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Bedside Obstetrics and Gynecology
Richa Saxena
SECTION 1: OBSTETRICS: NORMAL AND ABNORMAL PRESENTATIONS
CHAPTER 1:
Normal Pregnancy
Case Study
Introduction
History
General Physical Examination
Specific Systemic Examination
ABDOMINAL EXAMINATION IN ANTENATAL PERIOD
General Examination of the Abdomen
Preparation of the Patient for Examination
Inspection of the Abdomen
Abdominal Palpation
Examination of the Uterus and the Fetus
Determining the Fundal Height
Measurement of Symphysio-Fundal Height (Figure 1.2)
Palpation of the Fetus
Diagnosis of Fetal Presentationand Position
Obstetric Grips or Lepold's Maneuvers of Abdominal Palpation (Figure 1.6)
Special Points about the Palpation of the Fetus
Assessment of the Amount of Liquor Present
Uterine Contractions
Auscultation of Fetal Heart
EXAMINATION OF THE PATIENT IN LABOR
Abdominal Examination in Labor
Uterine Contractions
VAGINAL EXAMINATION
Prerequisites for a Vaginal Examination
Indications for a Vaginal Examination in Pregnancy
Contraindications to a Vaginal Examination in Pregnancy
Preparation for Vaginal Examination
Parameters to be Observed during Vaginal Examination
Fetal Presentation
Fetal Position
Assessment of the Membranes
The Condition of the Liquor When the Membranes Rupture
Determining the Descent and Engagement of the Head
Molding
PELVIC ASSESSMENT
Assessment of Pelvic Inlet
Assessment of Midpelvis
Assessment of the Pelvic Outlet
Abdominal Method for Assessment of Pelvic Disproportion
Abdominal Vaginal Method (Muller Munrokerr Method)
Management
Investigations
Treatment/Obstetric Management
LABOR AND ITS STAGES (TABLE 1.19)
First Stage
Second Stage of Labor
Mechanism of Normal Labor (Figure 1.31)
Preparation for Normal Vaginal Delivery
Complications
Important Questions and Answers
CHAPTER 2:
Breech Presentation
Case Study
Introduction
History
RISK FACTORS
Maternal Factors
Fetal Factors
General Physical Examination
Specific Systemic Examination
ABDOMINAL EXAMINATION
Abdominal Palpation
VAGINAL EXAMINATION
Management
Investigations
Treatment/Obstetric Management
MANAGEMENT DURING PREGNANCY
External Cephalic Version (ECV)
MANAGEMENT DURING LABOR
Mode of Delivery
Elective Cesarean Section
Trial of Breech (Vaginal Breech Delivery)
Post-Delivery Care
Complications
FETAL COMPLICATIONS
Low APGAR Scores
Fetal Head Entrapment
Preterm Birth
Neonatal Trauma
Cord Prolapse
MATERNAL COMPLICATIONS
Important Questions and Answers
CHAPTER 3:
Transverse Lie
Case Study
Introduction
History
RISK FACTORS
Maternal Factors
Fetal Factors
General Physical Examination
Specific Systemic Examination
ABDOMINAL PALPATION
VAGINAL EXAMINATION
Management
Investigations
Treatment/Obstetric Management
MANAGEMENT DURING PREGNANCY
External Cephalic Version (ECV)
MANAGEMENT DURING LABOR
Complications
Important Questions and Answers
SECTION 2: OBSTETRICS: COMPLICATION OF PREGNANCY
CHAPTER 4:
Antepartum Hemorrhage
Case Study
Introduction
History
CLINICAL FEATURES
RISK FACTORS
General Physical Examination
Specific Systemic Examination
ABDOMINAL EXAMINATION
VAGINAL EXAMINATION
RECTAL EXAMINATION
Differential Diagnosis
Management
Investigations
Treatment/Obstetric Management
PREVENTION
Antenatal Period
Intrapartum Period
DEFINITIVE MANAGEMENT/TREATMENT
Management of Patients with Severe Bleeding
Management of Patients with Moderate Bleeding
Management of Patients with Mild Bleeding
Expectant Management
Hospitalization vs. Outpatient Management in Placenta Previa
Mode of Delivery
Indications for Emergency Delivery
Complications
MATERNAL
Bleeding
Placenta Accreta, Increta, Percreta
Anemia and Infection
FETAL
Premature Birth
Fetal Death or Fetal Distress
Important Questions and Answers
Case Study
Introduction
History
CLINICAL PRESENTATION
Vaginal Bleeding
Abdominal Pain
RISK FACTORS
General Physical Examination
Specific Systemic Examination
ABDOMINAL EXAMINATION
VAGINAL EXAMINATION
Differential Diagnosis
Management
Investigations
Treatment/Obstetric Management
PREVENTION
DEFINITIVE TREATMENT
Mild Placental Abruption
Moderate Placental Abruption
Severe Placental Abruption
Expectant Management for Mild Placental Abruption
Cesarean Section
Complications
MATERNAL
Maternal Shock due to Severe Bleeding
Maternal Death
Renal Failure
Couvelaire Uterus or Uteroplacental Apoplexy
Risk of Recurrence of Abruption in Future Pregnancies
Postpartum Uterine Atony and Postpartum Hemorrhage
Disseminated Intravascular Coagulopathy (DIC)
FETAL COMPLICATIONS
Fetal Distress
Premature Delivery
Stillbirth and Fetal Death
Important Questions and Answers
CHAPTER 5:
Twin Pregnancy
Case Study
Introduction
TYPES OF TWIN GESTATION
Dizygotic Twins
Monozygotic Twins
History
RISK FACTORS
CLINICAL PRESENTATION
General Physical Examination
Specific Systemic Examination
ABDOMINAL EXAMINATION
Inspection
Palpation
Auscultation
Differential Diagnosis
Management
Investigations
Treatment/Obstetric Management
PREVENTION
Primary Prevention
Secondary Prevention
MANAGEMENT IN THE ANTENATAL PERIOD
Steps for Prevention of Preterm Labor
Increased Daily Requirement for Dietary Calories, Proteins and Mineral Supplements
Increased Frequency of Antenatal Visits
Increased Fetal Surveillance
MANAGEMENT IN THE INTRAPARTUM PERIOD (Flow charts 5.1A and B)
MANAGEMENT AT THE TIME OF DELIVERY
Delivery of the First Baby
Delivery of Second Baby
Mode of Delivery of Second Twin
Technique for Internal Podalic Version
Delivery of the Placenta
Indications for Cesarean Section in Twin Pregnancy
Management of Third Stage of Labor
Complications
MATERNAL COMPLICATIONS
During Antenatal Period
During Labor
FETAL COMPLICATIONS
Fetal Complications Due to Twin Gestation
FETAL COMPLICATIONS SPECIFIC TO TWIN GESTATION
Discordant Growth
Twin to Twin Transfusion
Acardiac Twin or Twin Reversed Arterial Perfusion (TRAP) Syndrome
Conjoined Twins
Long Term Complications
Important Questions and Answers
CHAPTER 6:
Rh Negative Pregnancy
Case Study
Introduction
ABO CLASSIFICATION
Blood Group A
Blood Group B
Blood Group AB
Blood Group O
RHESUS CLASSIFICATION
Rh Positive
Rh Negative
Rh INCOMPATIBILITY DISEASE
History
RISK FACTORS
Maternal History
Obstetric History
General Physical Examination
Specific Systemic Examination
ABDOMINAL EXAMINATION
Management
Investigations
Treatment/Obstetric Management
ANTENATAL MANAGEMENT
Management of Rh Negative Nonimmunized Women (Flow chart 6.2)
Rh Negative Immunized Women (Flow charts 6.3A and B)
INTRAPARTUM MANAGEMENT
Precautions to be Taken at the Time of Delivery
Timing of Delivery (Flow chart 6.4)
Treatment of Fetal Anemia
Complications
FETAL COMPLICATIONS
Erythroblastosis Fetalis
Hydrops Fetalis
MATERNAL
Important Questions and Answers
CHAPTER 7:
Previous Cesarean Section
Case Study
Introduction
History
General Physical Examination
Specific Systemic Examination
Management
Investigations
Treatment/Obstetric Management
VAGINAL BIRTH AFTER CESAREAN DELIVERY
Criteria for VBAC
Advantages of VBAC
Contraindications for VBAC
Risk of VBAC
Counseling of Women for VBAC
Intrapartum Management
ELECTIVE REPEAT CESAREAN SECTION
Disadvantages of Cesarean Delivery
Timing for Cesarean Delivery
Preparations for an Elective Cesarean Section
Surgery for Cesarean Section
Type of Abdominal Skin Incision (Figure 7.2)
Sharp (Pfannenstiel) vs. Blunt (Joel Cohen)
Types of Uterine Incision
Closure of the Uterine Incision
Peritoneal Closure
Closure of Subcutaneous Space
Skin Closure
Prophylactic Antibiotics with Cesarean Section
Use of Uterotonics
Immediate Postoperative Care
The Hemostatic Cesarean Section
Complications
Important Questions and Answers
CHAPTER 8:
Hydatidiform Mole
Case Study
Introduction
History
RISK FACTORS
Race and Ethnicity
Maternal Age
Faulty Diet
Blood Group
CLINICAL PRESENTATION
General Physical Examination
Specific Systemic Examination
ABDOMINAL EXAMINATION
VAGINAL EXAMINATION
Differential Diagnosis
Management
Investigations
Treatment/Obstetric Management
TREATMENT OF BENIGN DISEASE
Treatment by Suction Evacuation
Hysterectomy with Mole in Situ
Chemotherapy Following Evacuation
TREATMENT OF PERSISTENT DISEASE
Treatment of Nonmetastatic Disease
Treatment of Metastatic Disease
Follow up After Chemotherapy
Complications
Important Questions and Answers
CHAPTER 9:
Bad Obstetric History
Case Study
Introduction
DEFINITION
ETIOLOGY
Genetic Causes
Hormonal Causes
Infectious Causes
Anatomical Causes
Cervical Incompetence
Surgical Procedures
Inherited Thrombophilias
Immune Causes
Antiphospholipid Antibody Syndrome
Environmental Factors
Unexplained Cases of Recurrent Miscarriage
History
RISK FACTORS
General Physical Examination
Specific Systemic Examination
EXAMINATION OF EXTERNAL GENITALIA
ABDOMINAL EXAMINATION
PELVIC EXAMINATION
Management
Investigations
Treatment/Obstetric Management
Important Questions and Answers
CHAPTER 10:
Postpartum Hemorrhage
Case Study
Introduction
History
RISK FACTORS
Risk Factors During Labor
General Physical Examination
Specific Systemic Examination
ABDOMINAL EXAMINATION
PER SPECULUM EXAMINATION
Differential Diagnosis
Management
Investigations
Treatment/Obstetric Management
PREVENTION OF PPH
MANAGEMENT OF PPH
Communication
Resuscitation
Patient Monitoring and Investigations
Treating the cause of bleeding
Placenta has Delivered
Medical Management of Atonic Uterus
Available Surgical Options
Blood Supply to the Female Pelvis
TYPES OF SURGICAL OPTIONS
B-Lynch Compression Sutures
Hypogastric Artery Ligation
Uterine Artery Ligation
Uterine Artery Embolization
UTERINE INVERSION
THE PLACENTA HAS YET NOT DELIVERED
Nonadherent Placenta
Adherent Placenta
Management of an Adherent Placenta
SECONDARY POSTPARTUM HEMORRHAGE
Complications
Important Questions and Answers
CHAPTER 11:
Intrauterine Growth Restriction
Case Study
Introduction
History
RISK FACTORS
General Physical Examination
Specific Systemic Examination
ABDOMINAL EXAMINATION
Management
Investigations
Treatment/Obstetric Management
Complications
FETAL COMPLICATIONS
Antepartum Complications
Intrapartum Complications
NEONATAL COMPLICATIONS
Long Term Sequel of IUGR
Important Questions and Answers
SECTION 3: OBSTETRICS: MEDICAL DISORDERS RELATED TO PREGNANCY
CHAPTER 12:
Preeclampsia
Case Study
Introduction
History
RISK FACTORS
SYMPTOMS
General Physical Examination
Specific Systemic Examination
ABDOMINAL EXAMINATION
Differential Diagnosis
Management
Investigations
Treatment/Obstetric Management
PREVENTION
Other Nutritional Advice Commonly Prescribed for Preeclampsia
MANAGEMENT OF MILD PREECLAMPSIA
Maternal Management
Fetal Evaluation
Mode of Delivery
Postpartum Period
MANAGEMENT OF SEVERE PREECLAMPSIA
Maternal Stabilization
Fetal Management in Case of Severe Preeclampsia
Maternal Management During Labor
Management of Hypertension Postpartum
Complications
FETAL COMPLICATIONS
Prematurity
Intrauterine Growth Restriction (IUGR)
MATERNAL COMPLICATIONS
Abruption Placenta
Cerebral Hemorrhage
ECLAMPSIA
Prevention of Eclampsia
Management of Eclampsia
HELLP SYNDROME
Symptoms
Pathophysiology
Diagnosis
Differential Diagnosis
Classification
Treatment
Complications
Important Questions and Answers
CHAPTER 13:
Gestational Diabetes
Case Study
Introduction
DIABETES MELLITUS
Gestational Diabetes
Physiological Effects of Pregnancy on Glucose Metabolism
History
RISK FACTORS
General Physical Examination
Specific Systemic Examination
ABDOMINAL EXAMINATION
Management
Investigations
Treatment/Obstetric Management
MANAGEMENT DURING THE ANTENATAL PERIOD
Exercise and Diet Therapy in the Antenatal Period
Antihypoglycemic Therapy in the Antenatal Period
Education Regarding Diabetes
Fetal Monitoring During the Antenatal Period
Timing and Mode of Birth
Management During the Intrapartum Period
Neonatal Care
Postnatal Care
Complications
FETAL COMPLICATIONS
Congenital Malformations
Macrosomia
IUGR
Shoulder Dystocia
MATERNAL COMPLICATIONS
Important Questions and Answers
CHAPTER 14:
Anemia in Pregnancy
Case Study
Introduction
DEFINITION
Grading of Anemia
Physiological Changes Taking Place in Anemia
History
SYMPTOMS
Dietary History
History of Hemorrhage
Obstetric History
Socio-economic History
Behavioral History
Medical History
Menstrual History
Treatment History
General Physical Examination
Specific Systemic Examination
ABDOMINAL EXAMINATION
CARDIOVASCULAR SYSTEM
Differential Diagnosis
Management
Investigations
Treatment/Obstetric Management
PREVENTION
Prevention of Iron Deficiency Anemia
TREATMENT
Treatment with Iron Supplements
Management of Anemic Patients During Intrapartum Period
Complications
MATERNAL
FETAL
Important Questions and Answers
CHAPTER 15:
Heart Disease during Pregnancy
Case Study
Introduction
CONGENITAL OR ACQUIRED CARDIAC LESIONS
Low-Risk Lesions
Moderate-Risk Lesions
High-Risk Lesions
Acquired Cardiovascular Disorders During Pregnancy
Coronary Artery Disease
Arrhythmias in Pregnancy
Congenital Heart Disease in Pregnancy
History
General Physical Examination
Specific Systemic Examination
EXAMINATION OF CARDIOVASCULAR SYSTEM
Palpation
Auscultation
ABDOMINAL EXAMINATION
Management
PREPREGNANCY MANAGEMENT
ANTENATAL MANAGEMENT
Investigations
Antenatal Care
Intrapartum Care
Management of the Third Stage of Labor
Postpartum Care
Pregnancy in the Presence of Prosthetic Heart Valve
Complications
MATERNAL COMPLICATIONS
FETAL COMPLICATIONS
Important Questions and Answers
SECTION 4: GYNECOLOGY: NORMAL AND ABNORMAL MENSTRUATION
CHAPTER 16:
Normal Gynecological Examination
Case Study
Introduction
History
General Physical Examination
Specific Systemic Examination
ABDOMINAL EXAMINATION
Inspection
Palpation
Percussion
Auscultation
CARDIOVASCULAR SYSTEM EXAMINATION
EXAMINATION OF THE PULMONARY SYSTEM
PELVIC EXAMINATION
Positioning the Patient for Pelvic Examination
The Steps of the Pelvic Examination
Management
Investigations
Treatment/Gynecological Management
Important Questions and Answers
CHAPTER 17:
Abnormal Uterine Bleeding due to Endometrial Cancer
Case Study
Introduction
History
General Physical Examination
Specific Systemic Examination
ABDOMINAL EXAMINATION
PELVIC EXAMINATION
Differential Diagnosis
Management
Investigations
Treatment/Gynecological Management
Important Questions and Answers
CHAPTER 18:
Menorrhagia due to Leiomyomas
Case Study
Introduction
History
General Physical Examination
Specific Systemic Examination
ABDOMINAL EXAMINATION
PELVIC EXAMINATION
Differential Diagnosis
Management
Investigations
Treatment/Gynecological Management
CONSERVATIVE TREATMENT
MEDICAL TREATMENT
Aims of Medical Management
Endometrial Ablation
SURGICAL OPTIONS
Hysterectomy
Myomectomy
Risks Associated with Myomectomy
Deciding the Type of Myomectomy to be Performed
DESTRUCTION OF THE FIBROIDS
Myoma Coagulation (Myolysis)
Uterine Artery Embolization (UAE)
Laparoscopic Uterine Artery Ligation
Focused Ultrasound (MRgFUS) for Treatment of Fibroids
Complications
Important Questions and Answers
CHAPTER 19:
Dysfunctional Uterine Bleeding
Case Study
Introduction
ETIOLOGY OF DUB
Anovulatory DUB
Ovulatory Dysfunctional Bleeding
History
General Physical Examination
Specific Systemic Examination
PELVIC EXAMINATION
Differential Diagnosis
Management
Investigations
Treatment/Gynecological Management
Important Questions and Answers
SECTION 5: GYNECOLOGY: ABNORMALITIES OF VAGINA AND CERVIX
CHAPTER 20:
Vaginal Discharge
Case Study
Introduction
PATHOLOGICAL VAGINAL DISCHARGE
Pathophysiology
Bacterial Vaginosis
Diagnosis
Vulvovaginal Candidiasis
Trichomoniasis
Atrophic Vaginitis
Sexually Transmitted Diseases (STDs)
Chlamydial Infection
Genital Herpes
Gonorrhea
Granuloma Inguinale (Donovanosis)
Lymphogranuloma Venereum
Chancroid (Soft Sore)
Syphilis
History
General Physical Examination
Specific Systemic Examination
PELVIC EXAMINATION
Per speculum Examination
Bimanual Pelvic Examination
Differential Diagnosis
Management
Investigations
Treatment/Gynecological Management
Complications
Important Questions and Answers
CHAPTER 21:
Cancer Cervix (Postcoital Bleeding)
Case Study
Introduction
History
RISK FACTORS
Symptoms of Cervical Cancer
General Physical Examination
Specific Systemic Examination
PER SPECULUM EXAMINATION
Differential Diagnosis
Management
MANAGEMENT OF PREINVASIVE CANCER
Investigations
DIAGNOSIS OF CERVICAL DYSPLASIA
Cytologic Screening: Pap Smear
Visual Inspection of Cervix
Types of Cell Changes in Pap Smear
Liquid-based Cytology in Cervical Screening: A Rapid and Systematic Review
Colposcopy
Cervicography
Treatment/Gynecological Management
TREATMENT OF DYPLASTIC CHANGES
Locally Destructive Methods
Excision of the Abnormal Tissue
Surgical Options
Follow up after Therapy
Management: Invasive Cancer
Investigations
Treatment/Gynecological Management
PREVENTION
Nutrition
DEFINITIVE TREATMENT FOR INVASIVE CANCER
Stage IA Tumors
Stage IB and IIA Tumors
Stage IIB, III and IV Tumors
Radiation Therapy
Chemotherapy
Pelvic Exenteration
Complications
Important Questions and Answers
SECTION 6: GYNECOLOGY: UTERINE, OVARIAN AND TUBAL PATHOLOGY
CHAPTER 22:
Prolapse Uterus
Case Study
Introduction
History
RISK FACTORS
Medical History
Obstetric History
SYMPTOMS OF PROLAPSE
General Physical Examination
Specific Systemic Examination
PER SPECULUM EXAMINATION
PELVIC EXAMINATION
Evaluation of the Degree of Prolapse
POP-Q Staging System
Differential Diagnosis
Management
Investigations
Treatment/Gynecological Management
PREVENTION
NONSURGICAL MANAGEMENT
Pessary Treatment for Prolapse
Expectant Management
SURGERY: DEFINITIVE TREATMENT
Preoperative Treatment
Principles of Surgery for Pelvic Organ Prolapse
DESCRIPTION OF VARIOUS SURGICAL PROCEDURES
Hysterectomy
Anterior Repair
Posterior Repair
Manchester Repair
Shirodhkar's Modification of Manchester Repair
Uterine Suspension
Obliterative Procedures
Le Fort Colpocleisis
Complications
Important Questions and Answers
CHAPTER 23:
Pelvic Pain
Case Study
Introduction
History
General Physical Examination
Specific Systemic Examination
ABDOMINAL EXAMINATION
Carnett's Sign for Patients with Pelvic Pain (Figure 23.2)
PELVIC EXAMINATION
Per Speculum Examination
Bimanual Pelvic Examination
Differential Diagnosis
Management
Investigations
Treatment/Gynecological Management
MEDICAL TREATMENT
Analgesics
Antidepressants and Anticonvulsants
Hormonal Therapy
SURGICAL TREATMENT
Laparoscopic Surgery
Conservative Surgery
Semi-conservative Surgery
Radical Surgery
Important Questions and Answers
CHAPTER 24:
Abdominal Lump(Ovarian Cancer)
Case Study
Introduction
TYPES OF OVARIAN NEOPLASTIC GROWTH
Epithelial Tumors
Sex Cord-Stromal Cell Tumors
Germ Cell Tumors
History
RISK FACTORS FOR OVARIAN CANCER
SYMPTOMS OF OVARIAN CANCER
General Physical Examination
Specific Systemic Examination
ABDOMINAL EXAMINATION
PELVIC EXAMINATION
Differential Diagnosis
Management
Investigations
Treatment/Gynecological Management
PREVENTION
Screening for Ovarian Cancer
DEFINITIVE THERAPY
Second Look Laparoscopy
Radiation Therapy
Chemotherapy
Combination Chemotherapy
Important Questions and Answers
CHAPTER 25:
Ectopic Pregnancy
Case Study
Introduction
History
RISK FACTORS
SYMPTOMS
General Physical Examination
Specific Systemic Examination
ABDOMINAL EXAMINATION
PELVIC EXAMINATION
Differential Diagnosis
Management
Investigations
Treatment/Gynecological Management
Important Questions and Answers
SECTION 7: GYNECOLOGY: ABNORMALITIES IN CONCEPTION
CHAPTER 26:
Infertility
Case Study
Introduction
History
General Physical Examination
Specific Systemic Examination
ABDOMINAL EXAMINATION OF FEMALE PARTNER
PELVIC EXAMINATION OF FEMALE PARTNER
Per Speculum Examination
Bimanual Examination
EXAMINATION OF MALE PARTNER
Differential Diagnosis
Management
Investigations
EVALUATION OF THE MALE PARTNER
Semen Analysis
EVALUATION OF THE FEMALE PARTNER
Evaluation of Cervical Factor
Tests for Uterine Factor
Hysterosalpingogram (HSG)
Saline Infusion Sonography
Ultrasonography
Hysteroscopy
Endometrial Biopsy
Tubal and Peritoneal Factors
Laparoscopy
Falloposcopy
Ovarian Factors
Ultrasound
Treatment/Gynecological Management
Important Questions and Answers
CHAPTER 27:
Amenorrhea
Case Study
Introduction
History
General Physical Examination
Specific Systemic Examination
Differential Diagnosis
Management
Investigations
Treatment/Gynecological Management
Complications
Important Questions and Answers
INDEX
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