2023-2024

Obstetrics & Gynecology

Apprenticeship

| Halder Jamal
Lectures and clinical files of Stage 5 are essential, everything with notes is in my drive:
tiny.cc/halder. My anki cards are very well orgnazied & summarized from the lectures so
you can solely rely on them.

Reproductive Health Block

All stage 5 materials
Obstetrics Gynaecology
1. Epidemiology 15 1. Anomalies 29
2. Physiological Changes 39 2. Primary Amenorrhea 48
3. Puerperium 51 3. Secondary Amenorrhea 47
4. History & Examination 69 4. Dysmenorrhea & PMS 30
5. Antenatal Care 44 5. PCOS 50
6. Prenatal Diagnosis 38 6. Disorders of Sexual Development 26
7. Drugs in Pregnancy 14 7. Hyperandrogenism 48
8. Antenatal Fetal Infections 30 8. Subfertility 48
9. Intrauterine Fetal Death 14 9. Male Infertility 14
10. IUGR 17 10. Assisted Reproduction 29
11. Prolonged Pregnancy 11 11. Contraception 53
12. Rh Incompatibility & Hydrops 45 12. Abnormal Uterine Bleeding 28
13. Multiple Gestation 46 13. Endometriosis & Adenomyosis 30
14. Amniotic Fluid Abnormalities 36 14. Fibroids 40
15. Early Pregnancy Vaginal Bleeding 85 15. Genital Prolapse 26
16. Imaging 97 16. Urinary Incontinence 45
17. Maternal Pelvis & Fetal Skull 51 17. Menopause 47
18. Normal Labor 54 18. Endometrial Cancer 29
19. Abnormal Labor 25 19. Disorders of Cervix 58
20. Labor Analgesia 38 20. Vulval & Vaginal Diseases 48
21. Breech & Shoulder Dystocia 38 21. Benign Ovarian Diseases 27
22. Malposition 25 22. Ovarian Cancer 36
23. Transverse Lie 26 23. Genital Tract Infection 77
24. Cord Presentation & Prolapse 19 24. Gynaecologic Surgeries 36
25. Instrumental Delivery 28
26. Caesarean Section 46
27. Antepartum Haemorrhage 51
28. Postpartum Haemorrhage 52 Clinical Files
29. Preterm Labor & PROM 31 1. Hx
30. Intrapartum Fetal Monitoring 31 2. Ex
31. Induction of Labor 13 3. Instruments
32. Hypertensive Disorders 61
4. CTG, Partogram, HSG
33. Diabetes Mellitus 29
34. Cardiac & Pulmonary Diseases 38
5. Emergency
35. Thyroid Disorders 17 6. Seminars
36. Anemia 21 • Obstetric Emergencies
37. Coagulation Disorders 29 • Endoscopy & Laparoscopy
38. Renal Diseases 33 • Fluid & Blood Transfusion
39. GIT Disorders 33 • Functional Ovarian Cyst
40. Epilepsy 23 • Management of Labor
• Obesity
• Cesarean Section
• Surgical Instruments
• Suture Materials
• Partogram
Regarding stage 6 materials, here are the seminar & homework titles and all the files are
in my drive, but I have written (in upcoming pages) any other additional notes that the
doctors have mentioned and not present in our stage 5 materials.
Also the questions of our theory and OSCE exams are at the end.

Presentations
1. Caesarean Section
2. Drugs therapy in pregnancy
3. Pap Smear & HPV Vaccination
4. DIC in obstetrics + perimortem C/S
5. Fetal Wellbeing Assessment
6. Acute abdomen in pregnancy
7. Cord prolapse & Uterine inversion
8. Placental Abnormalities
9. D&C, D&E and Suction curettage
10. Pre & Post-operative care
11. Acute fatty liver of pregnancy
12. Labor Analgesia
13. Pelvimetry & Cardinal Movements of Labor

Homework (Dr Melad)

1. Retroversion of uterus
2. Endometrial hyperplasia
3. Endometriosis - infertility association
4. Emergency contraception
5. Non-hormonal medications of menopause
6. Normal puerperium
7. Benign ovarian cysts
8. Amniotic Fluid Embolism
9. Biophysical Profile (BPP) indications
10. Hazards of Preterm Delivery
11. Non-hemorrhagic Obstetric Shock
12. Normal labour
13. Partogram
14. Ovarian cancer
15. Cervical cancer

Professionalism
1. Patient’s Rights
2. Medical Ethics
3. Act with Honesty & Integrity
4. Treat patients and colleagues fairly and without discrimination
 OBGYN for Legends

Obstetrics Gynaecology
1. Epidemiology 15 1. Anomalies 29
2. Physiological Changes 39 2. Primary Amenorrhea 48
3. Puerperium 51 3. Secondary Amenorrhea 47
4. History & Examination 69 4. Dysmenorrhea & PMS 30
5. Antenatal Care 44 5. PCOS 50
6. Prenatal Diagnosis 38 6. Disorders of Sexual Development 26
7. Drugs in Pregnancy 14 7. Hyperandrogenism 48
8. Antenatal Fetal Infections 30 8. Subfertility 48
9. Intrauterine Fetal Death 14 9. Male Infertility 14
10. IUGR 17 10. Assisted Reproduction 29
11. Prolonged Pregnancy 11 11. Contraception 53
12. Rh Incompatibility & Hydrops 45 12. Abnormal Uterine Bleeding 28
13. Multiple Gestation 46 13. Endometriosis & Adenomyosis 30
14. Amniotic Fluid Abnormalities 36 14. Fibroids 40
15. Early Pregnancy Vaginal Bleeding 85 15. Genital Prolapse 26
16. Imaging 97 16. Urinary Incontinence 45
17. Maternal Pelvis & Fetal Skull 51 17. Menopause 47
18. Normal Labor 54 18. Endometrial Cancer 29
19. Abnormal Labor 25 19. Disorders of Cervix 58
20. Labor Analgesia 38 20. Vulval & Vaginal Diseases 48
21. Breech & Shoulder Dystocia 38 21. Benign Ovarian Diseases 27
22. Malposition 25 22. Ovarian Cancer 36
23. Transverse Lie 26 23. Genital Tract Infection 77
24. Cord Presentation & Prolapse 19 24. Gynaecologic Surgeries 36
25. Instrumental Delivery 28
26. Caesarean Section 46 Clinical Files
27. Antepartum Haemorrhage 51 1. Hx
28. Postpartum Haemorrhage 52 2. Ex
29. Preterm Labor & PROM 31 3. Instruments
30. Intrapartum Fetal Monitoring 31 4. CTG, Partogram, HSG
31. Induction of Labor 13 5. Emergency
32. Hypertensive Disorders 61 6. Seminars
33. Diabetes Mellitus 29
34. Cardiac & Pulmonary Diseases 38
35. Thyroid Disorders 17 Most important
36. Anemia 21
37. Coagulation Disorders 29
Important
38. Renal Diseases 33 Less Important
39. GIT Disorders 33
40. Epilepsy 23 Meh
W1D1 Dr Banav
Antenatal steroids for fetal lung maturity:
• Dexamethasone or Betamethasone 12 mg every 12 h for 24 h (only 2 doses = 24 mg)
• Betamethasone is Better. There can be ↓ fetal movement after dexamethasone
• Maximum effect is after 48 h
• Can repeat the same dose after 1 week if not delivered yet.
………………………
Misoprostol (PGE1) for medical termination of pregnancy:
• There will be increased response with increased gestational age:
• If GA is 6-13 weeks: bring 12 tabs each 200 μg, put 4 in the posterior vaginal fornix, then 2 tabs orally or sublingually
every 3-4 hours. It starts effect after 2 hours. We often prefer sublingual as it is irritating to stomach.
• If GA > 13 weeks → only put 2 tabs vaginally.
• Scientific way (Dr Banav): give 3 tabs of mifepristone (each 200 mg) together which is usually enough, then if not
delivered after 48, h you can give misoprostol.
• NICE guidlines (Dr Shang): Single dose Mifeprostone 200 mg, next day Misoprostol 600-800 μg (3-4 tabs) vaginally.
• You can put Misopristol tabs rectally instead if there is too much vaginal bleeding.
• You need to reduce the dose if she is multiparous or had a uterine surgery (C/S or myomectomy): put 2 tabs vaginally,
and sublingual/oral ones would be 5 hours apart.

Misopristol for Induction of labour:

• Give 25-50 μg orally or sublingually by cutting a 200 μg tab to a quarter or even half a quarter (hama bas behna wi bchte)
• You can repeat it every 6 h if labour hasn’t started.

Misopristol for PPH: Put 4-5 tabs rectally (max dose is 1600 μg which is 8 tabs)

Misopristol is more dangerous than oxytocin if overdosed because you cannot control how much it is absorbed or remove it
from blood, but oxytocin you can reduce or stop the infusion rate.
………………………
What can you do if the cervix is closed for termination of pregnancy (also IOL):
• You can do extramniotic catheter: bring a foley catheter, put it inside the cervix and fill
the ballon, and a weight (e.g a NS bottle) will be attached to the other side of
foley so that gravity would pull the ballon to ripen & dilate the cervix.
• Although not necessary, but you can also instil 50 cc of normal saline every 1 hour -

to accelerate the process.

• When the foley catheter falls → cervix is dilated → give prostaglandin.

• Anti D for miscarriage is given if GA is > 9-12 weeks. (if too much bleeding can give even at 8 weeks).

W1D2 Dr. Zeelan

• 1200 - 1600 (1500) β hCG titer is the discriminate zone for TVUS to detect gestational sac inside uterus (4-5 weeks)
• 6000 - 10000 (5000) is the discriminate zone for TAUS (6-7 weeks)
• If β-hCG is more than this value and intrauterine pregnancy is not detected by US → check other locations for ectopic, if
no ectopic is seen → pregnancy of unknown location.
• If the titer has not reached this cutoff and can’t detect intrauterine pregnancy → it is either early pregnancy that is not yet
visible or ectopic pregnancy.
W1D3 Dr. Melad
If on semen analysis there is prolonged liquefaction time, what can be given?
• N-acetyl cysteine (NAC) (same drug used for paracetamol toxicity, and as mucolytic)

When you would suspect aggressive D&C is done? → → for missed abortions.

Things used for hysterosonography: Cusco speculum (with the gap on one side), tenaculum, sponge forceps, hegar dilator,
TVUS device, Syringe & goldstein catheter to fill uterus with 10-20 cc of NS.

You can bend this catheter (according to

direction of uterus) and it will maintain
its shape

**

TVUS

& for anteverted or retroverted uterus

Post-coital test: typical sample taken from endocervix 6-8 hours after intercourse. 3-5 motile sperms is normal, < 3 is not.

Why start clomiphene or letrozole in early days of cycle? To recruit the youngest follicle to progress through follicular
maturation (otherwise you cannot control which follicles to go if started later).

You can clean vagina with saline or antiseptics during any procedure except for ovum pickup and embryo transfer.

• FSH should be checked in early cycle: if more than 10 (some say 15), it means ovaries are failing and you would need a
higher dose of FSH to stimulate them and still may have low quality of quantity of follicles for IVF.
• Estradiol level should not exceed 50 IU at the begging of cycle.

• Novarel (β-hCG?): 10 000, 5000 or 1500 IU (based on number of follicles).

• Ovidrel (α-hCG?) 250 μg (6500 IU) is better for those with risk of OHSS.

W1D4 Dr Alaa, Dr Khalida

• C/S notes (they are added to my seminar)
• Keep preeclampsia patient for 2 days after delivery
• Start heparin at least 6 hours after delivery (vaginal or C/S)

W1D5 Dr Melad
Examples of IUCD (hormonal IUD = LNG-IUS = levonorgestrel releasing intrauterine system vs copper IUD)
• Jaydess works for 3 years, insertion & removal procedure: https://youtu.be/EuNdTrafbS0?si=t6UvtSC5dIW2G_l2
• Mirena works for 5 years, insertion & removal procedure is same: https://youtu.be/aVZoH0Pda-4?si=cxc_o0PfTsVrHVVl
• Copper IUD must be initially loaded then inserted like here: https://youtu.be/AkPaoEk_wRA?si=xEsWMVYrijCQiBia
or here https://youtu.be/_eb-z8YmTKs?si=JazKfnU3x283tQJK
Chance of perforation in IUD placement is high in retroverted uterus (also if put immediately post delivery but we try to
avoid it at that time).

• Applying male condom https://youtu.be/tbg4jevro0g?si=SuGFFndAe-yKbueg

• Applying diaphragm https://www.caya.us.com/how-to-use-caya/
W2D1 Dr Shang, Dr Suad
• Surgical options of ectopic: Salpingectomy is preferred over salpingostomy unless there are fertility reducing factors
(other tube is absent, age >35, no children, spot of endometriosis).
• Partial mole can be treated as a case of abortion (Misopristol or Surgical evacuation)
• Episiotomy is a surgical incision in the mediolateral aspect of perineal body under local anesthesia (lidocaine) to enlarge
the birth canal to prevent perineal lacerations.
• Meconium stained liquor indicates fetal distress: do CTG, CST, assess bishops score.

W2D2 Dr Iman 1
• Oxytocin vial is 10 IU in 1 mL. Put it in a syringe of 10 cc. then put 9 cc of normal saline so now 1 IU per 1 mL.
• Or insulin syringe (each line is 1 IU/1 mL)
• Or syringe of 5 cc and put 4 mL of normal saline so now you have 2 IU per mL.
• Don’t give oxytocin if there is no ROM.
• The more para, the less the oxytocin is given and with follow up you will know whether to ↑ or ↓ the dose.
• If scar → risk of scar dehiscence → don’t give oxytocin.

W2D3 Dr Melad
HPV Vaccines

Name Cervarix Gardasil 4 Gardasil 9

Coverage (HPV types) Bivalent: 16, 18 Quadrivalent: 6, 11, 16, 18 Nonavalent: 6, 11, 16, 18, 31, 33, 45, 52, 58

2 doses if ≤ 14 years 0, 6-12 months (2nd dose is given 6-12 months after first dose)

3 doses if ≥ 15 years 0, 1, 6 months 0, 2, 6 months

• It is recommended to give vaccine at age 9 - 26, But you can give up to the age of 45 (but the efficacy decreases)
• If the women got pregnant before finishing the course, she will stop and get vaccinated after delivery.

W2D4 Dr Alaa, Dr Khalida

• T2DM, return to baseline insulin dose (like that prior to pregnancy) immediately after delivery.
• GDM should stop insulin after delivery.

W2D5 Dr Melad
What to do if you are doing the NST and it is non-reactive (is the baby sleeping?, how to wake it up?)
• Shake the head of baby
• Ask the mother “hara farake u wara va”
• Vibro-acoustic stimulation test: Put the speaker on maternal abdomen, 2-3 cm away from
fetal head, creates sound waves to go to auditory system to awaken the baby for 1-3 s
and can repeat after 1 min (or 10 min??). Baby should either respond (and you would see
accelerations on NST) or the baby is abnormal and needs BPP or CST.
It does not affect auditory system or leads to anomalies later in life.

CST is done either by the patient already having contractions (labor) or by inducing
contractions (by giving oxytocin or nipple rolling)
W3D1 Dr Banav
• If β-hCG start to decrease in cases of ectopic, there is no risk of rupture (esp if there is no free fluid in cul de sac). But the
ectopic mass may take time (2-3 months) till it become absorbed.
• If β-hCG continues to rise or remain plateau, then it will need treatment.
• 3 possibilities of ectopic: spontaneously aborted / absorbed, needs MTX or grow and rupture (needing surgery).
• Salpingectomy of ectopic pregnancy improves the outcomes of pregnancy from other tube (bcz if you do salpingostomy,
then you are gambling on future pregnancy to be recurrent ectopic as you’ve done another surgery on already risky tube).

• Hydrosalpinx releases toxic substances that affect the outcome of pregnancy (even IVF), it needs removal.
• If Placenta previa is within ≤ 2 cm of cervical os → C/S, if ≥ 4 cm → vaginal delivery.

Which patient need CST?

• ROM causing severe oligohydramnios → chance of cord compression → CST
• If Oligo + IUGR and patient stressing on having vaginal delivery → do CTG → need consent for delivery.
• CST for those in labor with high risk (e.g meconium)

W3D2 Dr Amal
Nothing new

W3D3 (holiday)

W3D4 Dr Khalida, Dr Alaa

Expectant management in ectopic pregnancy (follow up by β-hCG titrer every 3-7 days), indications:
• β-hCG < 3000
• Hemodynamically Stable
• No pain (just US diagnosis)

When to test for GDM before 24 weeks:

• Age > 35
• Obese
• History of GDM, Macrosomic baby, IUFD, PCOS
• FHx of GDM

upwards
Saline
Follow up of GDM: instil

• Serial growth scan every 2 weeks start from 24 weeks

• Start fetal survalance at 36 weeks Port
Te ballon

durin ,
drainage port
How to do controlled ARM for polyhydramnios?
How to fill the bladder with Foley’s catheter (2 way) for cord prolapse? clump here

W3D5 Dr Melad
• Why IVH in Preterm babies? Soft skull bones, Fragile capillaries on underdeveloped brain tissue & ↓ clotting factors.
• Why shortness of breath? Immature lung (↓Surfactant), immature intercostal muscles, immature brainstem.
• Not all placental abruptions need emergency C/S, as retroplacental bleeding makes it difficult to do surgery and abruption
itself stimultes vaginal delivery and there is also risk of DIC.
W4D1 Dr Shang
Clues:
• Regular HMB with mild pain → Fibroid
• Severe dysmenorrhea with HMB → Endometriosis
• Irregular heavy bleeding → endometrial hyperplasia

Submucosal fibroids causes infertility as it obliterates endometrial cavity (which is a definitive indication of surgical removal)
If the surgeon has breached the endometrium during removal of a fibroids, you would suspect some vaginal bleeding but if
not breached endometrium and you saw heavy vaginal bleeding → this indicates inadvertent breaching.

Difference between D&C, D&E?

• D&C is mainly used for gynecologic purposes → it is better to do hysteroscopic guided biopsy as it will be more targetted
• D&E is mainly used for obstetric purposes → surgical termination of pregnancy or GTD.

When to stop curettage in D&C?

• Procedure finished: feel uterine crag or see bubbles.
• Uterus perforated: loss of resistance, curette passed more than length of uterus by sound, new gush of blood.

Approach to abdominal-pelvic pain (see next two pages)

W4D2 Dr Iman 2
Pap smear is done every 3 years from 21-29 and every 5 year from 30-65 years (if did HPV testing with it).
Below are just few examples of cases (I don’t think they are important)
• ASCUS: repeat after a year.
• CIN I: need follow up & checking, if low risk HPV → repeat after 1 year, if still CIN I → colposcope, if normal change to
routine pap screening.
• If CIN II or III → do colposcopy and punch biopsy. If confirmed the results, treat according to age & parity:
• If completed her family & CIN III → abdominal hysterectomy
• If CIN II, husband with warts, confirmed HPV 16 → pap smear CIN II → punch biopsy confirmed CIN II → scientifically
follow up every year but for patient sake do every 4 months in first year.

Hysterectomy approaches: Abdominal, Vaginal (for procidentia), Laparoscopic.

Hysterectomy indications:
• Gynecologic Malignancy (cervix, uterus, ovaries or fallopian tubes): depends on stage.
• Endometrial hyperlapsia (complex with atypia, completed family)
• CIN II, III (completed family)
• Endometriosis, Adenomyosis (not responding to medical & completed family)
• Fibroid (multiple, not responding to medical)
• Severe PPH (last option)
• Placenta accreta spectrum.
• Severe DUB (last option)
• Severe PID (not responding, risk of sepsis)
• Procidentia
 Approach to Abdominal-Pelvic Pain
Pain is an unpleasant sensory and emotional experience associated with actual or
potential tissue damage.
• It is the most common reason for searching medical attention (chief complaint).
• Perception of pain depends on many factors e.g. subjective feel, emotional status,
genetic factors, experience, gender, pain threshold, anxiety and expectations.
You must categorize your cases:
• Acute < 2 weeks: It is of short duration, generally severe or progressive pain and the
symptoms are proportionate to the extent of tissue damage. The goal is to save the
life of the patient.
• Sub-acute 2 weeks - 6 months.
• Chronic > 6 months: It is of insidious onset, long duration, generally less severe the
degree of pain is not proportionate to the extent of tissue damage. The goal is to
improve the quality of life.

Acute OBGYN related pain:

Obs: (confirmed by ⊕ β-hCG test)

Early pregnancy (GA< 24):
• Ectopic pregnancy: top priority, you MUST exclude this first.
• Abortion.
• Acute urinary retention due to retroverted gravid uterus.
• Ligamental stretching: just give analgesics & reassure.
Late pregnancy (GA > 24):
• Labor.
• Abruptio placenta.
• Severe PET: imminent eclampsia, HELLP, subcapsular hematoma.
• Uterine rupture.
• Chorioamnionitis.
• AFLP: suspect when there is hypoglycemia & coagulopathy.
Gyn: ⊖ β-hCG: Can occur during pregnancy but you must initially exclude above causes
• Complicated ovarian cyst: Rupture, Torsion or Bleeding into the cyst.
• Ovarian (adnexal) torsion.
• OHSS: Hx of ovulation induction (clomiphene, FSH….)
• Complicated fibroid: Torsion, Red degeneration (occurs during pregnancy)
• Infection: Acute PID, Tubo-ovarian abscess, Pyometra.
• Hematometra: imperforate hymen, transverse septum, cervical stenosis.

Dx:
Hx: detailed history, focus on SOCRATES.
Ex: general, vitals, abdominal & pelvic examinations.
Ix:
• Lab: β-hCG, CBC, MSU (for GUE, Culture & sensitivity)
• Imaging: US (TVUS, TAUS), Abdominal X-Ray, CT, MRI.
• Laparoscope or Laparotomy: if others are inconclusive. (DO NOT open anybody if
you don’t have a good reason).

*Pelvic pain or amenorrhea → β-hCG (Obs causes). *Any bleeding → CBC then β-hCG.
*Hx, Ex, Lab Ix & US are usually sufficient to diagnose the case. You may add other
investigations based on the findings and your suspicion. Treatment is based on the cause.
Acute non-OBGYN related pain:
Many classifications but the best is to divide the causes according to the systems involved:

GIT:
• Acute appendicitis (Alvarado score)
• Acute pancreatitis
• Acute intestinal obstruction
• Perforated viscus (e.g peptic ulcer)
• Acute cholecystitis
• Acute mesenteric ischemia
• Complicated Hernia: Obstructed bowel, Strangulated, Infarcted.
• Mesenteric lymphadenitis (children)
• Diverticulitis
• Viral hepatitis
Urinary:
• UTI: Cystitis, Pyelonephritis.
• Stone: Renal, Ureteric, Bladder.
MSK-Dermatologic:
• Trauma-Fractures
• Lumbo-Sacral disk prolapse
• Herpes Zoster (Shingles): usually with dermatomal rash.
• Polymyalgia rheumatica: often associated with temporal arteritis.
Medical:
• Sickle Cell (abdominal crisis)
• DKA
• Acute intermittent porphyria
• Familial Mediterranean Fever (FMF): Recurrent attacks of fever & pain.
• SLE: what cannot be due to SLE?!
• Lower lobe pneumonia
• Malaria

Generally follows the same previous approach for diagnosis initially as it is very difficult to
know whether this is gynaecological or non-gynaecological pain. But after that, the
subsequent investigations should be targeted towards the cause based on your initial
approach e.g do amylase & lipase for pancreatitis, LFT for hepatitis…
The things that are difficult to think of are: SLE, Porphyrias, Polymyalgia, Psychosomatic
pain (multiple doctor visits, unassociated complaints), Pheochromocytoma (panic attacks!)

Chronic pain:
Gynecologic causes Non-Gynecologic causes
W4D3 Dr Melad, Dr Iman 1
How to know she is in labor? → Examine patient for half to 1 hour by putting your hand over uterine fundus:
• if have 1-2 contractions per 10 min (regularly for the next 10 contractions) of at least 20 seconds
• 1-2 cm cervical dilatation
Consider this as labor and admit the patient.

Cardinal movements: Most sites mention engagement before descent but how it is engaged before descended?
• Decent - Engagement (largest AP head diameter passes through TD of pelvis)
• Flexion so that the occiput hits the pelvic floor first (as the first part which hits pelvic floor will rotate anteriorly)
• Internal rotation (so that the occiput is brought anteriorly, shoulder pass through TD of inlet)
• Extension (of the head)
• Restitution and external rotation (so that the shoulder passes through APD of outlet)
• Expulsion of fetal body

IUCD complicated by pregnancy (normal or suspected ectopic pregnancy) = ⊕ β-hCG.

• If detected during early pregnancy (around 5-6 weeks), remove it bcz it carries risk of threatened abortion, PTL, APH.
• If detected later, gravid uterus will pull the thread upward so you cannot remove it.
• If ectopic pregnancy confirmed → remove IUCD and do not use it again.

Why HSG done on day 7, end of bleeding (not earlier not later)?
• to prevent retrograde menstruation
• to ensure the patient is not pregnant (otherwise it will abort the embryo)
* but we would do on day 21 for diagnosis of cervical incompetence as the progesterone would relax it and give true picture

When PROM occurs in a primigravida lady → think of the head not applied well to the cervix → probably CPD.

W4D4 Dr Khalida, Dr Alaa

US criteria of ovarian masses:
Malignant ~~~~~~ Benign
Bilateral ~~~~~~ Unilateral
Irregular outline ~~~~~~ Smooth outline, thin walls
Larger size ~~~~~~ Smaller size
Complex, solid components, multilocular with thick septations ~~~~~~ Simple, cystic, no locules
Ascites ~~~~~~ No ascites

• Follicular cyst up to 7-8 cm, can follow up with U/S for 6-8 weeks before deciding to remove. But remove it if larger.
• Remove dermoid cyst if larger than 5 cm

W4D5 Dr Melad, Dr Iman 1

3 presentations of ectopic:
• Acute: missed period, slight bleeding, abdominal pain → risk of rupture if kept
• Subacute: there will be peri-sac bleeding, clotting will become adnexial mass and β-hCG remain plateu level.
• Chronic: There will be slight bleeding intraperitoneally, accumulates as hematoma in cul de sac (has a specific name) and
the ectopic might be aborted into that hematoma.
Dx of
OP position

Dr Iman 1: For colposcopy:

• Avoid vaginal cleaning, creams, douching for 2 days
• Avoid intercourse for 2 days
• Better not to be during menses

Hormonal contraception is best to be started with the starting of menses but can be used up to day 5.
If it is beyond day 5:
• Avoid intercourse till the time of next menses.
• Or use barrier contraception.

What if developed continuous bleeding afteir giving Depoprovera?

• Mefanemic acid and transexamic acid
• if not controlled after 7 days → give conjugated estrogen or COCPs or Mirena (check DUB lecture)
• If nothing works → do D&C

IUCD:
• Make sure there are no contraindications.
• Put in lithotomy position with cusco speculum or sims position with sims speculum.
• Hold the lip of cervix with Vulsellum or Tenaculum.
• Measure size & direction of uterus with uterine sound.
• Insert the IUCD accordingly (check Dr Melad videos of Jaydess/Mirena)
• Wait for few (2) minutes before standing up (to avoid vasocagal syncope).
• Confirm it is correctly placed by US.
• Give antibiotic if patient is at risk of infection.
• Tell patient it is okay to have some crumps and spotting of blood for few days-one week.
• But if more than 1 week, return back (mirena may cause irregular cycles)
• It is immediately effective but better to wait for one week.
• Follow up after 1 months, then after 3 months then 6 monthly visits until removal (check the thread)
• Removal is similar procedure but you would catch the thread by by sponge or artery forceps and remove it easily.

If patient can’t feel the thread → Missed loop

• Hx: did she expelled it?
• Ex: check the thread.
• Ix:
- US to check if it’s inside the uterus.
- X-ray to check if it’s inside the abdomen/pelvis (only if not seen by US)
• Rx:
- If inside uterus & correct position → you can leave it there but subsequent follow ups would be by US
- If inside uterus but incorrect position → remove either by hysteroscope or D&C
- If inside the abdomen → remove by laparoscopy as much as possible.
W5D1 Dr Banav
Most dangerous cervical laceration is those on 3 or 9 o’clock bcz the cervical branch of uterine artery passes just lateral to
cervix.

W5D2 Dr Amal
• Pfannenstiel incision is 2-3 cm above symphysis pubis.
• Peritoneum & subcutaneous tissue you can suture or leave it but rectus sheath must be sutured.

W5D3 Dr Melad, Dr Iman 1

Example of borderline ovarian tumor is brenner tumor
PCOS pathophysiology (figure below) https://youtu.be/-DHUiObuX5s?si=O5dmSExDAhRAJiLN
Hormones to check in PCOS: LH, FSH, Prl, Testosterone, AMH (will find higher AMH)

For D&C Hold the lip of cervix by Vulsellum until 12 weeks, and by sponge forceps after 12 weeks bcz cervix is friable, soft

Shirodkar is more difficult and need incision which might lead to more complications so it is less preferable than McDonald.
Trans-abdominal cerclage is a permanent suture.

W5D4 Dr Alaa
Amenorrhea:
• Drugs that cause primary amenorrhea: cimetidine, chemotherapies, antipsychotics (hyperprolactinemia)
• If kallman syndrome → give GnRH in a pulsatile manner via a pump (similar to insulin pump).
• If functional hypothalamic amenorrhea → treat anorexia nervosa, reduce exercise & dietary restrictions.

AUB:
• Disordered proliferative hyperplasia → give progesterone therapy for 3 months.
• Simple endometrial hyperplasia → give progesterone therapy for 3-6 months (longer course).
• Complex endometrial hyperplasia → high dose progesterone or hysterectomy depending on whether she finished family
or not. (If there is atypia with it, it is highly recommended to do hysterectomy).

W5D5 (holiday)

Week 6 (holiday) except W6D4 is the final destination

 2023-2024

OBGYN Apprenticeship Exam

Theory: 6 cases/slides (1 hour):

1. PMB with thick endometrium on US:
• What is diagnosis? → Endometrial hyperplasia.
• Mention 6 risk factors that this patient has in history? Old, obesity, no OCP….
• What are 4 histological types? Simple vs complex each with vs without atypia.
2. Smoking:
• How smoking affects pregnancy?
• What are effects of smoking on pregnant mother?
• What are effects of smoking on fetus?
• What are effects of smoking on maternal health?
3. Pre-eclampsia:
• Mention 6 investigations to be done?
• Mention 6 lines of management?
4. Diabetic patient received IV antibiotics developed white vaginal discharge:
• Diagnosis? Vulvovaginal candidiasis.
• Two risk factors in history? Diabetic, antibiotic use.
• Mention 3 kinds of treatment?
• How to treat recurrent cases? 3 doses of fluconazole each 72 h apart then once
weekly dose for 6 months.
• Does it need to treat partner and how to do so? NO need because it is not STD.
5. Pelvic Examination:
• Mention 4 obstetrical indications of pelvic exam?
• What are 4 things we assess on clinical pelvimetry?
6. Secondary amenorrhea 4 months after D&C for miscarriage:
• 4 causes? (Pregnancy, asherman, premature ovarian failure, thyroid disorder)
• 4 investigations? (β-hCG, HSG, FSH, LH, TFT….)
• If patient had high FSH & LH, what is Dx & 3 risks? Premature Ovarian Failure.

OSCE: 4 stations each 7.5 min:

1. Obstetrical Case discussion: IVF case resulted in twin pregnancy now at 38 weeks
presented in labor with full cervical dilation and first fetus is cephalic:
• How do you delivery first baby? Vaginally
• How do you delivery second baby? (If cephalic → vaginally, if breech & intact
membrane → ECV, if membranes ruptured → IPV)
• What are indications of C/S to deliver second baby? Fetal distress, shoulder
presentation.
• What are types of twin? Dizygotic vs monozygotic (Di-Di, Mono-Di, Mono-Mono)
• What are maternal risk after delivery? PPH.
• How do you prevent PPH? Active management of 3rd stage of labor.
• How do you treat PPH? Oxytocics, uterine massage, bimanual compression……
• How do you shorten 2nd stage of labor? Instrumental delivery.
• What are types of instrumental? Ventose vs Forceps
• How to do instrumental delivery? Pre-requisites (ABCDEFGHIJ).
2. Gynaecological case discussion: Contraception counselling (expect any question):
• What to ask in history (Focus on name, age, GPA, LMP, menstrual cycle history in
details, does she want a short or long term method, reversible or permanent, which
methods knows of or wants to use, any prior methods she used and failed or side
effects developed, contraindications of each method like breast cancer, endometrial
cancer, side effects of each methods, benefits of each methods) for example an old
lady who smokes and has heavy cycles and want better to use progesterone based
methods and so on.

3. Communication skills (breaking bad news on endometrial cancer):

• How do you tell her she has cancer.
• What information you need to tell her regarding further investigations.
• What treatment methods do we have.
• Where will you send the patient for treatment (oncology center).
• Which specialities should be involved in her management.
4. Logbook:
• One of your cases (how it present, diagnosis, what was her management plan).
• Questions about your OBGYN seminar.
• Questions about your professionalism seminar.

This approach of breaking bad news wasn’t the thing they wanted, they didn’t know about
this and wanted direct expression of the diagnosis and discussion of the case with patient.
So yeah, don’t do our mistakes and keep it simple.
https://youtu.be/MKnWkrPLGOs?si=92GUefFxGuhjJf6F