Solved Sendups Obs

(Solved by AI)
 QIMC

1. A 40-year-old G2P1L1 came to you at 11 weeks of gestation. She has a previous child with
Down's syndrome. She is worried about the risk of Down's syndrome in this pregnancy.
a) Which diagnostic test will you offer?
b) What are the complications associated with the test?
c) Name the screening tests for Down's syndrome.

Q1:
a. Diagnostic test:
• Chorionic Villus Sampling (CVS) at 11–14 weeks or Amniocentesis at 15–18 weeks can be
offered to confirm the diagnosis of Down's syndrome.
b. Complications of the test:
1. Miscarriage (1–2% for CVS, 0.5–1% for amniocentesis).
2. Infection (rare but possible).
3. Amniotic fluid leakage (especially with amniocentesis).
4. Rh sensitization (if the mother is Rh-negative).
c. Screening tests for Down's syndrome:
1. Combined first-trimester screening: Nuchal translucency, β-hCG, and PAPP-A.
2. Quadruple test (second-trimester): α-fetoprotein, β-hCG, estriol, and inhibin A.
3. Non-invasive prenatal testing (NIPT): Cell-free fetal DNA from maternal blood.

2. An unbooked pregnant woman presents in OPD at a gestational age of 28 weeks. Her

hemoglobin is 9 g/dl, and she has a family history of Thalassemia major.
a) What investigations will you advise?
b) Name a diagnostic test for Thalassemia.
c) How will you treat this patient if she has Thalassemia minor?

Q2:
a. Investigations:
1. CBC (to confirm anemia and hemoglobin levels).
2. Hemoglobin electrophoresis (to detect hemoglobin variants, especially β-thalassemia).
3. Iron studies (serum ferritin, total iron-binding capacity) to rule out iron deficiency anemia.
 4. Genetic testing for partner if hemoglobin electrophoresis suggests thalassemia trait.
b. Diagnostic test for Thalassemia:
• Hemoglobin electrophoresis or DNA analysis to identify β-thalassemia mutations.
c. Treatment for Thalassemia minor:
1. Folic acid supplementation (1 mg daily) to support erythropoiesis.
2. Monitor hemoglobin levels throughout pregnancy.
3. Avoid iron supplements unless iron deficiency is confirmed, as Thalassemia minor does not
require routine iron therapy.

3. A G2P1L1 presents to OPD for a booking visit. She is at 10 weeks of gestation and is a known
case of Type 2 Diabetes mellitus with HbA1C 9%.
a) What investigations will you offer?
b) What medication will you prescribe?
c) What are the associated risks with this condition?

Q3:
a. Investigations:
1. Fasting blood glucose and oral glucose tolerance test (OGTT).
2. Renal function tests (urea, creatinine, electrolytes).
3. Liver function tests.
4. Urine analysis (proteinuria, ketones).
5. Fetal ultrasound for growth and anomalies.
b. Medication:
• Insulin is the preferred treatment during pregnancy for glycemic control in diabetic women.
• Metformin can also be used if insulin is not available or well tolerated.
c. Risks associated with Type 2 Diabetes in pregnancy:
1. Increased risk of congenital anomalies (e.g., neural tube defects, cardiac anomalies).
2. Macrosomia and associated delivery complications (shoulder dystocia).
3. Pre-eclampsia and gestational hypertension.
4. Preterm delivery and risk of neonatal hypoglycemia.
4. A 35-year-old lady, unbooked, presented in the ER with heavy vaginal bleeding. She delivered a
baby girl at home 2 hours ago.
a) What is your diagnosis?
b) What are the likely causes?
c) How will you manage?

Q4:
a. Diagnosis:
• Postpartum hemorrhage (PPH).
b. Likely causes:
1. Uterine atony (most common cause of PPH).
2. Retained placenta or placental fragments.
3. Genital tract trauma (e.g., perineal tears).
4. Coagulopathy (rare).
c. Management:
1. Immediate resuscitation: IV fluids, blood transfusion if needed.
2. Uterine massage to stimulate contraction.
3. Medications:
• Oxytocin to stimulate uterine contractions.
• Ergometrine or misoprostol if oxytocin is ineffective.
4. Inspect for trauma: Repair genital tract tears if present.
5. Manual removal of placenta if retained.

5. A 30-year-old G3P2 presents to you in the ER with lower abdominal pain. She is at 38 weeks of
gestation. Ultrasound shows breech presentation.
a) What are the causes of breech presentation?
b) What will be your management options?
c) What are the complications of vaginal breech delivery?

Q5:
a. Causes of breech presentation:
1. Prematurity.
2. Uterine anomalies (e.g., fibroids).
3. Polyhydramnios or oligohydramnios.
4. Multiple gestation.
5. Placenta previa.
b. Management options:
1. External cephalic version (ECV) at 36–37 weeks if no contraindications.
2. If unsuccessful ECV or contraindicated:
• Elective cesarean section.
• Vaginal breech delivery (only if criteria for safe vaginal delivery are met).
c. Complications of vaginal breech delivery:
1. Cord prolapse.
2. Head entrapment during delivery.
3. Fetal hypoxia.
4. Birth trauma (e.g., fractures, nerve injury).

6. A 38-year-old primigravida comes to you in OPD at 32 weeks of gestation. Her fundal height is
38 cm.
a) What is your differential diagnosis?
b) How will you evaluate the case?
c) What will be your mode and timing of delivery?

Q6:
a. Differential diagnosis:
1. Polyhydramnios (excessive amniotic fluid).
2. Macrosomia (large fetus for gestational age).
3. Multiple gestation (twins or more).
4. Incorrect dating (miscalculated gestational age).
5. Fetal anomalies (e.g., hydrocephalus, skeletal dysplasias).
b. Evaluation:
1. Confirm dating by reviewing early ultrasound or last menstrual period (LMP).
2. Ultrasound to assess:
• Amniotic fluid index (AFI) or deepest vertical pocket (DVP).
• Fetal growth (to rule out macrosomia or multiple gestation).
• Fetal anomalies.
3. Diabetes screening (if not already done) with oral glucose tolerance test (OGTT) to check for
gestational diabetes.
4. Monitor maternal vitals and assess for symptoms like dyspnea or abdominal discomfort due to
polyhydramnios.
c. Mode and timing of delivery:
 1. Mode:
• Vaginal delivery if there are no contraindications (e.g., macrosomia, fetal distress).
• Cesarean section if the fetus is too large (macrosomia) or other complications arise.
2. Timing:
• 37–39 weeks if polyhydramnios is mild and controlled.
• Earlier delivery if complications like preterm labor or fetal distress develop.

7. A 22-year-old unbooked G1P1L0 comes to you at 22 weeks with an ultrasound report showing
AFI of 28 cm. She has a previous stillbirth (good-sized baby).
a) What could be the possible causes of increased liquor in this case?
b) What complications may occur during this pregnancy?
c) How will you manage this case?

Q7:
a. Possible causes of increased liquor (Polyhydramnios):
1. Gestational diabetes.
2. Fetal anomalies (e.g., esophageal atresia, anencephaly).
3. Fetal anemia (e.g., due to Rh incompatibility).
4. Multiple gestation.
5. Idiopathic polyhydramnios (no known cause).
b. Complications during this pregnancy:
1. Preterm labor due to uterine overdistension.
2. Cord prolapse after rupture of membranes.
3. Malpresentation (e.g., breech or transverse lie).
4. Postpartum hemorrhage (PPH) due to uterine atony.
5. Fetal demise or stillbirth.
c. Management:
1. Glucose tolerance test (OGTT) to rule out gestational diabetes.
2. Detailed ultrasound to assess for fetal anomalies.
3. Regular antenatal follow-up for monitoring AFI and fetal growth.
4. Amnioreduction (removal of amniotic fluid) if polyhydramnios is severe.
5. Steroids if preterm labor is suspected, to enhance fetal lung maturity.
6. Monitor for complications: early delivery if complications like fetal distress or preterm labor
arise.
8. A 30-year-old G3P2L2 is admitted to your labor ward. She is an unbooked case with
uncontrolled blood sugar levels and polyhydramnios. Your registrar performs ARM, and the fetal
heart rate suddenly drops to 60 bpm.
a) What is your provisional diagnosis?
b) What could be the possible causes?
c) How will you manage?

Q8:
a. Provisional diagnosis:
• Umbilical cord prolapse (sudden fetal heart rate drop after amniotic rupture suggests cord
prolapse).
b. Possible causes:
1. Polyhydramnios (excessive fluid increases the risk of cord prolapse).
2. Malpresentation (abnormal fetal position, such as breech).
3. Premature rupture of membranes (PROM) with uncontrolled fluid loss.
4. Large fetus (as seen in diabetes with macrosomia).
c. Management:
1. Immediate call for help (obstetric emergency).
2. Manually elevate the presenting part to relieve pressure on the cord.
3. Position the mother in Trendelenburg or knee-chest position to reduce pressure on the cord.
4. Emergency cesarean section to deliver the baby and prevent hypoxia.
5. Continuous fetal heart rate monitoring until delivery.

9. A 40-year-old primigravida is brought to you in the labor ward in a collapsed state. She is at 40
weeks of gestation, unbooked, and collapsed in OPD 2 minutes ago while waiting for a routine
check-up. She is pulseless, and BP is not recordable.
a) Enlist causes leading to maternal collapse.
b) What is the timeline for performing perimortem C-section in this case?
c) Where is perimortem C-section performed?

Q9:
a. Causes of maternal collapse:
1. Massive hemorrhage (e.g., placental abruption, uterine rupture).
2. Pulmonary embolism (amniotic fluid or thromboembolism).
 3. Eclampsia or severe pre-eclampsia.
4. Cardiac arrest (e.g., due to underlying heart disease).
5. Anaphylaxis (e.g., drug reaction or anesthesia).
6. Sepsis (septic shock).
7. Hypovolemic shock (due to dehydration, blood loss).
b. Timeline for performing perimortem C-section:
• Within 4–5 minutes of maternal cardiac arrest for the best chance of fetal survival.
c. Where is perimortem C-section performed?
• In situ (wherever the collapse occurs, such as the OPD or labor ward). This is an emergency
procedure and should be done without moving the patient to the operating room if time does not
permit.
 KHARIAN
1. A 36-year-old female G6P5+0 at 38 weeks of gestation is admitted to the labor ward due to
gestational diabetes mellitus and polyhydramnios. At 6 cm of dilation, she complains of a sudden
gush of fluid from the vagina. CTG shows signs of fetal distress. On examination, you notice a
tubular structure coming out of the vagina.
a. What is the most likely diagnosis?
b. What are the risk factors for this obstetric emergency? Write any four.
c. How will you manage this case?

Q1:
a. Most likely diagnosis:
• Umbilical cord prolapse.
b. Risk factors for umbilical cord prolapse:
1. Polyhydramnios (excessive amniotic fluid).
2. Multiparity (multiple pregnancies).
3. Fetal malpresentation (e.g., breech or transverse lie).
4. Preterm rupture of membranes or premature rupture of membranes (PROM).
c. Management:
1. Immediate call for help (obstetric emergency).
2. Manually elevate the presenting part (to relieve pressure on the umbilical cord).
3. Position the mother in Trendelenburg or knee-chest position to reduce pressure on the cord.
4. Continuous fetal heart rate monitoring to assess fetal distress.
5. Immediate cesarean section to prevent fetal hypoxia and ensure rapid delivery.
6. Administer oxygen to the mother and consider tocolytics if indicated to reduce uterine
contractions.

2. A 30-year-old female G8P2+5 at 30 weeks of gestation presents in OPD for the first time. Her
obstetric scan shows increased generalized skin thickness of the fetus along with ascites,
pericardial, and pleural effusion.
a. What is your diagnosis?
b. What are the causes responsible for this condition?
c. What other signs of severe fetal anemia will you find on ultrasound and CTG?
Q2:
a. Diagnosis:
• Non-immune hydrops fetalis.
b. Causes responsible for this condition:
1. Fetal anemia (e.g., alpha-thalassemia, parvovirus B19 infection).
2. Cardiac abnormalities (e.g., congenital heart disease).
3. Chromosomal abnormalities (e.g., Down syndrome, Turner syndrome).
4. Infections (e.g., cytomegalovirus, syphilis).
c. Other signs of severe fetal anemia on ultrasound and CTG:
• Ultrasound:
• Cardiomegaly.
• Hepatosplenomegaly.
• Enlarged placenta.
• Polyhydramnios.
• CTG:
• Sinusoidal heart pattern (indicative of severe fetal anemia).

3. A 41-year-old woman had a baby with Down syndrome 10 years ago. She is anxious to know
the chromosomal status of the fetus in her current pregnancy. She is currently at 14 weeks of
gestation.
a. What test will provide the most rapid and reliable diagnosis of Down syndrome at this gestation?
b. What are the different invasive options that can be advised if she reaches 20 weeks of pregnancy to
confirm the diagnosis?
c. What is combined testing for Down syndrome?
d. What is quadruple screening?

Q3:
a. Test providing the most rapid and reliable diagnosis of Down syndrome at 14 weeks:
• Chorionic villus sampling (CVS).
b. Invasive options to confirm diagnosis at 20 weeks:
1. Amniocentesis.
2. Cordocentesis (also known as percutaneous umbilical blood sampling).
c. Combined testing for Down syndrome:
 • Involves nuchal translucency measurement (via ultrasound) along with maternal serum
levels of free beta-hCG and PAPP-A. It is performed between 11 and 14 weeks of pregnancy.
d. Quadruple screening:
• This test measures four serum markers:
• Alpha-fetoprotein (AFP).
• Estriol.
• Beta-hCG.
• Inhibin-A.
• It is performed between 15 and 20 weeks of pregnancy to assess the risk of Down syndrome
and other chromosomal abnormalities.

4. A 25-year-old primigravida presents to the clinic at 10 weeks of pregnancy with complaints of

mild fever, arthralgia, and maculopapular rashes. She has no previous history of rubella
immunization, and you suspect that she has active rubella infection.
a. How will you confirm your diagnosis of rubella infection?
b. If her fetus has also been infected, what congenital effects may he/she suffer from?
c. What are the risks of transmission of the rubella virus from the mother to the fetus in the 1st, 2nd,
and 3rd trimesters?
d. What treatment options will you offer to this woman?

Q4:
a. How to confirm diagnosis of rubella infection:
1. Rubella-specific IgM antibodies in maternal serum.
2. PCR (polymerase chain reaction) test for viral RNA from maternal blood or amniotic fluid.
b. Congenital effects of fetal rubella infection:
1. Congenital heart defects (e.g., patent ductus arteriosus, pulmonary artery stenosis).
2. Congenital cataracts.
3. Sensorineural deafness.
4. Microcephaly and developmental delays.
c. Risk of rubella virus transmission:
• 1st trimester: Highest risk (>80%) of severe congenital defects.
• 2nd trimester: Reduced risk, but still possible.
• 3rd trimester: Risk of transmission remains but with fewer severe consequences.
d. Treatment options:
 • No specific antiviral treatment for rubella.
• Offer termination of pregnancy if infection occurs in the first trimester (due to high risk of
congenital defects).
• Provide supportive care and closely monitor fetal development.

5. A 40-year-old G4P3+0 with a BMI of 35 kg/m² delivered a male baby by emergency C-section.
After 7 hours postpartum, she suddenly developed shortness of breath, blood-stained sputum,
and became unconscious in the recovery period.
a. What is the diagnosis?
b. What are the risk factors for pulmonary embolism?
c. What is the drug of choice?
d. What is the ratio of chest compressions to breaths in cardiopulmonary resuscitation?

Q5:
a. Diagnosis:
• Pulmonary embolism (PE).
b. Risk factors for pulmonary embolism:
1. Obesity (BMI >30).
2. Cesarean section (increased risk of thrombosis).
3. Prolonged immobility after delivery.
4. Multiparity (multiple pregnancies).
c. Drug of choice:
• Low molecular weight heparin (LMWH).
d. Ratio of chest compressions to breaths in cardiopulmonary resuscitation (CPR):
• 30:2 (30 compressions to 2 breaths).

6. A 26-year-old primigravida presents for booking at 8 weeks of pregnancy. She is known to be

epileptic, and her seizures are controlled on carbamazepine for the last 2 years.
a. Enumerate the feto-maternal risks of epilepsy in pregnancy.
b. What steps will you take to minimize the complications?
c. What pre-pregnancy counseling would be done if she had visited prior to pregnancy?
Q6:
a. Feto-maternal risks of epilepsy in pregnancy:
• Maternal risks:
1. Increased frequency of seizures due to physiological changes.
2. Risk of status epilepticus (life-threatening seizure activity).
3. Complications from antiepileptic drugs (AEDs) like teratogenicity.
• Fetal risks:
1. Congenital malformations (neural tube defects, cleft palate) due to AED exposure.
2. Intrauterine growth restriction (IUGR).
3. Developmental delays or cognitive impairment.
4. Preterm birth and low birth weight.
b. Steps to minimize complications:
1. Optimize seizure control with the lowest effective dose of a single AED (preferably one with a
lower teratogenic risk).
2. Regular prenatal care and frequent monitoring of drug levels (e.g., carbamazepine).
3. Folic acid supplementation (5 mg/day) before and during pregnancy to reduce the risk of
neural tube defects.
4. Vitamin K supplementation in the third trimester to prevent neonatal bleeding due to AEDs.
5. Detailed anomaly scan at 18–20 weeks to detect fetal malformations.
c. Pre-pregnancy counseling:
1. Switch to safer AEDs if needed (monotherapy preferred).
2. Emphasize the importance of folic acid supplementation (5 mg/day) prior to conception.
3. Discuss the risks of seizures during pregnancy and the potential impact of AEDs on fetal
development.
4. Optimize seizure control before conception with a multidisciplinary approach (neurologist and
obstetrician).
5. Ensure good seizure diary and medication compliance.

7. A 26-year-old second gravida with moderate aortic stenosis and a history of intrauterine death
in her first pregnancy attends the antenatal clinic at 6 weeks of gestation.
a. Name two maternal risks that adversely affect this patient.
b. Name two fetal risks in this patient.
c. Give important steps for the management of labor in this patient.

Q7:
a. Two maternal risks that adversely affect the patient with aortic stenosis:
 1. Heart failure due to increased cardiac output during pregnancy.
2. Arrhythmias or sudden cardiac death, especially during labor or delivery.
b. Two fetal risks in this patient:
1. Intrauterine growth restriction (IUGR) due to reduced placental perfusion.
2. Preterm birth or intrauterine fetal demise (IUFD).
c. Important steps for the management of labor:
1. Multidisciplinary approach with cardiologist and obstetrician.
2. Avoid excessive physical exertion; offer early epidural anesthesia to minimize stress.
3. Continuous monitoring of maternal vitals (heart rate, BP) and fetal heart rate.
4. Assisted second stage of labor (e.g., forceps or vacuum) to reduce maternal effort and avoid
cardiac overload.
5. Plan for vaginal delivery unless cesarean section is indicated for obstetric reasons.

8. A 28-year-old primigravida is admitted to the hospital at 30 weeks of gestation with complaints

of painful uterine contractions for the past 4 hours.
a. What are the causes of preterm labor? List any four.
b. What relevant investigations will you send for this patient?
c. Outline the principles of management for preterm labor.

Q8:
a. Causes of preterm labor (list any four):
1. Infection (e.g., chorioamnionitis or urinary tract infection).
2. Multiple gestation (twins, triplets).
3. Polyhydramnios (excessive amniotic fluid).
4. Placental abruption or placenta previa.
b. Relevant investigations:
1. Vaginal swab for infection screening (e.g., group B streptococcus).
2. Urine culture to rule out UTI.
3. Cervical length assessment via transvaginal ultrasound.
4. Fetal fibronectin test to predict risk of preterm labor.
c. Principles of management:
1. Tocolytics (e.g., nifedipine) to delay labor and allow time for corticosteroid administration.
2. Corticosteroids (e.g., betamethasone) to promote fetal lung maturity.
3. Magnesium sulfate for neuroprotection if delivery is imminent before 32 weeks.
4. Antibiotic prophylaxis if preterm premature rupture of membranes (PPROM) is suspected.
 5. Close monitoring of maternal and fetal status.

9. An unbooked patient, G3P2+A0, at 34 weeks according to her last menstrual period, came for
an antenatal checkup. On examination, her symphysiofundal height is 37 cm. Fetal biometry on
ultrasound shows parameters corresponding to 37 weeks with an amniotic fluid index of 10 cm.
a. What is the differential diagnosis for increased symphysiofundal height on examination?
b. Write down the possible fetal and maternal complications.

Q9:
a. Differential diagnosis for increased symphysiofundal height:
1. Incorrect dating (miscalculated gestational age).
2. Macrosomia (large fetus for gestational age).
3. Polyhydramnios (excessive amniotic fluid).
4. Multiple gestation (twins, triplets).
5. Maternal obesity or large fibroids.
b. Possible fetal and maternal complications:
• Fetal complications:
1. Preterm labor due to increased uterine distension.
2. Fetal malposition or difficulty during labor (e.g., shoulder dystocia).
3. Neonatal respiratory distress syndrome (if preterm delivery occurs).
4. Stillbirth in cases of uncontrolled maternal conditions.
• Maternal complications:
1. Gestational diabetes leading to macrosomia.
2. Pre-eclampsia or hypertensive disorders.
3. Increased risk of cesarean section or labor complications.
4. Postpartum hemorrhage due to uterine overdistension.
 HITECH
1. A 28-year-old primigravida at 38 weeks presents with labor pains. She has had an uneventful
antenatal period. Her CTG is reactive, and she is having 2 mild and one moderate contraction in
10 minutes. Upon examination, her symphysiofundal height is according to dates, longitudinal lie,
cephalic presentation, and the head is 3/5 palpable. Vaginal examination reveals an os of 4 cm,
cervix 2.5 cm long, anterior, soft, and intact membranes.
How will you manage her?

Management:
• Observation: The patient is in early active labor. Given that the fetal monitoring is normal
(reactive CTG) and the contractions are mild to moderate, the management should focus on:
• Monitoring of maternal vitals and fetal heart rate.
• Reassessing contractions to ensure progression.
• Regular vaginal exams every 4 hours to assess cervical dilatation, effacement, and
descent of the fetal head.
• Pain Relief: Offer analgesia such as epidural analgesia or non-pharmacological methods
(breathing exercises, mobilization).
• Hydration: Encourage oral intake of clear fluids or administer IV fluids as necessary.
• Amniotomy: Consider artificial rupture of membranes (ARM) later if progress stalls, but
only after ensuring the head is well engaged.
• Support: Provide continuous emotional support during labor.
If labor progresses normally and fetal well-being is maintained, expect vaginal delivery. Should any
signs of fetal distress or labor dystocia occur, reevaluate management accordingly.

2. A primigravida at 32 weeks of pregnancy reports to the outpatient department for a routine

antenatal visit. On examination, her BP is 150/100.
How will you evaluate the patient?
This patient has a blood pressure of 150/100 mmHg at 32 weeks, which raises concern for gestational
hypertension or pre-eclampsia.

Evaluation:
1. History:
• Ask about symptoms such as headache, visual disturbances, epigastric pain, and
swelling (signs of pre-eclampsia).
• Ask about prior history of hypertension or pre-eclampsia.
 2. Physical Examination:
• Look for signs of edema (hands, face, ankles).
• Assess for hyperreflexia and clonus (neurological signs of severe pre-eclampsia).
3. Investigations:
• Urine Dipstick or 24-Hour Urine Protein: To assess for proteinuria, indicating pre-
eclampsia.
• Liver Function Tests (LFTs) and Renal Function Tests: To assess for end-organ
damage.
• Complete Blood Count (CBC): Check for thrombocytopenia (a feature of severe pre-
eclampsia).
• Fetal Ultrasound: For fetal growth and assessment of amniotic fluid volume (potential
IUGR or oligohydramnios).

Management:
• Antihypertensive Therapy: Initiate treatment with labetalol, nifedipine, or methyldopa if
required.
• Monitoring: Regular BP monitoring, close fetal surveillance, and weekly labs (including liver
and renal function).
• Delivery Plan: If pre-eclampsia is confirmed and does not respond to medical management,
plan delivery around 37 weeks or earlier if complications arise.

3. A G5P4 weighing 95 kg attends the antenatal clinic at 24 weeks of pregnancy. On examination,

her fundal height is 28 cm. An ultrasound report shows a normal single fetus with excessive
liquor. Her fasting blood glucose level is 125 mg/dl.
How will you manage this patient?
This patient has polyhydramnios (fundal height of 28 cm at 24 weeks) and gestational diabetes
mellitus (GDM) (fasting glucose of 125 mg/dL).

Management:
1. Glycemic Control:
• Initiate dietary modifications and a diabetic meal plan.
• Start insulin therapy if blood glucose levels remain elevated despite dietary measures.
• Regularly monitor fasting and postprandial blood glucose.
2. Fetal Monitoring:
• Ultrasound: Monitor for fetal anomalies and excessive growth (macrosomia), which can
be associated with uncontrolled GDM.
• Amniotic Fluid Index (AFI): Serial monitoring of AFI to assess polyhydramnios
progression.
3. Surveillance:
 • Perform regular non-stress tests (NST) from 32 weeks onwards to assess fetal well-
being.
• Consider amnioreduction if polyhydramnios becomes symptomatic (e.g., maternal
discomfort or breathlessness).
4. Delivery Planning:
• Given the risk of macrosomia and complications like shoulder dystocia, plan for delivery
at 38-39 weeks, possibly via induction or cesarean section if the estimated fetal weight is
>4500g.

4. A G5P4-0 presents in OPD at 38 weeks of gestation with a history of vaginal bleeding. On

examination, her pulse is 92/min, and blood pressure is 160/100 mmHg. She appears pale.
How will you evaluate this patient to reach a diagnosis?
This patient presents with vaginal bleeding at 38 weeks, along with hypertension and pale
appearance, which is concerning for placenta previa, placental abruption, or severe pre-eclampsia
with coagulopathy.

Evaluation:
1. History:
• Ask about the onset, duration, and amount of bleeding.
• Check for associated abdominal pain (suggestive of abruption) or painless bleeding
(suggestive of previa).
2. Physical Examination:
• Vital Signs: Monitor for signs of shock (tachycardia, hypotension).
• Abdominal Examination: Check for tenderness, particularly over the uterus (sign of
placental abruption).
• Speculum Examination: Avoid vaginal examination until previa is ruled out by
ultrasound.
3. Investigations:
• Ultrasound: To check for placenta previa or placental abruption.
• CBC: Assess for anemia (pallor).
• Coagulation Profile: Look for DIC (Disseminated Intravascular Coagulation) in cases
of severe abruption.

Management:
• Immediate Stabilization: IV fluids and possibly blood transfusion for anemia.
• Antihypertensive Therapy: To manage BP.
 • Plan Delivery: Depending on the findings (cesarean for previa or abruption if the bleeding is
severe).

5. A primigravida presented in the outpatient department at 30 weeks with preterm rupture of

membranes for 2 hours. She has had an uneventful pregnancy until now.
How will you monitor this patient for chorioamnionitis?
The patient presents with preterm rupture of membranes (PROM) at 30 weeks.

Monitoring for Chorioamnionitis:

1. Clinical Signs:
• Maternal Fever: Monitor temperature regularly for signs of infection.
• Fetal Tachycardia: Check fetal heart rate for tachycardia (>160 bpm).
• Maternal Tachycardia: Look for maternal tachycardia (>100 bpm).
• Uterine Tenderness: Check for uterine tenderness on palpation.
• Foul-Smelling Vaginal Discharge: Look for signs of infection in the discharge.
2. Investigations:
• CBC: Monitor WBC count for leukocytosis (a sign of infection).
• CRP: Elevated levels of C-reactive protein can indicate infection.
• High Vaginal Swab: Send a sample for culture to check for causative organisms.

Management:
• Antibiotics: Administer prophylactic antibiotics (e.g., ampicillin and erythromycin) to reduce
the risk of chorioamnionitis.
• Steroids: Administer betamethasone to accelerate fetal lung maturity.
• Tocolysis: Consider tocolysis only if there are no signs of infection, to delay delivery and allow
for steroid administration.
• Delivery Planning: If chorioamnionitis develops or labor starts spontaneously, proceed with
delivery.

6. A 32-year-old booked G2P1 at 30 weeks is diagnosed with fetal growth restriction. She is type 1
diabetic and a smoker. Previously, she had a 4 kg baby girl delivered by ISCS at 34 weeks due to
reverse flow on Doppler.
• Fetal Monitoring: Serial ultrasound for estimated fetal weight (EFW) and amniotic fluid
index (AFI).
• Doppler Studies: Assess umbilical artery Doppler and middle cerebral artery Doppler to
monitor placental insufficiency and blood flow.
 • NST and BPP: Conduct non-stress tests (NST) and biophysical profile (BPP) regularly to
evaluate fetal well-being.
• Timing of Delivery: Consider early delivery if Doppler shows absent/reversed end-diastolic
flow or if fetal compromise is suspected.
7. A 38-year-old G6P5 after a prolonged labor had a ventouse delivery of a male baby weighing
4.5 kg. The placenta is delivered, and the doctor notices active bleeding from the vagina, which is
more than 1000 ml.
How will you medically manage this case?
• Uterotonics: Administer oxytocin (10 IU IM/IV) and consider ergometrine or carboprost if
bleeding persists.
• Tranexamic Acid: Give TXA (1g IV) to control bleeding.
• Bimanual Compression: Apply uterine massage and bimanual uterine compression.
• Blood Products: Initiate blood transfusion and monitor for coagulopathy.
• Surgical Options: If medical management fails, proceed with balloon tamponade or surgical
intervention (e.g., B-Lynch suture, hysterectomy).

8. A 26-year-old G4P1+2, with one preterm delivery at 27 weeks and early neonatal death at 1
hour, along with 2 first-trimester missed miscarriages, presents in the OPD at 10 weeks.
Justify the investigations you will do in this patient.
• Thrombophilia Screen: Test for antiphospholipid syndrome and inherited thrombophilias
(e.g., factor V Leiden).
• Genetic Testing: Consider karyotyping of parents to rule out genetic abnormalities.
• Infection Screen: Perform tests for TORCH infections and cervical cultures.
• Cervical Length Measurement: Conduct transvaginal ultrasound to assess for cervical
incompetence.
• Endocrine Evaluation: Check for thyroid dysfunction and progesterone levels.

9. A G5P4 at 37 weeks with polyhydramnios presents in early labor. On abdominal examination,

the fundal height is at term, longitudinal lie, and cephalic presentation. The fetal heart rate is 140
bpm, and the head is 5/5 palpable. Upon spontaneous rupture of membranes, cord prolapse
occurs.
How will you manage this case?
• Call for emergency assistance: Immediate delivery is the priority.
• Manual elevation of the presenting part: Push the fetal head off the cord while the patient is
positioned in Trendelenburg or knee-chest position.
• Oxygen and tocolysis: Administer oxygen and consider terbutaline to relax the uterus.
• Emergency cesarean section: Expedite the delivery via cesarean to prevent cord compression
and fetal hypoxia.
 CMH Lahore
Q1. A female presented in emergency with abdominal pain at 40 weeks of pregnancy. On initial
examination, the cervix is 3 cm dilated, the fetal head is engaged, the membranes are intact, and
the presenting part is palpable. Two hours later, the cervix is 5 cm dilated, uterine contractions
are absent, the fundus of the uterus is not palpable, and the presenting parts of the fetus cannot
be palpated. Membranes are still intact.
a. What is your diagnosis?
b. What are the risks to the mother and baby?
c. What is the management plan?
a. What is your diagnosis?
• Diagnosis: Uterine rupture. The absence of contractions and inability to palpate the fundus or
presenting part after 2 hours suggests possible uterine rupture, especially with prior uterine
surgery or multiple pregnancies.
b. What are the risks to the mother and baby?
• Risks to the mother:
• Hemorrhage and hypovolemic shock.
• Potential for hysterectomy.
• Increased morbidity and mortality.
• Risks to the baby:
• Fetal distress or demise due to compromised blood flow.
• Neurological injury or complications due to lack of oxygen.
c. What is the management plan?
1. Immediate stabilization:
• Establish IV access and administer fluids.
• Monitor vital signs closely.
2. Prepare for emergency delivery:
• Arrange for an emergency cesarean section if uterine rupture is suspected.
3. Surgical intervention:
• Surgical exploration to assess and repair the uterus, control bleeding, and evaluate fetal
status.
4. Postoperative care:
• Intensive monitoring of mother and newborn, including blood transfusions if necessary.
5. Counseling:
• Discuss future pregnancy risks with the patient.
Q2. A 28-year-old female presented for a regular antenatal check-up at 32 weeks of pregnancy,
with a symphysiofundal height (SFH) of 28 cm.
a. What are the differential diagnoses?
b. What investigations should be performed?
a. What are the differential diagnoses?
1. Intrauterine growth restriction (IUGR): Fetus not growing as expected.
2. Oligohydramnios: Reduced amniotic fluid leading to lower fundal height.
3. Fetal demise: Absence of growth could indicate the loss of fetal activity.
4. Uterine abnormalities: Such as fibroids or structural issues affecting fundal height.
b. What investigations should be performed?
1. Ultrasound: To assess fetal growth, amniotic fluid index (AFI), and placental position.
2. Doppler studies: To evaluate blood flow to the fetus.
3. Biophysical profile (BPP): To assess fetal well-being and movement.
4. Maternal blood tests: Including glucose levels and a complete blood count (CBC) to rule out
underlying conditions.

Q3. A 35-year-old female presented with complaints of recurrent miscarriage. She is diabetic,
obese (BMI of 30+), and has an enlarged goiter. Her husband is a smoker and abuses alcohol.
a. What are the risk factors?
b. What investigations should be conducted?
c. What advice would you provide?
a. What are the risk factors?
1. Diabetes: Poorly controlled diabetes can lead to complications in pregnancy.
2. Obesity: Increased body mass index (BMI) is associated with higher miscarriage rates.
3. Thyroid dysfunction: Enlarged goiter indicates possible thyroid imbalance.
4. Smoking and alcohol use: Husband's lifestyle can affect paternal contributions to fertility and
potential genetic factors.
b. What investigations should be conducted?
1. Karyotyping: For both parents to assess for chromosomal abnormalities.
2. Thyroid function tests: To evaluate thyroid hormone levels.
3. Glucose tolerance test: To assess for gestational diabetes or uncontrolled diabetes.
4. Hysterosalpingography (HSG): To evaluate uterine anatomy and patency.
c. What advice would you provide?
1. Preconception counseling: Importance of managing diabetes and weight before conception.
 2. Nutritional advice: Healthy diet and exercise to achieve an optimal BMI.
3. Avoidance of teratogens: Emphasize quitting smoking and alcohol before pregnancy.
4. Regular monitoring: Ensure regular follow-ups during the next pregnancy with close
monitoring of fetal growth and development.

Q4. A 25-year-old female primigravida presented in the emergency department with complaints
of tonic-clonic seizures at 28 weeks of pregnancy. There is no history of epilepsy.
a. What is your diagnosis?
b. What is the first-line drug and its dose?
c. What is the antidote and its dose?
• Diagnosis: Eclampsia. The presence of tonic-clonic seizures in a pregnant woman without a
prior history of epilepsy suggests eclampsia, a severe complication of pre-eclampsia.
b. What is the first-line drug and its dose?
• First-line drug: Magnesium sulfate. The standard loading dose is 4-6 grams IV over 15-30
minutes, followed by a maintenance dose of 1-2 grams/hour.
c. What is the antidote and its dose?
• Antidote: Calcium gluconate. The recommended dose is 1 gram IV (10 mL of a 10% solution)
to reverse the effects of magnesium sulfate in case of toxicity.

Q5. A multiparous female presented in emergency with complaints of fatigability, dizziness, and
headache. She eats chalk. CBC shows an MCB of 72.
a. What is your diagnosis?
b. What are the risk factors in her history?
c. What investigations should be performed?
a. What is your diagnosis?
• Diagnosis: Iron deficiency anemia (IDA). The history of chalk eating (pica) suggests a
deficiency in iron or other minerals, with an MCB of 72 supporting this diagnosis.
b. What are the risk factors in her history?
1. Multiparity: Increased risk of nutrient depletion with each pregnancy.
2. Dietary habits: Pica indicates possible nutrient deficiencies.
3. Menorrhagia: Any history of heavy menstrual bleeding contributing to anemia.
 4. Poor dietary intake: Lack of iron-rich foods in the diet.
c. What investigations should be performed?
1. Complete blood count (CBC): To confirm anemia and assess other red blood cell indices.
2. Serum ferritin levels: To evaluate iron stores in the body.
3. Reticulocyte count: To assess bone marrow response to anemia.
4. Peripheral blood smear: To check for microcytic or hypochromic red blood cells characteristic
of iron deficiency anemia.

Q6. A female presented for pre-pregnancy planning. History shows two miscarriages at 26 and 28
weeks, with the death of the infant soon after birth.
a. What are the risk factors in her history?
b. What are the possible causes?
c. What are the advantages and management steps for this case?
a. What are the risk factors in her history?
1. Previous miscarriages: Two miscarriages at 26 and 28 weeks raise concerns about cervical
insufficiency, uterine anomalies, or underlying medical conditions.
2. Neonatal death: Indicates possible congenital anomalies, infections, or maternal conditions
affecting fetal well-being.
3. Age: If the patient is older, advanced maternal age can increase the risk of chromosomal
abnormalities.
4. Medical history: Any underlying conditions such as diabetes, hypertension, or autoimmune
disorders should be considered.
5. Genetic factors: Family history of genetic disorders can also be a risk factor.
b. What are the possible causes?
1. Anatomical abnormalities: Uterine abnormalities such as septate uterus or cervical
incompetence.
2. Genetic abnormalities: Chromosomal translocations or abnormalities in either parent.
3. Hormonal factors: Conditions like luteal phase defect or polycystic ovary syndrome (PCOS).
4. Infectious causes: Infections during pregnancy (e.g., listeriosis, TORCH infections).
5. Autoimmune disorders: Conditions like antiphospholipid syndrome or lupus.
c. What are the advantages and management steps for this case?
• Advantages:
• Preconception counseling: Helps identify risks and optimizes maternal health before
conception.
• Screening for underlying conditions: Early identification can lead to appropriate
interventions.
 • Individualized management plan: Tailored approach to improve pregnancy outcomes.
• Management Steps:
• Comprehensive evaluation: Detailed obstetric history, family history, and any prior
medical issues.
• Genetic counseling: If indicated, especially if there’s a family history of genetic
disorders.
• Diagnostic tests: Hysterosalpingography or ultrasound to assess uterine anatomy;
karyotyping if chromosomal abnormalities are suspected.
• Treat underlying conditions: Manage any medical conditions identified (e.g., diabetes,
thyroid disorders).
• Supplementation: Initiate folic acid supplementation (at least 400-800 mcg daily) to
reduce neural tube defects.
• Close monitoring: During the subsequent pregnancy, increased surveillance for
complications and regular follow-up with an obstetrici

Q7. A 20-week pregnancy with exposure to chickenpox affecting her elder son.
a. What investigations should be done to check for immunity?
b. If immunity is negative, what is the management plan?
c. What are the complications for the baby, and how should follow-up be conducted?

Q7. 20-week pregnancy with exposure to chickenpox

a. What investigations should be done to check for immunity?
1. Serological testing: Check for VZV IgG antibodies in maternal blood to determine immunity to
varicella (chickenpox).
2. History assessment: Previous history of chickenpox or varicella vaccination can also guide
immunity status.
b. If immunity is negative, what is the management plan?
1. Vaccination: Avoid vaccinating during pregnancy; if non-immune, advise the patient to receive
the varicella vaccine postpartum.
2. Exposure management: Provide varicella zoster immune globulin (VZIG) within 96 hours of
exposure for non-immune pregnant women to reduce the risk of severe infection.
3. Monitoring: Close follow-up for any signs of varicella infection, such as fever and rash.
c. What are the complications for the baby, and how should follow-up be conducted?
• Complications for the baby:
 1. Congenital varicella syndrome: If the mother contracts varicella during the first or
early second trimester, leading to potential limb hypoplasia, scarring skin lesions, and
ocular defects.
2. Neonatal varicella: If the mother develops chickenpox shortly before delivery, the
newborn may develop severe varicella.
• Follow-up:
1. Regular monitoring: Assess fetal development through ultrasounds for any signs of
congenital anomalies.
2. Postnatal follow-up: Monitor the newborn for any signs of varicella infection or
congenital varicella syndrome and provide supportive care as needed.
3. Vaccination planning: Schedule varicella vaccination for the mother postpartum and
ensure her children are vaccinated according to the recommended immunization
schedule.

Q8. After a normal vaginal delivery, the patient starts experiencing heavy vaginal bleeding a few
minutes later.
a. What is your diagnosis?
b. Outline the management steps, step by step.
a. What is your diagnosis?
• Diagnosis: Postpartum hemorrhage (PPH). This is defined as blood loss greater than 500 mL
after vaginal delivery.
b. Outline the management steps, step by step:
1. Assess the situation:
• Check the patient’s vital signs (pulse, blood pressure) to assess hemodynamic stability.
• Inspect the perineum and vaginal canal for any lacerations or retained placental
fragments.
2. Initiate resuscitation:
• IV access: Establish two large-bore intravenous lines for fluid resuscitation.
• Fluid resuscitation: Start with crystalloids (e.g., Normal Saline or Lactated Ringer’s)
and prepare for blood products as needed.
3. Medications:
• Uterotonics: Administer oxytocin (10-40 units in 1000 mL of IV fluid or 10 units IM) to
promote uterine contraction.
• If bleeding persists, consider administering other uterotonics such as methylergometrine
(Methergine) or carboprost (Hemabate) per protocol.
4. Uterine massage:
 • Perform bimanual uterine compression and massage to stimulate contraction and reduce
bleeding.
5. Investigate cause:
• Determine the cause of hemorrhage:
• Uterine atony: Confirmed by a soft, boggy uterus on examination.
• Lacerations: If identified, control bleeding through surgical repair.
• Retained products of conception: Evaluate via ultrasound or manual
exploration if necessary.
6. Consider surgical intervention:
• If bleeding does not stop with medical management and uterine massage, prepare for
surgical interventions, such as:
• Uterine artery embolization.
• Surgical exploration and repair: If retained products or lacerations are
identified.
• Hysterectomy: As a last resort in life-threatening situations.
7. Continuous monitoring:
• Monitor vital signs, output, and uterine tone continuously.
• Assess for signs of shock and ongoing bleeding.
8. Documentation:
• Thoroughly document the events, management steps taken, and patient response.
 BAHAWALPUR
Eclampsia (HELP Syndrome) Management
Diagnostic Points for Eclampsia (HELP Syndrome):
1. Seizures:
• Generalized tonic-clonic seizures occurring in a pregnant woman with pre-eclampsia.
2. Severe Hypertension:
• Blood pressure ≥160/110 mmHg.
3. Proteinuria:
• Urine protein ≥5 grams in a 24-hour collection or +3 on a dipstick.
4. Additional Symptoms:
• Headache, visual disturbances, or epigastric pain.
5. Laboratory Findings (HELLP Syndrome):
• Hemolysis: Elevated lactate dehydrogenase (LDH), decreased haptoglobin.
• Elevated Liver Enzymes: Elevated AST/ALT.
• Low Platelets: Platelet count <100,000/μL.

Management:
1. Stabilize the Patient:
• Admit to ICU or high-dependency unit for close monitoring and management.
2. Seizure Prevention:
• Administer magnesium sulfate (4-6g IV loading dose followed by 1-2g/hour infusion).
3. Control Blood Pressure:
• Use antihypertensives like labetalol, nifedipine, or hydralazine to lower BP to safer
levels (target <160/110 mmHg).
4. Supportive Care:
• Monitor vital signs, urine output, and laboratory parameters regularly.
• Manage pain and discomfort with appropriate analgesics.
5. Deliver the Baby:
• Immediate delivery is often necessary regardless of gestational age due to the severity of
the condition. Cesarean section is usually preferred if there are signs of maternal or fetal
distress.
6. Postpartum Care:
• Continue magnesium sulfate for 24 hours after delivery.
• Monitor for postpartum complications and ensure recovery from pre-eclampsia
symptoms.
Cholestasis Management
Diagnostic Points for Cholestasis of Pregnancy:
1. Pruritus:
• Intense itching, particularly on the palms and soles, with no rash.
2. Elevated Liver Enzymes:
• Elevated serum bile acids (primary diagnostic marker).
• Elevated ALT/AST levels.
3. Normal or Mildly Elevated Liver Function Tests:
• Normal bilirubin levels, as jaundice is not typically present.
4. Symptoms:
• Fatigue and abdominal discomfort may also be reported.
5. Timing:
• Symptoms usually occur in the third trimester.

Management:
1. Monitor Maternal and Fetal Health:
• Regular fetal monitoring to assess well-being.
• Monitor liver function tests and serum bile acids.
2. Medications:
• Ursodeoxycholic acid: Reduces bile acid levels and relieves itching.
• Antihistamines: For symptom relief if itching is severe.
• Vitamin K: Supplement if necessary to address any potential coagulopathy.
3. Delivery:
• Induction of labor is often considered at 37-38 weeks due to the increased risk of
adverse fetal outcomes, including stillbirth.
4. Supportive Care:
• Monitor for complications like vitamin K deficiency, fetal distress, and preterm labor.
• Educate the patient about potential signs of worsening symptoms and the importance of
timely follow-up.

Intrauterine Fetal Death (IUFD) Management

Diagnostic Points for Intrauterine Fetal Death (IUFD):
1. Absence of Fetal Heart Tones:
 • No detectable fetal heartbeat on Doppler or ultrasound.
2. Ultrasound Findings:
• Absent fetal movements and no fetal heartbeat.
• Possible signs include Spalding’s sign (overlapping skull bones), Robert’s sign (fetal
gas), or decreased amniotic fluid.
3. Maternal Symptoms:
• Decreased fetal movement or no fetal movements.
4. Confirmation:
• Confirm with ultrasound to ensure there is no cardiac activity and to assess fetal position
and placental condition.

Management:
1. Immediate Care:
• Provide emotional support and counseling to the patient and family.
• Explain the situation clearly and compassionately.
2. Delivery Planning:
• Induction of labor: Usually recommended to deliver the fetus vaginally if possible. Use
prostaglandins, oxytocin, or a combination based on the clinical scenario and gestational
age.
• Cesarean section: Considered if there are contraindications to vaginal delivery or if
induction fails.
3. Post-Delivery Care:
• Postpartum support: Provide grief counseling and discuss options for future pregnancies.
• Pathological examination: Perform a post-mortem examination of the fetus to determine
potential causes if the family consents.
• Monitoring and follow-up: Ensure appropriate follow-up for maternal health and mental
well-being.
4. Investigations:
• Check for underlying conditions: Investigate maternal conditions such as pre-eclampsia,
diabetes, infection, or chromosomal abnormalities.
• Placental examination: Assess for placental abnormalities or other causes of IUFD.

Long-term Considerations:
1. Genetic Counseling and Preconception Care:
• Offer genetic counseling and provide preconception care for future pregnancies if
needed.
Gestational Diabetes Mellitus (GDM) Fetomaternal Complications and
Management
Fetomaternal Complications:
1. Maternal Complications:
• Pre-eclampsia: Increased risk of high blood pressure and related issues.
• Hydramnios: Excessive amniotic fluid due to fetal polyuria.
• Infection: Increased risk of urinary tract infections.
• Labor Complications: Higher likelihood of cesarean delivery due to macrosomia or
fetal distress.
2. Fetal Complications:
• Macrosomia: Excessive fetal growth leading to a large baby, which may complicate
delivery.
• Neonatal Hypoglycemia: Risk of low blood sugar after birth.
• Respiratory Distress Syndrome (RDS): Risk of immature lung development.
• Jaundice: Increased risk of hyperbilirubinemia.
• Stillbirth: Elevated risk if GDM is poorly controlled.

Management of GDM:
1. Blood Glucose Control:
• Diet: Implement a balanced diet with carbohydrate control and frequent meals.
• Exercise: Encourage regular physical activity to help manage blood glucose levels.
• Medication: Use insulin if lifestyle changes are insufficient; oral hypoglycemic agents
(e.g., metformin or glyburide) may be considered if insulin is not feasible.
2. Monitoring:
• Self-Monitoring: Regular home blood glucose monitoring.
• Prenatal Visits: Increased frequency of visits to monitor maternal and fetal health.
3. Fetal Monitoring:
• Ultrasound: Regular ultrasounds to monitor fetal growth and amniotic fluid levels.
• Non-Stress Tests (NST) or Biophysical Profile (BPP): Assess fetal well-being.
4. Delivery Planning:
• Timing: Plan delivery around 38-39 weeks to reduce the risk of complications
associated with prolonged GDM.
• Mode of Delivery: Consider cesarean section if macrosomia or other complications are
present.
5. Postpartum Care:
• Monitoring: Continue to monitor blood glucose levels after delivery, as GDM often
resolves postpartum, but the patient is at risk for type 2 diabetes later.
 • Lifestyle Counseling: Provide guidance on maintaining a healthy diet and regular
exercise.

6. Education and Support:

1. Patient Education:
• Teach about the importance of blood glucose control, signs of complications, and when
to seek medical help.
2. Support Services:
• Offer access to dietitians, diabetes educators, and support groups for additional guidance
and assistance.

Q8) Primary Postpartum Hemorrhage (PPH) Management

Management of Primary Postpartum Hemorrhage:
1. Immediate Care:
• Fundal Massage: Perform uterine massage to promote uterine contraction.
• Medications: Administer uterotonic agents such as oxytocin, misoprostol, or
ergometrine.
• IV Fluids and Blood Products: Replace blood loss with IV fluids and consider blood
transfusion if necessary.
• Monitor Vitals: Keep a close watch on blood pressure, pulse, and other vital signs.
2. Surgical Interventions:
• Uterine Tamponade: Balloon tamponade may be used if bleeding is unresponsive to
medical management.
• Surgical Repair: Repair any lacerations or tears. In severe cases, consider laparotomy
or hysterectomy.

Q9) Cord Prolapse Management

Management of Cord Prolapse:
1. Immediate Measures:
• Positioning: Place the mother in the knee-chest or Trendelenburg position to relieve
pressure on the cord.
• Manual Elevation: Use sterile gloves to manually elevate the presenting fetal part off
the cord.
2. Emergency Delivery:
• Immediate Cesarean Section: Delivery via cesarean section is usually indicated to
prevent fetal compromise.
 • Oxygen Administration: Provide maternal oxygen to optimize fetal oxygenation.
3. Monitoring:
• Fetal Heart Monitoring: Continuous monitoring to assess fetal well-being while
preparing for delivery.
 WMC
Breech Presentation:
Risk Factors:
• Prematurity
• Uterine abnormalities (fibroids, septate uterus)
• Polyhydramnios or oligohydramnios
• Fetal anomalies (e.g., anencephaly, hydrocephalus)
• Multiple pregnancy
Investigations:
• Clinical examination: Abdominal palpation (soft mass in the fundus)
• Ultrasound: To confirm presentation, rule out anomalies, and assess amniotic fluid
Treatment:
• External cephalic version (ECV): Attempt at 36-37 weeks if no contraindications
• Planned C-section: If ECV fails or contraindicated
• Vaginal breech delivery: In selected cases with experienced providers
Complications:
• Cord prolapse
• Birth asphyxia
• Fetal injury (fractures, brachial plexus injury)
• Uterine rupture

Diabetes Pre-pregnancy Counseling:

1. Optimize glycemic control:
• Achieve HbA1c <7% before conception.
• Avoid teratogenic medications (e.g., ACE inhibitors, statins).
2. Screen for complications:
• Retinopathy, nephropathy, cardiovascular disease.
3. Folic acid supplementation:
• High-dose folic acid (5 mg daily) at least 3 months before conception.
4. Lifestyle modifications:
• Diet and exercise guidance to maintain a healthy BMI.
5. Medication adjustment:
• Switch from oral hypoglycemics (except metformin) to insulin if needed.
Placenta Previa:
Risk Factors:
• Previous C-section or uterine surgery
• Multiparity
• Advanced maternal age
• Smoking
• Multiple gestations
Investigations:
• Ultrasound: To confirm placental location (transabdominal or transvaginal)
• CBC: For anemia if bleeding is present
• Coagulation profile: In cases of significant bleeding
Treatment:
• Observation: If asymptomatic or mild bleeding; rest and follow-up ultrasounds
• Hospitalization: For significant bleeding or if delivery is imminent
• C-section: Planned at 36-37 weeks or earlier if there is heavy bleeding
Complications:
• Severe hemorrhage
• Preterm delivery
• Placenta accreta
• Maternal anemia or hypovolemic shock

Uterine Inversion:
Risk Factors:
• Excessive traction on the umbilical cord
• Fundal placental attachment
• Uterine atony
• Short umbilical cord
Investigations:
• Clinical diagnosis: Visible or palpable inverted uterus after delivery
Treatment:
• Immediate manual repositioning (Johnson’s maneuver)
• Tocolytics (e.g., nitroglycerin) to relax the uterus before repositioning
• Surgical correction if manual replacement fails
 • Oxytocics after repositioning to maintain uterine tone
Complications:
• Hemorrhage
• Shock
• Uterine rupture
• Infection

External Cephalic Version (ECV):

Definition:
• A procedure to turn a breech fetus into a cephalic position after 36 weeks of gestation.
Indications:
• Breech presentation with no contraindications to vaginal delivery
Contraindications:
• Placenta previa
• Oligohydramnios
• Uterine abnormalities
• Fetal distress
Complications:
• Fetal bradycardia
• Premature rupture of membranes
• Placental abruption
• Failure to turn

Internal Podalic Version:

Definition:
• Turning a second twin from transverse or breech to cephalic by grasping the feet during
delivery.
Indications:
• Breech or transverse second twin during vaginal delivery
Complications:
• Uterine rupture
• Cord prolapse
• Fetal trauma
 • Fetal distress

Eclampsia:
Risk Factors:
• Pre-eclampsia
• First pregnancy
• Advanced maternal age (>35 years)
• Multiple gestation
• Hypertension
• Obesity
Investigations:
• CBC: To check for thrombocytopenia
• Liver function tests (LFTs): Elevated transaminases in HELLP syndrome
• Renal function tests: Elevated creatinine, proteinuria
• CT or MRI brain: If neurological symptoms persist after seizure control
Treatment:
• Seizure control: Magnesium sulfate (drug of choice)
• Blood pressure control: Antihypertensives (e.g., labetalol, hydralazine)
• Delivery: Definitive treatment; usually immediate after stabilization regardless of gestational
age
Complications:
• Maternal: Cerebral hemorrhage, renal failure, pulmonary edema
• Fetal: Preterm birth, IUGR, stillbirth

Intrauterine Growth Restriction (IUGR):

Risk Factors:
• Maternal hypertension or pre-eclampsia
• Smoking, alcohol, or drug use
• Placental insufficiency
• Multiple pregnancies
• Fetal chromosomal abnormalities
Investigations:
• Ultrasound: Fetal biometry, estimated fetal weight, and Doppler studies (umbilical artery)
• NST or CTG: To assess fetal well-being
• Amniotic fluid assessment: To check for oligohydramnios
Treatment:
• Close monitoring: Frequent ultrasounds, Doppler, and CTG
• Early delivery: If fetal distress is detected or growth is severely restricted
• Steroids: If preterm delivery is anticipated to enhance fetal lung maturity
Complications:
• Stillbirth
• Neonatal hypoxia
• Low birth weight
• Long-term developmental delays

Obstetric Cholestasis:
Risk Factors:
• Family history of cholestasis
• Multiple pregnancies
• Previous history of obstetric cholestasis
• Hepatitis C infection
Investigations:
• Liver function tests (LFTs): Raised bile acids and transaminases
• Coagulation profile: As vitamin K absorption may be reduced
Treatment:
• Ursodeoxycholic acid (UDCA): To relieve itching and reduce bile acid levels
• Vitamin K supplementation: To prevent bleeding due to impaired absorption
• Planned delivery at 37-38 weeks: To reduce the risk of stillbirth
Complications:
• Preterm delivery
• Meconium-stained amniotic fluid
• Stillbirth
• Postpartum hemorrhage (PPH) due to vitamin K deficiency

Polyhydramnios:
Risk Factors:
• Maternal diabetes
• Fetal anomalies (e.g., anencephaly, gastrointestinal obstruction)
• Multiple gestation
 • Fetal infections (e.g., parvovirus, syphilis)
Investigations:
• Ultrasound: To assess amniotic fluid index (AFI >25 cm)
• Fetal anomaly scan: To check for structural anomalies
• Glucose tolerance test (GTT): To rule out gestational diabetes
Treatment:
• Monitoring: Regular ultrasounds and fetal surveillance
• Amnioreduction: In severe cases to relieve maternal symptoms
• Indomethacin: May reduce fluid production in some cases (not commonly used in late
pregnancy)
Complications:
• Preterm labor
• Premature rupture of membranes
• Cord prolapse
• Placental abruption
 AMC 1st Module

1. A 30-year-old Primigravida presents at 29 weeks of gestation with complaints of vaginal

leaking for the past 3 hours. On speculum examination, there is pooling of clear fluid in the
vagina. She is vitally stable and gives no history of fever. What is the probable diagnosis?
a. Which relevant investigations will you order for this case?
b. Enumerate the management steps.

Q1:
Diagnosis: Preterm Premature Rupture of Membranes (PPROM)
a. Relevant investigations:
1. Sterile speculum examination: Confirm amniotic fluid pooling.
2. Nitrazine or Fern test: To confirm amniotic fluid.
3. Ultrasound: Assess amniotic fluid index and fetal well-being.
4. Fetal heart rate monitoring (CTG): For fetal distress.
5. Vaginal swab for culture: To check for infection.
6. Complete blood count (CBC): To check for infection markers.
b. Management steps:
1. Hospital admission: For close monitoring.
2. Antibiotic prophylaxis: To prevent infection (e.g., erythromycin).
3. Corticosteroids: For fetal lung maturation (e.g., betamethasone).
4. Tocolysis: If labor begins, but only if there is no infection or contraindication.
5. Fetal monitoring: Regular CTG to monitor fetal heart rate.
6. Monitor for signs of chorioamnionitis: Fever, maternal tachycardia, fetal tachycardia, uterine
tenderness.
7. Delivery: If infection or fetal distress develops, or at 34 weeks if stable.

2. A 32-week pregnant G2P1 with a previous SVD presents to you with complaints of increased
frequency of urination and thirst. She has a history of a good-sized baby in her previous
pregnancy. Ultrasound shows a single fetus in cephalic position with an estimated fetal weight of
3.9 kg.
a. What is the likely diagnosis?
b. What are the maternal and fetal risks in this case?
c. What preconception counseling will you give before her next pregnancy?
Q2:
Diagnosis: Gestational diabetes mellitus (GDM)
a. Maternal and fetal risks:
• Maternal risks:
1. Increased risk of preeclampsia.
2. Increased risk of type 2 diabetes in the future.
3. Increased risk of cesarean section due to large baby.
• Fetal risks:
1. Macrosomia (leading to shoulder dystocia during delivery).
2. Neonatal hypoglycemia.
3. Increased risk of obesity and diabetes later in life.
b. Preconception counseling:
1. Weight control and healthy lifestyle: Optimize BMI before pregnancy.
2. Pre-pregnancy screening for diabetes: Oral glucose tolerance test (OGTT).
3. Tight glucose control: Maintain HbA1c within normal limits.
4. Folic acid supplementation: 5 mg daily before conception and during early pregnancy.
5. Exercise and diet: Advice on diet and physical activity to maintain normoglycemia.

3. A pregnant lady collapsed in the gynecological OPD and is not responding. Her fundal height is
that of 35 weeks. You are the only doctor with the patient.
a. What are the possible causes of collapse in this patient?
b. Explain how you will attempt to resuscitate this lady.
a. Possible causes of collapse:
1. Amniotic fluid embolism
2. Pulmonary embolism
3. Hypovolemic shock due to concealed hemorrhage (e.g., placental abruption, uterine rupture).
4. Eclampsia
5. Cardiac arrest due to other causes.
b. Resuscitation steps:
1. Call for help immediately.
2. Position: Left lateral tilt to relieve aortocaval compression.
3. Airway and breathing: Ensure airway patency and administer 100% oxygen.
4. Circulation: Start chest compressions if no pulse, and initiate intravenous access with 2 large-
bore cannulas.
5. Rapid fluid resuscitation with isotonic fluids (normal saline or Ringer’s lactate).
 6. Emergency delivery (Perimortem C-section) if resuscitation is not effective within 4 minutes.
7. Administer drugs (adrenaline if needed) and manage based on the underlying cause.

4. A Grand-multipara lady just delivered a 3.7 kg baby boy in the labor ward. Despite using
active management of the third stage of labor, her uterus fails to contract, and she is bleeding
profusely. She has lost about 1 liter of blood. Her pulse is 130/min, and BP is 80/40 mmHg.
a. Enumerate the causes of uterine atony.
b. What investigation will you advise?
c. How will you manage this case?

Q4:
Diagnosis: Postpartum hemorrhage due to uterine atony
a. Causes of uterine atony:
1. Overdistension of the uterus (e.g., multiple gestation, macrosomia).
2. Prolonged or rapid labor.
3. Oxytocin desensitization (due to prolonged use during labor).
4. Chorioamnionitis.
5. Retained placental fragments.
b. Investigations:
1. CBC: To assess hemoglobin and platelet levels.
2. Coagulation profile: To rule out coagulopathy (DIC).
3. Ultrasound: To check for retained placental tissue or clots.
c. Management:
1. Uterine massage: Immediate to stimulate uterine contraction.
2. Pharmacological agents:
• Oxytocin IV infusion.
• Misoprostol rectally.
• Ergometrine or Carboprost if no contraindications.
3. Fluid resuscitation: IV fluids and blood products if necessary.
4. Surgical management if bleeding persists (e.g., balloon tamponade, B-Lynch suture, uterine
artery ligation).
5. Hysterectomy: As a last resort if bleeding cannot be controlled.
5. A 28-year-old G2P1L1 at 34 weeks of gestation presents in gynecology MRC with generalized
tonic-clonic seizures. Her blood pressure is 180/120 mmHg, her urine albumin is +3, and serum
uric acid is 590.
a. What is your diagnosis?
b. What are the risk factors that can lead to this condition?
c. What are the management steps in this case?

Q5:
Diagnosis: Eclampsia
a. Risk factors:
1. Previous history of preeclampsia or eclampsia.
2. Chronic hypertension.
3. Diabetes mellitus.
4. Obesity.
5. Multiple pregnancies (e.g., twins).
b. Management:
1. Stabilization of the patient:
• Place in the left lateral position to prevent aspiration.
• Administer magnesium sulfate IV for seizure control (loading and maintenance dose).
2. Antihypertensives:
• IV labetalol or hydralazine to control BP.
3. Fluid management: Avoid fluid overload due to the risk of pulmonary edema.
4. Fetal monitoring: Continuous fetal heart rate monitoring.
5. Delivery: Once the patient is stabilized, deliver the baby (preferably via induction or C-section
if indicated).

6. A Primigravida presented at 33 weeks of gestation to the emergency with complaints of lower

abdominal pain. On examination, she has regular painful uterine contractions (3 every 10
minutes). There is no vaginal bleeding; however, the cervical os is 3 cm dilated with absent
membranes. Transabdominal ultrasound reveals a single alive fetus in cephalic position.
a. What is the diagnosis?
b. How will you manage this patient in order to achieve the best maternal-fetal outcome?

Q6:
Diagnosis: Preterm labor at 33 weeks of gestation.
b. Management:
1. Admission to the hospital for close monitoring.
2. Tocolysis: Administer tocolytic drugs (e.g., nifedipine or atosiban) to delay labor and gain time
for fetal maturation, unless contraindicated.
3. Corticosteroids: Administer betamethasone or dexamethasone to enhance fetal lung maturity.
4. Magnesium sulfate: Administer if the gestational age is between 24 and 34 weeks to provide
neuroprotection and reduce the risk of cerebral palsy.
5. Antibiotic prophylaxis: Administer antibiotics (e.g., ampicillin) to prevent neonatal sepsis,
especially if Group B Streptococcus (GBS) colonization is suspected.
6. Fetal monitoring: Perform continuous cardiotocography (CTG) to assess fetal well-being.
7. Consider delivery: If fetal distress, maternal instability, or failure of tocolysis occurs, proceed
with delivery (vaginal or C-section depending on the situation).

7. A Primigravida at 36 weeks of gestation comes for a routine antenatal visit. Her

symphysiofundal height is 33 cm. Ultrasound shows a single fetus in cephalic position, AFI of 2
cm, and a disparity of 3 weeks between LMP and fetal biometry.
a. What is the differential diagnosis?
b. What investigations will you advise?
c. How will you manage this case?

Q7:
Diagnosis: Oligohydramnios with possible intrauterine growth restriction (IUGR).
a. Differential diagnosis:
1. Intrauterine growth restriction (IUGR)
2. Oligohydramnios due to placental insufficiency.
3. Fetal anomaly affecting amniotic fluid production.
b. Investigations:
1. Doppler ultrasound: To assess umbilical artery blood flow and fetal well-being.
2. Biophysical profile (BPP): To assess fetal health.
3. Non-stress test (NST): For fetal heart rate monitoring.
4. Urinalysis: To check for proteinuria (pre-eclampsia risk).
5. Blood tests: Including complete blood count (CBC), liver function tests (LFTs), and renal
function tests to rule out maternal conditions.
c. Management:
1. Frequent fetal monitoring: Regular Doppler studies and CTG to assess fetal well-being.
2. Maternal hydration: Increase fluid intake and consider IV fluids.
 3. Steroid administration: To enhance fetal lung maturity if delivery is anticipated.
4. Delivery: Consider early delivery if fetal distress or worsening oligohydramnios occurs,
especially after 34 weeks.

8. A G2P1 is in labor. Her cervix is 5 cm dilated. She had spontaneous rupture of membranes, and
the midwife noticed a cord-like structure in the vagina. There are variable decelerations on CTG.
a. What is your diagnosis?
b. How will you manage this patient?

Q8:
Diagnosis: Umbilical cord prolapse.
b. Management:
1. Call for help immediately.
2. Elevate the presenting part: Manually elevate the presenting part (fetal head) to relieve
pressure on the prolapsed cord.
3. Position the patient: Place the patient in the Trendelenburg or knee-chest position to reduce
pressure on the cord.
4. Oxygen administration: Provide 100% oxygen to the mother.
5. Immediate delivery: Proceed to an emergency C-section to avoid fetal hypoxia and prevent
perinatal death.
6. Monitor fetal heart rate: Continuous CTG until delivery is completed.

9. A 26-year-old G2P1, gestational diabetic with an estimated fetal weight of 4 kg, is fully dilated
and has been pushing for the past 1 hour. The head subsequently delivers but fails to restitute.
a. What is your diagnosis?
b. Describe the steps of management in this case to prevent intrapartum death of the baby.

Q9:
Diagnosis: Shoulder dystocia.
b. Steps of management:
1. Call for assistance immediately.
2. McRoberts maneuver: Flex and abduct the mother’s hips (knees to chest) to widen the pelvic
outlet.
3. Suprapubic pressure: Apply firm downward pressure just above the pubic bone to dislodge the
fetal shoulder.
4. Episiotomy: Consider episiotomy to facilitate other maneuvers.
5. Deliver posterior arm: Reach into the vagina and attempt to deliver the posterior arm to rotate
the baby and relieve the impaction.
6. Rotational maneuvers (e.g., Woods corkscrew): Rotate the fetal shoulders to facilitate delivery.
7. Zavanelli maneuver: As a last resort, replace the fetal head into the vagina and proceed with an
emergency C-section if all other maneuvers fail.
 AMC 2nd Module
1. A G2P1L1 at 11 weeks of gestation with a previous child with Down syndrome presented to the
OPD for screening of Down syndrome.
a. What test will you offer for screening in the first trimester?
b. What is the diagnostic test for Down syndrome?
c. What is the percentage of miscarriage associated with the diagnostic test performed in the first
trimester?
a. First trimester screening for Down syndrome:
• Offer combined screening: This includes nuchal translucency (NT) ultrasound along with
maternal serum markers (free β-hCG and PAPP-A) between 11 to 14 weeks of gestation.
b. Diagnostic test for Down syndrome:
• The diagnostic test is chorionic villus sampling (CVS), which is performed between 10 to 13
weeks of gestation.
c. Miscarriage risk associated with CVS:
• The risk of miscarriage following CVS is approximately 0.5% to 1%.

2. A G4P3L3 at 35 weeks of gestation presented to the gynae OPD with complaints of decreased
fetal movements for 2 days. On examination, her symphysiofundal height is 30 cm. A hand-held
Doppler shows a fetal heart rate of 145 bpm.
a. What is your diagnosis?
b. How will you manage this patient?

2. Decreased fetal movements and management

a. Diagnosis:
• The most likely diagnosis is intrauterine growth restriction (IUGR), as suggested by the
discrepancy between the gestational age (35 weeks) and the symphysiofundal height (30 cm),
with decreased fetal movements.
b. Management:
1. Immediate evaluation: Admit the patient for further evaluation.
• Non-stress test (NST): Perform to assess fetal well-being.
• Ultrasound: Assess fetal growth, amniotic fluid volume, and Doppler studies (umbilical
artery Doppler) to check for any signs of compromised placental function.
 2. Further management:
• If fetal compromise is confirmed (e.g., abnormal Doppler), consider early delivery
depending on the results.
• If results are reassuring, continue close monitoring with regular ultrasounds and fetal
movement counting.

3. A 26-year-old G3P2L2 with gestational diabetes mellitus is fully dilated and has been pushing
for the past 1 hour. The head subsequently delivers, but there is difficulty in the delivery of the
shoulders.
a. What is your diagnosis?
b. Describe the steps of management in this case.
a. Diagnosis:
• The diagnosis is shoulder dystocia, where the fetal shoulders fail to deliver after the head,
commonly associated with large fetal size (macrosomia), especially in gestational diabetes.
b. Steps of management (HELPERR mnemonic):
1. H: Help: Call for assistance immediately (obstetrician, pediatrician, etc.).
2. E: Episiotomy: Consider performing an episiotomy to provide more room.
3. L: Legs (McRoberts maneuver): Flex the maternal legs toward the abdomen to widen the
pelvis.
4. P: Suprapubic pressure: Apply pressure just above the pubic bone to dislodge the shoulder.
5. E: Enter (internal maneuvers): Perform rotational maneuvers such as the Rubin or Woods
screw maneuver to rotate the anterior shoulder.
6. R: Remove posterior arm: If necessary, reach in to deliver the posterior arm, reducing the
shoulder diameter.
7. R: Roll (Gaskin maneuver): Consider placing the mother in an all-fours position if the above
maneuvers fail.

4. A grand multipara just delivered a 4.8 kg baby boy in the labor ward. She is bleeding
profusely, and her uterus fails to contract. She has lost 1 liter of blood. Her pulse is 110/min and
BP is 80/40 mmHg.
a. Define PPH.
b. What are the causes of uterine atony?
c. How will you manage this case?
a. Definition of PPH:
 • Postpartum hemorrhage (PPH) is defined as blood loss of ≥500 mL after vaginal delivery or
≥1000 mL after cesarean delivery, or any amount of blood loss that causes hemodynamic
instability.
b. Causes of uterine atony:
1. Overdistension of the uterus: Due to multiple gestations, polyhydramnios, or macrosomia.
2. Prolonged labor or rapid labor.
3. Infection: Chorioamnionitis can lead to ineffective uterine contractions.
4. Uterine muscle exhaustion: From prolonged or augmented labor.
5. Previous uterine surgery: Leading to scarring and poor contractility.
c. Management of this case:
1. Immediate resuscitation:
• Airway, Breathing, Circulation: Ensure an open airway, provide oxygen, and initiate
IV fluid resuscitation (2 large bore IV cannulas) with crystalloids or blood products if
necessary.
• Medications: Administer uterotonics:
• Oxytocin 10 IU IM or IV infusion.
• If bleeding continues, give ergometrine, carboprost (hemabate), or
misoprostol.
2. Mechanical interventions:
• Bimanual uterine massage to stimulate contractions.
• If the uterus fails to contract, consider a balloon tamponade (e.g., Bakri balloon) or
surgical interventions such as B-Lynch suture or arterial ligation.
3. Blood loss management: Transfuse blood and blood products as per the amount of blood loss
and hemodynamic stability.

5. A G6P5L5 is in labor. Her cervical os is 5 cm dilated. She had spontaneous rupture of

membranes, and the midwife noticed a cord-like structure in the vagina. There are variable
decelerations on CTG.
a. What is your diagnosis?
b. How will you manage this patient?
a. Diagnosis:
• The diagnosis is cord prolapse, where the umbilical cord descends through the cervix into the
vagina, potentially compressing the cord and compromising fetal circulation.
b. Management of cord prolapse:
1. Immediate management:
 • Positioning: Place the patient in the knee-chest position or Trendelenburg position to
relieve pressure on the umbilical cord.
• Manual elevation of the presenting part: Using a sterile gloved hand, push the
presenting fetal part upward to relieve pressure on the cord.
• Tocolytics: Administer tocolytics (e.g., terbutaline) to reduce uterine contractions.
2. Emergency delivery:
• If the patient is fully dilated, attempt assisted vaginal delivery (forceps or vacuum) if
feasible.
• If the patient is not fully dilated, perform an emergency cesarean section to deliver the
baby as soon as possible.

6. A pregnant woman at 33 weeks of gestation presented to the emergency department with

complaints of lower abdominal pain. On examination, she has regular painful uterine
contractions, 4 in 10 minutes. On per vaginal examination, the cervical os is 2 cm dilated.
Transabdominal ultrasound reveals a single alive fetus in cephalic presentation.
a. What is your diagnosis?
b. What are the causes of the given condition?
c. How will you manage this case?
a. Diagnosis:
• The diagnosis is preterm labor, defined as regular uterine contractions associated with cervical
changes (dilation of 2 cm) between 20 and 37 weeks of gestation.
b. Causes of preterm labor:
1. Infections: Urinary tract infections, bacterial vaginosis, or intra-amniotic infections.
2. Multiple gestations: Twins or higher-order pregnancies.
3. Uterine anomalies: Such as uterine fibroids or septate uterus.
4. Placental problems: Placental abruption or previa.
5. Cervical insufficiency: Shortened or weakened cervix.
6. Polyhydramnios: Excess amniotic fluid leading to uterine overdistension.
c. Management:
1. Tocolysis: Administer tocolytics (e.g., nifedipine, atosiban) to delay labor for 48 hours to allow
corticosteroids to take effect.
2. Corticosteroids: Administer betamethasone or dexamethasone to promote fetal lung maturity.
3. Magnesium sulfate: Given for neuroprotection if delivery is imminent before 34 weeks.
4. Antibiotics: If infection is suspected or if preterm premature rupture of membranes (PPROM)
occurs.
5. Continuous fetal monitoring: Assess fetal heart rate and maternal condition closely.
7. A 35-year-old pregnant woman at 30 weeks of gestation presented to the gynecology emergency
with complaints of headache and epigastric pain. On examination, her BP is 150/100 mmHg and
urine albumin is +2.
a. How will you define pre-eclampsia?
b. What are the risk factors for pre-eclampsia?
c. How will you manage this case?
a. Definition of pre-eclampsia:
• Pre-eclampsia is defined as new-onset hypertension (≥140/90 mmHg) after 20 weeks of
gestation, accompanied by proteinuria (≥+1 on dipstick or ≥300 mg/24 hours) or signs of
organ dysfunction (e.g., elevated liver enzymes, low platelets, or renal impairment).
b. Risk factors for pre-eclampsia:
1. Nulliparity or first pregnancy.
2. Advanced maternal age (>35 years).
3. Pre-existing hypertension or diabetes.
4. Family history of pre-eclampsia.
5. Multiple pregnancies (twins or more).
6. Obesity or pre-pregnancy high BMI.
c. Management:
1. Hospital admission: Close monitoring of mother and fetus.
2. Antihypertensive therapy: Administer labetalol, nifedipine, or methyldopa to control blood
pressure.
3. Magnesium sulfate: For seizure prophylaxis if severe features of pre-eclampsia are present.
4. Corticosteroids: Betamethasone for fetal lung maturation if delivery is likely before 34 weeks.
5. Delivery: Timely delivery is the only definitive cure. Consider the severity of the condition and
fetal maturity in determining the timing.

8. A pregnant woman presented to the gynecology department with complaints of low abdominal
pain since night. On per vaginal examination, her cervical os is 7 cm dilated, the cervix is soft,
central, 1.5 cm long, and the vertex is at -1 with intact membranes.
a. Define labor.
b. Enumerate the stages of labor.
c. What is the active management of the third stage of labor?
a. Definition of labor:
• Labor is defined as regular uterine contractions leading to progressive cervical dilation and
effacement, ultimately resulting in the delivery of the fetus and placenta.
b. Stages of labor:
1. First stage: From the onset of labor to full cervical dilation (10 cm).
• Divided into latent phase (slow cervical dilation) and active phase (rapid cervical
dilation).
2. Second stage: From full cervical dilation to the delivery of the baby.
3. Third stage: From the delivery of the baby to the delivery of the placenta.
4. Fourth stage: The immediate postpartum period (first hour after delivery), focusing on the
prevention of postpartum hemorrhage (PPH).
c. Active management of the third stage of labor:
1. Uterotonic administration: Oxytocin 10 IU IM or IV immediately after the delivery of the
baby.
2. Controlled cord traction: Gentle traction on the umbilical cord with counterpressure on the
uterus to aid placental separation.
3. Uterine massage: Performed after placental delivery to ensure firm contraction and minimize
bleeding.

9. A pregnant lady collapsed in the gynecology OPD and is not responding. Her fundal height is
30 cm. She has no previous records or documents with her.
a. What are the possible causes of collapse in this patient?
b. Explain how you will attempt to resuscitate this patient.
a. Possible causes of collapse:
1. Severe pre-eclampsia/eclampsia: Can lead to seizures or hypertensive crisis.
2. Amniotic fluid embolism: Sudden cardiovascular collapse due to amniotic fluid entering the
maternal circulation.
3. Pulmonary embolism: Thromboembolism causing obstruction of pulmonary blood flow.
4. Hypovolemia: Possibly from acute hemorrhage or placental abruption.
5. Cardiac event: Underlying cardiac conditions or arrhythmias.
b. Resuscitation steps (ABCD approach):
1. A – Airway: Ensure the airway is open and clear. Consider intubation if the patient is
unconscious and not breathing adequately.
2. B – Breathing: Administer high-flow oxygen and assess respiratory rate and oxygen saturation.
3. C – Circulation: Insert two large-bore IV cannulas and initiate rapid fluid resuscitation with
crystalloids. Start CPR if the patient is in cardiac arrest.
• Monitor blood pressure, heart rate, and signs of perfusion.
4. D – Definitive management: Identify and treat the underlying cause:
• For suspected eclampsia, administer magnesium sulfate.
• For hemorrhage, provide blood transfusion and consider immediate delivery.
• For embolism, initiate thrombolysis or emergency C-section if amniotic fluid
embolism is suspected.
 AMC 3rd Module
1. A 38-year-old G8P7 just delivered a baby boy weighing 1.7 kg in the labor ward and is bleeding
profusely. She has lost about 1 liter of blood. Her pulse is 120/min and BP is 80/40 mmHg. The
uterus fails to contract.
a. How will you manage this case?
b. What investigations will you advise?
c. Enumerate the causes of uterine atony.
a. Management of postpartum hemorrhage with uterine atony:
• Immediate resuscitation: Start IV fluids (crystalloids) and initiate blood transfusion if
required. Administer oxygen.
• Uterotonic agents: Begin with oxytocin 10 IU IV bolus followed by infusion, and add
ergometrine 0.5 mg IM or carboprost 250 mcg IM (up to 8 doses if needed).
• Bimanual uterine massage to stimulate contraction.
• Surgical intervention: If medical management fails, proceed with uterine balloon tamponade,
B-Lynch suture, or even hysterectomy if necessary.
b. Investigations:
• Complete blood count (CBC) to assess hemoglobin and platelets.
• Coagulation profile (PT, aPTT) to detect coagulopathy.
• Cross-match for blood transfusion.
• Uterine ultrasound to check for retained products or clots.
c. Causes of uterine atony:
• Overdistended uterus (multiple pregnancies, polyhydramnios).
• Prolonged labor.
• Chorioamnionitis.
• High parity.
• Use of uterine relaxants (magnesium sulfate, tocolytics).
• Uterine fatigue after prolonged oxytocin use.

2. A young pregnant woman collapsed in the gynae OPD and is not responding. Her fundal height
is of 35 weeks.
a. What are the possible causes of collapse in this patient?
b. Explain how you will attempt to resuscitate the patient.
a. Possible causes of collapse:
 • Amniotic fluid embolism.
• Eclampsia or severe preeclampsia.
• Massive hemorrhage (placental abruption, uterine rupture).
• Pulmonary embolism.
• Cardiac event (e.g., peripartum cardiomyopathy).
b. Resuscitation:
• Immediate basic life support: Initiate CPR if no pulse.
• Left lateral tilt: To relieve aortocaval compression.
• Airway and breathing: Administer oxygen and consider intubation if needed.
• Circulation: Establish 2 large-bore IV lines and give rapid IV fluids (crystalloids). Administer
blood products if hemorrhage is suspected.
• Immediate obstetric consultation: If collapse is refractory, consider emergency perimortem
cesarean section within 4 minutes of collapse if gestation is over 24 weeks.

3. A 26-year-old primigravida at 35 weeks of gestation comes to the OPD for a routine antenatal
visit. Her symphysiofundal height is 22 cm. Ultrasound shows a single fetus in cephalic position,
AFI of 2 cm, and a disparity of 4 weeks between LMP and fetal biometry.
a. What is the differential diagnosis?
b. What investigations will you advise?
c. How will you manage this case?
a. Differential diagnosis:
• Fetal growth restriction (FGR).
• Oligohydramnios (possibly secondary to placental insufficiency).
• Inaccurate gestational age estimation.
b. Investigations:
• Doppler studies of the umbilical artery, middle cerebral artery to assess placental function.
• Detailed fetal biometry ultrasound.
• Biophysical profile (BPP) for fetal well-being.
• Amniotic fluid index (AFI) assessment serially.
c. Management:
• Serial ultrasound for fetal growth and Doppler studies.
• Non-stress test (NST) or BPP to monitor fetal well-being.
• Discuss early delivery if signs of fetal distress or worsening oligohydramnios are noted,
possibly via induction or cesarean section depending on the cervix and fetal condition.
4. A 35-year-old female G3P2L2 with a history of previous normal vaginal deliveries at 36 weeks
of gestation presents in the gynae OPD with an ultrasound report showing a single active fetus in
breech presentation, adequate liquor, and normal umbilical artery Doppler indices. The patient
wishes to undergo normal vaginal delivery.
a. Enlist the options for delivery that can be attempted in this case.
b. What is ECV and how is it performed?
c. Enlist contraindications of ECV.
a. Options for delivery:
• External cephalic version (ECV): Attempt to turn the fetus to cephalic.
• Planned vaginal breech delivery: Only if conditions are favorable (e.g., adequate pelvis,
experienced clinician).
• Elective cesarean section: If breech presentation persists or contraindications for vaginal
delivery exist.
b. External cephalic version (ECV):
• ECV involves manually turning the fetus from breech to cephalic presentation.
• Performed after 36-37 weeks, with ultrasound guidance and the use of tocolytic agents like
terbutaline to relax the uterus.
• Requires monitoring of fetal heart rate and potential immediate delivery if complications arise.
c. Contraindications to ECV:
• Multiple gestation.
• Uteroplacental insufficiency.
• Oligohydramnios.
• Fetal growth restriction.
• Antepartum hemorrhage.
• Uterine anomalies.

5. A 26-year-old G2P0A1 at 30 weeks of gestation presented in the gynae ER with complaints of

headache. On examination, BP is 150/100 mmHg, pulse is 76 bpm, and the patient is afebrile.
Ultrasound showed a single active fetus with reduced liquor. Urine dipstick shows +1 proteins.
a. What is the most likely diagnosis and how will you define it?
b. What are the likely risk factors for the diagnosed condition?
c. How will you manage this patient?
a. Most likely diagnosis:
 • Preeclampsia: Defined as BP ≥140/90 mmHg on two occasions at least 4 hours apart after 20
weeks of gestation in a previously normotensive woman, along with proteinuria (≥300 mg/24
hours or +1 on urine dipstick).
b. Risk factors for preeclampsia:
• Nulliparity.
• Advanced maternal age.
• Chronic hypertension or renal disease.
• History of preeclampsia in a prior pregnancy.
• Diabetes mellitus or obesity.
c. Management:
• Antihypertensive therapy: Labetalol or nifedipine to maintain BP <140/90 mmHg.
• Magnesium sulfate for seizure prophylaxis.
• Fetal surveillance: Ultrasound for fetal growth and Doppler studies, NST.
• Plan for delivery: Consideration of delivery based on maternal and fetal condition, typically
around 37 weeks, or earlier if severe features of preeclampsia develop.

6. A 36-year-old nulliparous woman with known type 1 diabetes is referred to the diabetic
pregnancy clinic as she is planning for pregnancy. She has mild retinopathy and is non-compliant
with medication. Her HbA1c is 7.0%.
a. How will you conduct pre-pregnancy counseling?
b. What is the effect of diabetes on pregnancy?
a. Pre-pregnancy counseling for a woman with type 1 diabetes:
1. Optimize glycemic control: Aim for an HbA1c <6.5% before conception. Educate about the
importance of strict blood sugar control to reduce risks of miscarriage, congenital
malformations, and preeclampsia.
2. Medications: Switch to safer medications, e.g., insulin analogs if not already on them.
Discontinue teratogenic medications like ACE inhibitors or statins, replacing them with
pregnancy-safe alternatives.
3. Retinopathy management: Advise regular ophthalmologic assessments due to the potential
worsening of retinopathy during pregnancy.
4. Folic acid supplementation: Start folic acid 5 mg daily to reduce the risk of neural tube
defects.
5. Lifestyle advice: Emphasize the importance of a healthy diet, regular exercise, and smoking
cessation if applicable.
6. Multidisciplinary care: Refer to a diabetic team, including an obstetrician, endocrinologist,
and dietician for comprehensive management.
b. Effects of diabetes on pregnancy:
 1. Maternal risks: Increased risk of preeclampsia, diabetic ketoacidosis (DKA), infections
(urinary tract, wound infections), and progression of diabetic complications (e.g., retinopathy,
nephropathy).
2. Fetal risks: Higher incidence of congenital malformations (especially neural tube defects and
cardiac anomalies), macrosomia, shoulder dystocia, intrauterine growth restriction (IUGR), and
preterm birth.
3. Perinatal risks: Polyhydramnios, stillbirth, neonatal hypoglycemia, and respiratory distress
syndrome.

7. A G6P5L5 at 39 weeks of gestation is in labor. Her FHR is normal. On PV examination, she is

fully dilated with station at zero and clean liquor. She is augmented with 10 units of syntocinon in
1000 ml R/L.
a. How will you define the stage of labor for this patient?
b. What are the signs of placental separation? How will you manage the third stage of labor?
a. Defining the stage of labor for a G6P5L5 at 39 weeks in labor:
• The patient is in the second stage of labor, as she is fully dilated, and the fetal head is at station
0. The second stage extends from full cervical dilation (10 cm) to the delivery of the baby.
b. Signs of placental separation and management of the third stage:
• Signs of placental separation:
1. Gush of blood: Sudden outflow of blood as the placenta separates from the uterine wall.
2. Lengthening of the umbilical cord: As the placenta descends into the lower uterine
segment or vagina.
3. Uterine contraction and rise: The uterus becomes firm and rises in the abdomen as the
placenta moves down.
• Management of the third stage of labor:
1. Active management: Administer a uterotonic (e.g., oxytocin 10 IU IM) immediately
after the baby is delivered to promote uterine contraction.
2. Controlled cord traction: Gently apply traction to the umbilical cord while supporting
the uterus to assist in placental expulsion.
3. Uterine massage: After placental delivery, perform uterine massage to promote
contraction and reduce bleeding.
4. Examine the placenta: Inspect for completeness and any retained fragments.
8. A 38-year-old G5P4+0, with previous normal vaginal deliveries, presents in the labor room
with complaints of painless mild vaginal bleeding at term. On examination, her pulse is 78 bpm,
BP is 120/70 mmHg, and her abdomen is soft and non-tender. Her CTG is reactive.
a. What are the likely differential diagnoses?
b. Outline the management plan for this patient.
a. Likely differential diagnoses of painless vaginal bleeding at term:
1. Placenta previa: Implantation of the placenta in the lower uterine segment, causing painless
bleeding.
2. Vasa previa: Fetal blood vessels cross or are near the internal os, risking rupture and bleeding.
3. Bloody show: A small amount of bleeding mixed with mucus as the cervix begins to efface and
dilate.
b. Management plan for painless vaginal bleeding at term:
1. Stabilization: Monitor vital signs and assess for signs of hemodynamic instability (e.g.,
tachycardia, hypotension).
2. Fetal monitoring: Continue cardiotocography (CTG) to ensure fetal well-being.
3. Ultrasound: Perform an ultrasound to determine placental location and exclude placenta previa
or vasa previa.
4. Delivery plan:
• If placenta previa is confirmed and bleeding continues or becomes heavy, a cesarean
section is indicated.
• If vasa previa is suspected, immediate cesarean delivery is required.
5. Prepare for delivery: If the bleeding is minimal and not of concerning origin (e.g., bloody
show), labor can be allowed to proceed with close monitoring.

9. A G2P1L1 at 30 weeks of gestation presents with increased liquor and a fundal height of 36
weeks. Her blood sugar level is 11.2 mmol/L.
a. What is your provisional diagnosis?
b. What are the maternal and fetal risks associated with this condition? (List 3 each)
a. Provisional diagnosis:
• The most likely diagnosis is polyhydramnios secondary to gestational diabetes mellitus
(GDM), given the elevated blood sugar level (11.2 mmol/L) and increased liquor volume.
b. Maternal and fetal risks associated with polyhydramnios:
• Maternal risks:
 1. Preterm labor: The overdistended uterus can lead to premature contractions and early
labor.
2. Placental abruption: Rapid decompression of the uterus, such as in the case of rupture
of membranes, can lead to placental separation.
3. Postpartum hemorrhage (PPH): An overdistended uterus may not contract effectively
after delivery.
• Fetal risks:
1. Malpresentation: The excessive amniotic fluid allows the fetus to move freely,
increasing the risk of abnormal positions such as breech.
2. Umbilical cord prolapse: The excess fluid can cause the cord to prolapse when the
membranes rupture.
3. Fetal macrosomia: Poorly controlled maternal diabetes can lead to overgrowth of the
fetus, increasing the risk of complications during delivery.