• Cardiac failure due to structural malformation
• Abnormalities in the extracellular matrix
• Abnormal or delayed development of the lymphatic system

1. NEET PG / USMLE – MCQ 29
2. Hyperlipidemia in nephrotic syndrome – Mechanism
3. Horner’s syndrome

Classification of Diabetes complicating pregnancy
Part 1 – Gestational diabetes

Part 2 – Overt diabetes

1. Diagnosis of diabetes mellitus
2. Obstetrics & Gynaecology – MCQ 69 – Intrauterine growth retardation
3. Starling’s curve of the pancreas

1. Obstetrics & Gynaecology – MCQ 8 – Lady with Jaundice, abdominal distension and pedal edema
2. Obstetrics & Gynaecology – MCQ 59 – Prenatal diagnosis at 16 weeks of pregnancy
3. RGUHS Karnataka PGET 2011 – MCQ 106

Class 4 cardiac conditions:

• Pulmonary artery hypertension of any cause (such as Eisenmenger complex)
• Severe systemic LV dysfunction with:
  • NYHA class III – IV
  • LV ejection fraction less than 30%
• Previous peripartum cardiomyopathy with residual impairment of LV function
• Obstructive lesion of left heart – aortic or mitral stenosis with valve area less than 1cm²
• Marfans with aortic root dilatation more than 4cm

Reference:
Heart disease and pregnancy By Philip J. Steer, Michael A. Gatzoulis, p12

1. Obstetrics & Gynaecology – MCQ 27 – Heart disease in pregnancy
2. Obstetrics & Gynaecology – MCQ 12 – Heart disease mortality during pregnancy
3. Obstetrics & Gynaecology – MCQ 37 – Maternal mortality and heart disease

Monochorionic monoamniotic placenta with cord entanglement
Click on image for an enlarged view

Monochorionic monoamniotic twins have single placenta and lie in a single amniotic cavity.

Mechanism:

• It arises from division of the implanted blastocyst 8-13 days after fertilisation
• Division of blastocyst beyond this period results in conjoint twins

Incidence:

• It occurs in 1 in 35000 to 1 in 60000 pregnancies
• It constitutes 1% of monozygotic pregnancies

Complications:

• High risk of cord entanglement – up to 71% (more than 50% of perinatal deaths occur due to this)
• Cord compression – one twin may compress the cord of the other
• Twin – twin transfusion syndrome

Diagnosis:

• Ultrasound scan
  • Single placenta
  • Absence of inter twin dividing membrane
  • Single yolk sac (in most cases)
  • Concordant gender
  • Cord entanglement later in pregnancy

Management:

• Regular foetal monitoring
• Check for development of complications
• Early termination of pregnancy by caesarean section by 32-34 weeks
  • There is increased incidence of cord entanglement after this period
• Steroid administration to promote foetal lung maturity
• Maternal sulindac (selective COX2 inhibitor) has been tried to reduce amniotic fluid volume and thereby risk of cord entanglement

Image credits: Rinoop Ramachandran, Calicut Medical College

1. Obstetrics & Gynaecology – MCQ 65 – Risk of postpartum hemorrhage
2. Artificial rupture of membranes (amniotomy)
3. Tracheoesophageal fistula – Clinical features, Diagnosis and Management

• Medical Termination of Pregnancy

1. Anaesthesia – MCQ 11 – Anesthetic for day care surgery
2. Maternal Death – Definition
3. MEDLARS – Acronym

1. Paediatrics – MCQ 43 – Late onset hemorrhagic disease of newborn
2. Obstetrics & Gynaecology – MCQ 22 – Late hyperglycemia in pregnancy
3. Physiology – MCQ 15 – Males and females show difference in the age of onset of puberty

Maternal and fetal outcome after treatment with Sibai regimen:

• In a study published by Sibai et al in 1990, treatment of eclampsia with Sibai regimen had a maternal mortality of 0.5% and a perinatal mortality of 5%.

1. Zuspan regimen for eclampsia
2. Online test series 17 – Obstetrics & Gynaecology
3. Obstetrics & Gynaecology – MCQ 59 – Prenatal diagnosis at 16 weeks of pregnancy

1. Sibai regimen
2. Drug of choice in eclampsia
3. Pharmacology – MCQ 75 – Ethosuximide

• Hemolysis, Elevated Liver enzymes, and Low Platelets

1. Obstetrics & Gynaecology – MCQ 8 – Lady with Jaundice, abdominal distension and pedal edema
2. ARM – Acronym
3. MTP – Acronym

1. Surgery – MCQ 35 – Patient anuria following road traffic accident
2. Physiology – MCQ 30 – Structure of adrenergic receptors
3. AIIMS November 2011 – MCQ 105

Actions of oxytocin

• Main action is on uterine myometrium
  • It promotes uterine muscle contraction
  • The action is greater on pregnant uterus as it has increased number of oxytocin receptors
• Contraction of myoepithelial cells in breast cause expression of breast milk
• Smooth muscle relaxation and vasodilation
• ADH (Anti Diuretic Hormone) like effect in large doses, causes water intoxication

Mechanism of action on uterine myometrium:

• It acts by releasing cAMP
• This in turn results in the release of Ca2+ from the sarcoplasmic reticulum
• Calcium causes contraction of muscle

Uses of oxytocin

• Induction and accentuation of labour
• Active management of third stage of labour – given after separation of placenta for promoting uterine contraction and stoppage of bleeding
• Atonic PPH – to control bleeding and promote uterine contraction
• Second trimester abortion (medical termination of pregnancy) as an adjunct to prostaglandins
• Abortion and hydatidiform mole – to decrease bleeding during suction evacuation and to promote uterine contraction
• Oxytocin challenge test (Contraction stress test) – to test whether fetus can cope with the stress of labour
• Oxytocin sensitivity test

Side effects of oxytocin

• Hyperstimulation of uterus
• Hypotension – due to vasodilation
• Hypertension – especially when given with methergine
• Water intoxication – when high dose is given with large quantities of fluids – can cause convulsions and coma
• Neonatal jaundice
• Ventricular premature beats – in case of IV bolus of oxytocin
• Myocardial ischemia and ventricular fibrillation – especially in those with heart disease

1. Forensic medicine – MCQ 12 – Abortion stick used in criminal abortion
2. Obstetrics & Gynaecology – MCQ 36 – Manning scoring system of biophysical profile
3. Obstetrics & Gynaecology – MCQ 15 – HIV transmission in pregnancy

Data recorded in a partogram are:

• Patient data – Name, Age, Parity, Hospital identification number, Date of admission, Time of admission
• Dilatation of cervix
• Station of fetal head
• Fetal heart rate
• Number of uterine contractions in 10 minutes
• Moulding (+ / ++ )
• Liquor amni
  • Intact membranes – I
  • Clear liquor – C
  • Meconium staining – M
• Oxytocin units, drops/min
• Drugs
• Oral and IV fluids
• Blood pressure, pulse, temperature
• Urine for acetone

How to use a partogram in active management of labour:

• Labour is divided into 2 stages
  • Latent phase – from onset of true labour pains till 3 cm dilatation of cervix
  • Active phase – 3 cm dilation of cervix till complete dilatation (10cm)
• Once labour is in active phase, cervical dilation is expected to progress at the rate of at least 1cm per hour
• This minimum rate is plotted as alert line on the partogram
• Another line – alert line – is plotted 4 hours to the right
• As long as the plotted cervical dilatation curve is to the left of the alert line, it is considered normal
• If the curve crosses the alert line, intervention is necessary – if the patient is in a peripheral hospital, referral to a higher level hospital is necessary

Advantages of using a partogram:

• All the data regarding the progress of labour can be understood at a glance from the partogram
• It is necessary for active management of labour
• Decreases incidence of prolonged labour and caesarean section.
• Reduces maternal mortality and morbidity

1. Artificial rupture of membranes (amniotomy)
2. Hospital Bed Turnover Rate
3. Modified Bishop’s Score

Advantages of ARM:

1. Accentuates labour by release of endogenous prostaglandins
2. Meconium staining of liquor can be diagnosed
3. Application of foetal scalp electrodes is possible

Disadvantages of ARM:

1. Chance of spread of infection, especially if many per vaginal examinations are conducted
2. Risk of abruption in case of polyhydramnios
3. If ARM is done before presenting part is fixed, cord prolapse can occur

1. Partogram
2. Basic Fuchsin
3. Obstetrics & Gynaecology – MCQ 15 – HIV transmission in pregnancy

• Artificial Rupture of Membranes (amniotomy)

1. Artificial rupture of membranes (amniotomy)
2. RGUHS Karnataka PGET 2011 – MCQ 165
3. MTP – Acronym

1. Maternal Death – Definition
2. Obstetrics & Gynaecology – MCQ 68 – Smallest diameter of true pelvis
3. AIIMS November 2011 – MCQ 18

Total score is calculated by adding the individual scores. A value more than 6 indicated that the cervix is favourable for induction (high probability for vaginal delivery). Values less than 3 indicates that caesarian section may be required.

1. SPM – MCQ 104 – Z score calculation
2. AIIMS November 2011 – MCQ 18
3. Partogram