Topic: Primigravida with 34 weeks of gestational age came with pedal edema, headache,

vomiting, blurring of vision and increased blood pressure.

a) What is the diagnosis? Write definition (10 Marks)

Heading: Severe Pre-eclampsia (PE)

Diagnosis: The clinical picture of a primigravida at 34 weeks of gestation presenting with pedal edema,
headache, vomiting, blurring of vision, and increased blood pressure is highly suggestive of
Severe Pre-eclampsia (PE).

Definition of Pre-eclampsia (PE):

●​ PE is defined as new onset of hypertension (systolic BP ≥ 140 mm Hg or diastolic BP ≥

90 mm Hg, or both, measured two times with at least 4-hour apart).
●​ AND either proteinuria (urinary excretion of ≥ 0.3 g protein/24 hours or urine
protein-creatinine ratio > 0.3 mg or dipstick ≥ 1+) or other signs of end-organ
dysfunction.
●​ Occurs after 20 weeks of gestation in a previously normotensive woman.
●​ It is a progressive multisystem disorder.

Severe features include:

●​ Systolic BP ≥ 160 mm Hg and/or diastolic BP ≥ 110 mm Hg on two occasions at least

4 hours apart.
●​ Symptoms of central nervous system dysfunction (photopsia, blurred vision,
scotomata, cortical blindness, severe headache, altered mental status, stroke).
●​ Hepatic abnormality (severe persistent right upper quadrant or epigastric pain; or serum
transaminase concentration ≥ 2 times upper limit of normal range).
●​ Pulmonary edema.
●​ Thrombocytopenia (platelet count < 100,000/mm³).
●​ Renal insufficiency (serum creatinine > 1.1 mg/dL or doubling of serum creatinine).

b) How will you manage this case? (10 Marks)

Heading: Management of Severe Pre-eclampsia

Management/Treatment:

1.​ Immediate Hospitalization: Mandates hospitalization until delivery.

2.​ Stabilization and Monitoring:
○​ Rest: Bed rest, ideally in a lateral recumbent position.
○​ Vitals: Monitor pulse, BP, respiratory rate, and SaO2 every 10-30 minutes.
Temperature and lung sounds every 2 hours.
○​ Fluid Balance: Intake and output record. IV crystalloids, colloids. Total fluid
should be ≤ 125 mL/h. Avoid excessive dextrose or crystalline solutions.
○​ Laboratory Tests: Complete blood count, platelet count, coagulation profile (if
platelet count ≤ 100,000/ml), uric acid, creatinine, LFT (AST, ALT, LDH), urine for
protein/[P/C ratio]. Ophthalmoscopic examination.
3.​ Antihypertensive Therapy:
○​ Goal: To maintain BP < 160/110 mm Hg (target SBP: 140-160 mm Hg, DBP:
90-100 mm Hg).
○​ First-line drugs:
■​ Labetalol: 10-20 mg IV every 10 minutes, max 300 mg IV.
■​ Hydralazine: 5 mg IV every 30 minutes, max 30 mg IV.
■​ Nifedipine: 10-20 mg oral, repeated in 30 minutes, max 240 mg/24h.
4.​ Seizure Prophylaxis:
○​ Magnesium Sulfate (MgSO4) is the drug of choice.
○​ Regimen: IV/IM regimens. Acts as a membrane stabilizer and neuroprotector.
○​ Monitoring MgSO4 Toxicity: Respiratory rate (>12/min), urine output
(>100mL/4h), deep tendon reflexes (present). Calcium gluconate is the antidote.
5.​ Corticosteroid Therapy (for fetal lung maturation):
○​ Recommended if pregnancy is < 34 weeks gestation (patient is 34 weeks, so
consider if delivery is anticipated soon).
○​ Benefits: Reduces neonatal RDS, IVH, NEC, BPD, and PDA.
○​ Dosage: Betamethasone or Dexamethasone.
6.​ Fetal Wellbeing Assessment:
○​ Daily Non-stress Tests (NSTs).
○​ Twice weekly Biophysical Profile (BPP).
○​ USG for fetal growth including Doppler study of umbilical artery every 2 weeks.
○​ Monitor for non-reassuring fetal status (NRFS).
7.​ Timing and Mode of Delivery:
○​ Definitive treatment for PE is delivery.
○​ If pregnancy is ≥ 34 weeks, delivery should be done.
○​ Mode of delivery:
■​ If cervix is favorable: Surgical induction by low rupture of membranes (+
oxytocin).
■​ If cervix is unfavorable: Cervical ripening with PGE2 gel.
■​ Cesarean section for obstetric indications (malpresentation, NRFS, prior
CD) or if urgent termination is needed with unfavorable cervix or prolonged
induction-delivery interval.
■​ Regional anesthesia is preferred.
8.​ Postpartum Management:
○​ Closely watch for at least 48 hours for convulsions.
○​ Continue antihypertensive drug if BP is high.
○​ Continue MgSO4 for at least 24 hours following delivery or after the last
seizure.
○​ Monitor BP, urine output, and blood tests.
○​ In breastfeeding women: Labetalol, nifedipine, or enalapril may be used.
Methyldopa is avoided.

Prognosis:

●​ Maternal and perinatal morbidity and mortality are significantly increased.

Topic: Write an essay on antepartum fetal surveillance. (10 Marks)

Heading: Antepartum Fetal Surveillance

Definition/Objectives:

●​ Definition: Antepartum fetal surveillance refers to the assessment of fetal well-being

before labor begins.
●​ Primary Objectives:
1.​ Assessment of fetal well-being.
2.​ Prevention of fetal death.
3.​ Avoidance of unnecessary interventions.

Methods of Fetal Surveillance: Fetal surveillance encompasses clinical, biochemical, and biophysical
methods.

1.​ Clinical Assessment:​

○​ Daily Fetal Movement Counting Rate (DFMCR): Maternal perception of fetal

movements, usually started from 28 weeks. A significant decrease may indicate
fetal jeopardy.
○​ Uterine Size and Fundal Height (SFH): Serial measurements help in assessing
fetal growth. Discrepancy > 3 cm or SFH < 10th centile may indicate FGR.
○​ Abdominal Girth: Documentation in the last trimester to assess steady increase.
Gradual diminution may suspect placental insufficiency.
2.​ Biochemical Tests:​

○​ Fetal Lung Maturity Assessment:

■​ Lecithin:Sphingomyelin (L:S) ratio: A ratio of 2:1 in amniotic fluid
signifies full maturity of the fetal lung.
■​ Phosphatidylglycerol (PG): Presence indicates lung maturity.
○​ Maternal Serum Screening:
■​ Maternal Serum Alpha Fetoprotein (MSAFP): Elevated levels can
indicate neural tube defects or omphalocele.
■​ Quadruple test: Includes MSAFP, uE3, hCG, and inhibin A.
■​ Cell-free DNA (cf-DNA) analysis: From maternal plasma/blood, detectable
from the first trimester, used for prenatal diagnosis of chromosomal
abnormalities (e.g., Down's Syndrome).
3.​ Biophysical Assessment (Ultrasonography-based):​

○​ Fetal Growth Profile: Ultrasonographic measurements of Biparietal Diameter

(BPD), Head Circumference (HC), Abdominal Circumference (AC), and Femur
Length (FL) are used to estimate fetal weight and assess growth.
○​ Amniotic Fluid Volume (AFV) Assessment:
■​ Amniotic Fluid Index (AFI): Sum of the largest vertical pocket in four
quadrants. AFI < 5 cm indicates oligohydramnios, and AFI > 25 cm
indicates polyhydramnios.
■​ Single Deepest Vertical Pocket (DVP).
■​ Clinical Significance: Oligohydramnios (liquor pool < 2 cm) is associated
with cord compression and meconium-stained liquor.
○​ Non-stress Test (NST): Evaluates fetal heart rate accelerations in response to
fetal movement. A reactive NST is reassuring.
○​ Biophysical Profile (BPP): A comprehensive assessment including: Fetal
breathing movements, Gross body movements, Fetal tone, Reactive FHR (NST),
Amniotic fluid volume.
○​ Doppler Velocimetry Studies: Used to assess fetal and uteroplacental circulation:
■​ Umbilical Artery (UA) Doppler: High impedance/absent/reversed
end-diastolic velocity indicates increased vascular flow resistance and
fetal hypoxia.
■​ Middle Cerebral Artery (MCA) Doppler: Decreased S/D or pulsatility
index indicates vasodilatation (brain sparing effect) in response to
hypoxemia.
■​ Ductus Venosus (DV) Doppler: Abnormal flow (absent/reversed a-wave)
indicates fetal acidemia.
■​ Uterine Artery (UtA) Doppler: High PI or notching can predict
pre-eclampsia and FGR.

Significance:

●​ Antepartum fetal surveillance allows for early detection of potential complications like
fetal hypoxia, growth restriction, or congenital anomalies.
●​ This enables timely intervention, such as planned delivery or in-utero therapy, to
improve perinatal outcomes and reduce morbidity and mortality.
●​ It also helps in counseling parents about prognosis and risks associated with identified
conditions.

Topic: MTP Act (5 Marks)

Heading: Medical Termination of Pregnancy (MTP) Act

Definition of Medical Termination of Pregnancy (MTP):

●​ MTP refers to the deliberate termination of pregnancy.

Legislative Framework:

●​ The Medical Termination of Pregnancy Act 1971, amended in 2021.

Indications for MTP (as per MTP Act 2021 amendments):

1.​ To save the life of the pregnant woman.

2.​ To prevent grave injury to the physical or mental health of the pregnant woman.
3.​ Substantial risk that if the child was born, it would suffer from a mental or physical
abnormality as to be seriously handicapped.
4.​ Pregnancy has occurred as a result of failure of any contraceptive device (applicable to
married and unmarried women).
5.​ Special Categories of Women for MTP up to 24 weeks:
○​ Survivors of sexual assault, rape, or incest.
○​ Minors.
○​ Change of marital status during the ongoing pregnancy (e.g., widowhood, divorce).
○​ Women with physical disabilities.
○​ Mentally ill women.
○​ Fetal malformation with a substantial risk of serious handicap.
○​ Women in humanitarian settings or disaster/emergency situations.

Gestation Limits and Required Opinions:

●​ Up to 12 weeks: Opinion of one Registered Medical Practitioner (RMP).

●​ Beyond 20 weeks to 24 weeks: Opinions of two RMPs.
●​ Beyond 24 weeks (anytime during pregnancy): For cases of substantial fetal
abnormalities, diagnosis and decision by a Medical Board.

Qualifications of a Registered Medical Practitioner (RMP) to perform MTP: An RMP is qualified if:

1.​ They have assisted in at least 25 MTPs in an authorized center and possess a certificate.
2.​ They have 6 months house surgeon training in Obstetrics and Gynecology.
3.​ They hold a diploma or degree in Obstetrics and Gynecology.

Key Requirements/Procedures:

●​ Confidentiality: Must be strictly maintained.

●​ Reporting: Abortion must be reported to the Director of Health Services of the State.
●​ Methods:
○​ Medical methods (up to 63 days of gestation): Mifepristone (progesterone
antagonist) and misoprostol (PGE1).
○​ Surgical methods: Dilatation and Evacuation (D&E), Suction Evacuation (SE).

Topic: Define postpartum haemorrhage and write the management of postpartum haemorrhage.
(5 Marks)

Heading: Postpartum Hemorrhage (PPH)

Definition of Postpartum Hemorrhage (PPH):

●​ PPH is defined as the excessive bleeding following delivery (> 500 mL in vaginal
delivery or > 1000 mL in cesarean delivery) accompanied by signs and symptoms
of hypovolemia.
●​ Average blood loss: Vaginal delivery (~500 mL), Cesarean delivery (~1000 mL).
●​ Classification by amount: Minor (< 1 L), Major (> 1 L), Severe (> 2 L).
●​ Timing:
○​ Primary PPH: Occurs within 24 hours of delivery.
○​ Secondary PPH: Occurs between 24 hours and 12 weeks postpartum.

Causes of Primary PPH (The 4 'T's):

1.​ Tone (Uterine Atony - most common): Failure of the uterus to contract and retract after
placental expulsion. Accounts for 80% of PPH.
2.​ Trauma: Lacerations of the birth canal (cervix, vagina, perineum), rupture of the uterus.
3.​ Tissue: Retained placental tissue (cotyledon or membranes) or morbidly adherent
placenta.
4.​ Thrombin: Coagulation disorders (e.g., DIC, pre-existing coagulopathy).

Management of Postpartum Hemorrhage (PPH): The management of PPH is a simultaneous,

multidisciplinary approach, often referred to as "The Golden Hour".

Principles:

1.​ Communication: Call for extra help immediately (senior staff, anesthetist, blood bank).
2.​ Resuscitation:
○​ IV access: Establish 2 large-bore (14 or 16 gauge) IV cannulas.
○​ Fluids: Rapidly infuse warm isotonic crystalloids (up to 2 liters). Colloids (up to 1-2
liters).
○​ Blood products: Send blood for cross-matching, coagulation screening. Request
at least 2 units of packed red blood cells (PRBC) immediately. Transfuse
PRBCs as available. Administer Fresh Frozen Plasma (FFP) (4 units for every 6
units of PRBC). Platelets (if count < 50 x 10⁹/L) and Cryoprecipitate (if fibrinogen <
1 g/L).
○​ Oxygen: Administer oxygen via face mask (8-10 L/min).
○​ Catheterization: Insert Foley catheter to monitor urine output.
○​ Monitoring: Continuous monitoring of pulse, BP, temperature, respiratory rate,
SpO2, and urine output every 5-15 minutes. Assess Shock Index (SI).
3.​ Identify the cause and Arrest of Bleeding:
○​ Uterine Atony (most common):
■​ Uterine Massage: Control the fundus and perform vigorous bimanual
uterine compression and massage.
■​ Oxytocics:
■​ Oxytocin: 10-20 units in 1 L crystalloid IV infusion.
■​ Methergine: 0.2 mg IM/IV (contraindicated in cardiac cases or
severe pre-eclampsia).
■​ Carbetocin: 100 µg IM/IV.
■​ Prostaglandins:
■​ Carboprost: 250 µg IM/intramyometrial (contraindicated in
asthma).
■​ Misoprostol: 600-1000 µg rectally or sublingually.
■​ Tranexamic Acid (TXA): 1 g IV in 10 mL over 30 min (WHO
recommendation).
■​ Uterine Tamponade (if medical management fails): Intrauterine balloon
tamponade (e.g., Bakri balloon), tight intrauterine packing.
■​ Surgical Methods (if conservative measures fail): B-Lynch compression
sutures, ligation of uterine/internal iliac arteries, Hysterectomy (subtotal
preferred).
○​ Traumatic Hemorrhage: Requires exploration of the uterovaginal canal under
anesthesia to identify lacerations and hematomas. Hemostatic sutures placed.
○​ Retained Placental Tissue: If placenta not expelled, Manual Removal of
Placenta (MRP) under general anesthesia. If retained bits suspected, exploration
of uterus with ovum forceps and gentle curettage.
○​ Coagulopathy: Manage underlying cause (e.g., DIC). Administer blood
components (FFP, platelets, cryoprecipitate) based on coagulation profile.

Prevention:

●​ Antenatal: Screen high-risk patients, plan delivery in well-equipped hospitals, blood

grouping, placental localization.
●​ Intranatal: Active management of the third stage of labor (AMTSL) for all women
(reduces PPH by 60%). Includes:
○​ Administer parenteral oxytocic (e.g., Oxytocin 10 IU IM) within 1 minute of baby's
delivery.
○​ Controlled cord traction.
○​ Uterine massage.

Complications of PPH:

●​ Hemorrhagic shock
●​ Disseminated Intravascular Coagulation (DIC)
●​ Acute Kidney Injury (AKI)/Anuria
●​ Pulmonary embolism
●​ Uterine inversion
●​ Sepsis
●​ Maternal death

Topic: Write a short essay on puerperal complications. (5 Marks)

Heading: Puerperal Complications

Definition of Puerperium:
●​ The period following childbirth, during which the mother's body, including the reproductive
organs, returns to its non-pregnant state. This typically lasts about 6 weeks.

Puerperal Complications: Puerperal complications can broadly be classified as those affecting

physical recovery and those with psychological impact.

1.​ Puerperal Pyrexia / Sepsis:​

○​ Definition: A rise of temperature reaching 100.4°F (38°C) or more (orally) on

two separate occasions, 24 hours apart (excluding first 24 hours) within the
first 10 days following delivery.
○​ Causes: Genital sepsis (most common), Urinary Tract Infection (UTI), mastitis,
C-section wound infection, pulmonary infection, septic thrombophlebitis,
recrudescence of malaria/tuberculosis, or unknown.
○​ Clinical Features: Fever, chills, rigor, localized pain (e.g., uterine tenderness,
wound site pain), purulent discharge, features of shock.
○​ Management: General care (isolation, fluids). Empirical broad-spectrum
therapy (e.g., gentamicin + clindamycin + metronidazole) initially, then tailored.
Surgical intervention for severe cases with abscesses or necrotic tissue.
○​ Complications: Septic shock, multiorgan failure, DIC, ARDS, thrombophlebitis,
subinvolution.
2.​ Subinvolution:​

○​ Definition: Failure of the uterus to return to its normal size and position in the
puerperium.
○​ Causes: Retained placental fragments, infection (endometritis), uterine fibroids.
○​ Clinical Features: Prolonged or excessive lochial discharge (often foul-smelling),
uterine tenderness, larger than expected uterus.
○​ Management: Oxytocics (methergine), antibiotics for infection, surgical evacuation
for retained products.
3.​ Urinary Complications:​

○​ Urinary Retention: Common. Management: Catheterization (intermittent or

indwelling for 48 hours), urinary antiseptics.
○​ Incontinence of Urine:
■​ Stress Incontinence: Due to weakened pelvic floor muscles.
Management: Pelvic floor muscle training (PFMT).
■​ True Incontinence: Due to genitourinary fistula. Management: Surgical
repair.
○​ Urinary Tract Infection (UTI): Management: Antibiotics.
4.​ Breast Complications:​

○​ Engorgement, Cracked Nipples.

○​ Mastitis: Inflammation of the breast, usually infectious (Staphylococcus aureus).
Management: Continue breastfeeding (or express milk), antibiotics,
analgesics.
○​ Breast Abscess: Untreated mastitis. Management: Incision and drainage,
continued antibiotics.
5.​ Puerperal Venous Thrombosis and Pulmonary Embolism (PE):​

○​ Risk Factors: Previous VTE, heart disease, SLE, surgical procedure (LSCS),
obesity, immobility. Pregnancy itself is a hypercoagulable state.
○​ Clinical Features: Pain, tenderness, swelling in leg for DVT. Dyspnea, chest pain,
hemoptysis for PE.
○​ Management: Anticoagulation (LMWH), ambulation, compression stockings.
6.​ Puerperal Emergencies: Examples include acute kidney injury, eclampsia
(postpartum), septic shock.​

7.​ Psychiatric Disorders during Puerperium:​

○​ Postpartum Blues: Common, transient mood swings, anxiety, irritability, usually

resolves within 10 days.
○​ Postpartum Depression: More severe and persistent, requiring professional
help.
○​ Postpartum Psychosis: Rare but severe, with hallucinations, delusions, high risk
of self-harm or harm to baby; medical emergency.
○​ Management: Counseling, support, medication (antidepressants, antipsychotics),
psychotherapy.

Overall Significance:

●​ Puerperal complications significantly contribute to maternal morbidity and mortality. Early

detection, prompt management, and adherence to aseptic practices are crucial for a
healthy postpartum recovery.

Topic: Cardiovascular changes in pregnancy. (5 Marks)

Heading: Cardiovascular Changes in Pregnancy

Introduction: Pregnancy induces significant physiological changes in the cardiovascular system to
accommodate the demands of the growing fetus and uteroplacental unit.

1.​ Blood Volume:​

○​ Markedly raised: Increases progressively from about 6th week, peaking at

40-50% above non-pregnant levels by 30-34 weeks.
○​ Plasma Volume: Increases by 40-50%.
○​ Red Cell Volume: Increases by 20-30%.
○​ Physiological Anemia of Pregnancy: Due to a greater increase in plasma
volume compared to red cell volume, there is a relative fall in hemoglobin and
hematocrit.
2.​ Cardiac Output (CO):​

○​ Increased: Starts to increase from 5th week of pregnancy, reaching its peak
40-50% higher than non-pregnant levels by 30-34 weeks.
○​ Positional Variation: Lowest in sitting or supine position, highest in right or left
lateral or knee-chest position.
○​ During Labor: Increases further by +50% over prelabor values.
○​ Immediately Postpartum: Maximum increase (up to +70%) occurs within 10-30
minutes after delivery due to autotransfusion from the uterus.
3.​ Stroke Volume (SV): Increases by +27%.​

4.​ Heart Rate (HR): Increases by +17%.​

5.​ Blood Pressure (BP):​

○​ Generally unaffected or shows a mid-pregnancy drop in diastolic pressure by

5-10 mm Hg.
○​ Blood pressure measurement technique: Cuff should be 1.5 times upper arm
circumference, patient in upright or sitting/left lateral position after 10-min rest.
6.​ Venous Pressure:​

○​ Increases significantly, especially in the femoral veins (+100%) due to

compression of the inferior vena cava and pelvic veins by the gravid uterus.
7.​ Colloid Oncotic Pressure:​

○​ Decreases by 14% (from 20 mm Hg to 18 mm Hg) due to hemodilution,

contributing to physiological edema.
8.​ Systemic Vascular Resistance (SVR) and Pulmonary Vascular Resistance (PVR):​
○​ Both decrease: SVR by -21% and PVR by -34%.
9.​ Heart Sounds and Murmurs (Physiological Changes):​

○​ Splitting of the first heart sound.

○​ Systolic ejection murmur at the left sternal border.
○​ Continuous hissing murmur over the tricuspid area ('mammary murmur').
○​ Third heart sound (S3) due to rapid diastolic filling.
10.​ Physiological Edema:​

○​ Mild edema of the legs is common due to diminished colloid osmotic tension
(hemodilution) and increased venous pressure in the lower extremities.
11.​ Renin-Angiotensin-Aldosterone System (RAAS) and Natriuretic Peptides:​

○​ RAAS activity increases. Atrial and brain natriuretic peptides are secreted, acting
as antagonists to RAAS.

Clinical Significance:

●​ Familiarity with these physiological changes is crucial for a cautious approach in

diagnosing and managing heart disease during pregnancy, as many normal
pregnancy findings can mimic pathological conditions.
●​ Cardiac failure commonly occurs around 30 weeks, during labor, and especially
soon after delivery due to the maximal hemodynamic stress.

Topic: Blood components. (5 Marks)

Heading: Blood Components

Introduction: Blood components are primarily discussed in the provided sources in the context of
physiological changes during pregnancy and in relation to specific medical conditions or
transfusions.

Blood Components mentioned in the sources:

1.​ Whole Blood/Blood Volume:

○​ Refers to the total volume of blood circulating, consisting of plasma and cellular
components. Increases significantly during pregnancy.
2.​ Plasma (Plasma Volume):
○​ The liquid matrix of blood. Its volume increases more than red cell volume in
pregnancy, leading to hemodilution.
○​ Contains components like fibrinogen, other proteins (e.g., globulin, albumin,
enzymes).
3.​ Red Blood Cells (RBCs) / Erythrocytes:
○​ Responsible for oxygen transport due to hemoglobin.
○​ Red Cell Volume: Increases during pregnancy, but less proportionally than
plasma.
○​ Hemoglobin (Hb): Oxygen-carrying protein in RBCs. Fetal hemoglobin (HbF) has
greater affinity for oxygen than adult hemoglobin (HbA).
○​ Hematocrit (PCV): Percentage of blood volume occupied by RBCs. Decreases in
physiological anemia of pregnancy.
4.​ White Blood Cells (WBCs) / Leukocytes:
○​ Involved in immune response. Elevated WBC count may indicate infection.
Neutrophils, lymphocytes, monocytes are types of WBCs.
5.​ Platelets (Thrombocytes):
○​ Crucial for hemostasis and blood clotting.
○​ Thrombocytopenia: Low platelet count, can indicate severe pre-eclampsia or
bleeding disorders.
6.​ Clotting Factors / Coagulation Profile:
○​ Proteins in plasma essential for blood clotting.
○​ Fibrinogen: A key clotting factor.
○​ Prothrombin Time (PT), Activated Partial Thromboplastin Time (APTT): Tests
to assess coagulation pathway function.
○​ D-dimer: Elevated in DIC and thrombotic states.
○​ Antithrombin III: An anticoagulant.
7.​ Serum Electrolytes:
○​ Ions in the blood, e.g., sodium, potassium, calcium. Important for fluid balance and
cellular function.
8.​ Glucose:
○​ Blood sugar levels are critical, especially in diabetes in pregnancy.
9.​ Bilirubin:
○​ A breakdown product of hemoglobin, elevated levels cause jaundice.

Contextual mentions of blood products for transfusion:

●​ Packed Red Blood Cells (PRBC)

●​ Fresh Frozen Plasma (FFP)
●​ Platelet Concentrates
●​ Cryoprecipitate
Topic: Hormonal contraception. (5 Marks)

Heading: Hormonal Contraception

Introduction: The provided sources offer limited specific details on hormonal contraception beyond
mentioning common types and certain contraindications/recommendations in postpartum or
specific medical contexts.

1.​ Combined Oral Contraceptives (COCs):​

○​ Description: Contain both estrogen and progestin.

○​ Use: Can be used once serum beta hCG is negative following treatment of molar
pregnancy.
○​ Contraindications (WHO Category-3 - risks outweigh advantages):
■​ Active liver disease, liver adenoma, carcinoma.
■​ Migraine with focal neurological symptoms (aura).
■​ Breastfeeding (postpartum 6 weeks).
■​ Major surgery or prolonged immobility.
■​ Hyperlipidemia.
■​ Unexplained vaginal bleeding.
■​ Thyroid disease.
■​ Epilepsy.
■​ Tuberculosis.
■​ Varicose veins.
■​ Benign breast disease.
■​ Sickle cell disease.
■​ Diabetes with vascular complications.
■​ Mild hypertension.
■​ Gallbladder disease.
■​ Endometriosis, uterine fibroid, ovarian or endometrial cancer.
■​ Dysmenorrhea, DUB (Dysfunctional Uterine Bleeding).
■​ Pelvic inflammatory disease.
■​ Cancer cervix or CIN (Cervical Intraepithelial Neoplasia).
2.​ Progestin-only Contraception:​

○​ Types mentioned: Progestin-only pills or parenteral progestins.

○​ Depot Medroxyprogesterone Acetate (DMPA): An injectable progestin.
○​ Use: Safe and effective, especially in postpartum women with cardiac disease.
Can be used after molar pregnancy.
○​ Side effect: May cause irregular bleeding, especially if the patient is
anticoagulated.
3.​ Levonorgestrel-Intrauterine System (LNG-IUS): Mentioned as an abbreviation,
implying it's a known contraceptive.​

4.​ Intrauterine Device (IUD):​

○​ Mentioned in context of postpartum family planning (insertion and removal).

○​ Caution: Avoided after molar pregnancy due to risk of bleeding.

General Principle of Contraception in Obstetrics:

●​ Counseling for contraception is a mandatory part of postpartum care.

●​ Barrier methods (e.g., condom) are considered a good option.
●​ Sterilization (tubal ligation or vasectomy) is an option for family completion.

Topic: Write a short note on mechanism of normal labor. (5 Marks)

Heading: Mechanism of Normal Labor

Definition:

●​ Normal Labor: The process by which the fetus, placenta, and membranes are expelled
from the uterus through the birth canal.

Mechanism of Normal Labor (in Left Occipito-Anterior (LOA) position - most common): Normal
labor is a series of active movements of the fetal head and body through the birth canal to adapt
to the changing dimensions of the maternal pelvis. The process involves several cardinal
movements:

1.​ Engagement:​

○​ The widest diameter of the fetal presenting part (usually biparietal diameter in
vertex presentation) passes through the plane of the pelvic inlet.
○​ In LOA, the sagittal suture is in the right oblique diameter of the pelvis, and the
occiput points towards the left iliopectineal eminence.
2.​ Descent:​

○​ Continuous movement of the fetal head downwards through the pelvis.

○​ It is the first essential movement and progresses throughout labor.
3.​ Flexion:​

○​ As the descending head meets resistance, it undergoes flexion.

○​ This converts the presenting diameter from the relatively larger occipitofrontal (11.5
cm) to the smaller suboccipitobregmatic (9.5 cm).
4.​ Internal Rotation:​

○​ The occiput rotates anteriorly from the oblique position to the midline (under
the symphysis pubis).
○​ In LOA, the occiput rotates 3/8th of a circle (45 degrees) from the left anterior to
the symphysis pubis.
5.​ Crowning:​

○​ Occurs when the largest diameter of the fetal head (biparietal diameter) is
encircled by the vulvar ring, and the head no longer recedes between contractions.
○​ The suboccipital region of the fetal head rests against the inferior border of the
symphysis pubis.
6.​ Extension:​

○​ Once crowning occurs, the head extends (deflects) as it passes under the
symphysis pubis.
○​ The nape of the neck acts as a pivot, and the forehead, nose, mouth, and chin are
born successively over the perineum.
7.​ Restitution:​

○​ After the birth of the head, it immediately rotates 1/8th of a circle to align itself with
the fetal shoulders.
○​ In LOA, the occiput turns towards the left thigh of the mother.
8.​ External Rotation (or Further Restitution):​

○​ The shoulders enter the pelvis in an oblique diameter and rotate internally to the
anteroposterior diameter under the symphysis pubis.
○​ This causes the head to rotate further externally (1/8th of a circle) to align with the
shoulders. In LOA, the occiput turns towards the mother's left side.
9.​ Expulsion of the Body:​

○​ The anterior shoulder delivers under the symphysis pubis, followed by the posterior
shoulder sweeping over the perineum. The rest of the body follows rapidly by
lateral flexion.

Clinical Significance:
●​ Understanding the mechanism of labor is fundamental for assessing labor
progress, identifying deviations from normal, and intervening appropriately to
ensure a safe delivery.

Topic: Write the management of primigravida with 32 weeks of gestation with fetal growth
restriction. (5 Marks)

Heading: Management of Primigravida with 32 Weeks of Gestation with Fetal Growth Restriction
(FGR)

Diagnosis: Fetal Growth Restriction (FGR)

●​ Definition of FGR: FGR is a syndrome where the fetus fails to reach its growth potential
due to underlying maternal, fetal, or placental disorders.
●​ It is often defined as an estimated fetal weight (EFW) below the 10th percentile for
gestational age.
●​ Distinguish from "Small for Gestational Age (SGA)" where fetus is constitutionally
small but healthy; FGR implies a pathological process.

Types of FGR:

●​ Early Onset (Symmetrical) - 20%: Affects fetus early, resulting in proportionally small
head, abdomen, and femur. Often due to genetic abnormalities, congenital infections
(TORCH), or early severe hypertension. Pathology is intrinsic to the fetus.
●​ Late Onset (Asymmetrical) - 80%: Occurs later, with head relatively larger than
abdomen (head-sparing effect). Often due to chronic placental insufficiency. Pathology is
extrinsic to fetus.

Etiology / Risk Factors of FGR:

●​ Maternal Factors: Constitutional, age (> 40 years), BMI (< 20 or > 35), poor weight gain,
anemia, smoking, alcohol, chronic medical conditions (Hypertension, SLE, DM, CKD),
previous pre-eclampsia, SGA, stillbirth.
●​ Placental Factors: Poor uterine blood flow (maternal vascular malperfusion), infarction,
abruption, mosaicism.
●​ Fetal Factors: Genetic (chromosomal abnormalities), structural anomalies, congenital
infection (CMV, TORCH), teratogen exposure, multiple pregnancy.
●​ Umbilical Cord Factors: Increased/decreased cord length, single umbilical artery,
velamentous cord insertion, true knot.
●​ Unknown: ~40% of cases.
●​ Mnemonic for FGR Causes: MFPUTU (Maternal, Fetal, Placental, Umbilical, Toxins,
Unknown).

Pathophysiology:

●​ Reduced availability of nutrients (maternal cause) or reduced transfer by placenta

(placental cause) or reduced utilization by fetus (fetal cause).
●​ Brain cell size and number reduced (in symmetrical FGR), liver glycogen reduced.
●​ Oligohydramnios common.
●​ Risk of intrauterine hypoxia and acidosis.

Complications of FGR (Fetal):

●​ Antenatal: Chronic fetal distress, IUFD, preterm birth.

●​ Intrapartum: Hypoxia and acidosis.
●​ Immediate after birth: Asphyxia, hypoglycemia, meconium aspiration syndrome,
hypothermia, polycythemia, necrotizing enterocolitis, intraventricular hemorrhage,
multiorgan failure.
●​ Increased perinatal morbidity and mortality.

Management of Primigravida with 32 Weeks of Gestation with FGR: Management is based on

comprehensive diagnostic workup, considering the gestational age and severity.

1.​ Confirm Diagnosis and Assess Severity:​

○​ History & Clinical (SFH measurement).

○​ USG: Fetal biometry (EFW or AC <10th centile), rule out congenital anomalies.
○​ Doppler Study:
■​ Umbilical Artery (UA): Check for increased resistance (high PI), absent
(AEDFV) or reversed (AREDV) end-diastolic flow.
■​ Middle Cerebral Artery (MCA): Check for decreased PI or increased
diastolic flow (brain sparing effect).
■​ Cerebroplacental Ratio (CPR): < 5th percentile is abnormal.
■​ Ductus Venosus (DV): Abnormal flow indicates acidemia.
■​ Uterine Artery (UtA): High PI or notching.
2.​ Medical Management / Supportive Care:​

○​ Increased Rest, adequate Nutrition/Hydration.

○​ Cessation of harmful habits (smoking, alcohol, and illicit drugs).
○​ Low-dose Aspirin (75-150 mg daily): Started at 12-16 weeks for selected
high-risk cases.
○​ Folic Acid Supplementation. Treat underlying pathology.
○​ No proven treatment to improve FGR.
3.​ Fetal Surveillance:​

○​ Monitoring frequency: Serial assessment of fetal growth and wellbeing is needed.

○​ Kick counts (DFMCR), Non-stress Test (NST) / Cardiotocography (CTG)
(twice weekly), Biophysical Profile (BPP).
○​ Amniotic Fluid Volume (AFV) assessment (DVP): Oligohydramnios needs
careful monitoring.
○​ Doppler ultrasound parameters: Regularly assess UA, MCA, DV, and UtA for signs
of hypoxia/acidemia.
4.​ Corticosteroids for Fetal Lung Maturity:​

○​ Indicated: As the gestational age is 32 weeks, antenatal corticosteroids

(Betamethasone or Dexamethasone) should be administered to enhance fetal
lung maturation and reduce neonatal RDS, IVH, and NEC.
5.​ Magnesium Sulfate (Neuroprotection):​

○​ Indicated: For preterm labor (delivery anticipated) < 32 weeks, Magnesium sulfate
should be administered to the mother for neuroprotection to reduce neonatal
cerebral palsy. (Patient is at 32 weeks, so relevant if labor is imminent).
6.​ Timing and Mode of Delivery:​

○​ Critical issue: Balance the risks of prematurity against the risks of continued
pregnancy (IUFD, organ damage due to hypoxia).
○​ Generally: If Doppler studies show normal flow or increased resistance only and
fetal status is stable, pregnancy may be continued with close monitoring. If
Doppler studies show absent (AEDFV) or reversed (AREDV) end-diastolic
flow in UA, or abnormal DV flow, indicating severe compromise, delivery
should be considered even if preterm.
○​ Mode of delivery: Vaginal delivery is possible if fetal status is reassuring.
Cesarean section is indicated for non-reassuring fetal status, severe FGR, or
obstetric indications.
○​ Delivery Location: Preterm infants < 34 weeks should be delivered in hospitals
equipped with Neonatal Intensive Care Unit (NICU) facilities.
7.​ Post-delivery Care:​

○​ Neonatologist: Presence of a neonatologist at delivery is crucial.

○​ Placenta: Should be sent for histopathological examination for counseling future
pregnancies.