Gynaecology and Obstetrics Orals Questions and Answers PDF

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GYNECOLOGY ORALSI GROUP OF QUESTIONS1 Classification of breech presentations In a breech pregnancy or breech presentation, the baby is positioned with the buttocks down and the head up Classification  Breech presentation o Incomplete (frank) breech presentation o Complete (flexed) breech presentati...

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GYNECOLOGY ORALS I GROUP OF QUESTIONS 1.1 Classification of breech presentations In a breech pregnancy or breech presentation, the baby is positioned with the buttocks down and the head up Classification  Breech presentation o Incomplete (frank) breech presentation o Complete (flexed) breech presentation  Foot presentation o Complete o Incomplete  Knee presentation (complete or incomplete) 1.2 Definition of complete breech presentation A breech pregnancy or breech presentation called a complete breech presentation occurs when the hips and the knees of the fetus are flexed.

1.3 Definition of frank breech presentation

A frank breech presentation, in which the hips of the fetus are flexed and the legs extend straight upward with the knees straight and the feet touching the fetus head 1.4 Definition of incomplete foot-link presentation It is characterized by one leg presenting through the cervix. One leg is fully extended and the other fully flexed at hips and knee joints. 1.5 Definition of complete foot link presentation It is characterized by both legs presenting through the cervix. Both legs are fully extended. 1.6 Classification of fetal malpresentations Malposition’s are abnormal positions of the vertex of the fetal head relative to the maternal pelvis. Malpresentations are all presentations of the fetus other than vertex. Classification  Breech (Complete, incomplete or frank, foot, knee)  Transverse  Vertex (Face, brow, sinciput)  Compund (there is more than one body part presenting) 1.7   

Classification of deflexed presentations First degree: Sincipital presentation Second degree: Brow presentation Third degree- face presentation

1.8 Definition of sinciput vertex presentation A fetal position during delivery in which the frontal part of the skull including forehead and the top of the head is first to descend into the birth canal. Distance that passes is occipitofrontalis (12.5cm) Picture B

1.9 Definition of brow presentation In a brow presentation, the fetal head is midway between full flexion (vertex) and hyperextension (face) along a longitudinal axis. The presenting portion of the fetal head is between the orbital ridge and the anterior fontanel. The face and chin are not included. Presenting part is mento-occipitalis distance 13.5cm 1.10 Definition of face presentation In a face presentation, the fetal head and neck are hyperextended, causing the occiput to come in contact with the upper back of the fetus while lying in a longitudinal axis. The presenting portion of the fetus is the fetal face between the orbital ridges and the chin. The fetal chin (mentum) is the point designated for reference during an internal examination through the cervix. Presenting part is the hyobregmaticus distance 9.5cm 1.11 Classification of multiple pregnancies  Number of fetus: Twins, triplets, quadruplets etc.  Number of fertilized eggs (dizygotic or monozygotic)  Number of placenta: Monochorionic or dichorionic  Number of amniotic cavities: diamniotic or monoamniotic 1.12 Definition of polyhydramnios. The most probable reasons

Polyhydramnios is the excessive accumulation of amniotic fluid — the fluid that surrounds the baby in the uterus during pregnancy. Normally, the volume of amntonic fluid increases to about 1L -1,5 L more by 36 weeks but decreases thereafter. Somewhat, more than 2000 mL of amniotic fluid is considered excessive, or hydramnios Some of the known causes of polyhydramnios include:  A birth defect that affects the baby's gastrointestinal tract or central nervous system  Maternal diabetes  Twin-twin transfusion — a possible complication of identical twin pregnancies in which one twin receives too much blood and the other too little  A lack of red blood cells in the baby (fetal anemia)  Blood incompatibilities between mother and baby  Infection during pregnancy 1.13 Definition of oligohydramnios. The most probable reasons Oligohydramnios is the condition of having too little amniotic fluid, less than 1l What causes low amniotic fluid?  Birth defects – Problems with the development of the kidneys or urinary tract which could cause little urine production, leading to low levels of amniotic fluid.  Placental problems – If the placenta is not providing enough blood and nutrients to the baby, then the baby may stop recycling fluid.  Leaking or rupture of membranes –This may be a gush of fluid or a slow constant trickle of fluid. This is due to a tear in the membrane. Premature rupture of membranes (PROM) can also result in low amniotic fluid levels.  Intrauterine growth retardation  Post Date Pregnancy– A postdate pregnancy (one that goes over 42 weeks) can have low levels of amniotic fluid, which could be a result of declining placental function.  Maternal Complications– Factors such as maternal dehydration, hypertension, preeclampsia, diabetes,

and chronic hypoxia can have an effect on amniotic fluid levels 1.14 Pelvic classification according to the degree of contraction Four degrees of pelvic contractions should be distinguished:  I degree – True conjugate is 11-9 cm. Vaginal delivery is possible.  II degree – True conjugate is 9-7, 5 cm. Vaginal delivery is possible.  III degree – True conjugate is 7,5 – 5,5 cm Cesarean section is performed.  IV – degree – True conjugate is less than 5.5 cm. Cesarean section is performed. 1.15 Classification of the pelvis according to the form of contraction  Contraction of the pelvic inlet: obstetric conjugate, anatomical conjugate, diagonal conjugate, oblique conjugate, transverse conjugate  Contraction of the midpelvis: anterior posterior conjugate, oblique and transverse conjugate equal in size  Contraction of the pelvic outlet: anterior posterior conjugate, oblique conjugate, tranverse conjugate  Generally contracted pelvis Often occurred  generally contracted pelvis;  Flat pelvis: simple flat pelvis, flat rachitic pelvis, generally contracted flat pelvis. 2. Rare occurred:  obliquely contracted pelvis,  obliqualy dislocated pelvis,  transverse contracted pelvis,  osteomalacic pelvis,  funnel-shaped pelvis,  spondylolisthetic pelvis,  Contracted pelvis as a result of exostosis and bone tumors.

1.16 Definition of anatomical and functional contracted pelvis  Anatomically contracted pelvis is characterized by shortening of all or one diameters of the true pelvis into 1,5 - 2 cm and more.  Clinically or functional contracted pelvis - pelvis with normal dimensions, but vaginally delivery is impossible due to “cephalopelvic disproportion”. 1.17 Clinical signs of the clinical (functional) contracted pelvis  Arresting of the head in the pelvic inlet  Uterine contractions abnormality.  Positive Vasten’ sign: if disproportion between fetal head and pubic symphysis is prominent  Signs of urinary bladder compression.  Edema of the cervix, and vaginal walls, productions of fistulas.  Danger of uterine rupture – over distension of lower uterine segment  Pushing occurs in location of fetal head in inlet. 1.18 Definition of the general contracted pelvis Is characterized by diminution of all true pelvic diameters (anteroposterior, transverse, and oblique) into 1-2 cm. Subpubic arch is narrow. Average sizes of the pelvis are:  D. spinarum – 23 cm,  D. cristarum – 26 cm.  D. trochanterica - 29 cm  C. externa – 18 cm  C. diagonalis – 11 cm  C. vera – 9 cm. 1.19 Definition of simple flat pelvis Is defined as shortening of anteroposterior diameters at all levels of true pelvis, as a result of this sacrum is inclined anteriorly to pubis.  D. spinarum – 26cm

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D. cristarum – 29 cm D. trochanterica - 31 cm C. externa – 18 cm C. diagonalis – 11 cm C. vera – 9 cm.

1.20 Definition of flat rachitic pelvis True conjugate is shortened.  Sidewalls tend to converge, as result of this D. spinarum and D. cristarum are the same.  Additional promontorium may be presented between 1 and 2 vertebrae of sacrum  Subpubic arch is shallow and wide  Top of the sacrum is situated posteriorly that’s why dimensions of the pelvic outlet are normal or even increased. Average sizes of the pelvis are:  D. spinarum – 26cm  D. cristarum – 26 cm  D. trochanterica - 31 cm  C. externa – 17 cm  C. diagonalis – 10 cm  C. vera – 8 cm. 1.21 Classification of uterine contractions abnormalities 1. False labor. 2. Uterine inertia (hypotonic dysfunction):  Primary: absence of progressing dilation of the uterine cervix  Secondary: cessation of birth pangs in active phase of labor  Inadequate voluntary expulsive forces. 3. Excessive uterine activity (hypertonic dysfunction). 4. Incoordinative uterine activity (hypertonic dysfunction):  dyscoordination,  hyperactivity of lower uterine segment,  circulative dystocia (contractile ring),  Uterine tetania. 1.22 Which fetuses are called as large and giant

 A large fetus (the weight of the fetus estimated 3700 g and more).  A giant fetus (the weight of the fetus estimated 4000g and more) 1.23 Definition if hypotonic uterine dysfunction Hypotonic uterine dysfunction: (Uterine inertia) - uterine contractions is less than normal 1.24 Definition of hypertonic uterine dysfunction Hypertonic uterine dysfunction - uterine tone elevated. 1.25 Etiology of hypotonic uterine dysfunction  Excess maternal nervous sickness and emotions (maternal exhaustion);  impairment of nervous mechanisms of labor regulation as a result of previous acute and chronic infectious diseases, nervous system disorders:  Pathological changes of uterine cervix and uterus;  “Cephalopelvic disproportion”  hydramnion, multiple pregnancy, oligohydramnion;  postdate pregnancy;  administration of excess anesthesia;  inadequate usage of uterotonic drugs 1.26 Indications for perineotomy, episiotomy Episiotomy is incision of the perineum towards the ischial tuberosity Indications;  Threatened rupture of the perineum  High perineum (more than 4cm)  Premature Labor  Breech presentation  Reducing the second stage of labor according to induction concerning the fetus  Application of obstetrical forceps  Perineotomy is incision of the perineum towards the anus. It is conducted when perineal rupture has already started.

1.27 Indications for amniotomy Amniotomy is rupture of the fetal bladder membranes Indications  Polyhydramnios  Oligohydramnios (flat fetal bladder)  Partial placental previa  Multifetation (after the birth of the first fetus)  Dilation of uterine orifice by more than 7cm  Administration of uterotonics in uterine inertia  Late gestosis  Extragenital pathology (hypertension, kidney disease, cardiovascular pathology) 1.28 Indications for c-section from mother side  Maternal diseases, Eclampsia, Cardiac disease,  Previous uterine surgery (cesarean section, previous uterine rupture, myomectomy),  Obstruction to the birth canal (cervical cancer, previous cervical or vaginal surgery, ovarian tumors),  Abnormal uterine action.  Pelvic abnormalities that preclude engagement or interfere with descent of the fetal presentation in labor 1.29 Indications for c-section from fetus side  Fetal distress,  Cord prolapse,  Fetal malpresentations (breech, transverse lie, brow),  Cephalopelvic disproportion,  Placenta previa, Abruptio placentae 1.30 Indications for vacuum extraction of the fetus Vacuum extraction of fetus is an assisted vaginal delivery in which the fetus is extracted through the parturient canal with a vacuum extractor Indications  Maternal indications include heart disease, pulmonary injury or compromise, intrapartum infection, certain neurological

conditions, exhaustion, or prolonged second-stage labor, Placenta abruptio in second stage of labor.  Fetal reasons: fetal distresss 1.31 The indications for application of obstetric forceps  Maternal indications include heart disease, pulmonary injury or compromise, intrapartum infection, certain neurological conditions, exhaustion, or prolonged second-stage labor, Placenta abruptio in second stage of labor.  Fetal reasons: fetal distress 1.32 The conditions for the operation of obstetrics forceps  Live fetus  Full dilation of the cervix  Absence of membranes  Cephalopelvic proportion  Location of fetal head in the pelvic cavity (+2) or in the plane of pelvic outlet (+3) 1.33 The conditions for the operation of c-section  Intact amniotic fluid  Normal temperature  Alive fetus 1.34 Anesthesia for the c-section  Spinal anesthesia: Spinal anesthesia has the advantages of being easy to perform, requiring less time, and being more reliable than epidural analgesia. The primary disadvantage is the potential for severe hypotension – consider prehydration with 20 cc/kg, proper positioning, and keeping phenylephrine AND epinephrine on hand  Epidural anesthesia: Epidurals offer the advantage of multiple use (which is ideal if an epidural was already placed for labor analgesia), a smoother hemodynamic course  General anesthesia Drugs: Thiopental, Propofol, Ketamine 1.35 Etiology and pathogenesis of perineal and cervical lacerations

Perineal lacerations usually occurs in inflexible, inelastic perineum in women who give birth for the first time. Scarchanged perineum after the first labour  Etiology: fast and rapid delivery, deflexion fitting of the head, breech presentation, large fetus, improper methods of protection of the perineum hampered disengagement of the shoulder girdle. Cervical lacerations may be voluntary and violent in case of forced or operative delivery.Minor side lacerations of the cervix are called physiological. They occur in all women during childbirth at first. 1.36 Classification of cervical lacerations  First-degree laceration is up to 2 cm. Such tears heal rapidly and are rarely the source of any difficulty. In healing, they cause a significant change in the shape of the external os from round before cervical effacement and dilation to appreciably elongate laterally after and recovery from effacement and dilatation.  Second-degree laceration is more than 2 cm but it doesn’t extend to the vaginal fornices.  Third-degree laceration extend to the vaginal fornices. 1.37 Classification of perineal lacerations  First-degree laceration involves the fourchette, the perineal skin, and vaginal mucous membrane but not the underlying fascia and muscle.  Second-degree laceration involves in addition to skin and mucous membrane, the fascia and muscles of the perineal body but not the rectal shincter.  Third-degree laceration extends through the skin, mucous membrane, and perineal body and involves the anal sphincter. In is called incomplete laceration. Complete laceration involves the rectal mucosa. 1.38 Etiology, pathogenesis of uterine rupture  The most predisposing factors to uterine rupture are separation of a previous cesarean scar, clinically contracted pelvis as a result of “fetopelvic disproportion”, previous

traumatizing operations or manipulations such as curettage or perforation, previous inflammatory and degenerative changes in endometrium, excessive or inappropriate uterine stimulation with oxytocin.  Pathogenesis: Uterine rupture results from overdistention of the lower segment associated with mechanical obstruction to birth of fetus 1.39 Classification of uterine rupture  By etiology: o Traumatic rupture as result of oxytocin stimulation, difficult forceps delivery, breech extraction, unusual fetal enlargement, such as hydrocephalus; o Spontaneous rupture of the uterus as a result of cephalopelvic disproportion – or abnormal fetal presentations, such as brow.  Depending on whether the laceration communicates directly with the peritoneal cavity or is separated from it by the visceral peritoneum over the uterus or that of the broad ligament complete and incomplete rupture of the uterus have been distinguished. An incomplete rupture may, of course, become complete at any moment.  By the time of occurring: during pregnancy; during labor.  By localization: in the uterus fundus; in the uterine body; in the lower uterine segment; colporrhexis.  By clinical duration: danger of uterine rupture; beginning of the uterine rupture; uterine rupture that has happen 1.40 Classification of puerperal genital tract infection after Sazanov and Bartels According to stages I stage: limited form of septic infection that has not spread outside the uterus  Postpartum endometritis  Postpartum ulcer of perineum, vulva or cervix

II stage: Infection spreads beyond the uterus but is limited to the pelvic cavity  Vulvitis, colpitis, paracolpitis, salpingooophoritis  Metritis, parametritis  Thrombophlebitis of pelvic or femoral veins  Adnescitis  Pelvioperitonitis III stage: Distributed infection (boundary between local and general septic process  Distributed peritonitis  Infectious-toxic shock  Progressive thrombophlebitis  Anaerobic gas gangrene IV stage: Generalized infection: Sepsis (septicemia, pyosepticemia) 1.41 Pathogenesis of puerperal genital tract infection  Systemic Inflammatory response syndrome (SIRS) of the organism to a destructive infectious process in the reproductive organs. Occurrence of postnatal infection is promoted by changes in vaginal biogenesis, development of immune deficiency before end of pregnancy, pregnancy complications.  Infection spread mostly hematogenously, less frequently lymphogenous routes, or tubular routes along cervical canal and tubes. 1.42 Pathophysiology and etiology of placenta previa abnormal location of the placenta over, or in close proximity to, the internal cervical os.  Pathological process that lead to degenerative changes of the endometrium preventing implantation of gestational sacs in a typical site (endometritis, hypoplasia of uterus).  Pathology of gestational sac causes delayed maturation of the trophoblast, the sac attaches in isthmus or cervix.  In Vitro Fertilization whereby the artificially inseminated trophoblast may be placed too low.

1.43 Classification of placenta previa  complete or total - if the entire cervical os is covered;  partial - if the margin of the placenta extends across part but not all of the internal os;  marginal , if the edge of the placenta lies adjacent to the internal os;  low lying - if the placenta is located near but not directly adjacent to the internal os till 6 cm. 1.44 Pathophysiology and etiology of placenta abruption Premature separation of the normally implanted placenta from the uterine wall. Etiology: when there is hemorrhage into the decidua basalis, leading to premature placental separation and further bleeding. The cause for this bleeding is not known. Patients at risk:  Maternal hypertension  Multiply pregnancy  Polyhidramnios  External trauma  Preterm prematurely ruptured membranes  Cigarette smoking  Cocaine abuse  Uterine leiomyoma, 1.45 Diagnostic evaluation of placental abruption  External bleeding can be profuse or there may be no external bleeding (concealed hemorrhage)  Uterine tenderness  Back pain  Fetal distress  Uterine hypertonus or high-frequently contractions  Dead fetus when placenta is totally shared.  Coagulation disorders  Ultrasonography can help in diagnosis 1.46 Etiology of postpartum hemorrhage

Postpartum hemorrhage is defined as blood loss in excess of physiologic blood loss at the time of vaginal delivery – 0,5% from body weight. Postpartum hemorrhage before delivery of the placenta is called third-stage hemorrhage. Postpartum hemorrhage after delivery of placenta during the first two hours is called as hemorrhage in early puerperal stage. Etiology  uterine atony  genital tract trauma  bleeding from the placental site (retained placental tissue, low placental implantation, placental adherence, uterine inversion)  coagulation disorders 1.47 Principles for monitoring women who are at risk of postpartum hemorrhage  Empty the urinary bladder by means of a catheter because an overdistended bladder predetermines uterine atony due to common innervation  Active management of placental removing  After detachment of placenta, check its integrity, if it is not complete, manual revision of uterus.  Uterotonics such as oxytocin or carbetocin are given for uterine atony  Suture all lacerations carefully 1.48 Etiology o...