Obstetrics & Gynecology: Clinical Correlations with Diagnostic Implications Richa Saxena
INDEX
Page numbers followed by f refers to figure and t refers to table
A
Abnormal uterine bleeding, types of 128f
Abortion
complete 101, 103
incomplete 101, 102f, 103
inevitable 101, 102f
missed 101, 102f, 103
spontaneous 85, 129
threatened 101, 102f, 103
Abruptio placenta 28
Adenomyosis 129, 134
Adnexal masses 56
Alanine transaminase 63
Amenorrhea 128, 141, 142f, 143, 144t, 145
causes of 144t
American Joint Committee on Cancer 149
Amniocentesis 10, 45
procedure of 11f
Amnionitis 85
Amniotic fluid
index 38, 52
volume 49, 51
Amsel's criteria 172
Anemia 67, 71
causes of 70, 70f
hemolytic 71
iron deficiency 69t, 71
macrocytic 83
megaloblastic 84f
microcytic 67
Anisocytosis 68
Antenatal period 82
Antibody screening 5
Artery, cerebral 49, 52
Ascites 166
Asherman's syndrome 104
Aspartate transaminase 63
Aspiration, endometrial 128, 135, 138f, 159
Atonic uterus 118
Atrophic vaginitis 136
Atrophy, endometrial 136
Azithromycin 176
B
Bacterial vaginosis 172
Baden-Walker halfway system 205, 205t
Biophysical profile 49, 51
Biopsy
cervical 189
endometrial 128, 135, 159, 160, 160t
Biparietal diameter 49
Bleeding
abnormal 127
intermenstrual 128
nature of 31
piles 71
postmenopausal 135
postpartum 116
vaginal 26
Blood
clotting disorders 32
dyscrasias 192
glucose screening 5
group typing 99
loss 71
amount of 31
pressure 32
typing 5
urea 63
Breast
cancer 147, 152t
TNM staging of 150t-152t
discomfort 4
disease 155
lump 155
malignancy 147
Brittle nails 92
C
Cancer 211
cachexia 167
cervical 136, 188, 189, 194, 194t
endometrial 158, 161, 192
ovarian 163, 169
staging of 189
vaginal 136
vulval 136
Candida albicans 174
Candida glabrata 174
Candida krusei 174
Candida tropicalis 174
Carcinoma in situ 190
Carcinoma, location of 148f
Cardiotocography, fetal 49
Cells
abnormal shape of 68
abnormal size of 68
Cephalic version, external 58
Cervical cancer, stage of 189t
Cervicitis 136, 192
Cervix 192
Cesarean delivery 40t
Cesarean wound inspection 113
Chadwick's sign 4
Chemoradiation 192
Chemotherapy 154, 192
Chlamydia trachomatis 176, 182
Chlamydial infection 177
Chondromalacia punctata 87
Choriocarcinoma 109
Chorionic villus sampling
transabdominal 13
transcervical 12f
Clue cells 172
Cold intolerance 92
Colpectomy, total 205
Colpocleisis 205
Colporrhaphy 205
Colposcopy 188, 193
Complete blood count 99
Complete hydatidiform mole 108, 109
Complex endometrial hyperplasia 140
Controlled ovarian hyperstimulation 201
Coomb's test 43f
direct 43f, 44
indirect 42, 43, 43f
Cord entanglement 55
Cordocentesis, procedure of 46f
Crown-rump length 39, 49
Cryotherapy 192
Cul-de-sac, obliteration of 206
Culdoplasty 205, 206
Cystoscopy 189
D
Daily fetal movement count 51
Danazol 157
Decubitus ulcers 192, 206
Deep tendon reflexes 92
Deep vein thrombosis 122, 122f
Diabetes mellitus 174
Douglas, pouch of 179, 200
Down syndrome 8, 9, 10
Ductus venosus 49, 52
Dysmenorrhea 131, 132f, 133, 133f, 134
causes of 134t
Dysplasia, cervical 194
E
Eclampsia 61
Edema 92
Endemic iodine deficiency 92
Endocervical polyp 184
Endometrial cancer
development of 136, 137t, 159
staging for 161t
treatment of 162t
Endometrial hyperplasia, management of 140f
Endometrial sampling, process of 137
Endometriosis 134, 198, 200, 201t
Endometriotic lesions 201f
Endometritis 129
Endoscopy 189
Enterocele sac, closure of 205
Epithelial cells, vaginal 172
Epithelioid trophoblastic tumor 109
Erosions, cervical 24, 192
Escherichia coli 113
Estimated fetal weight 48, 52
European Society of Hysteroscopy Classification of Myomas 211f
F
Fallopian tube 95, 145, 192
Femoral vein 123f
Femur length 49
Fertilization, normal process of 108
Fetal death 9
Fetal dysmaturity syndrome 40, 40t
Fetal echogenic bowel 10
Fetal growth restricted babies 49
Fetal movement
count 51
perception of 4
Fibroids 207, 208
Fibromyomas 208
Fistula 206
Fresh frozen plasma 88
Fundal height 31, 56
G
Galactorrhea 213, 216
Gestation
molar 108f
multifetal 32
multiple 9
period of 104
Gestational age
overestimation of 9
underestimation of 9
intrauterine 5f
Gestational trophoblastic disease, classification of 109t
Glucose challenge test 13, 73
Goiter 92
Growth restriction, intrauterine 48
H
Halban cul-de-sac closure 206
Hashimoto's thyroiditis 92
Hemoglobin 69, 91
Hemorrhage 87
antepartum 23, 28, 71
atonic postpartum 116
postpartum 71, 118, 119t
Hepatitis B serology 5
Hepatitis screen 80
HIV genotype 80
HIV serology 5
Homan's sign 122, 122f
Hookworm infestation 71
Hormone replacement therapy 136, 140
Hydramnios 32, 56
Hyperemesis 109
Hyperplasia 219
endometrial 136, 192
simple 139
Hypertension 32, 61, 192
degree of 64
gestational 61
Hypertensive disorders 60
pregnancy, classification of 61t
Hypoglycemia 41
Hypomenorrhea 128
Hypothyroidism 90
signs and symptoms of 91, 92t
Hysterectomy
abdominal 140, 167, 169, 205
simple 139
vaginal 203, 205
Hysterosalpingography 208
Hysteroscopy 189
I
Infertility 212
Injection vitamin K 88
Insemination, intrauterine 219
Internal podalic version 58f
International Association of Diabetes and Pregnancy Study Groups 73
International Federation of Gynecology and Obstetrics 168
Staging System for Cervical Cancer 190t
International Society for Study of Hypertension in Pregnancy 60
Intraepithelial neoplasia, cervical 193
Intrauterine growth restriction 48
Invasive cervical carcinoma, treatment of 192t
Iron binding capacity 69
Iron deficiency anemia
causes of 71t
treatment of 71f
K
Kallmann's syndrome 145
Kegel exercises 203, 204
Kidney function test 63, 99
Kleihauer-Betke test 44
L
Labor
abnormal 17, 18f, 21f
dysfunctional 20
induction of 35, 37, 39
normal 21f
stages of 19f
Lactate dehydrogenase 63
Laser ablation 197
Laser therapy 192
Le Fort colpocleisis 205
Leiomyomas 129, 208,211
types of 209f
Liver function test 63, 99
Loop electrosurgical excision procedure 192, 195
Loop excision of transformation zone, procedure of 196f
Low alpha-fetoprotein levels 9t
Low lying placenta previa 25f
Low molecular weight heparin 86
Lugol's iodine, application of 195
Lymph nodes
pathologic 151
regional 150, 168
M
Macrocytes 83f
Macrophages 201
Macrosomia 56
Malignancy
cervical 188
endometrial 136
Mammogram 148, 153, 155, 155f
Manchester operation 205
Mass
consistency of 166
malignant 149f
Mastitis 112, 113
Mayer-Rokitansky-Küster-Hauser syndrome 145
McCall's culdoplasty 204, 206
Mean corpuscular hemoglobin concentration 68, 69
Mean corpuscular volume 68, 69, 91
Meconium staining 40
Membranes
premature rupture of 34, 35, 36f
preterm rupture of 32
Menometrorrhagia 128
Menorrhagia 127, 128, 207
Menstrual abnormalities 71
Methotrexate, administration of 97
Metropathia hemorrhagica 192
Metrorrhagia 128
Miscarriage
incomplete 100
inevitable 103
spontaneous 47, 100
types of 103t
Mole
complete 109t
hydatidiform 56, 106, 107
invasive 109
partial 109t
Monochorionic twins 55
Morning sickness 4
Moschcowitz culdoplasty 205, 206
Mother-to-child transmission of infection 82
Müllerian agenesis 145
Muscle cramps 92
Myomas 207, 208
Myomectomy, hysteroscopic 210, 210f
N
National High Blood Pressure Education Program 60
Neisseria gonorrhoeae 182
Neoplasia, intraepithelial 190
Neural tube defects 9, 10, 10f
New York Heart Association Functional Classification of Heart Disease 89
Nipple retraction 147f
Nonstress test 49, 51, 78
Normal reference value 69
Normal umbilical artery Doppler ultrasound waveforms 53f
Nuchal translucency 10, 11f
O
Obstruction, intestinal 183
Oligohydramnios 9
Oligomenorrhea 128
Oliguria 65
Oral analgesic drugs 198
Oral contraceptive pills 219
Osteoporosis, maternal 87
Ovarian cancer, treatment of 168t
Ovarian carcinoma, staging of 167t
Ovarian hyperstimulation syndrome 219
Ovarian malignancy 163, 169
Ovarian tumor 192
Oxytocin challenge test 51
P
Palpation, abdominal 113
Pap smear 185, 186, 193, 197
Para-aortic lymphadenectomy 192
Pelvic inflammatory disease 134, 178
Pelvic lymph node sampling 162t
Pelvic lymphadenectomy 192
Pelvic organ
deformity of 201
prolapse, evaluation of 205t
Pelvic pain, chronic 198
PID, stages of 182t
Placenta abruption 31, 31t
Placenta previa 23-25, 31, 31t, 129
marginal 25f
partial 25f
total 25f
types of 24
Placenta, invasive 118
Placenta, normal 29f
Placental abruption 29, 31, 32
classification of 30f
Plot partogram 17
Poikilocytosis 68
Polycystic ovarian syndrome 216
Polymenorrhea 128
Polyps 24, 192
cervical 129
endometrial 129, 136
Postcoital bleeding, causes of 192t
Postmenopausal bleeding, causes of 136t
Postrenal failure 206
Powder-burn lesions 200
Preeclampsia 60, 61
classification of 64, 64t
Pregnancy
adolescent 16
anembryonic 104
complications of 129
ectopic 47, 94, 95, 95f, 96f, 97t, 98f, 129
heart disease in 86
HIV in 80
intrauterine 129
molar 9, 106
normal 3
postmature 39
postterm 38, 39
teenage 14
therapeutic termination of 47
thyroid disease in 90
Premenstrual syndrome 134
Proctoscopy 189
Progestogen challenge test 141, 144
Prostaglandins 39
Prosthetic valves in situ 86
Proteinuria 62t, 65
Prune juice discharge 107
Puerperal pyrexia 112
Puerperal sepsis 113
Pulsatility index 49, 52
Pyoperitoneum 183
Pyrexia, causes of 113
R
Radiation therapy 154
Radical trachelectomy 192
Rationale behind cytoreductive surgery 169
Rectosigmoidoscopy 189
Resistance index 49
Retroplacental clot, volume of 30
Rh isoimmunization 42, 44
pathogenesis of 45f
S
Sacral colpopexy 205
Sacrospinous colpopexy, transvaginal 206
Salpingoophorectomy, bilateral 140, 167
Sella turcica, MRI of 213
Senile endometritis 192
Senile vaginitis 192
Serum iron concentration 69
Serum uric acid 63
Sexually transmitted diseases 15, 134, 175
Sexually transmitted infection 175, 176
Simple endometrial hyperplasia with atypia 139
Small for gestational age babies 49
Smooth umbilical venous cord flow 52
Sonography, transvaginal 96f, 101, 107f
Squamous intraepithelial lesion, high-grade 193, 194
Submucosal pedunculated fibroids 134
Submucous fibroids 136
Submucous leiomyomas 210
Suprapubic urethrocolpopexy 205
Syphilis serology 5
Systolic blood pressure 64
T
Tachycardia
fetal 37
maternal 37
Tamoxifen 157
Thalassemia 69t
Theca cell tumors 192
Thrombocytopenia syndrome, heparin-induced 87
Thrombophilias 32
Thyroid dysfunction 216
Thyroid gland 92
Transverse cerebellar diameter 49
Trauma, vulval 192
Trichomonas vaginalis 175
Trichomoniasis 172
Triple screening tests 9t
Trophoblastic disease, gestational 108, 129
Tubercular endometritis 192
Tubo-ovarian abscess 178, 180
drainage of 182
Tumors
fixation of 166
stage 150-152
trophoblastic 109
vaginal 192
Twin gestation 54
Twin-to-twin transfusion syndrome 55
U
Ulceration 206
Ultrasonography 207
Ultrasound
Doppler flow velocimetry 49
estimated fetal weight 49
transvaginal 158
Umbilical artery 49, 51, 52
Umbilical vein 49
Urinary incontinence 206
Urine pregnancy test home kit 4f
Uterine artery 52
Uterine bleeding 128t
dysfunctional 127
Uterine compression, bimanual 117f
Uterine fibroids 56, 207
Uterine leiomyomas 32
Uterine procidentia 205f
Uterine prolapse 203, 205f
stages of 205f
Uterine tenderness 30
Uterosacral ligaments 200
Uterovaginal prolapse 203
V
Vagina 192
Vaginal bleeding, irregular 109
Vaginal colporrhaphy, combined 205
Vaginal discharge 171, 173f
Vaginal mucosa, changes in 4
Vaginal procedure 206
Vaginal repair and uterine suspension 205
Vaginitis 192
causes of 172t
VDRL test 5
Venous thromboembolism 121
Vision, blurring of 64
Voice, hoarseness of 92
Vulva 192
benign or malignant lesions of 192
Vulvovaginal candidiasis 171, 172
Vulvovaginitis 171
W
Whiff test 172
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1OBSTETRICS AND GYNECOLOGY: Clinical Correlations with Diagnostic Implications2
3OBSTETRICS AND GYNECOLOGY: Clinical Correlations with Diagnostic Implications
Richa Saxena MBBS, MD (Obstetrics & Gynecology) Obstetrician and Gynecologist PG Diploma in clinical research New Delhi, India
4
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Obstetrics and Gynecology: Clinical Correlations with Diagnostic Implications
First Edition: 2016
9789351529798
Printed at
5Dedication
Dedicated to a baby's beautiful smile…..6
7Preface
“The good physician treats the disease; the great physician treats the patient who has the disease.”
William Osler
(From The Medical Library in Postgraduate Work, BMJ. 1909;2:925-8)
Just as every individual is unique, every patient too presents with his or her distinct story. The same disease may affect two individuals in different ways. For example, one patient may present with chronic pelvic pain while the other one with infertility. However, both of them may be suffering from a similar disease, i.e. endometriosis in this case. Thus every patient presents as a unique jigsaw puzzle. The book “Obstetrics and Gynecology: Clinical Correlations with Diagnostic Implications” is the author's deeply contemplated effort in the direction of solving that jigsaw puzzle. The book presents a compilation of 42 clinical cases in the speciality of obstetrics and gynecology. Of these, 23 clinical cases are pertaining to obstetrics and 19 clinical cases are pertaining to gynecology. Each clinical case scenario is followed by multiple-choice questions, which will not only help in solving the jigsaw related to clinical case presentation, its diagnosis and management but would also enable the readers in using their own judgements before solving each case.
In clinical practice, “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” Each case presented in this book is distinctive, with each patient having an exclusive set of signs and symptoms. Through these cases, the reader would also be able to grasp the basics of obstetrics and gynecology. The book would be useful to the practitioners as well as the postgraduate students, residents and fellows in obstetrics and gynecology. Even the general practitioners who have not received formal training in obstetrics and gynecology may find this book useful.
I believe that writing a book involves a continuous learning process. It involves extreme hard labor and toil. For this, I would like to thank the Almighty for enabling me to initiate and complete this gigantic task. Though extreme care has been taken to maintain accuracy while writing this book, minor errors may inadverently creep in at times. Therefore, constructive criticism would be greatly appreciated. Please e-mail me your comments at the email address: richa@drrichasaxena.com. Also, please feel free to visit my website www.drrichasaxena.com for obtaining information related to various other books written by me and to make use of the free resources available for the medical students.
Richa Saxena
11List of Abbreviations ACC
American College of Cardiology
ACOG
American College of Obstetrics and Gynecologists
ADA
American Diabetes Association
AFB
Acid-fast bacilli
AFI
Amniotic fluid index
AHA
American Heart Association
AIDS
Acquired immunodeficiency syndrome
ALT
Alanine transaminase
ANC
Antenatal clinic
APGAR
Activity, pulse, grimace, appearance and respiration
APTT
Activated partial thromboplastin time
ART
Assisted reproductive technology
AST
Aspartate aminotransferase
AUB
Abnormal uterine bleeding
BMI
Body mass index
BP
Blood pressure
BPM
Beats per minute
BPP
Biophysical profile
CBC
Complete blood count
CC
Clomiphene citrate
CDC
Center for Disease Control and Prevention
CHM
Complete hydatidiform mole
CPP
Chronic pelvic pain
CRP
C-reactive protein
CT
Computed tomography
CVP
Central venous pressure
CVS
Chorionic villus sampling
D&C
Dilation and curettage
DIC
Disseminated intravascular coagulation
DLC
Differential leukocyte count
DNA
Deoxyribonucleic acid
DUB
Dysfunctional uterine bleeding
DVT
Deep vein thrombosis
EDD
Expected date of delivery
EFW
Estimated fetal weight
ESR
Erythrocyte sedimentation rate
FDA
Food and Drug Administration
FDP
Fibrin degradation products
FGR
Fetal growth restriction
FHR
Fetal heart rate
FHS
Fetal heart sound
FIGO
International Federation of Gynecology and Obstetrics
FMH
Fetomaternal hemorrhage
FSH
Follicle-stimulating hormone
GCT
Glucose challenge test
GDM
Gestational diabetes mellitus
GIT
Gastrointestinal tract
GnRH
Gonadotropin-releasing hormone
GTD
Gestational trophoblastic disease
12GTN
Gestational trophoblastic neoplasia
hCG
Human chorionic gonadotropin
HIV
Human immunodeficiency virus
HPV
Human papilloma virus
HRT
Hormone replacement therapy
IDA
Iron deficiency anemia
IM
Intramuscular
INR
International normalized ratio
IUCD
Intrauterine contraceptive device
IUD
Intrauterine death
IUGR
Intrauterine growth retardation
IUI
Intrauterine insemination
IV
Intravenous
IVF
In vitro fertilization
LDH
Lactate dehydrogenase
LH
Luteinizing hormone
LMP
Last menstrual period
LMWH
Low molecular weight heparin
MRI
Magnetic resonance imaging
NDDG
National diabetes data group
NSAIDs
Nonsteroidal anti-inflammatory drugs
NST
Nonstress test
OCP
Oral contraceptive pills
OGTT
Oral glucose tolerance test
OPD
Out patient department
Pap
smear Papanicolaou smear
PAPP-A
Pregnancy associated plasma protein A
PCOD
Polycystic ovarian disease
PE
Pulmonary embolism
PHM
Partial hydatidiform mole
PID
Pelvic inflammatory disease
PIH
Pregnancy-induced hypertension
PMS
Premenstrual syndrome
PPH
Postpartum hemorrhage
PPROM
Preterm premature rupture of membrane
PROM
Premature rupture of membrane
PT
Prothrombin time
RBC
Red blood cell
RNA
Ribonucleic acid
ROM
Rupture of membrane
STD
Sexually transmitted disease
STI
Sexually transmitted infection
TAH
Total abdominal hysterectomy
TAS
Transabdominal sonography
TLC
Total leukocyte count
TRH
Thyrotropin-releasing hormone
TSH
Thyroid-stimulating hormone
TT
Thrombin time
TVS
Transvaginal sonography
UTI
Urinary tract infection
VDRL
Veneral disease research laboratory test
VVC
Vulvovaginal candidiasis
WBC
White blood cell
WHO
World Health Organization
WNL
Within normal limit