TERM:

Infertility: is generally defined as the inability to conceive after 1 year of regular sexual intercourse
without contraception. Classification: Infertility is classified as primary Infertility and secondary
Infertility.

Secondary infertility: is defined that married couples living together for a year, with normal sexual
life, had been pregnant. Now never take any contraceptive measures, failed to conceive

Assisted Reproductive Technologies (ART): ART includes a group of “high tech”

treatment methods used to improve infertility which involves collecting the eggs and putting
them in direct contact with sperm

Dystocia is defined as difficult labor Associated with various abnormalities that prevent or
deviate from the normal course of labor and delivery

Postpartum hemorrhage: Be defined as a blood loss exceeding 500ml after delivery of the infant.

Abortion: delivery occurring before the 20th completed week of gestation. It implies
delivery of all or any part of the products of conception, with or without a fetus weighing less
than 500 grams

Spontaneous abortion: It is defined as delivery occurring before the 20th completed week
of gestation. It implies delivery of all or any part of the products of conception, with or without
a fetus weighing less than 500 grams. (The most common complication of pregnancy)

Complete abortion: the expulsion of all of the products of conception; bleeding with cervical
dilatation and closure.

Habitual abortion (Recurrent abortion): Recurrent abortion is defined as 3 or more

consecutive pregnancy losses before 20 weeks gestation, each with a fetus weighing less than
500 g. Every abortion times is or not same month of pregnancy

Inevitable abortion: bleeding with dilatation of the cervix without expulsion of the
products of conception with or without rupture of the membranes

Menstruation: The cyclic, hormonally generated sloughing of uterine endometrium

Menopause: The human ovary gradually becomes unresponsive to gonadotropins with advancing
age, and its function declines, so that sexual cycles and menstruation disappear.
Fertilization: the process of the capacitated sperms meets the ovum

Ectopic pregnancy: A fertilized ovum implants in an area other than the endometrial lining of the
uterus.

Hagar’s sign: widening of softened area of isthmus, resulting in compressibility of isthmus on

bimanual examination

Generally contracted pelvic: Each pelvic plane is 2 cm less than normal value or more, which is
called generally contracted pelvic.

Primary amenorrhea: Failure of menarche to occur when expected in relation to the onset of
pubertal development. No menarche by age 16 years with signs of pubertal development. No onset of
pubertal development by age 14 years

secondary amenorrhea: Secondary amenorrhea is the absence of menses for more than 6
months or for the equivalent of three menstrual cycles in a woman who previously had
menstrual cycles.

Polymenorrhea: frequent regular bleeding that occurs at interval of less than 21 days.

Pregnancy (gestation): is the maternal condition of having a developing fetus in the body.

Embryo: The human conceptus from fertilization through the eighth week of pregnancy is
termed an embryo.

Fetus: from the eighth week of pregnancy until delivery

GTD: is a diverse group of interrelated diseases resulting in the abnormal proliferation of
trophoblastic (placental) tissues. These tumors are unique from abnormal fetal tissue rather
than maternal tissue and it is also sensitive to chemotherapy.

Puberty: Puberty is the period when the endocrine and gametogenic functions of the gonads
first develop to the point where reproduction is possible.

Endometriosis: is usually defined as the presence of functioning endometrial glands and stroma
outside their usual location in the uterine cavity

Pelvic floor: The (muscles and fasciae) tissue closing down the pelvic outlet

Krukenberg Tumor/ Secondary (Metastatic) Tumors:

*5-10% all ovarian tumor
 *25% of all ovarian malignancy

*usually from the gastrointestinal tract, known as krukenberg tumors

Gestational Hypertension: SBP≥140 or DBP≥90mm Hg for first time during pregnancy OR

occure≥20 weeks and returns to normal before12 weeks postpartum, diagnosed only after
delivery.

Placenta previa: it is defined as abnormal implantation of the placenta over the internal
cervical os. Previa denotes the position of the placenta in relation to the presenting part.

Meigs syndrome: The triad of an ovarian Fibroma, ascites and hydrothorax is known as
Meigs syndrome.

Prolonged second stage:

≥2hr in primipara

≥1hr in multipara

latent phase (onset to <3cm, 8hs, <16hs)

active phase (>3cm to 10cm, 4hs, <8hs)

Amniotic fluid embolism: It is a life-threading complication that amniotic fluid entering

maternal circulation, result in acute pulmonary embolism, anaphylactic shock, DIC, renal
dysfunction and sudden death.

Placenta abruption: after 20 weeks of gestation or during the course of delivery, the
separation of the placenta from its site of implantation before the baby is delivered resulting in
hemorrhage→ fetal distress/death.

Molar pregnancy (hydatidiform mole): Molar pregnancy is an abnormal form

of pregnancy in which a non-viable fertilized egg implants in the uterus and will fail to come to
term.

Degeneration: lose the original typical structure.

Short Question:
 Endometriosis
1.Complication of endometriosis

 Endocrinopathy
 Rupture
 Infection
 Obstructive feature
 Malignancy is rare

Ligament
2. How many ligaments of uterus are there? What are they?

 round ligament
 broad ligament(ovarian ligament, infundibulopelvic ligament）
 cardinal ligament
 Uterosacral ligament

3. Ligaments of ovary

 Infundibulopelvic ligament
 Ovarian ligament
 mesovarium

Hemorrhage
4. Etiology (cause) of postpartum hemorrhage
 Uterine atony (50%)
 Obstetric lacerations (20%)
 Retained placental tissue (5~10%)
 Coagulation defects
5. Etiology/causes of post-partum hemorrhage

 Uterine atony (50%)

 Obstetric lacerations (20%)
 Retained placental tissue (5-10%)
 Coagulation defects

Placenta
6. The primary function of the placenta is the transport of oxygen and nutrients
to the fetus and the reverse transfer of C02, Urea, and other catabolites back to
the mother. The ways of transfer contains?
①simple diffusion ②facilitated diffusion ③active transport④Others—pinocytosis

7. The structure (composition) and function of placenta

Composition： basal decidua; chorion frondosum， Amniotic membrane

the human placenta may be described as a discoid, deciduate, hemochorial chorioallantoic
placenta. Placenta fetal surface and master surface

Function:

1：endocrine function

2： metabolic function

3：protective function

Vagina
8. The degree of the perineal and vaginal laceration?

 The first degree tear: involves only skin and a minor part of the perineal body
 the second degree tear: involves the perineal body and vagina
  the third degree tear: involves the anal sphincter and anal canal

Tumor
9. Complications of ovarian tumor?

 Ovarian Torsion (Axial rotation)

 Rupture
 Infection
 Malignant change

OR, if say explanation each complication of ovarian tumor

A. Torsion of the pedicle:

1. Common gynecologic emergency.

A. medium-sized tumors, pedicle is long, the center of gravity is instable;

B. During pregnancy and puerperium, due to uterine position change, or patients change position
suddenly;

C. When acute torsion happens,the venous return from the cyst is occluded→ hemorrhage and
hemotoma in tumors→the tumors will enlarge quickly.

if the arterial return from the cyst is occluded → necrosis, rupture and secondary infection of the
tumors.

2. Symptoms:

Acute severe pain with nausea and vomiting

3. Signs:

Tumor enlarged and tense ,tender, severe pain over pedicle.

※4. Treatment: Once confirmed diagnosis, surgery immediately

--unilateral salpingo-oophorectomy(benign)

caution:Pedicle should not be restored in order to prevent embolic thrombosis.

pathology during operation

B. Rupture of tumor:
 spontaneous rupture: malignant tumor

traumatic rupture:

abdominal pain

intra-abdominal hemorrhage

surgery if suspected

pathology during operation

C. Infection:

Rare,secondary to torsion and rupture

symptoms like those of the ordinary type of acute pelvic inflammatory disease.

D. Malignant change:

Bilateral, grow rapidly→surgery

10. Differential diagnosis (DD) of ovarian tumor

Benign Tumor:

1. Ovarian tumor like condition: in general ovarian masses can be divided into functional
cysts and neoplastic growths
≤8cm may disappear in 2-3 months.
 Follicular cyst
 Corpus luteum cyst
 Polycystic ovarian disease
2. Tubo-ovarian cyst
3. Myoma of uterus
4. Ascites

Malignant Tumor:

1. Endometriosis
2. Tuberculosis peritonitis
3. Metastatic tumor
11. Diagnosis of ovarian tumor
1. Imaging test
 Ultrasound examination: especially transvaginal, is the best method to diagnose
the ovarian tumor
 X-ray, CT, MRI, PET
2. Tumor Marker
 CA125, HE4, CA199, AFP, HCG, Sex hormone
3. Laparoscopy
4. Cytologic examination: Ascites

12. Diagnosis method of cervical tumor

5. cytology and/or high-risk HPV-DNA
colposcopy
biopsy of cervix and cervical canal---the most reliable method to make diagnosis
cervical conization

13. Complication of ovarian tumor

 Ovarian Torsion (axial rotation)

 Rupture
 Infection
 Malignant change

Pregnancy & Heart

14. Main reason can lead to ectopic pregnancy?

 “Block” – the passage

 “Delay” – the march
 chronic salpingitis (most common)
 congenital tubal abnormalities
 endometriosis
  IVF-ET
 IUD
 tumor

15. Complication of ectopic pregnancy

 tubal abortion
 tubal rupture
 tubal mole
 Secondary Abdominal Pregnancy
 Ovary pregnancy
 Abdominal pregnancy
 Cervical pregnancy
 Broad ligament pregnancy

16. Differential diagnosis (DD) of ectopic pregnancy

(1)Abortion
(2) salpingitis: HCG, sonography, WBC↑, T ↑
(3) appendicitis: tenderness at McBurney’s point, WBC↑
(4) torsion of an ovarian cyst: B-u, HCG
(5) ruptured corpus luteum

17. Indications of prophylactic chemotherapy in molar pregnancy

Prophylactic chemotherapy

High risk or poor follow-up

High risk：1, Beta-hCG>100,000U/L

2, Larger than expected for the gestational date

3, Theca lutein cysts>6cm

4, >40Y or recur

Suspected metastasis:
  MTX, Dactinomycin, single drug one course

 Surveillance toxicity

18. Three periods of pregnancy

• 32 to 34 gestation weeks

• delivery stage

• initial 3 days of puerperium

19. Three periods of heart failure (HF) in pregnant women OR cardiovascular

changes in normal pregnancy
• 32 to 34 gestation weeks

• delivery stage

• initial 3 days of puerperium

Cardiovascular changes in normal pregnancy

 gestational period

 During delivery

 Puerperium

Returned blood volume increased in 3 days in postpartum and return to normal after 2~6
weeks.

20. If a woman with cardiac disease suitable to pregnancy or not

1. suitable to pregnancy: the damage of heart function is slightly, heart function class I, II, does
not have heart failure history in the past and does not have other complications.
2. not suitable to pregnancy: the damage of heart function is seriously, heart function class Ⅲ
or above classⅢ, congestive heart failure history, serious cardiac arrhythmias, pulmonary
hypertension. age->35
21.Classification of Heart Disease
1. Congenital heart disease
Left-to right shunt
Right-to left shunt
2. Rheumatic heart disease
3. Hypertensive heart disease
4. Peripartum cardiomyopathy (PPCM)
5. Myocarditis

Pelvic
22. How many types of pelvis are there? What are they?

There are 4 types of pelvis. They are:

 Gynecoid pelvis
 Android pelvis
 Anthropoid pelvis
 Platypelloid pelvis

23. Treatment (surgical indications) of pelvic inflammatory disease

 Indications

-- failure of medical therapy(48-72h)

-- ruptured TOA/ pelvic abscess

-- persistent pelvic abscess

 Surgery

-- percutaneous drainage/colpotomy (posterior fornix)

-- laparotomy:

-- salpingectomy/ salpingo-oophorectomy
 Genitial tract
24. Natural defence function of female genital tract
• Vulvar--bilateral labium majus closed
• Vaginal is a potential cavity with posterior and anterior walls sticking tightly, Estrogen
thickens the vaginal epithelium and results in large quantities of glycogen which results
in the production of lactic acid. This acid environment (pH of 3.5-4.0) promotes the
growth of normal vaginal flora, chiefly lactobacillus--------self-cleaning
• Cervical canals closed and mucus plug
• Endometrium: menstruation (reproductive age female)
• Fallopian tube---peristalsis
• Immune system

Menstruation
25. Normal menstruation (periodic):
 The origin of menstrual blood: Predominantly arterial.
 Composition: tissue debris, prostaglandins, fibrinolysin (unclot)
 Duration of the menstrual cycle: 1to 8 days (3-5days).
 The amount of lost blood: Less than 80ml (30ml).

Cancer (carcinoma) + endometrial hyperplasia

26. Clinical finding of cervical cancer
Symptoms
 Asymptom
 Postcoital bleeding (Presenting symptoms)
 Vaginal discharge: sanguinous, purulent, watery
 Pelvic pain or pressure and rectal or urinary tract symptoms
27. Diagnosis of cervical cancer

 Physical examination
 Cervical diagnosis can be diagnosis only with a tissue biopsy
 Pap test
 colposcopy

28. Metastatic way of cervical cancer

 Direct extension
 Most often
 Lymphatic spread
 Hematogenous Spread

29. Follow up and treatment of cervical cancer

• CIN I:

60% can remove by itself---follow up.

Review 6-12 months.

≥2 years---treatment: Electrocoagulation, cryotherapy or laser ablation

Electrocoagulation uses temperature over 700°C and destroys the tissue up to 8–10 mm
deep. Since the procedure is painful, it is done under general anesthesia. Recurrence, bleeding,
sepsis and cervical stenosis are its complications. Squamocolumnar junction gets indrawn
within the cervical canal.

• CIN Ⅱ:

20% progress to CIN Ⅲ, 5% progress to cervical cancer

LEEP (loop electrosurgical excision procedure) or cold knife conization

• CIN Ⅲ:

Cold knife conization or hysterectomy

30. Classification of cervical squamous cell carcinoma

 squamous carcinoma: account for 75%~80% of cervical cancer

(1) macro examination:
(a). exogenic cancer: the most common type
 (b). endogenic cancer
(c). ulcer cancer
(d). cervical canal cancer
(2) microscopic examination
(a). Micro invasive Carcinoma: tear-drop or serrate cancer cell group growing through
basal membrane, Infiltrating stroma.
(b). invasive Carcinoma: invasiveness of stroma is beyond the micro invasive
Carcinoma.

31. Metastatic path of ovarian cancer

①local spread
②intra-abdominal spread
③lymphatic spread
④hemtogenous spread

32. Metastatic path of endometrial cancer

 Direct extension
 Lymphatic spread- It is the main way of spread
 Hematogenous spread

33. Categories of endometrial hyperplasia

Three
• 1. Hyperplasia Without Atypia
• 2. Hyperplasia with Atypia
• 3. Carcinoma in Situ

34. Sargical staging of endometrial carcinoma

 Stage I
 Stage I a G123 Tumor limited to endometrium
 Stage I b G123 Invasion to less than one-half the myometrium
 stage I c G123 Invasion to more than one-half the myometrium

 Stage II
 Stage II a G123 Endocervical glandular involvement only
  Stage II b G123 Cervical stromal invasion

 Stage III

 Stage III a G123 Tumor invades serosa and/or adnexa, and/ or positive peritoneal
cytology

 Stage III b G123 Vaginal metastases

 Stage III c G123 Metastases to pelvic and/or paraaortic lymph nodes

 Stage IV
 Stage IV a G123 Tumor invades bladder and/or bowel mucosa
 Stage IVb Distant metastases including intra-abdominal and/or
inguinal lymph nodes

ART (Assisted Reproductive Technologies)

35. Types of ART

1. Intrauterine insemination (IUI);
Indications:
1. male factor infertility;
2. psychological factors;
3. unexplained infertility;
4. genetic defects;
Types:
1. artificial insemination with husband’s sperm (AIH);
2. artificial insemination by donor (AID);
Method:
placement of about 0.3 ml of washed, processed and concentrated sperm into the
intrauterine cavity by trans-cervical catheterization.
2. In vitro fertilization and embryo transfer (IVF-ET);
Indications:
1. tubal factor;
2. endometriosis;
3. unexplained infertility;
4. IUI failure;
5. Immunologic factors;
Method:
1. Superovulation:
2. Aspiration of eggs;
3. Fertilization with capacitated sperm;
4. Culture of fertilized egg in the lab;
5. Replacement of fertilized egg into the uterus;

3. Intracytoplasmic sperm injection (ICSI);

4. Gamete intrafallopian transfer (GIFT);

36. Complications ART (Assisted Reproductive Technologies)

 Multiple gestations
 Pre-eclampsia
 Ovarian hyper stimulation syndrome (OHSS);
 Premature birth
 Low birth weight
 Long term emotional, social and psychological impact

Placenta
37. Complications of Premature separation of the placenta
①DIC
②Hypovolemic shock
③Amniotic fluid embolism
④Acute renal failure
38. Signs of Placental Separation?
(1) a fresh show of blood from vagina,
(2) the umbilical cord lengthens outside the vagina,
(3) the fundus of the uterus rises up
(4) the uterus becomes firm and globular.

39. Complete/central placenta previa

Complete or central placenta previa

The placenta completely covers the internal OS of cervix at the time of termination of
pregnancy is called complete placenta previa.

Onset- Earlier, 28th week

Amount- Severe, shock

Frequency- more

40. Complication of placental abruption

 fetal death
 DIC
 postpartum hemorrhage
 Acute renal failure
 Amniotic fluid embolism

MgS04
41. The attention of using Magnesium sulfate (MgSO4)?

 The patient should be checked every 4 hours to be sure that deep tendon reflexes are
present.
 Respirations are at least 12/min.
 Urine output has been at least 100 mL during the preceding 4 hours.
 The antidote for magnesium sulfate overdose is 10 mL of 10% calcium chloride or
calcium gluconate given intravenously. The remedial effect occurs within seconds.

Uterus
42. What are the characteristics of uterine contractility?

 regularity
 symmetry
 polarity
 retraction

43. The powers of uterine contractility and it characteristic

 The power of delivery from Uterine contraction

o Rhythmic (contraction-ascending, acme, descending: relaxation)

o Symmetrical,

o Polarity,

o Retraction

44. Etiology of Rupture of uterus

1 Obstructive dystocia

2 Injured rupture of uterus

3 scar uterus

4 previous uterine curettage or perforation

5 The misuse of hysterotonics

The contraindication of Oxytocin：

 cephalopelvic disproportion，
 fetal distress,
 scar uterus,
 mal match uterine contraction,
 Excess extend of uterus body

Abortion
45. Types of spontaneous abortion
• Threatened abortion: bleeding with or without uterine contractions, no cervical
dilatation and no expulsion of the products of conception.

• Inevitable abortion: bleeding with dilatation of the cervix without expulsion of the
products of conception. with or without rupture of the membranes

• Complete abortion: the expulsion of all of the products of conception; bleeding with
cervical dilatation and closure.

• Incomplete abortion: the expulsion of some, but not all of the products of conception.
Generally, bleeding is persistent and is often severe; prolonged cramps are usually
present. The fetus and placenta are usually passed together <10 weeks' duration. >10
weeks, they may be passed separately with a portion of the products retained in the
uterine cavity.

• Missed abortion: the embryo or fetus dies and is retained in utero(no heart motion)

• Septic abortion :infection of the uterus and sometimes surrounding structures

• Recurrent abortion: 3 or more consecutive pregnancy losses each with a fetus weighing
<500 g.

• Blighted Ovum: a failed development of the embryo only a gestational sac, with or
without a yolk sac

46. Factors of spontaneous abortion

 Spontaneous abortion occurs consecutively two or more times
 Associated factors:
 Chromosomal abnormality
 Immune conditions
 Endocrine disorders
 Cervical incompetence
 Uterine abnormality

47. Complication of abortion

 Severe or persistent hemorrhage:
Anemia
 Hypovolemia --- life-threatening
 Sepsis:
Develops in neglected care
Induced abortion in unsafe place and hands.
 Late complications: intrauterine synechiae
Infertility
Infection involving adnexa and uterus

Labor
48. Labor mechanism of occipital presentation OR mechanism of Labor
Engagement -> Descent-> Flexion-> Internal rotation-> Extension-> Restitution& External
rotation-> Fetus delivery

 Engagement: This occurs at various times before the forces of labor begin.
 Descent: This occurs as a result of active forces of labor.
 Flexion :the fetus neck vertebra further flexed, and the chin approach the chest
 Internal Rotation: This occurs as a result of impingement of the presenting part on the
bony and soft tissues of the pelvis.
 Extension: This is the mechanism by which the head normally negotiates the pelvic
curve.
 External Rotation (Restitution): This is the spontaneous realignment of the head with
the shoulders.
 Expulsion: This is anterior and then posterior shoulders, followed by trunk and lower
extremities in rapid succession

49. Factors of labor

The essential factors of labor:

 The power of delivery:

From Uterine contraction
o Rhythmic (contraction-ascending, acme, descending: relaxation)
o Symmetrical,
o Polarity,
o Retraction
 The passage (the pelvis)
 The passenger (the fetus)
  The psychic (the mother)

50. signs of labor

Sings:

(i) Painful uterine contractions at regular intervals

(ii) Frequency of contractions increase gradually

(iii) Intensity and duration of contractions increase progressively rhythm and gradually increase
the uterine contraction, and lasted for 30 seconds or more, intermittent 5 to 6 minutes;

(iv) Progressive effacement and dilatation of the cervix

(v) Descent of the presenting part

(vi) Did not relieve by sedatives.

51. Stage of Labor

 The first stage:
---onset of true labor to full cervical dilation (10cm)
The latent phase (onset to <3cm, 8hs, <16hs)
The active phase (>3cm to 10cm, 4hs, < 8hs)
 The second stage:
---full cervical dilation to the delivery of the fetus, <2hs
 The third stage:
---delivery of the fetus to expulsion of the placenta, <30m’
 The fourth stage:
---observation for at least 1h
52. Abnormal labor curve
Prolonged latent phase >16hr

(1 cm/2-3hr, 8h, <or equal to 16 h)

Prolonged active phase >8hr

Primipara <1.2cm/hr

Multipara <1.5cm/hr

(4h, <or equal to 8hr)

53. Cardinal movement of labor
Seven passive movements of the baby presentation are:
1. engagement
2. Descent
3. Flexion
4. Internal rotation
5. Extension
6. restitution and external rotation
7. Expulsion

Implantation
54. Implantation favoring conditions
Essential condition of Implantation

 the disappearance of zona pellucida

 syncytiotrophoblast is derived from the cytotrophoblast

 The synchronized development of blastocyst and endometrium function is in

coordination.

 The pregnant women can produce enough progesterone.

Female factor & infirtility

55. What is evaluation of Female factor in infertility?

1. Ovulatory factors (40%)
2. The pelvic factor: abnormalities of the uterus, fallopian tubes, ovaries, and adjacent pelvic
structures.
3. The cervical factor. infection, congenital abnormalities
4. Extra-genital tract factors: infection, congenital abnormalities
56. Causes & Treatment principle for female factors
1. Causes:
anovulation
tubal factor
anatomic factor
immunologic
azoospermia
genetic disease
after surgery
unexplained

2. Treatment:
induction of ovulation
tuboplasty
microsurgery
medication or surgery
immune inhibition
if failure of the above treatments  ART (Assisted Reproductive Technologies)

57. Factors causing infertility

1. Ovulatory disorders (32%)

2. Fallopian tube abnormalities - pelvic adhesions (34%)

-Endometriosis (15%)

3. Other factors uterine and cervical factors

 luteal phase defect

 genetic disorders

Bleeding
58. Categories of uterine bleeding are divided into and what are they
  bleeding associated with ovulation: little，15%.
 bleeding associated with anovulation: more , 85%.

59. Classification of dysfunctional uterine bleeding OR pathological classification

 By reason :

o spontaneous rupture
o Injured rupture

 By time :

o rupture during pregnancy

o Rupture during delivery

 By level of rupture :

o complete rupture
o incomplete rupture

 By the position of rupture :

o rupture at body of uterus

o rupture at lower uterine segment

0r pathological classification

1. Endometrial hyperplasia

o Simple hyperplasia

o Complex hyperplasia

o Atypical hyperplasia

2. Proliferative phase endometrium

3. Atrophic endometrium

60. Pathology of dysfunctional uterine bleeding?

4. Endometrial hyperplasia

o Simple hyperplasia
 o Complex hyperplasia

o Atypical hyperplasia

5. Proliferative phase endometrium

6. Atrophic endometrium

61. Treatment of dysfunctional/Abnormal uterine bleeding (AUB) young patient

1. Adolescents

Principle:

1).Hemostasis

2).regulate the cycle of menstruation;

3).promote the ovulation.

Regimens:

Estrogens followed by progesterone,

Progesterone alone or combination oral contraceptives.

2. Young women Same as above

3. Pre-menopausal women

Principle:

 Hemostasis
 Regulating bleeding cycle
 Reducing bleeding (usu. By accelerating the arrival of menopause)
 Preventing cancer

Myoma (leiomyoma)
62. Surgical indications of uterine myoma/uterine leiomyoma
Indications:

① Abnormal uterine bleeding, causing anemia.

 ② Severe pelvic pain.

③ Pressure-related symptoms--Urinary frequency, retention, hydronephrosis or constipation.

④ The only reason of recurrent miscarriage or infertility.

⑤ be suspicious of Sarcomatous degeneration --Growth after menopause, Rapid increase in size

The choice of surgery

1. Myomectomy: wish to preserve their fertility, myoma resection

2. Hysterectomy: It is the definitive treatment by laparotomy or laparoscopically

63. Classification of Uterine myoma and myometrium

 According to the relationship between myoma and uterine myometrium:
---Sub mucous myoma (10%~15%) : lie just beneath the endometrium and grow toward the
uterine cavity. Pedunculated.
---Intramural myoma (60%~70%): lie within the uterine wall and are completely surrounded
by normal myometrium, this is the most common type
---Sub serous myoma (20%): lie just beneath the serosal surface of the uterus .
---Pedunculated

64. Degeneration type myoma (uterine myoma)

 Lose the original typical structure
 The following types:
 Hyaline degeneration
 Cystic degeneration
 Red degeneration
 Sarcomatous change (malignant transformation)
 Degeneration with calcification

Degeneration
65. Types of degeneration
 Hyaline degeneration
 Cystic degeneration
 Red degeneration
 Sarcomatous change (malignant transformation)
 Degeneration with calcification

Amenorrhea
66. Characteristics of Primary Amenorrhea

 Failure of menarche to occur when expected in relation to the onset of pubertal

development.
 No menarche by age 16 years with signs of pubertal development.
 No onset of pubertal development by age 14 years

67. What are Uterine defects in amenorrhea

Asherman’s syndrome
History of pregnancy associated D&C
Rarely after CS, myomectomy T.B endometritis, bilharzia
Diagnosis: HSG or hysteroscopy
Treatment: lysis of adhesions; D&C or hysteroscopy + estrogen therapy (? IUCD or catheter)

Breech
68. Classification/types of breech, which is common
 Frank breech presentation
- It is commonly present in primigravidae
-70%
 Complete breech presentation
-it is commonly present in multiparae
-10%
 Incomplete breech presentation
 ** so, frank beech presentation is more common.

Torsion
69. What is the compose of torsion of ovary
-Adnexal mass. abnormal location adnexal mass
-Enlarged ovary. peripheral follicles enlarge ovary. uterine deviation
-Pelvic fat infiltration
-Hematoma
-Lack of exhaled sign
-Thicken fallopian tube
-Mature cystic teratoma, cytostome. theca cell tumor

CASE:
1. 26-year-old, married woman. Amenorrhea for 60 days. A small amount of vaginal bleeding
for 2 days, complicated with mild intermittent abdominal pain. Pelvic examination: the cervical
os is closed; the size of uterus is as large as that of 2months pregnant. Previous abortion one
time at 2 months of pregnancy.

a. What is the diagnosis of the disease?

b. How to deal with it?

A.threatened abortion

B.bed rest and pelvic rest

2. 36-year-old, female. Abnormal vaginal bleeding for 1year, menstruation is still normal. Pelvic
examination: bleeding, friable, cauliflower-like lesion of the cervix, the size of the lesion is less
than 2cm, The size of uterus is normal. Adnexa are normal too.

a. What examination we should do next?

b. What is the disease will be?

c. What is the method of treatment we choose?

a. Biopsy
b. cancer of the cervix stageⅠB1
c. Radical hysterectomy and pelvic lymphadenectomy
3. Female，58-year-old, menopause for 5 years. Abnormal vaginal discharge for six months,
Continuous vaginal bleeding for two weeks. Short stature, Fat, Hypertension. Examination：
old-type Vulva, Cervical atrophy, Uterus is in normal size, adnexal structures are normal.

a. What assistant examination should be done next?

b. What is the disease will be?

c. What are the risk factors of this patient?

d. How would you treat the patient?

a. fractional curettage and pathology

b. endometrial cancer

c. Short stature, Fat, Hypertension

d. surgery after Control of blood pressure

4. Female, 34 years old. Irregular vaginal bleeding for three months, Pale, Weak, Palpitations.
pelvic examination: Normal vulva, cervix is smooth, the uterus is as large as size of man fist，
Prominent anterior wall, a little hard, Adnexa is normal. Sonography: prominent hypoechoic
nodules at anterior wall. Blood Routine:HGB63g/L。

a. What is the diagnosis of the disease?

b. what is the diagnosis made according to?

c. How to deal with it?

a. uterine myoma, Moderate secondary anemia

b. Menstrual changes, Uterus enlarged; Sonography:

prominent hypoechoic nodules at anterior wall

Pale, weak, Palpitations, Blood Routine: HGB63g/L；

 c. to correct anemia
5. Female, 52 years old. Minimal irregular vaginal bleeding for two weeks after menopause, the
vagina is not congestion, cervical smooth, uterus slightly enlarged, endometrial curettage
samples looks like Bean dregs.

a. What is the disease will be?

b. what is the diagnosis made according to?

c. What is the method of treatment we choose first?

a. endometrial cancer
b. according: vaginal bleeding after menopause, uterus slightly
enlarged, endometrial curettage samples looks like Bean dregs.
C. method of treatment: surgical treatment

6. 18-year-old girl, sudden right lower abdominal pain 3 hours ago, complicated with nausea
and vomiting for several times.T:37.4 ℃. rectal examination: a fist-sized Cystic and solid mass is
palpable at the upper and right side of the uterus. Tension of the mass is great, activity of mass
is small. Ultrasonography: the right lower quadrant mass, the size of uterus is normal.

a. what is the most likely diagnosis ?

b. what is the diagnosis made based on?
c. What is the method of treatment we should choose?
a. torsion of ovarian tumor
b. According: sudden abdominal pain complicated with nausea and
vomiting mass is palpable at the upper and right side of the uterus,
tension of the mass is great, activity of mass is small.
c. Method of treatment: emergent surgery.

7. 28-year-old primigravida, 38 weeks of pregnancy, suffering from severe pregnancy-induced

hypertension, vaginal bleeding last night, suddenly appeared with lower abdominal pain.

a. What is the diagnosis we should make first?

b. What examination we should do next?
a. placental abruption
b. ultrasonography
8. 45-year-old, female, married and multiparous, the menstruation is regular, find lower
abdominal mass occasionally, complicated with urinary frequency and urgency. Pelvic
examination: cervix is smooth; the uterus is enlarged and irregular. Ultrasonography:
hypoechoic nodules have a diameter of about 6 cm at the anterior wall of the uterus.

a. What is the diagnosis of the disease?

b. what is the diagnosis made according to?
c. How to deal with it?
a. myoma of uterus
b. according: find lower abdominal mass, urinary frequency, the
uterus is enlarged and irregular. Ultrasonography: hypoechoic nodules at the
anterior wall of the uterus.
c. surgery
9. Female, 35 years old. Amenorrhea for 47 days, spot vaginal bleeding for 3 days, sudden
abdominal pain for 2 hours. Signs: Bp 12/8Kpa, P 120 times/min, abdominal tenderness and
rebound tenderness (+); sharp pain on motion of the cervix. ,sonography: a 4X5 cm irregular
mass, 3 cm-depth fluid in cul-de- sac

culdocentesis: 2 ml bloody fluid (did not clot) .urine HCG (+).

a. what diagnosis would you think of first?

b. How would you treat the patient?

a. Ectopic Pregnancy
b. Emergency surgery

10. A 28-year-old woman, 4-5/27-28, amenorrhea for 50 days, complains of vaginal bleeding for about 6
hours.

A. Please write down the most probable diagnosis of this patient.

b. What kind of other investigation should be done to help you make the definite diagnosis.

c. During the examination the patient feel abdominal pain and the cervix has already
dilatated, how to treat?

a. Threatened abortion.
b. pregnancy test, ultrasonography, vaginal examination
 c. If the diagnosis of inevitable or incomplete abortion is made,
evacuation of the uterus by suction D and C should be promptly performed.

11. Zhang Ping, female, 36 years old. Hospital chief complaint: "stop menses for 38 weeks, feeling fetal
movement for five months, two weeks of lower limbs edema, dizziness and blurred vision for one
hour.". Response and fetal movement pregnancy occurs as scheduled, two weeks ago, no obvious
incentive to both lower extremities edema, no improvement after the break. An hour ago appeared
dazed and confused. Past without hypertension, history of chronic nephritis. Palpation: T36.7 ℃, P78
beats / min, BP175/110mmHg, no abnormal heart and lung auscultation, abdominal bulging, full-term
abdominal, LOA, edema + + +. Laboratory examination: routine blood test showed HGB108g / L,
HCT0.45. Urinalysis showed protein + + +. Auxiliary examination: Ultrasound examination BPD9.0cm,
FL7.2cm, placental calcification Ⅱ. There reactive NST.

1.What is the diagnosis of the disease?

2.What is the diagnosis based on?

3.How to deal with it?

a). Severe pre-eclampsia

b). lower limbs edema, dizziness and blurred vision, dazed and
confused, history of chronic nephritis, BP175/110mmHg. protein + + +.

C). Close monitoring of maternal and infant

1. sedation Diazepam
2. antispasm MgSO4
3. antihypertension drugs labetalol
4. diuresis.
5. terminate the pregnancy

12. A 52-year-old woman attends the clinic for contacting bleeding. She had vaginal bleeding after sex in
the last 2 month ago, amount is not much, colour in red occasionally with rice water like discharge.
natural menopause for two years, G1P1, vaginal delivery. by vaginal examination we can see vulvar and
vaginal wall developed normally. cauliflower like neoplasm, on surface of cervix,2.5 cm in diameter,
easily haemorrhage, the uterine body is normal size, no tenderness, accessories are normal. ultrasonic
examination does not show abnormalmalities.
a.What is the reliable method to make diagnosis?

b. What is the diagnosis?

a. biopsy of cervix
b. Cervical cancer
13. 26-year-old, married woman. Amenorrhea for 60 days. a small amount of vaginal bleeding for 2
days, complicated with mild intermittent abdominal pain. Pelvic examination: the cervical os is closed,
the size of uterus is as large as that of 2months pregnant. Previous abortion one time at 2 months of
pregnancy.

a. What is the diagnosis of the disease?

b. How to deal with it?

a. Threatened abortion
b. Protect fetus, Bed rest and pelvic rest
14. A 26-year-old G1 P0 woman at 39 weeks’ gestation in labour is admitted to the hospital. She is noted
to have uterine contractions every 7 to 10 min. On examination, her blood pressure is 110/70 and heart
rate is 80 bpm. The estimated foetal weight is 3.5kg. On pelvic examination, she is noted to have a
change in cervical dilation from 4 to 7 cm over the last 2hr. The pelvis is assessed to be adequate on
digital examination.

A. What is your next step in the management of this patient?

1. FHR fetal heart rate

2. Cervical dilatation and descent of the fetal head
3. Rupture of membranes
4. Blood pressure
5. Diet
6. Ambulate and rest
7. Urination and defecation
8. Vaginal examination
9. Others