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Manual of Obstetrics & Gynecology for the Postgraduates
Hiralal Konar
SECTION 1: OBSTETRICS
1:
Objective Structured Clinical Examination in Obstetrics
CASE 1: SEVERE PRE-ECLAMPSIA
CASE 2: COUNSELING
CASE 3: ECTOPIC PREGNANCY
CASE 4: ABRUPTIO PLACENTAE; PLACENTA PREVIA
CASE 5: UNSTABLE LIE
CASE 6: NONPROGRESS OF LABOR
CASE 7: CARDIOTOCOGRAPHY-I
CASE 8: CARDIOTOCOGRAPHY-II
CASE 9: MANAGEMENT OF LABOR (PARTOGRAPH-I)
CASE 10: MANAGEMENT OF LABOR (PARTOGRAPH-II)
CASE 11: PRIMARY POSTPARTUM HEMORRHAGE
CASE 12: SECONDARY POSTPARTUM HEMORRHAGE
CASE 13: SURGICAL MANAGEMENT OF POSTPARTUM HEMORRHAGE (PPH)
Stepwise Uterine Devascularization
Uterine Artery Ligation (O'Leary-1966) (Fig. 1.17)
Hypogastric Artery Ligation
Indications of Internal Iliac (Hypogastric) Artery Ligation
Hemodynamic Alterations Following Ligation of Internal Iliac Artery
Techniques of Ligation (Figs 1.18A and B)
Steps of Internal Iliac (Hypogastric) Artery Ligation (Fig. 1.19)
Place of Unilateral or Bilateral Arterial Ligation
Maintenance of Reproductive Function
CONCLUSION
CASE 14: PREGNANCY AND LABOR IN A WOMAN WITH PRIOR CESAREAN DELIVERY
CASE 15: PUERPERAL PYREXIA
CASE 16: MULTIPLE PREGNANCY
FETAL CONGENITAL MALFORMATIONS
CASE 17: NEURAL TUBE DEFECTS
CASE 18: ANENCEPHALY
CASE 19: HYDROCEPHALUS
CASE 20: CYSTIC HYGROMA
2:
Self-Assessment in Obstetrics
SINGLE BEST ANSWER (SBA) AND MULTIPLE CHOICE QUESTIONS (MCQs)
SECTION 2: GYNECOLOGY
3:
Objective Structured Clinical Examination (OSCE) in Gynecology
CASE 1: POLYCYSTIC OVARIAN SYNDROME (PCOS)
CASE 2: ENDOMETRIOSIS
CASE 3: PRIMARY AMENORRHEA
CASE 4: SECONDARY AMENORRHEA
CASE 5: PELVIC PAIN
CASE 6: INFERTILITY
CASE 7: HEMATOCOLPOS
CASE 8: INFERTILITY
CASE 9: HYDATIDIFORM MOLE
CASE 10: ENDOMETRIOSIS
CASE 11: CERVICAL FIBROID
CASE 12: CARCINOMA CERVIX
CASE 13: CARCINOMA ENDOMETRIUM
CASE 14: CARCINOMA OF THE OVARY
OVARIAN CANCER
CASE 15: CARCINOMA CERVIX
CASE 16: MENOPAUSE AND HORMONE REPLACEMENT THERAPY (HRT)
CASE 17: CARCINOMA CERVIX
CASE 18: HYSTERECTOMY AND OOPHORECTOMY
CASE 19: POSTMENOPAUSAL BLEEDING
CASE 20: INHERITED CANCERS AND THE MANAGEMENT
4:
Self-Assessment in Gynecology
SINGLE BEST ANSWER (SBA) AND MULTIPLE CHOICE QUESTIONS (MCQs)
MODELS FOR MULTIPLE CHOICE QUESTIONS (MCQs)
SECTION 3: OBSTETRIC DISCUSSION
5:
Preterm Birth and Managemernt Issues
PRETERM BIRTH
MANAGEMENT ISSUES
Main Objectives in the Management of Preterm Birth
6:
Gestational Diabetes Mellitus
GESTATIONAL DIABETES MELLITUS (GDM)
Diagnosis and Management
Pathophysiology of GDM and Type 2 Diabetes
Therapeutic Strategies Include
Significance of 2-hour Plasma Glucose Level > 140 mg/dL (> 7.8 mmol/L)
Treatment for GDM (Based on New Evidence)
Pharmacological Interventions in the Management of GDM
Oral Hypoglycemic Agents in GDM
Sulfonylureas
Biguanides
Various Metabolic Effects of Metformin
7:
Obesity in Pregnancy
8:
Monochorionic Twin Pregnancy
SINGLE BEST ANSWER (SBA) AND MULTIPLE CHOICE QUESTIONS (MCQs)
MONOCHORIONIC TWIN PREGNANCY
Management Issues
Twin-to-twin Transfusion Syndrome
TWIN-TO-TWIN TRANSFUSION SYNDROME
Diagnostic Criterias of TTTS Based on Ultrasound
Grading for Severity of TTTS
Management of TTTS
Time and Mode of Delivery in a Woman with Monochorionic Twin Pregnancy
Monochorionic Twin Pregnancy without any Intrauterine Growth Restriction (IUGR) and TTTS
Growth Discordance in Twins (Discordant Twins)
Fetal Malformations and Morbidity in Twin Pregnancy
SINGLE FETAL DEATH IN TWIN PREGNANCY
Management Issues
TWIN REVERSED ARTERIAL PERFUSION (TRAP)
CONJOINT TWINS
Diagnosis and Management
MONOCHORIONIC MONOAMNIOTIC (MCMA) TWIN PREGNANCY
Selective Fetal Reduction
Selective Fetal Termination
9:
Prenatal Screening for Fetal Abnormalities
FIRST TRIMESTER SCREENING
Combined: Nuchal Translucency + Serum Tests
Nuchal Translucency
SECOND TRIMESTER SCREENING
Genetic Ultrasonography for Aneuploidy Marker(s)
INTEGRATED AND SEQUENTIAL SCREENING (FLOWCHART 9.1)
First and Second Trimester Evaluation of Risk (faster) Trial for Trisomy 21
Integrated Screening (Wald, et al. 1999)
Disadvantages of Integrated Screening
Alternative Protocols
MCQS
10:
Severe Pre-eclampsia and Eclampsia
SINGLE BEST ANSWER (SBA) AND MULTIPLE CHOICE QUESTIONS (MCQs)
Place of Antihypertensive Therapy
ANTIHYPERTENSIVE DRUGS IN THE POSTPARTUM PERIOD
ANTIHYPERTENSIVE DRUGS CONTRAINDICATED IN PREGNANCY
11:
HELLP Syndrome
SINGLE BEST ANSWER (SBA) AND MULTIPLE CHOICE QUESTIONS (MCQs)
12:
Cesarean Section
PLANNED CESAREAN SECTION
Common Indications 
Timing of Planned Cesarean Section
FACTORS THAT REDUCES THE LIKELIHOOD OF CS
PREOPERATIVE TESTS AND PREPARATION FOR CS
MORBIDLY ADHERENT PLACENTA
PROCEDURE OF CESAREAN SECTION
Abdominal Wall Incision for CS
Steps of Joel-Cohen Incision
Advantages of Joel-Cohen Incision
IMPORTANT ISSUE IN THE STEPS OF CESAREAN SECTION (NICE, 2011)
13:
Placenta Previa, Placenta Previa Accreta and Vasa Previa
SINGLE BEST ANSWER (SBA) AND MULTIPLE CHOICE QUESTIONS (MCQs)
PLACENTA PREVIA, PLACENTA PREVIA ACCRETA
Management Issues
Surgery in the Presence of Morbid Adherent Placenta
Choice of Incision
VASA PREVIA
Management Issues
14:
Perimortem Cesarean Section
PERIMORTEM CESAREAN SECTION
Clinical Issues
15:
Puerperal Sepsis
SINGLE BEST ANSWER (SBA) AND MULTIPLE CHOICE QUESTIONS (MCQs)
NECROTIZING FASCIITIS (HOSPITAL GANGRENE)3
Criteria for Diagnosis of Necrotizing Fasciitis
HEMODYNAMIC CHANGES AND ORGAN DYSFUNCTIONDUE TO SEVERE PUERPERAL SEPSIS
16:
Maternal Near Miss
MATERNAL NEAR MISS CRITERIA (WHO)
17:
Cesarean Delivery on Maternal Request
IMPORTANT ISSUES IN CESAREAN DELIVERY
Neonatal Outcomes
Maternal Outcome Favor Neither Vaginal nor Cesarean Delivery
Weak-quality Evidence to Favor CDMR
Neonatal Outcome Favor CDMR (Weak-quality Evidence)
Patients Specific Factors
Cultural and Societal Issue
18:
Classification of Evidence Levels and Grades of Recommendations
CLASSIFICATION OF EVIDENCE LEVELS
GRADES OF RECOMMENDATIONS1
GOOD PRACTICE POINT
SECTION 4: GYNECOLOGY DISCUSSION
19:
Recurrent Miscarriage (First and Second Trimesters)
SINGLE BEST ANSWER (SBA) AND MULTIPLE CHOICE QUESTIONS (MCQs)
MANAGEMENT ISSUES
A. Advanced Maternal Age
B. Antiphospholipid Antibody Syndrome (APAS)
C. Genetic Factors
D. Anatomical Factors
E. Endocrine Factors
F. Immune Factors
G. Infective Agents
H. Inherited Thrombophilias
Thrombophilias and Adverse Pregnancy Outcome
Diagnosis of APA Syndrome
MANAGEMENT OPTIONS FOR RECURRENT MISCARRIAGE
20:
Tubal Ectopic Pregnancy
MANAGEMENT ISSUES
Medical Management of Tubal Ectopic Pregnancy
Expectant Management for Unruptured Tubal Ectopic Pregnancy
PERSISTENT TROPHOBLASTS OR PERSISTENT ECTOPIC PREGNANCY
21:
Cervical Insufficiency (Incompetence)
SINGLE BEST ANSWER (SBA) AND MULTIPLE CHOICE QUESTIONS (MCQs)
MANAGEMENT OPTIONS
22:
Heavy Menstrual Bleeding
HISTORY, EXAMINATION AND INVESTIGATIONS FOR HMB
Investigations
PHARMACOTHERAPY FOR HEAVY MENSTRUAL BLEEDING
Treatment options are:
OPERATIVE TREATMENTS FOR HMB
Nonhysterectomy Surgery for HMB
Place of Oophorectomy during Hysterectomy
SIDE EFFECTS/COMPLICATIONS OF DIFFERENT TREATMENT OPTIONS FOR HMB
23:
Urinary Incontinence
CONSERVATIVE MANAGEMENT FOR SUI OR MIXED UI
ASSESSMENT AND INVESTIGATIONS OF A WOMAN WITH UI
MANAGEMENT OF URINARY INCONTINENCE
Treatment
Surgical Treatments for Overactive Bladder
Surgical Procedures for Stress Urinary Incontinence (SUI)
24:
Polycystic Ovary Syndrome
25:
Male and Female Sterilization
FEMALE STERILIZATION
Case Selection
MALE AND FEMALE STERILIZATION
Management Options
Other Long-term Reversible Methods of Contraception
Tubal Sterilization (Occlusion)
Laparoscopic Method of Tubal Sterilization (Occlusion)
Laparoscopic Method of Sterilization1
Timing of Tubal Occlusion
Failure of Tubal Sterilization
Concurrent Method of Sterilization
Long-term Risk of Tubal Occlusion
VASECTOMY
Methods of Vasectomy
Methods of Vas Occlusion (Figs 25.3A and B)
Postvasectomy Considerations
Failure of Vasectomy
Causes of Vasectomy Failure
Risks of Vasectomy
26:
Gestational Trophoblastic Disease
27:
Carcinoma of the Endometrium (Early Stage Diseases)
FIGO STAGE I (2009)
FIGO GRADING SYSTEM (1989)
Management Options
FIGO STAGE II
28:
Pregnancy of Unknown Location
29:
Abnormal Uterine Bleeding
CLASSIFICATION OF AUB (FIGO 2011)
Subclassification of Leiomyoma (AUB-L) (Figs 29.1 and 29.2)
Notation
Diagnosis of Chronic AUB
Differential Diagnosis of AUB (Age-based)
30:
Endoscopy in Gynecology (Laparoscopic Surgery)
31:
Robotic Surgery in Gynecology
TECHNOLOGY AND INSTRUMENTS USED IN ROBOTIC SURGERY
TECHNOLOGICAL AND OTHER ADVANTAGES OF ROBOTIC SURGERY
Advantages on the Part of the Surgeon
Technological Advantages2
COMPLICATIONS OF ROBOTIC SURGERY
DISADVANTAGES OF ROBOTIC SURGERY
LIMITATIONS OF LAPAROSCOPIC SURGERY
OVERALL ADVANTAGES OF ROBOTIC SURGERY
SECTION 5: INFERTILITY AND ASSISTED REPRODUCTIVE TECHNOLOGY (ART)
32:
Current Concept in Physiology of Ovulation
GERM CELL MIGRATION AND POPULATION IN THE GONADS
Follicular Growth and Atresia
Follicular Growth, Maturation and Emergence of Dominant Follicle
Endocrine Control of Ovulation
Menstrual Cycle and Ovulatory Cycle
Endocrinological and Biophysical Events in the three Different Follicular Phases of an Ovulatory Cycle
Important Endocrinological Events in the Process of Ovulation
Events in Nonovulatory Cycle
Events Leading to Failure of Ovulation
33:
Infertility Evaluation and Management
INTRODUCTION
EVALUATION OF INFERTILE COUPLES
Basic Parameters for Evaluation of an Infertile Couple
PATIENT CATEGORIZATION AND MANAGEMENT PROTOCOL
Management Options for Couples with Multiple Defects
34:
Female Infertility
OVULATORY DISORDERS
Classification of Ovulatory Disorders (Who)
Physiology of Ovarian Cycle in Menstruation and Ovulation
Management of Ovulatory Disorders
Hypogonadotropic Hypogonadism
Hypergonadotropic Hypogonadism (Premature Ovarian Insufficiency or Failure)
ASSESSMENT OF OVARIAN RESERVE
Management Options for Ovarian Insufficiency
Hypothalamic-pituitary Dysfunction
Current Research and Management Options for Women with PCOS
Summary of Management Options for Women with Pcos
TUBAL FACTORS FOR INFERTILITY
Tubal Patency Tests
Management Options for Tubal Factors for Infertility
IVF VERSUS REVERSAL OF TUBAL STERILIZATION
PERITONEAL FACTORS FOR INFERTILITY (FIG. 34.1)
UTERINE FACTORS FOR INFERTILITY
UNEXPLAINED INFERTILITY
Possible Explanations for Unexplained Infertility
Management options for Unexplained Infertility
Treatment for Luteal Phase Defect
35:
Male Infertility
MALE FACTORS FOR INFERTILITY
MANAGEMENT OPTIONS FOR MALE INFERTILITY
INFERTILITY AND INTRAUTERINE INSEMINATION (IUI)
Indications
Intrauterine Insemination
MALE INFERTILITY AND INTRACYTOPLASMIC SPERM INJECTION (ICSI)
Indications
Methods of Sperm Recovery
36:
Assisted Reproductive Technology (ART)
MCQs
Most Frequently and Currently Practiced ARTs
Steps of Assisted Reproductive Technology
Comparison of GnRH agonists to GnRH antagonists
Embryo Morphology and Selection of Embryo for Transfer
Morphological Assessment of Embryo Quality
Cryopreservation of Embryos/Oocytes
Benefits
Donor Oocyte
37:
Management Strategiesfor Low Responder Woman
MANAGEMENT ISSUES
SUMMARY
38:
Third Party Reproduction
SURROGACY
Specific Situations to Suggest Surrogacy
Procedure of Gestational Surrogacy
SECTION 6: MATERNAL MEDICINE (SHORT OBSTETRIC REVIEWS)
39:
Obstetric Case Presentation
HISTORY
EXAMINATION
SUMMARY
PROVISIONAL DIAGNOSIS
40:
Anemia in Pregnancy
41:
Hemoglobinopathy
42:
Sickle Cell Disease in Pregnancy
43:
Thyroid Dysfunction in Pregnancy
HYPERTHYROIDISM IN PREGNANCY
Management of Hyperthyroidism in Pregnancy
FETAL AND NEONATAL THYROID DYSFUNCTION
Treatment is done with Antithyroid Drug to the Mother
UNIVERSAL VERSUS SELECTIVE SCREENING FOR THYROID DISEASE
INDICATIONS FOR THYROID TESTING IN PREGNANCY
HYPOTHYROIDISM IN PREGNANCY
Important Issues in the Management of Hypothyroidism in Pregnancy3
44:
Heart Disease in Pregnancy
45:
Gestational Age and Cesarean Delivery
46:
Place of Thromboprophylaxis during Pregnancy
47:
External Cephalic Version
48:
Diminished Fetal Movements
49:
Transfusion in Obstetrics
TRANSFUSION IN CLINICAL PRACTICE
50:
Obstetric Cholestasis
51:
Diabetic Nephropathy
52:
Renal Transplant
53:
Non Hemorrhagic Shock in Obstetrics
A. AMNIOTIC FLUID EMBOLISM (AFE)
What are the Hemodynamic Abnormalities Associated with Amniotic Fluid Embolism?
Clinical Presentations with AFE
Management of AFE
B. CARDIAC DISEASE
C. SEPSIS (TABLE 53.1 AND FIG. 53.2)
Sepsis Resuscitation Bundle (CEMACH)6,7,8
E. SEVERE PRE-ECLAMPSIA AND ECLAMPSIA
Severe Pre-eclampsia (MRI Brain) (Figs 53.3A and B) (See Manual of Obstetrics and Gynecology for the Postgraduates, p. 4)
F. VENOUS THROMBOEMBOLISM (VTE)
Clinical Presentation
Diagnosis of VTE
Vena Cava Filters
G. DRUG TOXICITY
H. ANAPHYLAXIS
AORTOCAVAL COMPRESSION IN PREGNANCY
CLINICAL GOVERNANCE IN THE MANAGEMENT OF NON HEMORRHAGIC SHOCK IN OBSTETRICS
SECTION 7: SHORT REVIEWS IN GYNECOLOGY
54:
Place of Prophylactic Salpingectomy or Salpingo-oophorectomy in Current Gynecologic Practice
TYPES OF OVARIAN CARCINOMAS
55:
Endometrial Carcinoma
56:
Bariatric Surgery in Gynecology and Obstetrics
57:
Fertility ConservingOptions for Women with Gynecologic Malignancies
MALIGNANT OVARIAN TUMOR
58:
Fertility Conserving Options for Women with Cervical Cancer
59:
Fertility Conserving Options for Women with Endometrial Cancer
60:
Advances in Contraception
INTRAUTERINE CONTRACEPTIVE DEVICES (IUCDs)
COMBINED ORAL CONTRACEPTIVES (COCs)
IMPLANTS
TRANSCERVICAL STERILIZATION
VASECTOMY
(See Manual of Obstetrics and Gynecology for the Postgraduates, p. 332, Figs 25.3A and B)
61:
Interventional Radiology in Obstetrics and Gynecology
PLACE OF INTERVENTIONAL RADIOLOGY IN OBSTETRICS
62:
Surgical Site Infection
63:
Abnormal Uterine Bleeding: Investigations and Management Issues
64:
Subfertility and Pelvic Endometriosis
65:
Medical Methods of Termination of Pregnancy
SECTION 8: INTRAPARTUM ELECTRONIC FETAL MONITORING
66:
Fetal Response in Labor
67:
Fetal Heart Rate Patterns
FETAL HEART VARIABILITY
Decelerations
Accelerations
Sinusoidal patterns
68:
Fetal ECG
69:
Management of Nonreassuring Fetal Status (NRFS)
FHR PATTERN AND INTERPRETATIONS (NICHD-2008, ACOG-2009)
MANAGEMENT OF NRFS (NICHD CATEGORIES II AND III)
Medical Management (Noninvasive Measures)
EVALUATION AND MANAGEMENT OF A FETUS WITH NONREASSURING PATTERNS
SECTION 9: PERINATAL MEDICINE
70:
Immunization during Pregnancy and Breastfeeding
MCQS
71:
Noninvasive Prenatal Testing for Fetal Chromosomal Abnormality
72:
Congenital Perinatal and Neonatal Infections
73:
Congenital HIV Infection and AIDS
74:
Varicella Zoster Virus (Chickenpox) Infection
75:
Rubella in Pregnancy
76:
Cytomegalovirus Infection in Pregnancy
77:
Viral Hepatitis in Pregnancy
78:
Listeriosis in Pregnancy
79:
Toxoplasmosis in Pregnancy
80:
Group B Streptococci Infection in Pregnancy
SECTION 10: MRCOG EXAMINATION
81:
PART I MRCOG Examination
PART I MRCOG SYLLABUS SUMMARY
FORMAT FOR THE PART I MRCOG EXAMINATION
Number of Papers
Single Best Answer Questions
Answering the Questions
MODEL SBA MRCOG PART I
Sample Single Best Answer
Part I MRCOG: Sample SBA
MOCK SBA MRCOG PART I: PAPER 2
82:
PART II MRCOG Examination
PART II MRCOG SYLLABUS SUMMARY
EXAMINATION
Theory Examination
Oral Examination
PART II MRCOG OBSTETRIC SBA
PART II MRCOG: GYNECOLOGY SBA
SECTION 11: MRCOG (EMQS)
83:
Extended Matching Questions (EMQs)
EXTENDED MATCHING QUESTIONS (EMQs)
Examples of the EMQs Format
SECTION 12: IN WHOSE FOOTSTEPS WE FOLLOW
84:
History in Obstetrics and Gynecology
HISTORY IN OBSTETRICS AND GYNECOLOGY
INDEX
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