Key Obstetric and Gynecological Conditions: Diagnosis and Management

Analgesia for Labour

Labour pain in the first stage is visceral, arising from cervical dilatation and uterine contractions, transmitted via T10–L1. In the second stage, it becomes somatic due to stretching of the vagina and perineum, transmitted via S2–S4.

Methods for pain relief include:

• Non-pharmacological: Reassurance, breathing techniques, massage, warm baths, and TENS (Transcutaneous Electrical Nerve Stimulation).
• Pharmacological (Systemic): Opioids such as pethidine or fentanyl, which may cause maternal nausea and neonatal respiratory depression.
• Regional Analgesia: Epidural analgesia is the most effective method, using local anesthetics with or without opioids, but may cause hypotension and prolong the second stage.
• Inhalational: Entonox (a 50% nitrous oxide and oxygen mixture), which is rapid and safe.
• Local: Pudendal nerve block, mainly used in the second stage or for episiotomy.

Cardiovascular Diseases and Pregnancy

Pregnancy induces major cardiovascular changes: increased blood volume, cardiac output, and heart rate, with decreased systemic vascular resistance, potentially worsening pre-existing heart disease.

Common cardiac conditions include rheumatic heart disease, congenital heart disease, cardiomyopathy, and arrhythmias. Symptoms suggesting cardiac disease include dyspnea at rest, orthopnea, paroxysmal nocturnal dyspnea, hemoptysis, syncope, and cyanosis.

Pregnancy is contraindicated in severe pulmonary hypertension, Eisenmenger syndrome, severe aortic stenosis, and advanced cardiomyopathy.

Management requires multidisciplinary care, avoidance of anemia and infection, careful fluid balance, and use of safe cardiac drugs. Vaginal delivery is preferred in most cases with adequate analgesia and a shortened second stage; cesarean section is reserved for obstetric or severe cardiac indications. The postpartum period carries the highest risk due to the sudden increase in venous return.

Contracted Pelvis: Classification, Diagnosis, and Management

A contracted pelvis has reduced pelvic diameters, interfering with normal vaginal delivery. Classification includes generally contracted pelvis, flat pelvis, simple flat pelvis, and android pelvis.

Diagnosis is suspected antenatally in short stature, abnormal gait, or history of difficult labor, and confirmed by clinical pelvimetry and assessment during labor. Radiological pelvimetry is rarely used due to fetal radiation risk.

Management depends on the degree of contraction and fetal size. Mild contraction may allow a trial of labor with close monitoring, while moderate to severe contraction requires elective cesarean section. In labor, failure of descent, prolonged labor, or obstructed labor indicates cephalopelvic disproportion and requires operative delivery.

Fetal Macrosomia

Fetal macrosomia is defined as a birth weight of 4,000 g or more, regardless of gestational age. Risk factors include maternal diabetes, obesity, multiparity, prolonged pregnancy, and previous macrosomic infant.

Macrosomia increases the risk of shoulder dystocia, birth trauma, postpartum hemorrhage, and operative delivery. Antenatal diagnosis is difficult, based on clinical examination and ultrasound estimation of fetal weight, which has limited accuracy.

Management depends on estimated fetal weight and maternal factors. Elective cesarean section is considered when estimated fetal weight exceeds 4.5 kg in diabetic mothers or 5 kg in non-diabetic mothers. During vaginal delivery, preparedness for shoulder dystocia and neonatal resuscitation is essential.

Aseptic Thrombosis and Puerperal Thrombophlebitis

Pregnancy and the puerperium are hypercoagulable states due to increased clotting factors, venous stasis, and vascular injury.

• Aseptic Thrombosis: Venous thrombosis without infection, commonly affecting deep veins of the legs and pelvic veins. Presents with leg pain, swelling, warmth, and tenderness.
• Puerperal Thrombophlebitis: Inflammation and thrombosis of veins associated with infection, usually occurring postpartum. Presents with fever, pelvic pain, and tenderness unresponsive to antibiotics alone.

Diagnosis is clinical and supported by Doppler ultrasound. Management includes anticoagulation with heparin, limb elevation, and analgesia. In puerperal thrombophlebitis, broad-spectrum antibiotics are added. Pulmonary embolism is the most serious complication.

Amniotic Fluid Embolism: Shock

Amniotic fluid embolism is a rare but catastrophic obstetric emergency caused by amniotic fluid entering the maternal circulation, triggering an anaphylactoid reaction. It usually occurs during labor, delivery, or immediately postpartum.

Clinical features include sudden hypoxia, respiratory distress, hypotension, cyanosis, cardiovascular collapse, seizures, and disseminated intravascular coagulation with severe hemorrhage. Diagnosis is clinical and by exclusion.

Management involves immediate supportive care: airway protection, oxygen or ventilation, aggressive fluid resuscitation, vasopressors, correction of coagulopathy with blood products, and rapid delivery of the fetus if undelivered. Maternal mortality is high.

Emergency Conditions in Obstetrical Practice: Management

Obstetric emergencies include postpartum hemorrhage, eclampsia, uterine rupture, shoulder dystocia, cord prolapse, amniotic fluid embolism, and sepsis.

Initial management follows the ABC approach: airway protection, oxygen, intravenous access, and hemodynamic stabilization. Simultaneous identification and treatment of the cause are essential.

• Hemorrhage: Requires uterotonics, uterine massage, blood transfusion, and surgical intervention if needed.
• Eclampsia: Treated with magnesium sulfate and blood pressure control.

Prompt decision-making, multidisciplinary teamwork, and timely operative delivery are critical to reduce maternal and fetal morbidity and mortality.

Abnormalities and Disorders of Lactation

Lactation disorders include failure of lactation, delayed lactation, engorgement, cracked nipples, and galactorrhea. Failure or delay may be due to hormonal imbalance, retained placental fragments, maternal illness, or poor suckling technique.

Breast Engorgement: Occurs due to milk stasis, presenting with painful, tense breasts. Cracked nipples result from improper latch and predispose to infection.

Management includes correction of breastfeeding technique, frequent feeding or milk expression, local care, and reassurance. Early recognition prevents complications such as mastitis.

Puerperal Mastitis

Puerperal mastitis is an infection of the breast during lactation, commonly caused by Staphylococcus aureus entering through cracked nipples. It presents with fever, breast pain, localized redness, warmth, and systemic symptoms. If untreated, it may progress to breast abscess.

Management includes continued breastfeeding or milk expression, appropriate antibiotics, analgesics, and local supportive measures. Surgical drainage is required for abscess formation.

External Version of the Fetus

External cephalic version (ECV) is a maneuver performed to convert a breech or transverse lie into a cephalic presentation by external manipulation through the maternal abdomen. It is usually performed at 36–37 weeks of gestation in a singleton pregnancy with intact membranes.

Contraindications include placenta previa, multiple pregnancy, uterine scar, oligohydramnios, fetal compromise, and uterine anomalies. The procedure is done under ultrasound guidance with fetal monitoring before and after, often with tocolysis to relax the uterus. Complications are uncommon but include fetal bradycardia, placental abruption, and emergency cesarean section.

Internal Version: Indications, Conditions, and Technique

Internal podalic version is an obstetric maneuver where the fetus is turned to a breech presentation by introducing a hand into the uterus and grasping a fetal foot.

It is mainly indicated for delivery of the second twin in transverse lie or in certain cases of transverse lie with a dead fetus. Conditions required include full cervical dilatation, ruptured membranes, adequate pelvis, relaxed uterus, and a skilled operator.

The technique involves introducing the hand, grasping a foot, converting the lie to breech, and completing delivery by breech extraction. The procedure carries significant risk and is rarely used today.

Uterine and Vaginal Tamponade: Indications and Technique

Uterine and vaginal tamponade controls postpartum hemorrhage by exerting pressure on bleeding surfaces.

Indications include uterine atony unresponsive to uterotonics, bleeding from the placental site, uterine inversion after replacement, and vaginal lacerations when suturing is difficult.

The technique involves inserting a sterile uterine balloon or gauze packing into the uterine cavity, sometimes combined with vaginal packing, to provide uniform pressure. Continuous monitoring is required, and the tamponade is usually removed after 12–24 hours once bleeding is controlled.

Operations for Soft Birth Channel Dilation

These operations are performed when the cervix or perineum is insufficiently dilated to allow delivery.

Cervical dilation may be achieved manually or by instruments in cases of rigid cervix during labor. Episiotomy is the most common procedure, involving a surgical incision of the perineum to enlarge the vaginal outlet and facilitate delivery.

Indications for episiotomy include fetal distress, instrumental delivery, rigid perineum, and shoulder dystocia. Proper repair of incisions after delivery is essential to prevent infection and long-term complications.

Descending and Prolapsed Uterus and Vagina

Uterine and vaginal prolapse is the downward displacement of the uterus and vaginal walls due to weakness of pelvic floor muscles and ligaments, often following childbirth, especially after prolonged labor, multiparity, and instrumental delivery.

Degrees range from first degree (cervix descends within the vagina) to third degree or procidentia (uterus protrudes outside the vulva).

Symptoms include a feeling of heaviness, mass per vagina, urinary and bowel disturbances, and dyspareunia. Management depends on age, degree, and desire for fertility, including pelvic floor exercises, pessary use, and surgical correction.

Pelvic Inflammatory Disease (PID)

PID is an ascending infection of the female genital tract involving the uterus, fallopian tubes, and ovaries, most commonly caused by sexually transmitted organisms like Chlamydia trachomatis and Neisseria gonorrhoeae.

Clinical features include lower abdominal pain, fever, vaginal discharge, dyspareunia, and cervical motion tenderness. Complications include infertility, ectopic pregnancy, and chronic pelvic pain.

Diagnosis is mainly clinical, supported by laboratory tests and imaging. Management requires broad-spectrum antibiotics covering anaerobic and aerobic organisms, with hospitalization indicated for severe disease, pregnancy, or failure of outpatient treatment.

Gestational Trophoblastic Disease

Hydatidiform Mole

A gestational trophoblastic disease characterized by abnormal proliferation of trophoblastic tissue and swollen chorionic villi. It may be complete (no fetal tissue, markedly elevated hCG) or partial.

Clinical features include vaginal bleeding, excessive uterine enlargement, hyperemesis gravidarum, and early-onset preeclampsia. Diagnosis is based on ultrasound showing a snowstorm appearance and high serum hCG.

Management consists of uterine evacuation by suction curettage followed by serial hCG monitoring to detect persistent disease.

Choriocarcinoma

Choriocarcinoma is a highly malignant gestational trophoblastic tumor arising from trophoblastic tissue, often following a molar pregnancy, abortion, or normal pregnancy. It spreads early via the bloodstream to the lungs, brain, and liver.

Clinical features include irregular vaginal bleeding, high hCG levels, and symptoms from metastases such as hemoptysis or neurological signs. Diagnosis is confirmed by persistently elevated hCG and imaging for metastases. Management is primarily chemotherapy, which is highly effective.

Renal Disease and Pregnancy

Renal disease in pregnancy increases the risk of hypertension, preeclampsia, fetal growth restriction, and preterm delivery. Pregnancy normally increases renal blood flow and glomerular filtration rate, which may worsen pre-existing renal disease.

Clinical features include proteinuria, hypertension, and impaired renal function. Management requires close multidisciplinary monitoring, blood pressure control, treatment of urinary tract infections, and careful fluid and electrolyte balance. Severe renal impairment is associated with poor maternal and fetal outcomes.

Bleeding in Pregnancy (Not Menstruation)

True menstruation does not occur during pregnancy. Any bleeding in pregnancy is abnormal and must be investigated.

Early pregnancy bleeding may be due to implantation bleeding, hormonal breakthrough bleeding, threatened abortion, or ectopic pregnancy. Bleeding later in pregnancy may indicate placental causes such as placenta previa or placental abruption. Therefore, bleeding during pregnancy should never be considered normal menstruation and always requires evaluation.

Obstetrical Pelvimetry

Obstetrical pelvimetry is the assessment of pelvic size and shape to determine the feasibility of vaginal delivery. The pelvis is divided into the inlet, midpelvis, and outlet, each with specific diameters important for labor.

The four basic pelvic types are gynecoid, android, anthropoid, and platypelloid, with gynecoid being most favorable for vaginal delivery. Pelvimetry is usually assessed clinically by vaginal examination; radiological pelvimetry is rarely used due to fetal radiation exposure. The aim is to detect cephalopelvic disproportion and plan the mode of delivery.

Physiology of the Premature Newborn

A premature newborn is delivered before 37 completed weeks of gestation and has immature organ systems.

• Respiratory: Underdeveloped with deficient surfactant, predisposing to respiratory distress syndrome.
• Thermoregulation: Poor due to thin skin, large surface area, and low subcutaneous fat.
• Cardiovascular: May show patent ductus arteriosus.
• Metabolic/Immune: Immature liver function leads to hypoglycemia and hyperbilirubinemia; the immune system is weak, increasing infection risk.

Care focuses on thermal support, respiratory assistance, nutrition, and infection prevention.

Perineum Rupture and Fistulas

Perineal rupture is a tear of the perineum occurring during childbirth, commonly due to prolonged labor, macrosomia, or instrumental delivery. Tears are classified from first degree (skin only) to fourth degree (involving the anal sphincter and rectal mucosa).

Obstetric fistulas, such as vesicovaginal or rectovaginal fistulas, result from prolonged obstructed labor causing tissue necrosis. They present with continuous leakage of urine or feces per vagina. Prevention includes timely obstetric intervention, and management is mainly surgical repair.

Placental Insufficiency

Placental insufficiency is a condition where the placenta fails to supply adequate oxygen and nutrients to the fetus. It may result from maternal hypertension, preeclampsia, diabetes, smoking, or placental abnormalities.

Clinical features include fetal growth restriction, reduced fetal movements, and abnormal fetal heart rate patterns. Diagnosis is supported by ultrasound showing growth restriction and Doppler studies indicating reduced uteroplacental blood flow.

Management involves close fetal surveillance and timely delivery to prevent fetal hypoxia or intrauterine death.

Extragenital Changes During Pregnancy

Pregnancy causes physiological changes in multiple organ systems due to hormonal and mechanical factors:

• Cardiovascular: Increased blood volume and cardiac output; decreased systemic vascular resistance.
• Respiratory: Increased tidal volume and mild respiratory alkalosis.
• Renal: Increased renal blood flow and glomerular filtration rate; physiologic glycosuria.
• Gastrointestinal: Reduced motility, reflux, and constipation.
• Endocrine: Enlargement of the pituitary and thyroid glands; increased prolactin.
• Skin: Hyperpigmentation, linea nigra, chloasma, and striae gravidarum.

These changes are normal and usually regress after delivery.

Mechanism of Labour in Atypical Cephalic Presentations

Atypical cephalic presentations include deflexed vertex, brow, and face presentations, where normal flexion of the fetal head is altered.

• Deflexed Vertex: Presenting diameter is increased, leading to prolonged labor.
• Brow Presentation: Presents with the mentovertical diameter and usually obstructs labor unless it converts to vertex or face.
• Face Presentation: Occurs when the head is fully extended; labor may proceed if the mentum is anterior.

The mechanism of labor depends on the degree of head extension and pelvic dimensions. Cesarean section is indicated when vaginal delivery is unsafe.

Transverse and Oblique Lie of the Fetus: Diagnosis and Management

Transverse and oblique lie occur when the fetal long axis is perpendicular or oblique to the maternal spine. Diagnosis is made by abdominal palpation (absence of fetal poles in the fundus and pelvis) and confirmed by ultrasound.

Complications include cord prolapse and obstructed labor. Management depends on gestational age and labor status. Before labor, external cephalic version may be attempted. In labor with a viable fetus, cesarean section is the preferred mode of delivery. Internal podalic version may be considered only for the second twin or dead fetus under strict conditions.

Asynclitisms: Diagnosis and Management

Asynclitism is the oblique entry of the fetal head into the pelvic inlet, with the sagittal suture displaced toward the sacrum or symphysis pubis.

• Anterior Asynclitism (Naegle): Sagittal suture is closer to the sacrum.
• Posterior Asynclitism (Litzmann): Sagittal suture is closer to the symphysis.

Diagnosis is made by vaginal examination identifying the position of the sagittal suture and parietal bones. Mild asynclitism may correct spontaneously, while severe forms cause labor arrest and require operative delivery or cesarean section.

Peritonitis of Genital Origin: Symptoms, Diagnosis, and Management

Peritonitis of genital origin is an acute inflammatory condition of the peritoneum resulting from the spread of infection from the female genital tract (e.g., PID, septic abortion, puerperal infection, ruptured tubo-ovarian abscess).

Symptoms include severe lower abdominal pain, fever, vomiting, abdominal distension, and signs of peritoneal irritation such as guarding and rebound tenderness. Systemic signs of sepsis may be present.

Diagnosis relies on clinical findings, elevated inflammatory markers, and imaging (ultrasound or CT). Management is urgent, including broad-spectrum intravenous antibiotics, fluid resuscitation, correction of electrolyte imbalance, and surgical intervention if there is abscess formation, perforation, or failure of conservative treatment.

Gynecological Diseases in Childhood and Adolescence

Gynecological disorders in childhood and adolescence differ from adults due to hormonal immaturity and developmental factors. Common conditions include vulvovaginitis, labial adhesions, menstrual disorders, precocious or delayed puberty, and ovarian cysts.

Vulvovaginitis is the most frequent condition, related to poor hygiene, low estrogen levels, and infection. Menstrual disorders (primary amenorrhea, dysmenorrhea, abnormal uterine bleeding) are common in adolescents due to anovulatory cycles.

Management focuses on reassurance, conservative treatment, correction of underlying causes, and education, with attention to psychological and developmental aspects.

Preterm Labour and Management of the Premature Newborn

Preterm labour is defined as the onset of labor before 37 completed weeks of gestation. Risk factors include infection, multiple pregnancy, uterine overdistension, cervical insufficiency, and previous preterm birth.

Diagnosis is based on regular uterine contractions with cervical change before term. Management includes:

• Tocolysis to delay labor.
• Antenatal corticosteroids to enhance fetal lung maturity.
• Magnesium sulfate for fetal neuroprotection when indicated.

The premature newborn requires specialized care including thermal support, respiratory assistance (due to surfactant deficiency), careful fluid and nutritional management, and infection prevention.

Post-Term Pregnancy: Diagnosis and Management

Post-term pregnancy is defined as pregnancy extending beyond 42 completed weeks. Causes include inaccurate dating, primigravidity, and placental aging.

Diagnosis is based on reliable dating (LMP and early ultrasound). Risks include placental insufficiency, oligohydramnios, macrosomia, meconium aspiration, and intrauterine fetal death.

Management involves close fetal surveillance with non-stress testing and ultrasound assessment, with induction of labor recommended at or before 41–42 weeks if the cervix is favorable, or cesarean section if indicated.

Hemorrhages in the Placental Period

Hemorrhage in the placental period occurs after delivery of the fetus and before or immediately after placental expulsion.

Causes include uterine atony, retained placental tissue, abnormal placental adherence, and genital tract trauma. Clinical presentation is excessive vaginal bleeding with signs of hypovolemia.

Management includes uterine massage, administration of uterotonics, controlled cord traction, manual removal of retained placenta, and blood transfusion if required. Prompt recognition is essential to prevent postpartum hemorrhage.

Puerperal Infections of the Uterus and Pelvis

Puerperal Endometritis, Adnexitis, and Parametritis

Puerperal endometritis is infection of the uterine lining after delivery, commonly caused by ascending polymicrobial infection. It presents with fever, uterine tenderness, foul-smelling lochia, and subinvolution.

Puerperal adnexitis involves infection of the ovaries and fallopian tubes, while parametritis is infection of the pelvic connective tissue. Diagnosis is clinical, supported by laboratory tests. Management includes broad-spectrum intravenous antibiotics, uterine drainage if needed, and supportive care.

Puerperal Pelviperitonitis, Peritonitis, and Sepsis

Puerperal pelviperitonitis is localized peritoneal inflammation following spread of genital tract infection, which may progress to generalized peritonitis and sepsis.

Clinical features include high fever, severe abdominal pain, abdominal rigidity, and systemic signs of infection. Puerperal sepsis is a life-threatening condition characterized by systemic inflammatory response to infection during or after childbirth.

Management requires urgent broad-spectrum antibiotics, aggressive fluid resuscitation, hemodynamic support, and surgical intervention when indicated. Early diagnosis and treatment are crucial to reduce maternal mortality.

Morbidly Adherent Placenta (MAP)

Morbidly adherent placenta refers to abnormal placental attachment due to defective decidua basalis, including placenta accreta, increta, and percreta. Risk factors include previous cesarean section, placenta previa, uterine curettage, and uterine surgery.

The condition is often diagnosed antenatally by ultrasound or MRI showing loss of the placental–myometrial interface. It presents clinically with failure of placental separation and massive postpartum hemorrhage.

Management involves planned delivery in a tertiary center with blood products available. The definitive treatment is cesarean hysterectomy without attempting placental removal.

Malignant Tumours of the Uterine Corpus

Malignant tumors of the uterine corpus are most commonly endometrial carcinoma, usually affecting postmenopausal women. Risk factors include unopposed estrogen exposure, obesity, diabetes, hypertension, and nulliparity.

The typical presentation is abnormal uterine bleeding, especially postmenopausal bleeding. Diagnosis is confirmed by endometrial biopsy or curettage.

Management primarily involves surgical treatment with total hysterectomy and bilateral salpingo-oophorectomy, with radiotherapy or chemotherapy used in advanced stages.

Early Toxicosis of Pregnancy

Early toxicosis of pregnancy includes nausea, vomiting, hyperemesis gravidarum, and ptyalism, occurring mainly in the first trimester. Nausea and vomiting are common and related to rising hCG and estrogen levels.

Hyperemesis Gravidarum: A severe form characterized by persistent vomiting, dehydration, electrolyte imbalance, weight loss, and ketonuria. Ptyalism refers to excessive salivation.

Management ranges from dietary modification and antiemetics in mild cases to hospitalization, intravenous fluids, electrolyte correction, and vitamin supplementation in severe cases.

Fetal Malformations and Congenital Abnormalities

Fetal malformations result from genetic, environmental, or multifactorial causes. Etiological factors include chromosomal abnormalities, maternal infections, teratogenic drugs, radiation, alcohol, diabetes, and nutritional deficiencies (e.g., folic acid deficiency).

Prophylaxis: Preconception counseling, folic acid supplementation, avoidance of teratogens, and proper antenatal care.

Diagnosis is made by prenatal screening and ultrasound. Management depends on severity and includes prenatal monitoring, planned delivery, postnatal surgical correction when possible, or medical termination in lethal anomalies.

Lactation: Physiology

Lactation is the process of milk production and secretion after delivery.

• Prolactin is responsible for milk production.
• Oxytocin causes milk ejection through the let-down reflex.

After placental delivery, estrogen and progesterone levels fall, allowing lactation to begin. Colostrum (first 1–3 days) is yellow, protein-rich, and high in IgA. Transitional milk appears from day 4 to 10, followed by mature milk after day 10.

Suckling stimulates oxytocin release, causing milk ejection. Breast milk provides nutrition and immunity. Lactation benefits the mother by promoting uterine involution, reducing postpartum hemorrhage, and providing natural contraception.

Normal Puerperium

The puerperium is the period from delivery until six weeks postpartum, during which the body returns to the non-pregnant state.

Uterine Involution: Lies at the umbilicus immediately after delivery, becomes a pelvic organ by two weeks, and returns to normal size by six weeks.

Lochia Progression: Lochia rubra (first three days) $\rightarrow$ lochia serosa (day 4 to 10) $\rightarrow$ lochia alba (day 10 to about four weeks).

The cervix gradually firms, and the vagina slowly regains tone. Breast engorgement occurs around days two to three.

Systemic changes include postpartum diuresis, sweating, relative bradycardia, and a continued hypercoagulable state. Menstruation returns at six to eight weeks in non-lactating women and is delayed in breastfeeding women due to elevated prolactin levels.