
€ Hashimoto’s thyroiditis (Most common)
€ Iodine deficiency

b. Clinical Features
€ Fatigue, weight gain, cold intolerance, constipation, depression
€ Severe cases: Myxedema

c. Diagnosis
€ Elevated TSH with low free T4
€ Positive antithyroid peroxidase (Anti-TPO) antibodies in autoimmune cases

d. Maternal and Fetal Complications

€ Maternal: Preeclampsia, gestational hypertension, anemia, placental abruption
€ Fetal: Miscarriage, preterm delivery, low birth weight, neurodevelopmental delays

e. Management
€ Levothyroxine:
™ Adjust dose to maintain TSH < 2.5 mIU/L in the first trimester and < 3.0 mIU/L in
the second and third trimesters
€ Regular TSH monitoring every 4–6 weeks

Iodine Deficiency Disorders

€ Iodine is essential for thyroid hormone synthesis
€ Deficiency increases risk of hypothyroidism, goiter, cretinism, and stillbirth
€ Prevention:
™ Ensure adequate dietary iodine intake (250 µg/day during pregnancy)
™ Use iodized salt or iodine supplements as recommended

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 MedEd FARRE: Obstetrics and Gynaecology

HYPERTHYROIDISM IN PREGNANCY

a. Causes
€ Graves disease (Most common)

€ hCG-mediated hyperthyroidism (Transient)

b. Clinical Features
€ Weight loss, heat intolerance, palpitations, irritability, goiter, ophthalmopathy

€ Severe cases: Thyroid storm

c. Diagnosis
€ Low TSH with elevated free T4/T3.

€ TSH receptor antibodies (TRAb) are positive in Graves disease.

d. Maternal and Fetal Complications

€ Maternal: Preeclampsia, preterm labor, heart failure, thyroid storm

€ Fetal: Growth restriction, preterm birth, neonatal thyrotoxicosis (If TRAb crosses
placenta)

e. Management
€ Antithyroid Drugs (ATDs):

™ First trimester: Propylthiouracil preferred due to lower teratogenicity

™ Second/third trimester: Shift to methimazole to reduce hepatotoxicity risk

€ Beta-Blockers: For symptomatic relief of tachycardia

€ Severe Cases: Thyroidectomy (If ATDs are not tolerated)

€ Monitor TSH, free T4 every 4 weeks

Postpartum Thyroiditis
€ Transient autoimmune thyroid dysfunction occurring within the first year postpartum

€ Phases:

™ Hyperthyroid phase (2–6 months postpartum)

™ Hypothyroid phase (4–8 months postpartum)

€ Most cases resolve spontaneously

Thyroid Function Testing in Pregnancy

€ Use trimester-specific reference ranges for TSH and free T4.

€ First-trimester TSH upper limit: ~2.5 mIU/L

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Note on Management
€ Hypothyroidism: Levothyroxine
€ Hyperthyroidism: ATDs, regular monitoring of thyroid function, and fetal surveillance
€ Fetal Monitoring: Ultrasound for growth, fetal heart rate, and signs of fetal
thyrotoxicosis like tachycardia, goiter or hydrops

Reference: Williams Obstetrics, 26th Edition, Page no. 1090-1095.

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MedEd FARRE: Obstetrics and Gynaecology

12. Describe HELLP syndrome under following headings: (5 Marks)

a. Pathophysiology

b. Clinical features

c. Diagnostic criteria

d. Differential diagnosis

e. Complications

f. Management

Answer:

HELLP SYNDROME

HELLP syndrome stands for Hemolysis, Elevated Liver enzymes, and Low Platelets. It is
a severe form of preeclampsia.

Pathophysiology
€ Hemolysis: Microangiopathic hemolytic anemia caused by endothelial dysfunction
and fibrin deposition in small blood vessels.
€ Elevated Liver Enzymes: Hepatic sinusoidal obstruction and fibrin deposition lead
to hepatocellular injury.
€ Low Platelets: Platelet activation and consumption in response to endothelial
damage.

Clinical Features
1. Symptoms:
™ Epigastric or right upper quadrant pain
™ Nausea, vomiting, and malaise
™ Headache and visual disturbances
™ Anemia
™ Bleeding tendencies

2. Signs:
™ Hypertension and proteinuria
™ Jaundice

Diagnostic Criteria (Tennessee Classification)

1. Hemolysis: Schistiocytes, elevated LDH > 600, bilirubin > 1.2
2. Elevated Liver Enzymes: More than 2 times normal
3. Low Platelets: Less than 1 lac/mm3

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Differential Diagnosis
€ Acute Fatty Liver of Pregnancy (AFLP)
€ Thrombotic Thrombocytopenic Purpura (TTP)
€ Hemolytic Uremic Syndrome (HUS)
€ Severe preeclampsia without HELLP

Maternal Complications
1. Disseminated Intravascular Coagulation (DIC)
2. Placental abruption
3. Acute kidney injury
4. Hepatic rupture or subcapsular hematoma
5. Pulmonary edema and heart failure

Fetal Complications
1. Preterm birth
2. Intrauterine growth restriction (IUGR)
3. Placental insufficiency
4. Stillbirth or neonatal death

Management
€ Definitive treatment: Immediate delivery
€ Vaginal delivery preferred

Supportive Management
1. Blood Pressure Control:
™ Antihypertensives: Labetalol, hydralazine, or nifedipine

2. Seizure Prophylaxis:
™ Magnesium sulfate

3. Blood Product Replacement:

™ Platelets
™ Fresh frozen plasma

Reference: Williams Obstetrics, 26th Edition, Page no. 1061.

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 MedEd FARRE: Obstetrics and Gynaecology

13. Describe the etiology, risk factors, clinical manifestations, pathophysiology,

diagnosis, management and complications of chorioamnionitis. (10 Marks)

Answer:

CHORIOAMNIONITIS

Chorioamnionitis is a bacterial infection of the amniotic fluid, membranes, placenta,

and/or decidua during pregnancy. It is associated with significant maternal and neonatal
morbidity.

Etiology
€ Polymicrobial infection

Risk Factors
1. Prolonged Rupture of Membranes (PROM)
2. Prolonged Labor
3. Premature Rupture of Membranes (PPROM)
4. Genital Tract Infections
5. Invasive Procedures

Pathophysiology
€ Ascending infection from the vagina or cervix.
€ Then the bacteria invade the chorioamniotic membranes, amniotic fluid, and
eventually the fetus if untreated.

Clinical Features
1. Maternal symptoms:
™ Fever (>38°C or 100.4°F)
™ Uterine tenderness
™ Foul-smelling or purulent vaginal discharge
™ Maternal tachycardia (>100 bpm)

2. Fetal signs:
™ Fetal tachycardia (>160 bpm)

3. Systemic symptoms:
™ Malaise, nausea, vomiting.

Diagnosis
1. Clinical diagnosis:
™ Maternal or fetal tachycardia
™ Uterine tenderness.
™ Purulent or foul-smelling amniotic fluid or discharge

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 Disorders in Pregnancy

2. Laboratory findings:
™ Leukocytosis (>15,000/mm³).
™ Elevated C-Reactive Protein (CRP)
™ Positive Gram stain on culture of amniotic fluid

3. Amniotic fluid analysis:

™ Elevated interleukin-6 (IL-6)
™ Low glucose (<15 mg/dL)

Complications
1. Maternal complications:
™ Endometritis, postpartum hemorrhage
™ Sepsis and septic shock
™ Increased risk of cesarean delivery complications

2. Fetal complications:
™ Preterm birth
™ Neonatal sepsis, pneumonia, or meningitis
™ Cerebral palsy and long-term neurodevelopmental delays

Management
€ Broad-spectrum IV antibiotics:
™ Ampicillin + Gentamicin: Common initial regimen.
™ Add Clindamycin or Metronidazole if cesarean delivery is performed to cover
anaerobes.

Prevention
1. GBS Prophylaxis
2. Minimizing Interventions
3. Management of PROM/PPROM (Antibiotics and corticosteroids)
Reference: Williams Obstetrics, 26th Edition, Page no. 801.

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 MedEd FARRE: Obstetrics and Gynaecology

14. What is cervical incompetence? Briefly describe its etiology, risk factors, clinical
features, differential diagnosis, diagnosis, management and complications.
 (5 Marks)

Answer:

CERVICAL INCOMPETENCE

Cervical incompetence or cervical insufficiency is the inability of the cervix to retain a

pregnancy in the absence of uterine contractions or labor.
It is the painless dilatation of the cervix leading to recurrent pregnancy loss,
mainly in the second trimester.

Etiology
€ Idiopathic
€ Collagen disorders (e.g., Ehlers-Danlos syndrome).
€ Uterine anomalies (e.g., Mullerian defects).
€ Cervical trauma
€ Infections

Risk Factors
€ History of second-trimester pregnancy losses
€ Cervical surgery or trauma
€ Multiple gestations (Increased pressure on the cervix)

Clinical Features
1. Symptoms:
™ Painless cervical dilatation
™ Recurrent second-trimester pregnancy loss
™ Premature Rupture of Membranes (PROM)

2. Signs:
™ Dilated cervix without contractions.
™ Bulging of fetal membranes

Diagnosis
1. History:
™ Recurrent pregnancy loss or preterm birth in the second trimester.

2. Ultrasound findings:
™ Transvaginal Sonography (TVS) is the gold standard.
™ Shortened cervical length (<25 mm before 24 weeks).
™ Funnel-shaped opening of the internal os.

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 Disorders in Pregnancy

3. Clinical examination:
™ Painless cervical dilatation on physical or speculum exam in mid-trimester.

Differential Diagnosis
€ Preterm labor (With painful contractions)
€ Uterine anomalies
€ Infections causing cervical changes

Management
€ Bed rest
€ Progesterone
€ Cervical Cerclage

Types of cerclage:
€ McDonald cerclage
€ Shirodkar cerclage
€ Transabdominal cerclage

Complications
€ Recurrent second-trimester losses
€ Preterm delivery
€ Cervical or uterine rupture
€ Infections (Chorioamnionitis, endometritis)
€ Premature rupture of membranes

Reference: Williams Obstetrics, 26th Edition, Page no. 205.

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 MedEd FARRE: Obstetrics and Gynaecology

15. Write a short note on recurrent pregnancy loss. (10 Marks)

Answer:

RECURRENT PREGNANCY LOSS

€ Recurrent Pregnancy Loss (RPL) is three or more consecutive pregnancy losses.

€ Evaluation starts after two pregnancy losses.

Etiology
€ Chromosomal abnormalities (Balanced translocations in parents)
€ Congenital uterine anomalies (e.g., Septate or bicornuate uterus)
€ Acquired uterine anomalies (e.g., Adhesions, fibroids, or polyps)
€ Antiphospholipid syndrome

Risk Factors
€ Advanced maternal age (>35 years)
€ Previous history of pregnancy losses
€ Smoking, alcohol use, or obesity.
€ Chronic maternal diseases (e.g., Hypertension)

Clinical Features
€ Dysmenorrhea or abnormal uterine bleeding
€ Hypothyroidism
€ PCOS
€ Thrombotic events
€ Preeclampsia

Diagnosis
1. Clinical history:
™ Number and timing of pregnancy losses
™ Family and obstetric history

2. Laboratory tests:
™ Karyotyping
™ APLA antibodies
™ TSH

3. Imaging:
™ Hysterosalpingography
™ Sonohysterography

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 Disorders in Pregnancy

Management
1. Chromosomal anomalies
™ Genetic counseling for parents

2. Uterine anomalies:
™ Septate uterus: Surgical correction via hysteroscopy
™ Adhesions: Adhesiolysis with subsequent estrogen therapy

3. Antiphospholipid Syndrome (APS):

™ Low-dose aspirin (75–150 mg/day)
™ Low-Molecular-Weight Heparin (LMWH)

4. Endocrine disorders:
™ Control thyroid and sugar levels

Reference: Williams Obstetrics, 26th Edition, Page no. 204.

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16. What is APLA syndrome? Write a note on the pathophysiology, clinical features,
diagnosis and management of APLA syndrome.  (3 Marks)

Answer:

ANTIPHOSPHOLIPID ANTIBODY SYNDROME

Antiphospholipid antibody syndrome (APLA) is an autoimmune disorder that is associated

with thrombosis and/or pregnancy-related complications due to antiphospholipid
antibodies. It can result in recurrent pregnancy loss.

Pathophysiology
€ Endothelial damage and activation.
€ Platelet activation leading to hypercoagulability.
€ Trophoblastic dysfunction causing placental insufficiency.

Clinical Features
1. Thrombosis:
™ Venous thrombosis (Deep vein thrombosis, pulmonary embolism)
™ Arterial thrombosis (Stroke, myocardial infarction)

2. Obstetric complications:
™ Recurrent early pregnancy losses (<10 weeks)
™ Late pregnancy losses (>10 weeks)
™ Preterm birth due to preeclampsia or placental insufficiency
™ Intrauterine Growth Restriction (IUGR)

3. Others:
™ Livedo reticularis
™ Thrombocytopenia
™ Catastrophic APLA syndrome (Multi-organ thrombosis)

Diagnostic Criteria (Sydney Criteria)

A. Clinical criteria:
™ Vascular thrombosis
™ Pregnancy morbidity:

1. One or more unexplained deaths of a normal fetus after 10 weeks.

2. Three or more unexplained consecutive pregnancy losses before 10 weeks.
3. Preterm birth before 34 weeks due to severe preeclampsia, eclampsia, or
placental insufficiency.

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 Disorders in Pregnancy

B. Laboratory criteria:
™ Anticardiolipin antibodies (IgG/IgM) in medium or high titers
™ Lupus anticoagulant (LA)
™ Anti-beta-2 glycoprotein-I antibodies (IgG/IgM)

Management
During pregnancy:
€ Low-Dose Aspirin (75–150 mg/day)
€ Low-Molecular-Weight Heparin (LMWH)
€ Monitoring:
™ Serial fetal growth scans for IUGR
™ Regular Doppler studies for uteroplacental insufficiency

Reference: Williams Obstetrics, 26th Edition, Page no. 1114.

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 MedEd FARRE: Obstetrics and Gynaecology

17. What is gestational trophoblastic disease? Describe its classification,

pathophysiology, types, clinical features, diagnosis and management.
 (5 Marks)

Answer:

GESTATIONAL TROPHOBLASTIC DISEASE

Gestational Trophoblastic Disease (GTD) is a spectrum of disorders arising from

trophoblasts of placenta. These include hydatidiform mole, invasive mole,
choriocarcinoma, and placental site trophoblastic tumor (PSTT).

Classification
1. Benign:
™ Complete mole
™ Partial mole

2. Malignant GTD:
™ Invasive mole
™ Choriocarcinoma
™ Placental Site Trophoblastic Tumor (PSTT)
™ Epithelioid Trophoblastic Tumor (ETT)

Pathophysiology
€ GTD results from abnormal proliferation of trophoblastic tissue.
€ Complete mole: Diploid or tetraploid (entirely paternal origin)
€ Partial mole: Triploid (69XXX, 69XXY, or 69XYY)

Types of GTD
A. Complete hydatidiform mole:
™ Fertilization of an empty ovum by one or two sperm.
™ No fetal tissue, only trophoblastic proliferation.
™ Gross appearance: “Grapelike” vesicles filling the uterine cavity.

B. Partial hydatidiform mole:

™ Fertilization of a normal ovum by two sperm.
™ Contains some fetal tissue and amniotic sac but is non-viable.

C. Invasive mole:
™ Locally invasive form of molar pregnancy.
™ May invade the myometrium and cause uterine perforation.

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 Disorders in Pregnancy

D. Choriocarcinoma:
™ Highly malignant tumor derived from trophoblasts.
™ May metastasize to the lungs, liver, and brain.

E. Placental Site Trophoblastic Tumor (PSTT):

™ Rare, slow-growing tumor arising from intermediate trophoblasts.
™ Associated with low levels of beta-hCG.

Clinical Features
1. Symptoms:
™ Vaginal bleeding (Most common).
™ Hyperemesis gravidarum due to elevated beta-hCG.
™ Symptoms of hyperthyroidism (Increased beta-hCG mimicking TSH).

2. Signs:
™ Uterine size larger than gestational age.
™ Absence of fetal heart sounds.
™ Passage of vesicular tissue.

3. Complications:
™ Theca lutein cysts (Ovarian enlargement)
™ Anemia due to bleeding
™ Pulmonary embolism from trophoblastic emboli

Diagnosis
1. Laboratory tests:
™ Elevated serum beta-hCG (extremely high in complete mole)

2. Ultrasound findings:
™ Complete mole: “Snowstorm” or “honeycomb” appearance with no fetus
™ Partial mole: Irregular fetal parts with abnormal placenta

3. Histopathology:
™ Complete mole: Diffuse trophoblastic proliferation & hydropic villi
™ Partial mole: Focal trophoblastic hyperplasia with some normal villi

Management
A. Hydatidiform mole:
™ Suction evacuation with curettage

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B. Gestational Trophoblastic Neoplasia (GTN):

1. Chemotherapy:
Š Low-risk: Methotrexate or Actinomycin-D

Š High-risk: EMA-CO regimen - Etoposide, Methotrexate, Actinomycin-D, Cyclo-

phosphamide, and Vincristine

2. Surgery:
Š Hysterectomy for resistant or localized disease.

Reference: Williams Obstetrics, 26th Edition, Page no. 235.

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