Golden Pearls of Gynecology and Obstetrics by Dr. Nadeem Goraya

Golden Pearls of Gynecology and Obstetrics by Dr. Nadeem Goraya

Dr. Nadeem Goraya - A legend of OB-GYN.

Obstetrics Tips

Tip. PUERPERAL PYREXIA.

"Fever of more than 38 C after 24 hrs of delivery"

 8 causes of PP:

1- Chest infection

2- Throat infection

3- Wound infection

4- Mastitis

5- UTI

6- Endometritis

7- Deep venous thrombosis

8- Phlebitis of branula vein

Sites where you will look for the cause of PP.

1- Throat

2- Breast

3- Chest auscultation

4- Abdomen for fundal height & tenderness

5- Wound(incision or episiotomy)

6- Renal angle

7- Perinieum for infected discharge

8- Legs(DVT)

9- Branula site.

5 Imp tests for PP.

1- Urine

2- Pelvic USG(RPOCS)

3- X-ray chest.

4- Blood culture

5- High vaginal swab.

Tip 2. INDICATIONS OF OUTLET FORCEPS

Always keep this tip with you & read it daily..

1-Prolonged 2nd stage of labor

2- Maternal exhaustion

3- mother not able to push

4- When pushing is not required

5- Fetal distress .

6- High head at doing C section

7- After coming head of breech.

Obstructed labor is not an indication rather it is a contraindication.

PRE REQUISITES for APLICATION OF OUTLET FORCEPS (MNEMONIC: FORCEPS)

F - FULLY DILATED CERVIX.

O - Outlet adequate no CPD.

R - Ruptured membranes .

C - Contractions present.

E - Engagement of head and episiotomy.

P - Presentation: Cephalic. Position: occipito anterior

S - Surrounding structures empty: Rectum & bladder.

COMPLICATIONS OF FORCEPS.

Fetal facial nerve palsy

Intra cranial hemorrhage

Maternal injury to surrounding tissue and perineal tears.

Tip 16. PPH .

Bleeding from the genital tract after the delivery of the baby(>500 ml at V delivery or >1000 ml after c\section )till 42 days. one of the leading cause of maternal mortality.

primary PPH is bleeding occurs within first 24 hrs

 secondary PPH if after 24 hr till 42 days

major cause of p PPH is atony of the uterus (remember 4 Ts, aTony. Trama. Trombin.Tissue) and

secondary PPH is ENDOMETRitus due to RPOCS.

RX of PPH

1 Resuscitation

2double iv line

3blood for grouping crossmatching & coagelation profile

4fluid colloid or crystalline

5foleys catheter

6RX of cause BOTh would b done simultaneously. 
Stepwise Management of atony..
1.massage the fundus
2.iv syntocinon
3 syntocinon infusion
4syntometrine(avoid in hypersensive &cardiac pts)
5.f2 alpha in myometrium
6.misoprostol in rectum
7. Bimaual compresion
8.uteine packing
9. Temponade
10. B lynch 
11. Uterine arteries ligation
12. Ant devision of int artery ligation
13.hysterctomy last resort.....
truma needs repair...
 DIC treated by FFPs.
thromboctopenia by platelates or fresh blood,

Tip .3A+B=C (Breech Delivery)

Dont be afraid this is not a mathematical Q

Any obstetrical complication(A) associated with BREECH(B) mode of delivery is C/s(c).

COMPLICATIONS

1.Hypertension

2. Diabeties mellitus

3. Previous one c/s

4.p previa any type

5. IUGR

6.Rh incompatability

7.twins with ist fetus breech

8. Footling breech

9.wt of the fetus >3.75kg <2.5 kg

10. Poly or oligohydramnios

11.exteded attitute of fetal head. elective C/S for breech should be performed at 38weeks.

FEW MANOUVERS IN BRREECH DELIVERY.

PINARD MANOUVER for exteded legsLOVSET MANOUVER for exteded arms.

MARACEUIA SMELI VIET MANOUVER.

BURN'S MARSHAL TECNHNIQ&

PIPERS FORCEPS For aftercoming head.

Maternal complications of breech delivery

1.Increased ç/s

2tears

3.infections.

fetal.

1fracture of femur and dislocation of hip joint

2. Injury soft tissuesLIVER

3humers fracture

4clavicle fracture

5sublaxation of atlantoaxial joint

6intracranial haemorage

7hypoxia.read

Tip.4.Eclampsia

It is one of major cause of maternal mortality .

principles of management of Eclampsia

1Resusitation (ABC)

 2.control fits (Mgso4 or Diazepam)

3 control blood pressure (iv Hdrallazine or Labetalol)

4investgations(urine for protein,LFTS'urea &creatinine coaugulation profile aptt & fibrinogen)

5induction after stabilization

6 post delivery care .(anti hypertensives)

major cause of death in Eclampsia

intra cranial haemorrhage&pulmonay oedema.


Tip...APH..anepartum haemorrhage is defined as bleeding from the genital tract after 24 weeks of gestation till the delivery of the baby.  
Causes 1. Abruptio placentae 2.placenta previa 3. Vasa previa 4. Ruptured uterus 5. Local causes...
Evaluation...  Painless bright red bleeding,,, placenta previa... Painful dark colour bleeding.. Abruptio placentae.... 
Complications of abruptio placenate 1, DIC 2. Renal failure 3. PPH 4.FETAL DISTRESS 5. FETAL DEATH......NEVER DO PELVIC EZAMINATION IN A CASE OF APH UNLESS PLACENTA PREVIA IS RULED OUT BY ULTRASONOGRAPHY. 
TREATMENT.... INITIAL RESUCITATION..1. Double iv line with wide bore Canulae 2. Blood should be sent fo r grouping cross matching and coagualton profile 3. I v fluids preferably cryatalloids 4. Pass folye cather... Treatment of cause. P previs...type 1 and type 2 anterior vaginal delivery.. Type 2 post Type 3 and 4 c section..abruptio p.. If fetus alive c section. If fetus dead  induction of labour... Vasa previa.. Immediate c s..ruptured uterus.. Laparatomy..local causes ...conservative.

Gynecology Tips.

Tip 5. Pelvic mass

causes of lower abdominal mass

1 full bladder

2 pregnancy

3 fibroid uterus

4 adenomyosis

5 OVARIAN tumor(benign or malignant)

6 turbo OVARIAN mass

7 non gynacological causes(dnt forget appendicular mass

8 mesentriscyst

9pelvic kidney.

Three important investigations

1 abdominal pelvic usg

2 ct scan

3 doppler usg if OVARIAN tumor.

RX is cause directed .

Pregnancy needs antenatal care

fibroid myomectomy or hysterectomy.

Adenomyosis by hysterectony.

OVARIAN cyst by cystectomy.oophorectomy. laparatomy.

Tuboovaian mass needs laparatomy 

Non gynacological referred to surgeon\

Tip 6. Endomertriosis.

It is the presence of endmetrium out side the uterine cavity,

Adenomyosis is presence of this tissue in myometrium.

Endometriosis usually is a disease of nulliparous women & ademomyosis of PAROUS (mcq)

most common site of endo is ovaries(mcq)where they form Endometromas. Mostly effect 30-45 years age.major symptoms are Dysmenorrhea(D/D PID in PID dys starts before mens arnd relived at onset but in end it remains throghout mens )Dyspareunia&infertllity.

Investigation of choice is Laparoscopy(mcq)usg(endometroma)Ca 125(NON SPECIFIC)

TREATMENT DEPENDS UPON AGE PARITY &REPRODUCTIVE WISHES.

SURGERY IS RADICAL (TAH & BSO IF FAMILY IS COMPLETE AND AGE IS MORE THAN 40)CONSEVATIVE SURGERY .. REMOVAL OF ENDOMETROMA IF FAMILY NOT COMPLETE.

MEDICAL MANAGMENT IS DANAZOL(ANDROGENIS DRUG)ORAL CONTARCEPTIVE PILLS (CONTINEOUS WITHOUT A BREAK , PSEUDO PREGNANCY TREATMENT)PROGESTERONS OR GNRH ANALOUGES(DEPOT INJECTIONS THREE MONTHLY ENDOMETROSIS IS A V TROUBLSOME.

Tip11.D&C

It is one of the most commonly performed gynecological procedure which every student will be asked about. So you must know indications, procedure, instruments and complications of it.

INDICATIONS:-

1.Irregular vaginal bleeding after the age of 40years

2.Irregular vaginal bleeding before the 40years of age if medical management failed

3.Post menopausal bleeding

4.For the diagnosis of endometrial tuberculosis

5.Some procedures in which uterus retained like Manchester repair.

D&C is not always performed under GA it can also be performed in para-cervical block.

COMPLICATIONS of D&C:-

Immediate: Anesthesia complications, Hemorrhage, perforation, injury to surrounding tissues.

Late: Infection

Delayed: Asherman 's syndrome.

Tip1. Managment of imp gynaecological diseases in one word

 MOLAR PREGNANCY -Suction curettage(irrespective to gestational age).

MISSED ABORTION -

BEFORE12 WEEKS(D&C)

AFTER 12WKS(EXPULSION WT PGD2Alpa or PGE2 OR SYNTOCINON infusion.

INCOMPLETE ABORTION- E&C.

BARTHOLINE CYST-Marsupilization.

ADENOMYOSIS- Hysterectomy.

ECTOPIC PREGNANCY- Laporotomy with salpingectomy or salpingostomy

Tip 2. Gynecological oncology.

Few important symptoms of common gynecological malignancies.

CA CERVIX-INTERMENSTRUAL OR POSTCOITAL BLEEDING,

CA ENDOMETRIUM-POSTMENOPAUSAL BLEEDING,

CA OVARY-VAGUE SYMPTOMS,ABDOMINAL DISTENSION GASTRIC UPSET .

CHORIOCARCINOMA-IRREGULAR VAGINAL BLEEDING

Average age of presentation of gynacological malignancies

CA CERVIX-45-50 years

CA ENDOMETRIUM- 60 YEARS

EPITHILIAL OVARIAN TUMORS-60 YEAR

GERM CELL TUMORS 30 YEARS ,

today was teachers day, i kept on waiting a wish from my students of final year class , but unfortunately among my 300 students to whom a taught day and nite, round the clock and I took lot of pain for them only two students send me the msg. Thanks to all of u for removing my kushfahmee that my students are my assert, u ppl are not my assert u ppl are self directed.only concerned about ur goals and objectives and have no single word of thanks to ur teacher on teacher day .

Tip 9. Six major causes of vaginal discharge - Their distinguishing features, diagnosis and treatment (Summary).

1. Candidiasis curd like, thick, non-smelly discharge causing pruritus. Diagnosis under microscope fungus seen. Rx Clotrimazole cream

2. Trichomonisis greenish frothy smelly pruritus vulvae. Wet smear shows flagella. Rx Metronidazole.

3. Bacterial vaginosis Milk like homogeneous discharge fish like smell not causing pruritus. Diagnosis: Clue cells on KOH. Rx Clindamycin vaginal cream. 

4. Chlamydia Mucoprulent discharge non irritant . Diagnosis high vaginal swab, Elisa. Rx Doxycline.

5. Gonorrhea: Mucoprulent discharge. Diagnosis Endocervical swab and gram staining. Rx Third generation Cephalosporin.

6. Physiological discharge (leochorrea) White colour non smelly. Rx Reassurance.

Tip10. 10 Imp investigations for infertile couple.

1. Semen anaylasis

2. Pelvic USG

3. Day 21 Progesteron (>30nmol/l)

4. Follicle tracking by USG (20mm)

5. Fern test

[test no 3,4&5 are for ovulation detection]

6. HSG Hysterosalpingography

7. Laparoscopy

8. Hysterosalpingo contrast sonography

[6,7&8for tubal factor]

9. Postcoital test[cervical factor]

10. Hysteroscopy[for uterine factor]

Rx of anovulation: Ovulation inducing agents clomiphine or hmg

Rx of tubal factor tubal surgery or ivf

Rx of cervical factor ivf.

Dr Nadeem

Tip. uterovaginal prolapse
...protrusion of uterus or vagina beyond their normal anatomical confines,,
types of prolapse... Cystocel.. Urethrocel.. Uterovaginal..rectocel...enterocel...
normal support of pelvic viscera 1.  Cardinal ligaments 2. Uterosacral ligaments 3.pubocervical ligament 4. Pubo urethral ligament 5. Muscles of pelvic floor ,,round ligament keeps the uterus anteverted and have v little role in the support.... 
Degress of prolapse,,, 1st degree,, when leading part of prolapse is above the introitus.. 2nd degree.. When leading part outside of introitus,,, 3rd degree,,, when whole uterus lies outside the introitus,,also caled PROCEDENTIA...
Complications of prolapse.. Ulcer formation::incarceration,, STRESS INCONTINECE..
Treatment of prolapse.. Surgery is the defiantive treatment. If woman is postmeopausal or family is complete operation is VAGINAL HYSTERECTOMY and ANT  &POST calpoperinorraphy..if family is not complete than Manchester repair or sling operation,,,, if pt not fit for surgery than Ring pessary..

Mixed Gyne-Obs

Tip 7 .Effects of smoking in obstetrics.

1 preterm labour

2 preterm premature ruputure of membranes

3abruptio placentae

4 placenta previa

5IUGR

6increase incidence of resp tract inf after C/S.

NICOTINE Is not teratogenic.

INCIDENCE of preeclampsia is reduced in smokers.

EFFECTS of smoking  on GYNAECOLOGY

1. CIN

2 CA CERXIX

3 ECTOPIC PREGNANCY

4 EARLY MENOPAUSE

5 OSTEOPROSIS

6. Increased incidence of UV PROLAPSE due to chronic cough.  

CAUSES OF DIC In obstetrics and gynae

1 abruptio placentae

2 IUD

3preeclampsia

4 hydatidiform mole

5 missed abortion

6Amniotic fluid embolism

 7 intra uterine infection.

Dr Nadeem

Tip 8. Few important facts related to Gynecology and Obstetrics.

1. Largest diameter of the pelvic inlet is transverse diameter and outlet is antero-posterior diameter.

2. Woman presented with secondary amenorrhea should always rule out pregnancy

3. Triplets should be delivered by c/section.

4. Brow presentation: The presenting diameter is mento-vertical (13.5 cm )is an absolute indication of c\section.

5. Supports of the uterus are cardinal ligament and uterosacral ligaments round ligament only keeps the uterus in antroverted position.

6. Rh antbodies are not naturaly occuring antibodies like ABO antibodies, but only produced in Rh -ve woman when fetomaternal haemorrhage occurs.

7. Always reduce weight before any treatment of PCOD.

8. Term is defined as 37 to 42 completed weeks 

9. Complications of ovarian cyst are hemorrhage, infection, torsion, rupture and malignant transformation.

10. Insulin and heparin do cross placenta.

Tip 12. All of u r affraid of incidences..this tip is especially made to remove ur fear incidences of imp gynae & obs problems.
15%.(infertility,abortion, breach at 32 weeks)..
around 10 %.(preterm labour  
7-10% prolonged pregnancy 
3-10%.instrumental vaginal delivery 
10-12 %)desending order   
(APH  3 - 5 %breech at term 3%.  Asymptomatic bacteriuria 3- 10 % Shoulder dystocia  1%.transverse lie 1 in 300deliveris  face presentation 1 in 500..brow presentation  1 in 1500)ectopic pregnancy  9.6 in 1000 normal population. Twins 14 in 1000.monzygotic  3 -4 per 1000  dizygotic 8 -10 per 1000. Triplets 1 in 10000.recurrance of HELLP is 16%. MMR is 276/100000total births. PNMR is around 72\1000 births in pakistan. 90 % of cervical developed from HPV16&18 dr nadeem