Transcript for:
NEET PG Revision Notes

okay so good evening all of you uh am I Audible and am I visible to all of you uh Ankit I don't know how many hours but I think it will go up till two to three hours three uh there are around 30 slides which I have to cover with you so uh let's see how much time does that take and if you are uh you know a little worried about your time management then it's better that once the session ends you watch this entire video on 1.5 x speed because this video will be here till you give your neat exam now this session is important for neet PG students and also if you are an fmg aspirant then also this and you are going to give right your June 2023 exam then this is also important for you right okay now coming to the first thing and that is a neat PG revision session May the first question which I want to discuss with you is how to calculate edds right so this was a question which had come in your previous year exams calculate EDD of a female with LMP 27 December 2021 and this I generally take up in all my classes because all of you know that uh whenever you have to calculate EDD you have to to the first day of the last menstrual period you have to add 9 months and seven days now most of the times like we go for maths maths May if you add nine months first and seven months uh seven days later on that doesn't make any difference or if you add seven days first and you add nine months later on that also doesn't make any difference but when you are calculating EDD it is always preferable that you add seven days first and then nine months because in some cases it might make a difference right so uh you have to always add seven days first and then you have to add nine months so to 27th of December you have to add seven days 27 December May when you are going to add 7 Days 28 29 38 31st first second third so you come to third January of January May 3rd January May when you are going to add nine months you are going to come to third of October so over here the EDD is going to be 3rd of October now uh please remember that if I would have added seven days later on I would have added nine months first and then seven days then the answer would have been slightly different how if I would have added nine months to December I would have come to September right so I would have been on 27th September up 27 September May when you add seven days 28 September 29 9 30th first second third fourth then your answer would have been 4th of October right so please remember always it is preferable to add seven days first and then nine months but this rule doesn't apply to the month of Feb so do not apply this rule to the month of Feb if if you are calculating Edd and the LMP is in the month of Feb then add 9 months and seven days for example I am doing a example question with you you all have to calculate EDD if LMP is 25th Feb 2021 tell the EDD calculate the EDD if nmp is 25th Feb now whenever LMP is in the month of Feb add nine months first and then add 7 days so 25th Feb may you are going to add 26 27 oh sorry 25th February you are going to add nine months first so Feb May when you add nine months it comes to March April May June July August September October November right so you come to 25th of November up 25th November may add seven days so 26 27 28 29 30th first second so that brings you to Second December why I am telling you to remember this for the month of Feb because in the month of Feb if you would have added seven days first then your answer would have been different agar 25th Feb May if you would have added seven days first then your answer would have been 26 6th Feb 27th 28th first second third fourth right so fourth of March May you would have added nine months and you would have come to 4th of December that is why I remember always add seven days first and then nine months for all months except Feb in the month of Feb add nine months first and then add seven days yeah so that's right don't apply this rule on Valentine's month in Valentine month add month first and then the days clear to all of you now for calculating EDD in IVF Cycles remember this that if it is a fresh cycle the day of oocyte retrieval is the day of fertilization and if you know the day of fertilization day of fertilization is always day 14 so you will have to add 266 days to get the EDD so simply remember if it is a fresh cycle you have to add 266 days if it is a frozen cycle then in that case you have to see whether it is day three transfer or day five transfer print day 3 transfer you have to add 263 days in day five transfer you have to add 261 days why because because day 3 transfer Ka Matlab here you are transferring it on day 14 plus 3 that is day 17. right so all of you know that the period of pregnancy is 280 days the duration of pregnancy is 280 days to 17 may I will have to add 263 to get 280 as the answer right so if it is a D3 transfer you have to add 263 uh Mirage understand day three transfer Ka Matlab here you are transferring it on the third day after fertilization fertilization happens on day 14. so if this is a 28 day cycle this is first day this is 28 day on day 14 ovulation happens and on day 14 fertilization happen it's day three that you are transferring it on day 17 of the cycle three days after fertilization you are transferring you are doing the embryo transfer and you also know that the total duration of pregnancy is 280 days up 17 days and 280 days are calculated from the first day of the LMP so 280 Colony 17 how much you will have to add you will have to add 263. that means to day 17 when you add 263 you will get the EDD right similarly uh if it is a day 5 transfer then you have to add 261 days now please remember in case of IVF Cycles they are going to ask you these formulas only most of the times they do not expect you to calculate the EDD if you are well versed with these formulas and these formulas have been included for the very first time in Williams so you have to remember this that in IVF cycle in a fresh cycle or the day of oocyte retrieval may you have to add 263 six days in Frozen cycle for a day three transfer you have to add 263 days for a day 5 transfer you will have to add 261 days clear to all of you yes uh pankhuri you can do that you were what you are saying that you can subtract 16 from the day of transfer and then you can calculate EDD right okay but if I start speaking in Hindi English me now coming to obstetrical score I am going to do an example of obstetrical score with you but before that I want to tell you that obstetrical score can be written in three ways obstetrical score can be written where one single number represents gravida and one single number represents parity all of you know gravita is number of times a female has conceived and it includes present and past pregnancy parity is the number of past pregnancies which have gone beyond 28 weeks of pregnancy that is beyond the period of viability remember Twins and triplets are taken as a result of single conception right okay then comes there are certain cases jawab hospitals may you are going to see gravity but in parity there are two numbers written Whenever there are two numbers written in parity the first number represents parity that is the number of past pregnancies right past pregnancies which have gone beyond the period of viability that is parity remember parity make you are not going to include present pregnancy right if parity May there are two numbers written again though numbers retained are written in parity if two numbers are written then the second number represents the number of pregnancy losses which are happening at less than 20 weeks right clear to all of you so that is if two numbers are written in front of parity now sometimes what happens is that in front of parity four numbers are written now if four numbers are written then the first number represents the number of term pregnancies the previous number of pregnancies which have gone beyond 37 weeks second number represents number of preterm pregnancies preterm pregnancies the number of pregnancies which have gone between 20 to 36 weeks plus 60s third number represents number of abortions that is the number of pregnancies less than 20 weeks and the last number represents number of living children at present is GT pal system is very important GT pal system May for your exams remember that P over here is not parity p over here is pre-term pregnancies and whenever you are telling whenever you are telling the number of living children right the twins will be counted as two triplets will be counted as three this is the only place where twins will be counted as two and triplets will be counted as three clear to all of you so now do this question for me a 28 year old pregnant female at 30 weeks of pregnancy comes for the first antenatal visit her obstetrical history is significant for a son who is five years old who was born who's now five years old and was born at 38 weeks there is history of stillbirth three years ago at 30 weeks twin daughters who were born at 32 weeks two years ago and one ectopic pregnancy her obstetrical score is so this will be her fifth pregnancy this is her fifth pregnancy right one son then one preterm uh the daughters were preterned twin pregnancy one ectopic pregnancy one still birth and presently she is pregnant right she is G5 now tell me her GT pal score tell me her GT pal score so that means now her score will be the first is T number of term pregnancies specially pregnancies which have gone beyond 37 weeks so there is only one pregnancy which had gone beyond 37 weeks so one Plus T pal P P stands for number of preterm the previous Kitty pregnancies means pregnancy between 20 weeks to 36 weeks plus 60s clear so over here twins will be taken as a result of single conception then comes a abortion abortion means any pregnancy loss which is happening at less than 20 weeks that includes molar pregnancy that includes ectopic so there is history of one ectopic pre-term it is true sorry she has two preterms because she also has history of stillbirth right 32 weeks pay twin daughters an egg still worth who are 30 weeks but that is also prita then abortion now tell the number of living children living children living children just now she has a son and she has two twin daughters living children may you have to calculate twins as two and triplets as three right so G5 P1 plus 2 plus 1 plus 3. so 1 plus 2 plus 1 plus 3 so this is option A right pre-term will be happy term is anything and normally also pre-term is any pregnancy less than 37 weeks abortions up till 20 weeks you have to say that it is going to be preterm right now if it is given so yogender is asking if it is given that the baby was born dead at 37 weeks what should we take as parity now you tell me right so Suppose there is a female who is now presently pregnant and she's saying she has history of a baby who was born dead at 37 weeks so this is her second pregnancy and previous pregnancy one of the pregnancies has gone beyond period of viability a dead war that is a different thing but it has gone beyond the period of viability so G2 p 0 someone is asking me this question in chat box Suppose there is a female just may still birth at 37 weeks how are you going to write it so if it is still birth at 37 weeks and suppose this is her second pregnancy so now you tell me this is the second pregnancy gravida will be 2 and parity sorry parity is any number of pregnancies which have gone beyond the period of viability so 37 weeks per August still worth Hua so at least that pregnancy has gone beyond the period of viability 37 tickets now the baby is not alive but it has gone beyond the period of viability so it is going to be G2 P1 right now suppose same thing that there is a female who this is her second pregnancy first pregnancy was still birth which happened at 37 weeks so this is her second pregnancy 37 weeks where the pregnancy had gone beyond term right 37 weeks pre-term zero abortions zero number of living children 0. so much you just tell me this pregnancies which have gone beyond the period of viability that is 28 weeks so agar still at 37 weeks so obviously pregnancy has crossed 28 weeks that is why stillbirth has happened at 37 weeks foreign next question so this GT pal system and three ways of writing gravida and parity this is first way this is second way and this is third way of writing gravida and parity right now come to the next question post term pregnancy is associated with all except suppose term pregnancy is associated with all except option A macrosomia option b variable deceleration on ctg option C meconium option meconium aspiration option D transient tachapnia of newborn ectopic abortion that is here there was history of ectopic that is why foreign pregnancy whether it is abortion it has to be included in abortions only right now remember post term pregnancy May what are the problems which are happening number one macrosomia yes right so any pregnancy which is continuing more than equal to 42 weeks that's a post term pregnancy so baby is going to gain more weight there is going to be macrosomia right then number two there is going to be oligohydramnios all of you know that maximum amniotic fluid is seen between 32 to so my pen is not working okay maximum amniotic fluid is seen between 32 to 34 weeks and as pregnancy continues Beyond 40 weeks the amniotic fluid decreases drastically oligohydramnios because there is going to be oligohydramnios what is going to happen because of oligohydramnios the space will be less less so there will be cord compression right and all of you know that whenever there is cord compression what happens on ctg on ctg you get variable decelerations right so there is going to be variable deceleration then because of chord compression there will be fetal distress now when there will be fetal distress fetus is going to pass meconium into the amniotic fluid so there will be meconium in amniotic fluid and we all know that fetus swallows amniotic fluid also so this meconium stained amniotic fluid fetus is going to swallow so there is going to be meconium aspiration right but what you don't get is transient tachapnia of newborns so you don't get transient tachapnia of newborn next important thing now the third problem which happens whenever there is a post term pregnancy the third problem is that there is placental aging now because of placental aging because of placental aging there is utero placental insufficiency and whenever there is utero placental insufficiency ctgpay you get late decelerations this means that both variable and late decelerations are seen in ctg in a post-term patient so you can get both late decelerations and variable decelerations but the more characteristic ones are variable decelerations ACOG recommends that in all pregnant females who are more than equal to 41 weeks pregnancy should be terminated that's very very important we do not take pregnancy up till 42 weeks we have to do induction of labor at 41 weeks clear to all of you next important question which they can ask you on post term pregnancy is which congenital malformation can lead to post-term pregnancy so it is anencephaly which can lead to post-term pregnancy right so it is taken as a post term you people stop writing uh comments I am you know I'm getting uh my my mind is going there to what you are writing you have still not come out of the GT pal score what has happened ma'am twin babies resulted from single preterm pregnancy then why can't we take it as P1 in GT pal we are taking it as P1 where we are taking twins as two is number of living children right that is the only place where we are taking twins as to otherwise every other place we are taking twins as a result of single conception right okay now a next very important question what is the color of amniotic fluid in post term pregnancy the color of amniotic fluid in amniotic fluid in post term pregnancy is greenish yellow color right or saffron color amniotic fluid clear to all of you okay uh I also want all of you to tell me what do you understand by a term pregnancy term pregnancy means any pregnancy which is between 37 weeks to 41 weeks plus 60s right preterm means any pregnancy Which is less than 37 weeks right now and poster means any pregnancy which is beyond 42 weeks now term pregnancy can further be divided as term it is a early term pregnancy early term pregnancy full term and late term early term full term and late term early term pregnancy means any pregnancy between 37 weeks to 38 weeks plus six days full term means any pregnancy between 39 weeks to 40 weeks plus six days and late term means any pregnancy between 41 weeks to 41 weeks plus six days right so there is a lot of difference between early term and preterm and there is a lot of difference between late term and post term late term is 41 weeks to 41 weeks plus six days post term is more than equal to 42 weeks clear to all of you yes now coming to preterm labor there was this question which I've already discussed with you in pyqs which of the following is not a diagnostic criteria for pre-term labor now please remember that according to Acog the latest definitions for preterm labor is preterm labor is regular uterine contractions which are happening at 37 weeks of gestation with regular dilatation and effacement of cervix with Progressive dilatation and effacement of cervix number one number two any pregnant female who's coming to you at more than equal to 37 weeks and is having regular uterine contractions and at the time of presentation she's already dilated to more than equal to two centimeters right so new definitions are here now the new definition for preterm labor is either a female coming to you with regular uterine contractions and having Progressive dilatation and effacement or if she's coming to you with regular you trying contractions at less than 37 weeks and at the time of presentation the initial dilatation is more than equal to two centimeters right now the conventional definition for preterm labor was what was the conventional definition but it is if a female is having uterine contractions and how many contractions more than equal to four contractions in 20 minutes and more than equal to eight contractions in 60 minutes and along with these contractions if the dilatation of the cervix is more than three centimeters so now can you see the difference new definition with they are saying dilatation more than equal to two centimeters and new definition made they haven't told how many contractions conventional purani definition they were telling that if the number of contractions were more than equal to 4 in 20 minutes or more than equal to 8 in 60 minutes and along with that one of the three which I'm going to tell you dilatation more than equal to three centimeters length of the cervix less than equal to two centimeters or if fetal fibro nectin protein is present in cervical vaginal swab and how much more than equal to 50 nanograms per ml right now question I thought this question came in ioni set and in this question you had to know the new definition also and you had to know the whole definition also then only you would be able to solve this question so let's see this question which of the following is not a diagnostic criteria for preterm labor option A contractions four contractions in 20 minutes or 8 contractions in 60 minutes that is an old criteria so yes it is a definition for preterm labor then dilatation more than one centimeter purana three centimeters two centimeter right so one centimeters so I'm just keeping it in plus minus then more than 80 percent cervical effacement so night definition Progressive dilatation and effacement so yes more than 80 percent effacement again posterior cervix no now as far as dilatation one centimeter is concerned now I have to choose between option b and d a b and d may say which one am I going to include in the criteria for preterm labor I will include B in the criteria for preterm labor why because if there are regular uterine contractions and there is Progressive dilatation so suppose patient will be one centimeter dilated here maybe after some time she becomes two centimeter and she becomes three centimeters right Progressive dilatation right so although if they would have written more than two but because they I have not written more than two and they have written more than one and the next option is posterior cervix and if I have to choose between the two which one should be included in pre-term labor I will include this option b in preterm labor and my answer will be option D posterior cervix is never included in the definition or the diagnostic criteria for preterm labor clear to all of you now comes the question that which one are you going to remember you are going to remember both of them because if a question like this comes you have to know the conventional definition also and you have to know the new definition as well right but which one are you going to follow it has to be the new definition which you have to follow but right now next very important question in preterm labor is always the management of preterm Labor a pre-term labor May hum preterm labor early pre-term labor and late preterm labor divide early pre-term labor if pre-term labor is happening at less than 34 weeks late pre-term labor if it is happening between 34 weeks to 36 weeks plus six days right I am going to tell you a very easy chart by which you can remember the management of pre-term Labor remember induction of Labor is never done right kabibi induction of induction of Labor is never going to be done exact 37 here I'm writing 36 weeks to 36 weeks plus six days 37 weeks term right okay so induction of labor early you never do then whether it is early preterm or whether it is late P term in both the cases you have to give corticosteroids so that the lungs of the baby mature then in case of early preterm labor along with Cotto crystalloids you have to give to colitics please remember tocolytics are never given Beyond 34 weeks so you never give tocolytics Beyond 34 weeks so in case of late preterm labor you are not going to give to politics in case of early preterm labor you will give to politics then comes magnesium sulfate what is the role of magnesium sulphate in preterm labor magnesium sulfate prevents cerebral palsy in the fetus right it is for neuroprotection and it is believed that the baby's nervous system is fully mature by 32 weeks the other preterm labor is happening at less than 32 weeks then you have to give magnesium sulfate for neuroprotection so in case of early preterm labor agar early preterm labor is happening at less than 32 weeks you are going to give magnesium sulfate but in case of late preterm labor you never give magnesium sulfate what is the role of tocolytics in preterm labor the only role of tocolytics is they buy time for corticosteroids to act corticosteroid go 48 hours 48 hours so that a patient doesn't deliver we give tocolytics now it is believed that the lungs of the baby start maturing by 34 weeks so if it is a late preterm labor I will give corticosteroids but I will not give any two politics because by chance even after the first dose of corticosteroids that's okay right but in case of late in case of early preterm labor that means preterm labor which is happening at less than 34 weeks I want the lungs to be mature before the patient goes into labor and that is why I will give full time for the corticosteroids to act so I am going to give tocolytic now when we talk up the last thing is I will talk about tocolytics a little more but over here first remember what I'm telling you then comes GBS profile Axis or GBS screening now in case in both these cases whether it is early preterm labor or whether it is late preterm labor either you have to go for GBS screening that means you have to take out a recto vaginal swab for GBS screening or you give GBS profile access it has to be done in both the cases and if the you know that the patient will not deliver so you wait for the result of the result positive GBS profile access but if you feel you don't have time then rather than giving a swab and teach as a patient delivery go for GPS profile access right but GPS profile access or GBS screening should be done in both the cases whether it is early preterm labor or whether it is late preterm labor so whenever you quest get a question on preterm labor look at the gestational age at what preterm labor is happening and then remember this table and according to this table manage your patient clear to all of you okay so this is something which I told you just now okay what is early preterm early term full term late term pre-term and post term all this I have told you just now when we are talking about tocolytic this I told you in the last session also that in India the tocolytic of choice is nifitipine according to Acog up till 32 weeks up till 32 weeks it is indomethacin between 32 to 34 weeks it is nifedipine right and tocolytics are never given Beyond 34 weeks steroids corticosteroids pay this was a very important question which had come to you because those of corticosteroid is very very important so tell me what is the dose of dexamethasone given for fetal lung maturity what is the dose given for fetal lung maturity so please remember doses of dexamethasone and doses of betamethasone are very important for you dose of beta methazone is you have to give two injections 12 mge each 24 hours apart dose of dexamethasone is you have to give four injections six mg each 12 hours apart right both these have to be given either intramuscular at least whenever whichever you are choosing in India we choose dexamethasone and it has to be given intramuscularly worldwide the corticosteroid of choice is betamethasone the only contraindication for giving corticosteroids is choreo amnionitis now whenever you are doing lung maturity test and they ask you which is the best lung maturity Test please remember that the best lung maturity test is presence of phosphatidyl glycerol in amniotic fluid right phosphatidyl glycerol in amniotic fluid if phosphatidylslore is present in amniotic fluid then that means lungs of the baby are mature if it is not present then it means lungs of the PBR not mature this question they are going to ask you like this they are going to say that there is a diabetic female in a diabetic female which is the best lung maturity to test to know whether the baby's lungs are mature or not so why is it they ask this question in context of diabetic females this is because diabetic females May because of increased insulin the insulin has a decreased or it inhibits the release of surfactant insulin diabetic patients this insulin decreases the release of surfactant and that is why in diabetic patients there are increased chances of respiratory distress syndrome in the baby now whether they ask you uh you know a diabetic female or whether they ask you non-diabetic female right whether it is diabetic or whether it is non-diabetic always the best language test is phosphodide glycerol in amniotic fluid clear to all of you yes okay coming to the next question very very important question where you have to arrange the following investigations in increasing order of gestational age at which they are performed so tell me in increasing order of gestational age arrange it and tell me so uh number one is screening of diabetes then maternal serum Alpha phyto protein then nucle translucency and ultrasound for confirmation of placenta previa so arrange it in increasing order of gestational age in which you have to perform so tell me screening of diabetes screening of diabetes it is done in the first antenatal visit and then between 24 to 28 weeks maternal serum Alpha phyto protein it is done between 15 to 20 weeks translucency scan when do you do it between 11 to 13 weeks plus six days that is approximately 11 to 14 weeks ultrasound for confirmation of placenta previa this is done in third trimester around 30 two weeks right so my pen has stopped working 30 weeks so now the order is going to be a right so you are going to first do a then you are going to do c then you are going to do B and then you are going to do d clear to all of you yes so a c b and d that is the increasing order of gestational age at which these investigations are done very good Austin ACB and D clear okay now remember there are certain names given to ultrasounds which are performed at specific times so rating scan dating scan or a viability scan that's the first ultrasound which you do which is done between six to eight weeks nuclear translucency scan is done between 11 weeks to uh 13 weeks plus six days a normally target scan or booking scan this is level 2 scan which is done in all pregnant females between 18 to 20 weeks growth scan is done between 30 to 32 weeks and just in case Eco is needed anytime if fetal Eco is needed it is done between 22 to 24 weeks right now other than that remember maternal serum Alpha phyto protein levels whenever you have to check you check them between 15 to 20 weeks chorionic will I sampling you down do it at any time Beyond 10 weeks ideally you should do it between 11 to 13 weeks amniocentrisis is done again between 15 to 20 weeks best time is 16 to 18 weeks right then uh Group B streptococci screening Group B streptococci screening this has to be done in all pregnant females by taking out a recto vaginal swab and this is done between 36 to 37 weeks right so these are all investigations and their respective timings at which you have to do them clear to all of you yes so questions they are good they are going to ask you make different combinations and permutations of these questions and then they are going to ask you this clear to all of you now uh I want to just tell you suppose they ask you an entire pregnancy you have to do one ultrasound then that ultrasound should be then that ultrasound should be target scan or anomaly scan or booking scan which has to be done between 18 to 20 weeks right now ultrasound for placenta previa ultrasound for placenta previa it has to be done in third trimester you do it at 32 weeks followed by 36 weeks please remember whenever a patient of antipartum hemorrhage comes to you right now when a patient of antipartum hemorrhage comes to you and the first investigation you have to do then the first investigation which you are going to do will be a trans abdominal scan in the trans abdominal scan if you see that the placenta is located in the lower segment then the investigation of choice for placenta previa is TVs and this TBS has to be done at 32 weeks and it has to be done at 36 weeks right then the other thing in all high risk pregnancies in all high risk pregnancies you have to start anti-partum fetal monitoring and this anti-partum fetal surveillance is started from 30 two weeks right and in antipartum fetal surveillance we are going to include NST we are going to include biophysical score right and this has to be done either weekly so in all high risk pregnancies you do it either weekly or in certain cases you might have to do it twice weekly or you might even have to do it daily clear to all of you then in case of Rh negative pregnancy indirect comb test indirect comb test is done at the first antenatal visit and then you repeat it at 28 weeks right in case of p i h in case of PIH if you have to predict the PIH then a uterine artery Doppler it has to be done between 22 to 24 weeks right and this uh you know these days there is a trend for early uterine artery Doppler early you try an artery Doppler is done between 11 to 13 weeks right and this early uterine Doppler is going to detect early onset pre-eclampsia clear then comes your uh about twins in twins when are you going to do ultrasound because in twins the investigation of choice to detect Corona city is ultrasound so when are you going to do this ultrasound to find the Korean City the best time to do ultrasound to detectoronicity is 10 to 14 weeks right now just now I told you that chorionic villi sampling is always done Beyond 10 weeks ideally it is done between 11 to 13 weeks so you are going to tell me what is the most common complication of chorionic villi sampling what is the most common complication of chorionic villi sampling if they ask you this question that what is the most common complication of chorionic villi sampling your answer will be fetal loss but if they ask you what is the most common complication of chorionic villi sampling which is done at less than 10 weeks then the answer is oromandibular defects or limb defects oromandibular defects or limb defects that is why chorionic villi sampling is never done at less than 10 weeks clear so this is for all the investigations which you are doing in pregnancy now please remember fetal Eco which I told you over here it is done between 22 to 24 weeks and only if it is needed you know if you are suspecting a cardiac problem in the fetus or if mother is a case of overt diabetes in overt diabetes we know that the congenital malformations May the most common congenital malformations are cardiac malformations that is why in case of over diabetes I am going to do fetal Eco but otherwise in all cases fetal Eco is not required if fetal Eco is required it is done between 22 to 24 weeks clear to all of you all the investigations list clear okay now as advised by the government of India what are the antenatal visits so in antenatal visits the minimum number of antenatal visits which have been told I mean advised by government of India are four according to who they are eight and ideally they should be 12 to 15. now what is the caloric requirement according to park as I told you in all trimesters you can give 350 kilocalories per day according to a national guidelines in first trimester very small amount is needed roughly 85 kilocalories or no additional kilo calories is also fine in second trimester roughly 300 kilocalories and in third trimester roughly 400 kilocalories per day additional this is additional kilocalories which are needed right then they may ask you a question on uh you know RDA that is routine daily allowance routine daily allowance may you have to remember what is the routine daily allowance of iodine in uh pregnancy the routine daily allowance of iodine in pregnancy is 250 micrograms per day routine daily allowance of calcium in pregnancy is 1 000 milligrams per day and routine daily allowance of carbohydrates in pregnancy is 175 grams per day all this is very very important right then the amount of protein which is needed in a non-pregnant female is 45 grams per day in first trimester no additional protein requirement in second trimester additional 10 grams of protein and in third trimester additional 20 grams of protein is needed right then there are a requirement of fat in pregnancy is 28 normally it is you know 28 grams per day which you have to give the that is the requirement of fat in a pregnant female now over here I told you this is what our national guidelines say our national guidelines say that in the first trimester 85 kilocalories in second trimester 300 kilocalories and in third trimester 450 kilocalories I also want you to remember what has been advised by Acog and Indian Institute of Medicine Indian Institute of medicine Indian Institute of medicine says that in first trimester no additional kilocalories so this is zero calories no additional kilocalories in second trimester 350 additional kilocalories and in third trimester of 450 additional kilo calories this is what Indian Institute of medicine says so is this uh clear to all of you okay then comes so these are all the things which you need to know about orbs where you know all those PSM things which you need to know in Ops right now comes folic acid supplementation now folic acid supplementation that's again very important to prevent neural tube defect 400 micrograms per day this 400 micrograms per day should be given one month before conception and it should be continued for three months after conception to prevent the recurrence of neural tube defect four milligrams per day recurrence where patient already has one baby with neural tube defect right and this should be given three months before pregnancy and continued for three months after pregnancy but please remember that we are a gynecologists and Obstetricians we are not astrologers so since we are not astrologers that is why I cannot say that now after three months you are going to become pregnant so we say that whenever a female comes to me and she has previous history of baby with neural tube defect then whenever she's planning pregnancy then I am going to give her start her on folic acid so a better answer will be that whenever the patient comes prenatally I will put her on four milligrams of folic acid then to treat folic acid deficiency the dose of folic acid which is needed is one milligrams per day in diabetic patients again it is 400 micrograms per day in patients on anti-epileptics it is four milligrams per day and to treat sickle cell anemia it is 5 milligrams per day right now then comes vaccines in pregnancy the vaccines which are safe in pregnancy please remember they are hepatitis A Hepatitis B influenza vaccine rabies vaccine pneumococcus meningococcus and covid-19 vaccines now vaccines which are contraindicated in pregnancy are all live vaccines for examples MMR mumps measles rubella right then BCG smallpox chickenpox and HPV now someone is asking me what to write if they don't specify kcog guidelines or who guidelines so if they are not specifying always and always you should write ACOG guidelines whilst when they ask you about who guidelines and not all those places where our national guidelines are available we prefer giving answer with respect to our national guidelines right so just a diabetes memory natural guidelines there so I'm going to give answer as per our national guidelines right then what are those vaccines which can be given under special circumstances that is if a female is traveling to that area you know and that area is endemic for that particular problem so that is yellow fever polio and typhoid vaccine so this is a list of vaccines which are safe the ones which are contraindicated and the ones which are given under special circumstances remember TD vaccine is the one which you give normally in pregnancy if the female had received a complete tetanus course in any of the time in past three years then in this pregnancy you only have to give her a booster but if she did not receive any tetanus vaccine in previous three years then you have to give TD vaccine at the initial antenatal visit and then you have to repeat a dose after one month TD stands for tetanus and diphtheria toxoid right now weight gain in pregnancy normally the weight gain which is recommended in pregnancy is 11 to 12.5 kgs if the BMI of the patient is less that means she's thin then the recommended weight gain is 12.5 to 18 kgs and if BMI is more than 30 that means she's obese then the recommended weight gain is 7 kg right Sonu Kumar covet vaccine most of the times she will be fully vaccinated against kovid but just in case pregnant patient that and then at any time during pregnancy you can give covert vaccine you can give covet vaccine even in the first trimester right now coming to anemia in pregnancy so look at this question a G2 P1 female at 30 weeks of gestation presents with fatigability loss of appetite and lethargy so all these are pointing towards anemia symptoms on examination parallel is present and on examination her hemoglobin is 6.5 grams right her vitals are stable and there are no signs of CHF nestorov test is negative mensers index is 15. now you tell me what conclusion do you draw from this if nest what is nestrov test for nestrov test is for thalassemia screening so nestrov test negative test negative similarly mentors are index more than 15 means thalassemiah it is a case of iron deficiency anemia you should know that from your question how are you going to differentiate between iron deficiency anemia and thalassemia and physiological anemia so please remember most common anemia in pregnancy is physiological anemia physiological anemia is due to hemodilution in physiological anemia never will the hemoglobin be less than 11 always hemoglobin will be more than 11 right and physiological anemia is normocytic normochromic anemia now are in deficiency anemia and thalassembias are examples of pathological anemia and in both of them the hemoglobin is going to be less than equal to 11 gram percent right now in and in both of them the the on peripheral blood smell you are going to get microcytic hypochromic anemia a both important iron deficiency because both management is different iron deficiency anemia management is iron you always have to give blood transfusion so how are you going to know from your question whether you are dealing with thalassemia or iron deficiency anemia so there are three ways by which you are going to know from your question number one red cell distribution with red cell distribution width is increased in iron deficiency anemia it is normal in thalassemia number two nestorov test nestrov test will be negative in iron deficiency anemia it will be positive in thalassemia number three mentors index Mentos index will be more than 13 in RN deficiency anemia it will be less than 13 in thalassemias right so remember in iron deficiency anemia management can be oral iron parental iron or blood transfusion in case of thalassemia management is only blood transfusion clear so in this question I am dealing with iron deficiency anemia and update hemoglobin is six point 0.5 and at what time has the patient presented to you patient has come to you at 30 weeks now now you are going to follow this flowchart now if it is severe anemia severe anemia means hemoglobin less than seven and your patient has severe anemia she has hemoglobin 6.5 so whenever there is severe anemia you divide it into two categories hemoglobin less than five hair yeah hemoglobin between five to seven here if hemoglobin is less than five then always you have to give blood transfusion irrespective of gestational age but if hemoglobin is between 5 to 6.9 that is between 5 to 7 then you have to look at gestational age if gestational age is more than 34 weeks blood transfusion if gestational age is less than 34 weeks parenteral iron now in case of mild to moderate anemia that means any anemia which is lying between 7 to 11 you have to check the gestational age if gestational age is less than 34 weeks two tablets of iron and folic acid right two tablets and if gestational age is more than 34 weeks parenteral I another thing which I want you to remember is whether you are giving parental iron or whether you are giving oral iron in both these cases you have to check her hemoglobin after three weeks ideally we do it after one month because increase in hemoglobin is going to happen with both parental and oral iron after three weeks right clear to all of you yes anemia mukt Bharat program is for preventing anemia and anemia mukt Bharat program may you have to give one iron folic acid tablet daily starting from fourth month and throughout pregnancy plus 180 days after delivery to treat anemia you have to give two tablets to your happy you are giving two tablets per day clear to all of you and user two tablets your two tablets you are going to give it up till her hemoglobin becomes 11. the day her hemoglobin becomes 11 now from two tablets usual switcher to one tablet and you will continue that one tablet throughout pregnancy plus 180 days after delivery clear to all of you yes okay also remember this was about oraline and what you had to remember about parental iron remember that parenteral iron is contra indicated in first trimester never are you going to if your patient has anemia in first trimester you can give her oral iron or you can give her blood transfusion you can never give her parenteral iron now if your question says vital stable now if instead of stable vitals your question would have said unstable vital unstable vital Ka Matlab here that it is uh happening because of blood loss so whenever your question says unstable vitals then you don't have to think about anything else then your answer is going to be blood transfusion that means it is Thalassemia and that means again you are going to give blood transfusion and a good signs of congestive heart failure positive that patient is having signs of congestive heart failure again irrespective of gestational age irrespective of hemoglobin your answer is going to be blood transfusion clear yes so this is how you treat anemia in pregnancy so very very important topic now someone was asking me what is the dose of IFA I am not telling you the rows of IFA because in my pyq session I have dealt with IFA please remember it is 60 milligrams of iron and 500 micrograms of folic acid it is a red pill right now some important points which you need to know on MTP I know I am not see uh the pyq PDF I have made available for all of you now this PDF you are going to this the uh you are going to write it I am not going to make this PDF available okay now coming to the next question and that is as per the revised rules of MTP act which of the following is or are required by a registered medical practitioner to qualify for performing MTP right so what are the requirements for MTP uh requirements for a registered medical practitioner to be able to do MTP number one they are saying having a degree or diploma in OBS and guinea yes degree or diploma in OBS and gyne is necessary they should have assisted in 15 mtps no they should have assisted in 25 mtps in which five may he or she should have been the primary surgeon they should have done house training for 12 months in OB gy no house training for six months in OBG why right certified for six months in laparoscopic surgery no that's not a requirement at all the requirements are either degree or diploma in orbs and guinea then they should have assisted in at least 25 MTP days in which in five he or she should have been the primary surgeon number three they should have done house training or house job in OB gy for six months so yeah only one is correct and only one correct means option D is the correct answer right clear now the other things which you have to remember is as per the new MTP act the MTP Amendment act MTP can be done now up till 24 weeks but if pregnancy is a result of contraceptive failure then in that case MTP is done till 20 weeks right now if there is gross severe congenital anomaly of the fetus so in case of gross severe congenital anomaly of the fetus there is no upper limit for performing MTP right so please remember this if they ask you till now now till when can MTP be done it can be done till 24 weeks exception is if it is contraceptive failure you do it up till 20 weeks and in case of gross congenital anomalies you do there is no upper limit for performing MTP till 20 weeks only one doctor's opinion is needed between 20 to 24 weeks two doctors opinion is needed and if you want to see whether gross congenital anomalies are present or not then there is a board and this board comes consists of one gynecologist one pediatrician one radiologist and one person who is assigned by the state right so these are the four people who are going to decide whether the fetus has severe gross congenital anomalies or not clear then next question all statements are true about the device shown in the image except MTP Amendment law is very very important so please remember that all statements are true about the device shown in the image except option a volume 60 ml option b it can be used in outpatient setting option C generates a pressure of 60 millimeters of mercury option teeth can be used up till 12 weeks now remember that up till seven weeks your best method that is medical abortion right up till seven weeks best is medical abortion medical abortion May when you are doing medical abortion up till seven weeks then on day one you are going to give Memphis Stone 200 mg and then you are going to wait for 24 to 48 hours and on day three you are going to give mesoprost 400 micrograms which can be given sublingual buccal vaginal or oral and if you are doing up MTP between seven to nine weeks then again on day one you are going to give me 50 Stone and on day three now you are going to give misoprost up till 800 micrograms now remember in India medical abortion is done only up till seven weeks India maybe do it up till seven weeks who says you can do it up till nine weeks so if I'm doing medical abortion between seven to nine weeks I have to follow this protocol right now between up till seven weeks best method is medical abortion between 7 to 12 weeks best method is suction evacuation suction evacuation there are two methods one is the electrical suction evacuation the other one is manual vacuum suction evacuation of electrical suction evacuation we take a plastic cannula which is carbon cannula and that is attached to a suction machine and the size of the carbon cannula it should correspond to the period of gestation electrical suction evacuation here you can do it up till 16 weeks and when you do it up till 16 weeks it is called as dilatation and evacuation right and this means for electrical suction evacuation you can use a 16 mm cannula so I'm repeating suction evacuation can be done electrically it can be done manually electrical suction evacuation you can do it up till 16 weeks Java 12 weeks 12 weeks to 16 weeks you call it as dilutation and evacuation but nevertheless Joe suction evacuation you can do it up till 16 weeks that means suction evacuation can be done in first trimester MTP as well as for second trimester MTP right now then comes manual suction evacuation manual suction evacuation you do with the help of this syringe which is called as MVA syringe manual vacuum aspiration syringe is syringe the particular point about this syringes that this has got two pinch valves the pressure which is generated this doesn't need any electricity and the pressure which will be generated by this um you know mvs syringe is 660 millimeters of mercury if 660 is given in the option you are going to Mark 660 as the answer but if 660 is not given then the second best answer is going to be 600 millimeters of mercury and the volume of this syringe is 60 ml right clear to all of you now remember manual suction evacuation which you are doing using MVA syringe it can be done up till 12 weeks right and is 12 mm as I told you the size of the Canon it didn't catch that could you try again the size of the cannula depends upon corresponds to the period of gestation so because electrical suction evacuation can be done up till 16 weeks the maximum size cannula Johannes electrical suction evacuation may use 16 mm a plastic cannula will be attached to the front of the syringe suction machine hia you are going to attach the syringe to a carbon cannula and because this can be done only up till 12 weeks the maximum size for MVA is for manual vacuum aspiration is 12 mm clear right so remember about mvs range remember about manual suction manual suction evacuation and electrical suction evacuation now then a very important question which comes to you in your exams is you have to identify the type of abortion now whenever they give you a question and you have to identify the type of abortion the first thing which you have to see is whether the question is telling you about history of passage of any clot or not right now if there is history of passage of clot present history of passage of product of conception present then in that case either it is a case of incomplete abortion or it is a case of complete abortion complete abortion and incomplete abortion in both these cases there is history of passage of product of conception what have they told you about the OS if OS is closed that means it's a case of complete abortion right an agar OS closed here then I was open here then it is a case of incomplete abortion uh ma'am please tell about second trimester abortion methods as well okay so second trimester abortion methods if you are asking me second trimester abortion methods May let me write possible what has happened to my pencil today wait can I write it's not writing so you write it yourself my pencil I don't know what has happened to it second trimester methods in second trimester methods the first method which you have to know is again dilatation and evacuation dilatation and evacuation I told you you can do it up till 16 weeks then uh number two you can go for prostaglandins in prostaglandins you can use mesoprost or you can use pgf to Alpha number three you can use extra amniotic ethacridine extra amniotic ethical this is an outdated method but you can use it extra amniotic ethical number four you can give oxytocin and number five if nothing works then you can use go for hysterotomy not hysterectomy you can go for hysterotomy clear to all of you yes so these are your second trimester MTP methods in second trimester the best method for doing MTP is prostaglandins right and you are going to use mesoprost basically for second trimester MTP right any other thing which you need to ask foreign you know I am not in favor of giving you a PDF because otherwise you don't pay attention and you are just waiting for the PDF okay someone is asking me about the dose of mesoprost so remember the dose of mesoprost can range between 200 to 800 micrograms now this is different from first trimester abortion medical abortion because in second trimester abortion you have to admit the patient in first when you are doing first trimester abortion with medical abortion you don't need to admit then in this case it is like a mini labor now there are various protocols which can be used between 200 to 800 micrograms you have to give mesoprost there are various protocols and the most commonly used protocol is you have to give 400 micrograms mesoprost every four hourly right so that's the most commonly used protocol for giving mesoprost clear okay now coming to the type of abortion in the type of abortion whenever you get a question on type of abortion look at whether there is history of product of conception present or not right now if there is history of passage of product of conception then either you are dealing with incomplete abortion or you are dealing with a case of complete abortion how are you going to differentiate between them you are going to look at the internal loss if internal loss is closed it means you are dealing with complete abortion if internal loss is open then it is a case of incomplete abortion right now suppose if they say that there is no history of passage of product of conception then in your mind you have to keep missed abortion as a DDD as a as a differential diagnosis you have to keep threatened abortion as a differential diagnosis and you have to keep inevitable abortion as a differential diagnosis now how am I going to differentiate between them I am going to look in the question what they are telling me about the OS if they say us is open then in that case it means I am dealing with a case of inevitable abortion now if they see Alibaba you stop writing ma'am give the PDF actually I'm telling you my attention I'm just is getting diverted I am looking at your messages much more than I am concentrating here so I will give you the PDF stop writing now give us give me the PDF right stop writing that in the comment box I will share the PDF with you but let me concentrate okay now next is if the OS is closed now if the OS is closed either it can be threatened abortion or it can be missed abortion to differentiate between them you are going to look at the height of the uterus if height of the uterus corresponds to the gestational age then that means it is a case of threatened abortion if height of the uterus is less than the period of gestation then it is a case of missed abortion clear to all of you okay now I also want you to tell me what is the ultrasound criteria for missed abortion what is the ultrasound criteria for diagnosing missed abortion so there are two very important criterias which you have to remember number one if mean Sac diameter is more than equal to 25 millimeters and there is no fetal pole which is seen that means Crown rump length cannot be measured then that is a case of Mr portion number two if ground ramp length is more than equal to seven millimeters and there is no cardiac activity then that is the ultrasound criteria for missed abortion very very important clear to all of you now everything about cervical incompetence and about the circle art surgeries I have covered in my pyq session that is also important then I will also cover a few other important points related to Circular surgery in my upcoming session in the image based session right no coming to ectopic pregnancy ectopic pregnancy May most of the times the questions which they ask you is either on management of ectopic pregnancy or they ask you what is the next step right so in case of ectopic pregnancy I want first of all that you read this question what is this question a 26 year old female with five week seminaria with spotting PV her upt is positive TVs shows empty uterus and there is no fluid in pouch of Douglas what is the next line of management and this is how most of the times questions are asked right so whenever you are getting a question where they say that there is a minoria plus bleeding PV plus upt is positive and they ask you what is the next step next step is you have to do a TVs which is already done in this case right please remember that the most consistent or the most specific symptom of ectopic pregnancy is pain in abdominal right now in this case because TVs is already done so I am going to continue from here findings which are confirmatory that you are dealing with ectopic pregnancy and PBS May what are the findings which tell you that no it is not confirmatory for ectopic pregnancy on TBS if you are seeing a gestational Sac with a yolk sack with or without cardiac activity in the tube so if you are getting a gestational Sac along with a yolk Sac with or without cardiac activity in the tube then it is a confirmed sign for ectopic pregnancy and in that case The Next Step will be management of ectopic so suppose is instead of saying empty uterus if they would have said that a gestational Sac is seen and a yolk Sac is seen in fallopian tube and they would have asked you the next step then your next step would have been management of ectopic pregnancy right and then your answer would have been laparoscopy ideally the management is medical management because so we are going to go for laparoscopy but unfortunately a question yeah right so this is not the answer now there are certain findings which you get in case of ectopic pregnancy on ultrasound which are not confirmatory for ectopic pregnancy and these findings are if you are getting a gestational Sac without a yolk sac in the tube so agar cable gestational Sac decry fallopian tube made then that is not confirmatory for ectopic pregnancy right instead of saying that both yolk sac and gestational Sac is given cable gestational Sac death in fallopian tube then that does not confirmatory of ectopic pregnancy right then similarly if they say that on TVs a complex added Excel mass is seen then that is also not confirmatory for ectopic pregnancy if they say a ring of fire sign is seen on Doppler that is also not Conformity for ectopic pregnancy many of you do this mistake Jesse questioned my ring of fire sign Atta you feel okay this is confirmatory for ectopic pregnancy no it's not Conformity for ectopic pregnancy or if your question says empty uterus then also it is not confirmatory for ectopic pregnancy and any of these findings any of these foreign pregnancy and then your next step becomes beta HCG measurement right now if beta HCG comes out to be more than 2000 and still you are not seeing a gestational sac in the uterus that means ectopic pregnancy is confirmed so simply beta HCG more than 2000 and it means it is ectopic pregnancy beta HCG less than 2000 then in that case you have to repeat HCG after 48 hours why are you repeating HCG after 48 hours because if you see that the HCG values in 48 hours nearly double it means it's an intrauterine pregnancy if you see that the values increase but they do not double then it is ectopic pregnancy and if you see that the values decrease then that is abortion right so this flowchart is very very important for you now keeping this flowchart in mind come to this question now the question is saying that there is a 26 year old female who has amenoria she has potting PV her urine pregnancy test is positive TVs is showing empty uterus empty uterus is not confirmatory for ectopic pregnancy that means your next step is going to be you have to measure beta HCG value so you have to follow it up with beta HCG values right so option D is the correct answer over here now discriminatory score someone is saying 1500 no beta it is not 1500 this was the recent values and this I have been telling you for past one year that the values have changed and it has become 2 000 International unit right so the discriminatory score for HCG is 2000 international units now question on ectopic pregnancy which they ask quite oftenly and that is what is the management of ectopic pregnancy so whenever you get a question on management of ectopic pregnancy if your question is talking about ruptured ectopic right abruptured ectopic how are you going to know that your question is talking about ruptured ectopic because in the question they are going to say that patient has syncopal attacks that she is having pelvic pressure right then that means that they are talking about ruptured ectopic right now in case of ruptured ectopic always the management is surgery and the surgery which you do is self-injectomy whether the family is complete or not hardly matters family complete or not it doesn't matter because if the tube is ruptured you have to do salpinectomy they try to confuse you by saying that the family is not complete even the whether the family is complete whether the family is not complete you are going to go for self-injectomy this salpingectomy can be done by laparotomy or by laparoscopy if vitals of the patient are stable you can do laparoscopic salpingectomy also but if vitals are unstable you have to do a open abdominal salpingectomy that means leprootomy followed by salpingectomy right now this is not the case in unruptured ectopic in unruptured ectopic you can go for medical or surgical management and the Preferred Management is medical management medical management can be done only if vitals of the patient are stable surgical management can be done in stable as well as unstable vitals because surgical management can be done in case of ruptured ectopic as well now if your question says vitals of the patient are stable and patient go unruptured ectopic hair vital stable hair so I'm going to go for medical management but read your question very carefully if your question says family of the patient is complete agar family complete hair then instead of choosing medical management I am going to choose surgical management right HCG levels for medical management they should be less than 5 000 international units if HCG is more than 5 000 international units you have to go for surgical management size of the sac should be less than four centimeters if it is more than equal to four centimeters we will go for surgical management cardiac activity should be absent then we go for medical management if cardiac activity is present we go for surgical management but this is only a relative requirement cardiac activity so that doesn't mean that medical management is contraindicated only problem is that if cardiac activity is present and if you are doing medical management there are increased chances of failure so we prefer surgical management medical management is done with a single dose methotrexate whereas surgical management is done la proscopically and in this case the surgery depends upon whether the family is complete or not complete if family is complete then the surgery which I am going to do will be salpingectomy but if the family is not complete then I am going to do salping cost to me when you are doing salping cost to me you make a cut just above the place where ectopic is there so in the tube wherever the ectopic is located just above that you are going to make an incision you are going to remove the ectopic pregnancy by Hydro dissection and then you are going to let the tube remain like this only you do not suture it back right that is what is salping cost to me please remember in case of ectopic pregnancy ovaries are not removed unless and until it is an ovarian ectopic so salping go oophorectomy Is Never Done Right uh as far as your expectant management is concerned in case of expectant management expectant management will never be your answer of choice you are never going to say that in a patient I am going to go for expectant management this is because expectant management clear there are some stringent criterias which should be fulfilled number one expectant management is done in an ectopic pregnancy which is automatically resolving right so they are going they have to give you two values of HCG and those values and day after tomorrow yeah tomorrow the values should be decreased so they have to give you two values of hcgs which are automatically decreasing number two in case of expectant management patients should not come to you with any pain in abdomen there shouldn't be any gestational Sac which should be visible in the tube and the values of HCG they should be less than 200 international units so expectant management they are not going to ask you questions on expectant management clear now one question which they may ask you is what is the name of the criteria if ectopic if there is an ovarian ectopic now the name of the criteria for ovarian ectopic it is speigelberg criteria special work criteria then for a cervical ectopic it is permanent's criteria or a Reuben criteria then for abdominal ectopic it is study form criteria study from criteria right so this is what you have to remember in ectopic pregnancy now coming to gestational trophoblastic diseases what are the points which you have to remember for a gestational trophoblastic diseases in gestational trophoblastic diseases you have molar pregnancy and you have a gestational trophoblastic neoplesias right now in molar pregnancies we have partial mole and complete mole there are only two problems which come under molar pregnancy in partial mole the chromosome number is 69 x x y it is triploid and fetal tissue will be present in case of complete mole uh complete mole is also called as vesicular mole or it is also called as hydrated form mole the chromosome number is 46 XX patient of molar pregnancy will come to you with first trimester bleeding then pay question with yahoga patient is having excessive vomiting that is there is hyperemesis gravitarum there is increased levels of thyroid hormones and there is early onset PIH question will say that the height of the uterus is more than the period of gestation and question is going to show you an ultrasound this may snowstorm appearance will be seen all this points towards a complete mole right in case of partial mole all these symptoms are present but to a lesser extent in comparison to a complete mole now whenever you get a molar pregnancy whenever you get a molar pregnancy then the management which you have to say is that I am going to go for suction evacuation but if your question says specifically that the age of the patient is more than 40 years and her family is complete then in that case choose the answer as hysterectomy you will say I'm going to do hysterectomy right if they ask you that what is the management for thika lutein cyst there is no treatment needed for the collutian cyst Java suction evacuation for molar pregnancy then automatically after some time this thika lutein cyst is going to resolve on its own so no treatment needed for thecal lutein cyst so this they can ask you that what is the management of thikalutrances and options evacuation suction evacuation evacuation suction evacuation means suction evacuation of molar pregnancy right then indication indications sorry investigation which you are going to do for follow-up investigation which you are going to do for follow-up is HCG what is the investigation of choice in a molar pregnancy it is TBS what is the gold standard investigation in case of molar pregnancy it is histopathological examination so whether you are doing suction evacuation or whether you have removed the entire uterus you have to send the tissue for histopathological examination and you have to follow it up with beta HCG levels follow-up is done for six months and for these six months pregnancy is contraindicated the contraception of choice which you give in molar pregnancy is oral combined pills now what are the signs and symptoms again a very important thing that what are the signs and symptoms that tell you that a patient of molar pregnancy has developed gestational trophoblastic neoplasia so number one if your patient is having persistent bleeding after suction evacuation or if thika lutein cysts persist then that indicates that it has changed into a gtn if patient goes into shock if there is sub involution of the uterus or if there are signs of metastasis most common site for metastasis in case of gtn most common site is lungs and the most common appearance which you get on chest x-ray when there is lung metastasis it is Cannonball appearance followed by snow storm appearance followed by the snow storm appearance right the second most common site for metastasis is vagina so if you are getting any of these signs and symptoms then that indicates that patient has developed gtn or if you are getting any of these lab investigations so you have done HCG levels for three weeks and in three consecutive weeks you are getting increasing HCG levels how much increase more than 10 percent you have done HCG levels for four consecutive weeks and in four weeks you are getting almost the same level almost the same level means within 10 percent of previous levels if HCG can be detected even after six months of suction evacuation or when you had sent the tissue for histopathological examination the report is saying that gtn is present then all this are signs and symptoms and lab investigations which tell you that your patient has developed gtn now what is the most common gtn which develops after molar pregnancy it is invasive mole what are the other gtns which can happen it is choreo carcinoma PST and ett now choreo carcinoma most commonly occurs after choriocarcinoma most commonly occurs after molar pregnancy after full term delivery which is the most common gtn after full term delivery the most common gtn is choriocarcinoma so I have told you three questions after molar evacuation after molar pregnancy which is the most common gtn invasive mold after full term pregnancy which is the most most commonly occurs after it occurs after molar pregnancy right now whenever you are getting a gtn specifically for invasive mole and for choriocarcinoma management is chemotherapy in case of stage 1 gtn stage one gtn means that the tumor is limited to the uterus the chemotherapy which you have to give is multi-dose methotrexate in case of stage 4 gtn stage 4 gtn that the tumor has spread to brain or to liver in this case you have to give emacco regime so you don't have to use a single drug you have to use many drugs and this is what is e Mac origin now if it is a stage 2 or stage 3 gtn stage 3 gtn lung metastasis stage two Ka Matlab have vagina metastasis now if the metastasis is in lungs or vagina that is stage 2 or stage three now in order to decide whether I have to give a single drug or whether I have to give a macro regime we are going to do who scoring system if who scores comes out to be less than equal to 6 that means it is a low risk disease in this case you are going to use only Methotrexate and that is multi-dose methodrexate but if score comes out to be more than equal to 7 that's a high risk disease and in high risk disease you have to use e Maco Richie clear to all of you in case of gtn you have to do follow-up for one year and for one year pregnancy is contra indicated so it is only in stage two and stage three that you have to do a who scoring system if score comes out to be less than equal to 6 it's a low risk disease give Methotrexate only Methotrexate but you have to give it as multi-tools and in between I'm going to give folic acid right and if it is a high risk disease that means the score is coming as more than equal to seven then you give e mac o now what does emaco stand for e is for etopocyte M is for methotrexate A is for actinomycin d C is for cyclophosphamide and O is for on Co when right clear to all of you then now comes important points on p i h now when do you say that a female has hypertension we say that a female has hypertension if a BP is more than equal to 140 by 90 on two occasions four hours apart so suppose a patient comes to you and a BP and it is coming out to be 140 by 86. I am not going to call it as PIH I'm going to repeat her bp after four hours and if still it is more than so either systolic should be more than 140 or diastolic should be more than 90. this is one big area where you confuse even if systolic is more than 140 or if diastolic is more than 90 you are going to call it as high BP but then this reading should be taken twice right now uh the other thing which I want you to understand is suppose a patient comes to you and her bp is more than equal to 160 by 110 so either a systolic is more than 160 or a diastolic is more than 110. in that case please do not wait for four hours in that case repeat her bp in 15 minutes and still if her bp is increased immediately give her anti-hypertensive your four hours if BP is more than equal to 140 by 90 but less than 160 by 110. a PIH May the most important thing which they ask you is classification they are going to give you a scenario and you will have to classify whether it is uh you know um which type of hypertension is happening in pregnancy you will have to recognize that so suppose your question says that BP is more than equal to 140 by 90 at less than 20 weeks of pregnancy so Kabhi BP more than 140 by 90 hay at less than 20 weeks of pregnancy that means it is a case of chronic hypertension in pregnancy right this is a case of chronic hypertension now what has happened okay so uh if your BP is if the patient's BP is more than equal to 140 by 90 at less than 20 weeks it is chronic hypertension in pregnancy now suppose BP is more than equal to 140 by 90 at less than 20 weeks but suddenly at 20 Peaks her bp became uncontrollable she started having proteinuria or she started having signs of n Dharma can damage any of these three things then you are going to change your diagnosis and you are going to call it as chronic hypertension with super imposed pre-eclampsia right there now suppose your questions gives you a third situation question says that the patient's BP is high for the first time this High BP happened after 20 weeks so this High BP happened after 20 weeks there is no proteinuria and there are no signs of end organ damage now your diagnosis now your diagnosis is going to be gestational hypertension so if BP is more than equal to 140 by 90. right but there is no proteinuria there are no signs of end organ damage then that is gestational hypertension right now suppose they say that BP is more than equal to 140 by 90 and this increase in BP is happening after 20 weeks proteinuria present here yeah signs of end organ damage present to any of them is present then your diagnosis is going to change and now your diagnosis is going to become pre-eclampsia now you are going to say that the diagnosis is pre-eclampsia right now so if signs of proteinuria yeah signs of end organ damage present here and BP is increasing after 20 weeks then it is preeclampsia if BP is increasing after 20 weeks and there are no signs of proteinuria nor there are signs of end organ damage then that is gestational hypertension a pre-eclampsia May whenever you are making a diagnosis of pre-eclampsia the next thing which you should check is what BP have they given and whether they have given you signs of end organ damage or not other BP sorry if BP is more than equal to 140 by 90 if BP I don't know what has happened to my pencil today if BP is more than equal to 140 by 90 but less than 160 by 110 uh or there are no signs of end organ damage then this is mild preeclampsia if BP is more than equal to 160 by 110 or if Sines of end organ damage are present then this is severe preeclampsia severe preeclampsia there are two criterias one is BP criteria and another is signs of end organ damage criteria so signs of end organ damage present here or if BP is more than equal to 160 by 110 then you call it as severe pre-eclampsia right severe pre-eclampsia patients then that is what is a clampsia take agreed okay now so if you've understood the classification of ah you know various hypertensive disorders which can happen in pregnancy now let us deal with management now whenever they are asking you management of mild PIH mild PIH BP is more than 140 by 90 but less than 160 by 110 management main number one is anti-hypertensive scar there is no rule there is no role of anti-hypertensives nice guidelines says nice guideline if BP is more than 150 by 100 then you may give antihypertensives right but otherwise as such we don't give antihypertensives for mild pre-eclampsia mild preeclampsia see a pre-eclampsia it happens because of a problem which is there in the placenta and what problem is there just now we will revise that also quickly so always the best management for hypertensive disorders is or the definitive management for hypertensive disorders is termination of pregnancy and termination of pregnancy in case of mild preeclampsia you do it at third more than equal to 37 weeks right then severe PIH management severe PIH management main number one you have to give antihypertensives hunting hypertensives hundred percent anti-hypertensive which you can give is labetalol you can give hydralazine or you can give nifedipine tick now because severe PIH patient may patient any time can throw convulsions and she can have eclampsia so you have to give magnesium sulfate to prevent convulsions you have to give magnesium sulfate and number three termination of pregnancy that is the definitive management and when are you going to do termination of pregnancy at more than equal to 34 weeks another very important question is because severe PIH patient may uh they can be eclampsia so what are the signs of impending eclampsia in a patient of severe PIH so if your patient of PIH is having headache if she is having epigastric pain or if she is having visual symptoms then it means that she can throw convulsions at any time so you are going to give her magnesium sulfate you are going to give antihypertensive and you are going to do termination of pregnancy at more than equal to 34 weeks eclampsia patient eclampsia patient is throwing convulsions and coming to you so the first step in management is either of the two either Airway management the ahoga options May yeah it will be you have to prevent the patient from falling and that is why you have to you have to prevent the patient from falling down so you have to raise the bed rails right then number two because she's throwing convulsions you are going to give magnesium sulfate because her bp will be high you are going to give anti-hypertensives and again which antihypertensives labetalol hydralazine or nifitipine right and you are going to go for immediate termination of pregnancy have you understood that is the management for eclampsia as far as how to give magnesium sulfate is concerned what is the Pritchard regime and what are the toxicities which are seen with magnesium sulfate everything I have covered with you in the pyq session so everything related to magnesium sulfate is covered there right now what are the conditions where you are going to do immediate termination of pregnancy in a patient of preeclampsia or in a patient of PIH so if your patient has impending eclampsia or if your patient is a patient of help Syndrome again everything related to help syndrome I have taught in the cello pyq session if your patient has uncontrollable BP so could be acute eventually so you are not going to wait for termination of pregnancy you are going to do immediate termination of pregnancy for example impending eclampsia help syndrome uncontrollable BP placental abruption DIC if your patient has Mi stroke or pulmonary edema or if there is fetal distress in all these cases you are going to give the first dose of corticosteroid and you are going to immediately deliver you are not even going to wait for 48 hours to give the next dose no you are not going to do that clear to all of you yes they now coming to a very important topic point on PIH where they ask you questions they will ask you a question on the pathophysiology of PIH so if you remember in the LA cello pyq session I told you that in case of PIH there is incomplete trophoblastic Invasion by the extravillus cytotrophoblast right now extravilus cytotrophoblast endovascular cytotrophoblast now you people are asking me that in case of PIH how are we going to terminate pregnancy we are going to terminate pregnancy by induction of Labor which I always in PIH we go for vaginal delivery cesarean section is only reserved for obstetrical indications right and suppose question that there is a patient of PIH just may by due to some reason you are doing cesarean section then what is the anesthesia of choice the anesthesia of choice will be neuroxyl anesthesia that's the best answer agar neuroxyl anesthesia options then the second best answer is going to be epidural anesthesia right so always in case of PIH termination of pregnancy induction of Labor right unless and until there is some obstetrical indication for cesarean section clear okay now coming to a very important thing so as I was telling you pathophysiology may remember it is due to incomplete trophoblastic Invasion what you forget is that it is because of this incomplete trophoblastic invasion is of extravillus cytotrophoblast or endovascular trophoblast which are the cells which play a very important role in vascular remodeling which cells play a very important role so it is Mother's natural killer cells which play a very important role in vascular remodeling right now remember that there are certain uh mermaid mediators which are increased in a case of PIH and there are certain mediators which are decreased in a case of PIH vasoconstrictors increase and vasodilators decrease so SF LT1 increases in PIH there is increased serum endoglin levels and endothelial levels endothelene levels increase in PIH vascular endothelial growth factor decreases placental growth factor decreases nitric oxide decreases and prostate cyclin levels decrease in PIH very very important it has been asked in your ioni set exam and this may be asked in your neat exam right so sflt1 and endoglin levels and endothelene levels increase then nitric oxide prostacyclines vascular endothelial growth factor and placental growth factor levels decrease to predict PIH I told you you have to do you try notary Doppler which is normally done between 22 to 24 weeks these days we are doing it between 11 to 13 weeks to go for early uh onset pre-eclampsia to diagnose early onset preeclampsia to prevent PIH the drug of choice is aspirin this is something new which came in your Williams and that is in what are the risk factors where you have to give aspirin conditions where you have to give aspirin to prevent PIH so for that the mnemonic which you can remember is all hypertensive mothers can die right so a stands for appla in appla syndrome you have to give aspirin then hypertensive stands for previous history of PIH you have to give aspirin if it is multi-fetal pregnancy you have to give aspirin if mother has kidney disease you have to give aspirin if diabetes mother has you have to give aspirin so all hypertensive mothers can die in these conditions you have to give aspirin to prevent PIH there is no role of bed rest there is no role of antioxidants to prevent pis there is only role of aspirin to prevent PIH this aspirin should be started between 11 to 14 weeks and it should be continued up till 36 weeks right and you have to give low dose aspirin 75 to 180 mg of aspirin right so this is what you have to remember in case of PIH now coming to what are the important points which you have to remember in case of diabetes so in diabetes what you have to remember is that for the diagnosis of diabetes in India we follow the Tipsy criteria according to the Dipsy criteria the test you are going to do at the first antenatal visit and then you are going to repeat it between 24 to 28 weeks no fasting is needed and you have to give glucose 75 grams of glucose and then you are going to check blood sugar levels after two hours if after two hours blood sugar levels are less than 140 then there is no diabetes if levels are more than equal to 140 then gdm gestational diabetes if levels are more than equal to 200 then it is a case of pre-gestational diabetes right the IAD PSG criteria to diagnose gestational diabetes so for gestational diabetes the IAD PSG criteria or the American Diabetes Association criteria is see most commonly you have to remember Dipsy like an ID PSG has been asked in ini set that is why I'm telling you here so according to IAD PSG criteria the testing can be done between 24 to 28 weeks fasting is necessary for that test and again you are going to give 75 grams of glucose and you are going to check her fasting blood sugar levels 1 RPP levels and two RPP levels cut off for fasting blood sugar is 92 for 1 RPP it is 180 and for 2 RPP it is 153 92 pay question now out of so remember it is 92 many of you at that time marked it as 95 it is 92. out of these three values if one or more than one value is abnormal then you can diagnose it as a case of gestational diabetes Now for pre-gestational diabetes or overt diabetes the criteria is fasting if it is more than equal to 126 if 2 RPP is more than equal to 200 or if hba1c is more than equal to 6.5 then you make a diagnosis of pre-gestational diabetes now once the diagnosis is made and if you have a patient of gestational diabetes first thing what you are going to do is you are going to put her on diet modification and this diet modification has to be continued for two weeks after two weeks you are going to check her to RPP value if her 2 RPP value is less than 140 that means blood sugar diet modifications so you will continue diet modification and you are going to monitor her to RPP levels regularly why am I monitoring her two RPP levels regularly because insulin requirements increase in pregnancy and insulin resistance also increases in pregnancy Advance insulin resistance to maybe diet is sufficient just now to control her blood sugar but after some time it might not be sufficient so that is why if your patient is on diet modification regularly you have to check her two RPP levels are National guidelines say that up till 28 weeks of pregnancy you have to check her blood sugar levels once in two weeks and after 28 weeks you have to check her blood sugar levels once in a week right now if her two RPP levels at any point of time they come out to be more than equal to 140 then that means you have to start insulin because the drug of choice for treating diabetes is insulin and now once you have put her on insulin then you are initially you are going to measure her two RPP values initially after every two days sorry initially after every two days initially after every two days and then once her blood sugar levels are stabilized so you are going to measure her values after every two days and simultaneously increase the rules of insulin blood sugar levels they get stabilized then you check it off every weekly other than that in all patients of gestational diabetes you are going to do a level 2 scan at 18 to 20 weeks now because gestational diabetes does not lead to congenital malformation that doesn't mean level 2 scan has to be done in all pregnant females so in gestational diabetes also I have to do a level 2 scan at 18 to 20 weeks then from 32 weeks onwards because diabetes is a high risk pregnancy I will do anti-partum fetal surveillance and I am going to do her ultrasound for fetal growth not only for fetal growth also to check polyhydramnios because in diabetes polyhydramnios is carbon then when do I terminate pregnancy if it is well controlled diabetes then the termination of pregnancy has to be done around 39 weeks but if diabetes is not well controlled then it has to be done between 37 to 38 weeks this is the management of gestational diabetes in case of overt diabetes there is no role of only diet man modification never do you say cable diet modification the moment you make a diagnosis of overt diabetes you have to put your patients on insulin plus diet modification plus you are going to put her on aspirin as I told you just now all hypertensive mothers can die divorce for diabetes so in all diabetic patients I have to give aspirin to prevent Piers I have to give them aspirin to prevent diabetes investigations gestational diabetes all those investigations I have to do in overt diabetes also Plus in overt diabetes I have to do fetal Eco because congenital malformations are seen in word diabetes and the most common congenital malformations are related to cardiovascular system so gestational diabetes me fetal Eco is not needed but in Con in overt diabetes fetal Eco is needed complications of diabetes maternal complications of diabetes may it can lead to infection it can lead to preterm labor and it can lead to polyhydramnios because of polyhydramnios they can be placental abruption they can be PPH they can be caught prolapse then there are increased chances of PIH and increased diabetes in future fetal complications of diabetes very important the most common fetal complication of diabetes is macrosomia macrosomia can lead to shoulder dystocia in fetus again there is hyperglycemia then they can be abortion IUD stillbirth and rarely in a case of diabetes when do you get oligo or iugr in a case of diabetes if it is a case of diabetes with vasculopathy if your patient has diabetes with vasculopathy or she has diabetes and PIH then rarely you may give you may get oligohydramnios or iugr in a case of diabetes congenital malformations they are seen only in pre-gestational diabetes so if they ask you that what is the dose of folic acid which you give to a patient with diabetes it is 400 micrograms do not say 4 milligrams right the most common congenital malformation which you get is VST followed by neural tube defect the most specific congenital malformation which you get is sacral agenesis and the most specific cardiac malformation which you get is TGA in neonate you are going to get hypoglycemia hypocalcemia hypomagnesemia hypokalemia hyper viscosity syndrome hyperbilirubinemia polycythemia respiratory distress syndrome and necrotizing enterocolitis right now in entire orbs they do not ask you many questions on risk factors but other risk factors so they are going to ask you risk factors from five places one is risk factors of PIH another is risk factors for placenta previa third is risk factors for abruptio fourth is risk factors for PPH and 5 is risk factors for endometrial cancer so I have written all those risk factors over here risk factors for PIH risk factors for uh PPH plac placenta previa and abruptio and I have also written risk factors for endometrial cancer since you people are saying that uh to provide these slides to you so this is something which you are going to study on your own all the risk factors are written over here this is a very very important slide right then there are certain named classifications which you should be knowing in case of OB gy so number one is Page classification page classification is used for abruptio in abrupt show you have grade 0 grade 1 grade 2 and grade 3. grades Central plot that means patient symptoms of abruptio grade 1 means patient bleeding pain and abdomen but fetal heart sounds is normal grade two means pain and bleeding to hogai because that is a symptom of abrupture but now there is fetal distress grade three means there is fetal death plus mother is in shock or if there is DIC so if there is fetal death or if their mother is in shock or if there is DIC that is great three please remember in abruption par vaginal examination is not contraindicated only if you have ruled out placenta previa once you've ruled out placenta previa you can do a provisional examination in a patient of abruptio the first investigation which you do in case of aph is trans abdominal scan and the investigation of choice for placenta previa is TVs the new classification for placenta previous according to the new classification we have placenta previa and low line placenta in my pyq session I told you that placenta previa is the previous classification made type 2 type 3 and type 4th that is now placenta previa and previous classification major type 1 that is low-lying placenta always whether it is a low-lying placenta or whether it is placenta previa management is cesarean section right then comes Priscilla white classification Priscilla white classification is a classification of diabetes jisme we have type A diabetes and type non-type A Diabetes Type A diabetes gestational diabetes diabetes this is what I want you to remember up type AMA we have type A1 and A2 A1 gestational diabetes which is controlled on diet A2 Ka Matlab gestational diabetes which is controlled on drugs that drug can be insulin that drug can be metformin non-type pre-gestational diabetes remember in diabetes the drug of choices insulin the second point which you have to remember gestational diabetes may be drug of choice insulin hair but if patient refuses to take insulin you may give metformin but in case of pre-gestational diabetes whether patient wants or doesn't want always you have to give insulin you can never use metformin to treat pre-gestational diabetes then there is a who classification for heart disease who classification for heart disease made there are four classes and all heart diseases are classified based on how much maternal mortality and morbidity they lead to I am on slide 16 and there are slides 28 right so there are 12 more slides remaining I don't know when we are going to complete the session today if you have got tired I can end it over here but I'm not going to take the session again now whatever is done today is done after this is an image based session now I want you don't want you to remember the entire who classification I just want you to remember who class four who class 4 of heart diseases which are where there is absolute contraindication to pregnancy right so if they ask you in which heart diseases pregnancy is absolutely contra indicated that comes in who class four now sub absolute contraindicated if patient is coming to me in the preconception period and she's asking me should I conceive or not but if patient conceives and comes then I'm going to tell her please go and get an MTP done so whether they ask you what are the heart diseases where pregnancy is contraindicated or whether they ask you what are the heart diseases where MTP is indicated these are the heart diseases yes these slides include skinny also so both orbs and gyne I'm completing today so there are 10 heart diseases where pregnancy is contraindicated which come under who class four number one if left ventricular ejection fraction becomes less than 30 please remember in pregnancy normally left with ventricle ejection fraction remains normal kabibi left ventricular ejection faction decrease and normal ejection fraction is more than equal to 55 percent so if in pregnancy any time due to any heart disease if left ventricular ejection fraction is becoming less than 30 percent then that's a contra indication to pregnancy number two any wherever there is severe mitral stenosis severe mitral stenosis means area less than 1.5 centimeter Square severe iotic stenosis again severe iotic stenosis means area less than one centimeter Square whether it is severe iotic stenosis or mitral stenosis will decrease so automatically that becomes a contraindication then any heart disease which belongs to nyha class 3 or class 4. that comes that is a contraindication pulmonary hypertension if there is any heart disease this may pulmonary hypertension this pulmonary hypertension could be primary or it could be secondary an example of secondary pulmonary hypertension is icen Menger syndrome right then Marfan syndrome and bicuspid iotic valve please remember normally marfon syndrome is not a contraindication but if there is Marfan syndrome with iotic root dilatation or if there is a bicuspid iotic valve with root dilatation in other words severe quotation of Iota then that is a contra indication to pregnancy now if you are not a marrow subscriber then and you have been reading I don't know from where these are the two contraindications which you should add in your notes in Williams to all the marrow subscribers you have done this with me already I have updated Edition 6 as per the new Williams so these are the two new contraindications to pregnancy one is Fountain surgery remember Fountain surgery woe surgery which is done in hypoplastic left heart syndrome Fountain surgery Curry and there is some residual defect or if your patient has history of peripartum cardiomyopathy with residual defect then these are contra indications for pregnancy so these are 10 Contra heart diseases where pregnancy is contraindicated so I was talking to you about named classifications named classification May ache or name which you have to remember is robson's classification robson's classification it came in your ini set robson's classification code 10 point classification and robson's classification is for comparing the rate and the indications for cesarean section so institutions May basically use to see what are the major indications for cesarean section and what are the rates for cesarean section for those major indication just the name robson's classification which is also called as 10 point classification so these are the various named classifications which you have to remember in OB gy then you have to remember Bishop scoring now I am sure if you are a marrow subscriber you know this that Bishop score Kelly I tell you a mnemonic and that is Delhi police employed special Commandos special Commandos with b stands for dilatation of the cervix P stands for position of cervix e stands for effacement of cervix s stands for station of fetal head and C stands for consistency of cervix now Bishop score is done before you go for induction of Labor so before you go for induction of Labor you are going to do a Bishop score and you are going to check the score right now induction of Labor please remember Bishops that is 13. and if score is less than equal to 5. then it is a poor score if score is more than equal to 6 then induction of Labor can be done and your volume says that if score is more than equal to if score is more than 9 if the score is more than 9 then there are high chances of success of induction of Labor right so this is Bishop score I want key now what you are going to do I don't know whether you people have prepared a 20th notebook or not if you have prepared a 20th notebook the bifurcation of the score should go in how to calculate Bishop's core and need May sometimes they ask you to calculate the Bishop score so I want all of you to please write this down in a piece of paper and stick it either on your wall or in your 20th notebook how to calculate Bishop score it is very very important the other important thing is modified Bishop score May instead of effacement the parameter which you use is length of cervix and length of cervix is always measured by t v s I know you people are always my students for OB gy and this is the reason why I am bringing out these sessions for you already for marrow students the revision videos have been uploaded long time back because I did not want you people to miss out this is the reason why I am bringing out these these videos for you people especially because as I say all of you are my bachas right no matter to which app you subscribe no matter to which coaching you go but for OB gy I know you follow me blindly and that is why I have to give you the most and the maximum okay so yes uh Suraj in modified Bishop's core it is the effacement which is replaced by length of cervix right clear to all of you Bishop's core now there is one more score which you are going to remember and that score is biophysical score so there are two scores which you have to remember one is biophysical score and the other one is Bishop score biophysical score is uh you know it is the diagnostic test for knowing whether the fetus is well or not so what are the indications for biophysical score indication for biophysical score is whenever you get a non-stressed test non-reactive if NST is non-reactive whenever you get a non-reactive NST it should be followed by a biophysical score biophysical score biophysical score is calculated by ultrasound on ultrasound for 30 minutes you have to see the following parameters what are the parameters TB meningitis always notorious TB meningitis always notorious T stands for uh one second Avi modified Bishop score bifurcation you don't need to know you need to know the bifurcation only for Bishop's core see practically hum always we use Bishop score because Bishop's score May we are using effacement effacement is checked clinically and length of the cervix is checked with the help of ultrasound that is why modified Bishop score is never commonly used and could be modified Bishop's score May you will never get to calculate a modified Bishop score right now coming to biophysical score in biophysical score uh it is TB meningitis always notorious where T stands for fetal tone so in 30 minutes if you are getting more than one episode of flexion and extensions May more than one episode one or more than one episode of flexion or extension that means you are going to give a score of plus two right if if you are not getting any extension or any flexion then you are going to give a score of zero next thing which you have to see is breathing movements in 30 minutes you should get one or more than one episode of breathing I'm actually breathing to fetus this is chest wall movement so you should get one or more than one episode of chest wall movement and that should last for 30 seconds so the score will be given as plus two many then gross body movements in a period of 30 minutes you should get three or more than three movements if you are getting three or more than three movements you will give a score of plus two then you are going to look at the single largest vertical pocket so there should be at least one single largest vertical pocket measuring two by two centimeters if you are getting this then the score will be again plus two I don't know what has happened to my pencil then it is NST you are going to do NST and if you are getting 2 or more than two accelerations in a period of 20 to 40 minutes then you are going to give a score of plus 2. so in case of biophysical score to each of these parameters you either give a score of plus 2 or you give a score of 0. in between either it has to be plus 2 or 0 so maximum score which you can get is 10 by 10. so you are getting a score of 10 by 10 or if you are getting a score of 8 by 10 with amniotic fluid volume normal but the score is eight by ten in either cases we say that the fetus is normal and we have to repeat this test weekly right now if you are getting a score of 6 by 10 score 6 by 10 here but again amniotic fluid volume is normal that is an equivocal result in this case if the gestational age is more than equal to 37 weeks please deliver the baby but if gestational age is less than 37 weeks you have to repeat the test in 24 hours now comes if the score is 8 by 10 or 6 by 10 but amniotic fluid volume is decreased in that case you have to deliver at 36 weeks if score is 4 by 10 deliver at 32 weeks so remember 6 by 10 May delivery here six by ten with normal amniotic fluid delivery yeah 37 weeks pay amniotic fluid decreased here and eight by ten hey yeah six by ten so delivery at 36 weeks pay four by ten here at 32 weeks and if it is 2 by 10 or 0 by 10 immediate delivery all of you are going to note down this this is what is new in Williams or the you know how to treat uh what is the next step if biophysical score is 10 by 10 or 8 by 10 or 6 by 10 or 4 by 10 so this is very very important right okay now uh again something new which I want to tell you here CDC name contraindications to breastfeeding this is something new which has come up if you are a model subscriber I want you to write this again and if you are not a marrow subscriber you have to write it if you are a Mario subscriber please note this down this is something new which has come cdc's Contra indications for breastfeeding so CDC there is one absolute contraindication for breastfeeding and that is if there is galactosemia if baby has galactosemia then that is an absolute contraindication for breastfeeding other contraindications for breastfeeding are if mother is on any anti-cancerous drug or if she is on any chemotherapeutic agent or if she is used IV drug abuser if mother has infections like brucellosis HSV Ebola virus htlv1 or htlv2 if mother has chickenpox and this chickenpox has happened within five days prior to delivery or two days after delivery if there is active TB infection in case of active TB infection if a female has taken ATT for two weeks then she can breastfeed the baby in India HIV is not a contraindication for breastfeeding so brucellosis HSV Ebola virus htlv1 htl V2 varicella zoster which has happened within five days prior to delivery or two days after delivery active TB infection all these are contra indications to breastfeeding I don't know is the live session still going on in my this it is showing um are you able to see me and can you hear me is there some problem with my internet because I can't see you all my this is showing that no I am not visible going on then I won't waste time a few people are going on right now so I was telling you about we have done uh Bishop score we have done biophysical score now important point on twins very very important now twins may all of you know that there are four varieties of twins dichorionic diamniotic monochorionic diamniotic monochorionic monoamniotic and conjoined twins right so dichorionic diamniotic all diesygotic twins are dichorionic diamniotic monozygotic twins May if division happens at less than four days that means in a modular stage then you get dichoronic diamniotic twins dichorionic diamniotic twins always have best prognosis on ultrasound in dichoronic diamniotic twins you will see two placentas you are going to get thick membranes between the Twins and Twin Peak sign or Lambda sign will be positive please remember that in the image based session which I am going to conduct I will show you placentas of various Twins and I will also show you this Twin Peak sign just now I want you to remember that dichorionic diamniotic twins May there are thick membranes between the twins so if you draw dichorionic quickly draw dichorionic diamniotic twins so this over here is Korean this is amnion this is Twin one this is Twin Two this is uh corion of first twin this is amnion of first twin this is Korean of second Twin this is amnion of second Twin so what you are seeing you are seeing thick membranes between the Twins there are four layers of membranes or the thicknesses more than equal to two millimeters right now comes monochorionic diamniotic twins monochorionic diamniotic twins when a monozygotic twin made division happens between four to eight days that means in the blastocyst stage now in case of monochorionic diamniotic twins on ultrasound membranes will be thin there will be less than two millimeters and Twin Peak sign will be absent you are going to get a t sign present right now let us draw monochorionic diamniotic this is monochorionic diamniotic amnion amnion corion right so both the twins are surrounded by single chorion and separate amnions so as you can see over here the membranes will be only having only two layers and they will be less than two millimeters thick now monochorionic twins always have by a bad prognosis twins May there are certain specific complications which you get monochorionic diamniotic twins May the complication which you get is number one twin to Twin transfusion syndrome in Twin to Twin transfusion syndrome there is deep connection between artery and vein of the twins eight twenty deep artery is connected to deep vein of the other twin so donor twin Mage you are going to get anemia you are going to get poly oligohydramnios anemiah oligohydramnios and because there is anemia the there will be decreased renal blood flow so there is going to be renal failure there are chances of of heart failure and the growth will be less the most important thing which you have to remember that in case of twin to Twin transfusions in Rome you get oligohydramnios in donor twin right whereas in recipient twins there will be poly polycythemia polyhydramnios polycythemia say there will be increased chances of thrombosis then there are increased chances of congestive heart failure and the growth will be increased now whenever you have monochorionic diamniotic twins delivery should be done between 34 to 37 weeks why this bigger range the range is so big because if the twins do not have twin to Twin transfusion syndrome do the delivery at 37 weeks agar twin to Twin transfusion syndrome present here to do it near 34 weeks dichorionic diamniotic twins made deliveries done at 38 weeks very very important right now Suppose there is a vascular Connection in monochorionic twins but then that vascular connection is very small and it is leading only to hemoglobin difference it is not leading to any difference in amniotic fluid then that is called as Taps what is tabs twin anemia polycythemia sequence twin anemia polycythemia sequence difference between twin to Twin transfusion syndrome and twin anemia polycythemia sequences twin to Twin transfusion syndrome amniotic fluid difference there will be oligohydramnios in recipient twin there will be polyhydramnios twin anemia polycythemia sequence made there is no difference in amniotic fluid only the difference is in hemoglobin levels right then a third problem can be seen in monochorionic diamniotic Twins and that is trap that is Twin reversed arterial perfusion trap stands for twin reversed arterial perfusion twin reversed arterial perfusion so today I don't know what has happened to my pencil that I can't write properly twin reversed arterial perfusion up is condition in this condition one twin is absolutely normal other twin doesn't have an heart other twin is a cardiac twin a cardiac it will get deoxygenated blood from the normal twin through umbilical artery right so the a cardiac twin blood which will be deoxygenated and it will be brought by umbilical artery normally in fetuses blood is brought to the fetus by umbilical vein in this condition the twin is getting blood via umbilical artery and that blood is deoxygenated and that is why it is called as twin reversed arterial perfusion right because it is get it this twin doesn't have any heart so it may lead to development only of lower Limbs and that is what is called as a cardius acephalus a cardiac a capillary you are going to get a twin Jessica cable lower limbs developed or it can be a cardias amorphous that means no structure is developed so you will see a twin I will show you all these images on uh 21st so you will get a twin and his twin a piece of mass attached a bus only a piece of mass is attached you cannot identify any structure that is what is a cardius amorphous if you can identify only the lower limbs that is a cardius acephalus right now so these are complications of monoporionic diamniotic twins now if division is happening at more than equal to eight days then it results in monochorionic monoamniotic twins in monochorionic monoamniotic twins this is corion single chorion single amnion and this is how the fetus are lying umbilical cord is in the same amniotic fluid and that is why the complication which can happen is Chord entanglement right so there are no membranes between the Twins this can lead to chord entanglement and in this condition Caesarean section is to be done cesarean section is done between 32 to 34 weeks right then comes if division is happening at more than 12 days it results in conjoined twins conjoined twins May the question which they ask you is see please remember conjoined twins they are variety of twins maybe you have to do a cesarean section between 32 to 34 weeks most common variety of conjoined twins is paraphigus variety jisme the buttocks and the lower part of the body are fused second most common uh variety is thoracophagus then least common variety of conjoined twins is Rocky figures in which the vertebral column is fused and if that is not given then the answer is craniophagus if they ask you twins May what is the indication for cesarean so if it is monochorionic monoamniotic twin or if it is a conjoined twin or if first twin is breach or transverse lie these are indications for doing cesarean section now whenever you are doing vaginal delivery in a twin please do not give injection methyl ergometrine after the delivery of first twin do not give injection methylergometry number two if first twin is vertex and second Twin is transverse lie then for the second Twin transverse lie you have to do internal podalic version internal podalic version is done in OT it is done under general anesthesia you are going to take your hand inside you are going to root hold the baby by its leg and make it breach because you are making it breathe which it is called as internal podalic version what is the risk of internal product version because you are taking your hand inside the uterus and you are bringing the baby's leg out so that is why there is a risk of you trying rupture please remember internal podalic version is contra indicated in previous cesarean section patients right so the only indication for internal product version is if second Twin is transverse lie now someone is asking me when is termination of pregnancy done in conjoined twins please remember conjoined twin is a complication or it is a variety of monochorionic monoamniotic twins right monoamniotic twins Mr cesarean between 32 to 34 weeks similarly in conjoined twins you have to do a cesarean section between 32 to 34 weeks clear okay now suppose your question says that there is a female who has previous history of cesarean section lscs was done due to fetal distress and now in this pregnancy she has twins can you go for V back or 2 lakh yes you can attempt vaginal delivery so if there is previous history of cesarean section and in present pregnancy there is Twins then vaginal delivery can be attempted 2 lakh stands for trial of labor after cesarean section right so coming to what are the Contra indications for 2 lakh or V back what is V back vaginal birth after cesarean to lack is trial of labor after cesarean it is one and the same thing so if any female has previous history of classical cesarean section or a t-shaped incision that is a contraindication if there is history of uterine rupture that is a contraindication if there is history of a uterine scar you know you had done of any uterine surgery of complete you which had entered into the uterine cavity complete thickness of the uterus was involved so suppose myomectomy was done myomectomy you are doing entering into the uterine cavity so history of a uterine scar of complete thickness rights that is a contra indication for Caesarean a contraindication for vaginal delivery these are absolute contraindications for vaginal delivery then relative Contra indications are if there is previous two lscs in the past so if the lower segment cesarean section what twice now third time patient has come to you so it is a relative contraindication for vaginal delivery if in present pregnancy there is breach then that is a contraindication if in present pregnancy there is macrosomia these are contra indications for vaginal delivery after cesarean section please remember in present pregnancy if there is twins it is not a contraindication in present pregnancy if there is PIH it is not a contraindication now if you have if you are doing vaginal delivery in a patient of previous cesarean section is induction of Labor contraindicated no induction of Labor is not contraindicated in previous cesarean section patients but prostaglandins are contraindicated I am going to induce labor by mechanical methods right mechanical methods like foli's catheter whenever my patient is undergoing vaginal delivery and it is a vaginal delivery after cesarean section it is very important that I maintain a partogram and I keep on checking the scar Integrity after every 30 minutes uterine's car has to be checked two centimeters above the pubic symphysis there will be a lot of you trying tenderness right so whenever you are doing vaginal delivery after cesarean section check Force car Integrity after every 30 minutes right now if your question says that there was a case of previous cesarean section right if your question says that in a case of previous Caesarean section all of a sudden the contractions stop and the contractions are no longer felt right and Fetal Parts can be felt per abdominally up contractions but fetal parts are being felt free fluid is present in the peritoneum fetal heart sounds are absent and on per vaginal examination there is loss of fetal station loss of fetal station now I cannot identify any fetal station this means they are talking about uterine rupture fetal Parts sometimes they say that there is a break in the Contour of uterine wall so again that means they are talking about you try and rupture uterus rupture the fetus is dead now the management is you have to resuscitate the mother you have to do laparotomy and you have to repair the uterus other uterus repairs if it cannot be repaired you are going to go for hysterectomy right so this is how you identify you try and rupture in your clinical questions this was a question which came in fmg and I thought I should share it with you this is about obstetrical audit obstetrical audit includes uh is done in is done in all except so when do you do obstetrical audit Upstate see remember auditing whenever I have to report maternal death uh infant death or in case of severe morbidities right so like uh you know if there is uh maternal Miss right so if uh patient was about to die there was a case of severe morbidity then in that case we are going to do obstetrical audit right foreign now some important algorithms which you should know so in some important algorithms you should know management of shoulder dystocia shoulder dystocia is inability to deliver the shoulder even after one minute of delivery of the head and in shoulder dystocia you have to you know manage it in the same manner in which I am Telling You helper where H stands for call for help e stands for give a liberal episotomy L stands for you are going to do the leg maneuver which is Robert's Mech Roberts maneuver where you are going to hyperflex the thighs of the female then you are going to do P that is you are going to give Supra pubic pressure and again perform mcrobert's maneuver this is called as Ruben 1. please remember suprabubic pressure is given in shoulder dystocia but fundal pressure is contra indicated now if this also fails then you are going to go to enter maneuvers you are going to take your hand inside and you are going to rotate the baby this is called as Woods screw maneuver or Ruben 2 manure right if this also fails then you are going to take your hand inside and forcefully deliver the posterior arm of the baby which is called as Jack mirrors maneuver if this also fails to deliver the shoulder then you ask the mother to roll on all four limbs so mother will lie on her all four limbs which is called as Gaskins manure and if that also fails then the last step which you have to do is you have to put the head of the baby inside and do a cesarean section which is zavanelli's manure right in dead babies glidotomy can be done that means you can capture the clavicle of the brain there is a clavicle of the baby there is no role of symphiozotomy right so h e l p e double r helper this is the sequence each and every uh you know maneuver each of these men were has to be tried maximum for 30 seconds and 30 seconds May other shoulder delivered you go to the next step most common fetal complication of shoulder dystocia is herbs palsy which involves C5 C6 nerve roots and most common maternal complication is PPH now what is the man algorithm management for atonic PPH now this algorithm I have already discussed with you when I was doing pyqs right when I was doing the session on pyqs I have told you how to manage PPH this entire algorithm and the you know the dosages of the drugs also I have discussed with you there so please do from there PPH management is very important and you have to remember the sequence in which you manage PPH then infections in pregnancy infections in pregnancy pay if you get a question so there are certain catch points which you have to remember infection and they say that that infection leads to heart disease in the fetus so there is only one infection which leads to heart disease in the fetus and that is rubella right so that means it is talking about rubella so any infection leading to heart disease in the fetus is rubella rubella is the most deratogenic infection it leads to congenital rubella syndrome congenital rubella syndrome will be seen at less than 20 weeks if mother is acquiring rubella infection in congenital rubella's in syndrome you baby is going to have cataract sensory neural hearing loss and congenital heart disease the congenital heart disease which is seen with rubella is patent ductus arteriosis and pulmonary stenosis now if Mother acquires rubella before 20 weeks of pregnancy then the term management is termination of pregnancy now any female who's not vaccinated for rubella and she is not pregnant just now rubella vaccine is contraindicated in pregnancy but to all non-pregnant females you can give rubella vaccine and whenever you give rubella vaccine pregnancy is contraindicated for one month so pregnancy is contraindicated for one month right after giving rubella vaccine but suppose suppose if there is a patient female who gets pregnant in that one month then there is no need for doing MTP congenital rubella syndrome is an indication for doing MTP but patients rubella vaccine and you tell her that she doesn't have to become pregnant for one week right but in that for one month sorry and in that one month please stop writing making these fires I am as I told you my attention gets distracted and then you will learn all wrong things from me so for one instead of saying one month I wrote one I was telling you one week so if in that one month if Mother uh gets pregnant if a female gets pregnant then that doesn't mean that you have to terminate her pregnancy right but please remember rubella vaccine is contraindicated in pregnancy this is what you have to remember about rubella right now other infections of other infections if question is giving you history of eating raw or undercooked meat or if history is saying that there has been contact with cat feces then that means they are talking about Toxoplasma in Toxoplasma maximum transmission of Toxoplasma occurs in third trimester most severe Toxoplasma infection happens in first trimester in Toxoplasma you get a Triad of intracerebral calcification choreo retinitis and hydrocephalus clear now a similar picture you get with cytomegalovirus cytomegalovirus maybe you get chorio retinitis cytomegalovirus maybe you get calcification but that calcification is periventricular calcification and in cytomegalovirus infection instead of hydrocephalus you get microcephaly in case of cytomegalovirus infection question is going to say that mother had contact with toddlers so either she is in a crutch right or she's a nursery teacher right so she will have a contact with toddlers then so cytomegalovirus make choreo retinitis cytomegalovirus May in calcification which is periventricular and cytomegalovirus may there is going to be micro carefully now micro carefully micro carefully can happen because of zika virus also zika virus is the only teratogen which is insect Bond teratogen it is spread by ads mosquito The receptors which are needed for uh acquiring zika viruses Tim one receptor and Tam Axl receptors right because it has affinity for tem1 receptors and Tam Axl receptors and these receptors are present in the half bare cells of placenta that is why zika virus has vertical transmission also jab zika virus vertically transmit hoga and this happened long time back in Brazil there was a zika virus epidemic which had happened all babies which were born had micro carefully there was intracranial calcification there was increased tone of the limbs and they had club foot right so there was club foot micro carefully intracranial calcifications and the tone of the limbs was increased these are the features which you get with zika virus as I told you microcafe cytomegalovirus similarly whenever they say limb problems then you can think about zika virus and you can also think about varicella zoster that is chickenpox right now chicken pox car yeah maximum teratogenic period that is 12 to 20 weeks and if Mother requires infection between 12 to 20 weeks it leads to congenital varicella syndrome congenital varicella syndrome May again there is going to be microcephaly congenital varicella syndrome contractures with limb deformities and psychiatricial skin lesions if you are hearing these words that there are psychiatrician skin lesions there are limb contractures micro carefully then that means it is varicella zoster infection right congenital varicella's Oster infection neonatal varicella's Oster infection is seen if mother gets chickenpox five days before delivery or two days after delivery neonatal varicella syndrome May baby is going to have pneumonia hepatitis and meningo Encephalitis right then now if your question says that in fetus there is High Drops Fatalis there is anemia in mother there was polyhydramnios and when the baby was born we were seeing some skin rashes which is like a slapped cheek appearance so mother may be mil sakti has slapped cheek appearance right then it means which infection they are talking about which infection are they talking about quickly tell me in the chat box babies you are getting a slapped cheek appearance or you are getting reticular rash on the trunk this means it is parvovirus b19 infection right so this is what you have to remember about infections in pregnancy right then comes quickly about partogram Labor care guide this is the new partogram which has come which is based on who's new guidelines right and according to who's new guidelines active phase begins at five centimeters and that is why plotting in labor care guide begins at five centimeters in a labor care guide there is focus on individualizing intra-partum care there is no action line there is no alert line now other thing is which was a modified who partogram in modified who partogram we had Action Line we had alert line in modified who partogram active phase began at four centimeters so plotting began at four centimeters in modified who partogram second stage of labor was not represented monitoring of second stage of labor was not done but in labor care guide monitoring of second stage of Labor is done then in labor care guide whenever a female starts pushing we write the word p there then in labor care guide there is a new section which is called as supportive section is supportive section may we are going to write down what are the drugs we have given for pain relief what are the drugs we are giving for how much oral fluid we are giving to the mother what posture delivery was conducted and who was the companion so these are four things which we are going to include in labor care guide then in who's modified partogram home uterine contractions in labor care guide we are going to tell only about the duration and about the frequency so that reminds me okay modified who partogram a you are going to tell me you trying contractions so there were boxes which were squares which were present and you had to color those squares so number of squares which you color write in 10 min that represented the number of contractions in 10 minutes so you trying contractions were measured after every 30 minutes and for after every 30 minutes we used to see how many contractions are happening in 10 minutes now if we made dots that means the contraction lasted for less than 20 seconds if we made oblique lines that means contraction lasted for 20 to 40 seconds and if we colored it in a solid manner that means contraction lasted for more than 40 seconds clear to all of you now a few questions which I have included in Marrow also and I teach in my classes also I am just sharing with you them or with you over here all of the following are true regarding partogram except right side of alert line indicates referral to fru as I told you modified who partogram Tha in modified who partogram there were two lines Action Line sorry alert line and Action Line the time difference between these two lines was four hours now if your patients progress lied towards the left of alert line that means it is normal if your patients progress lied between alert and action line that means you have to get alerted and you have to send the patient to a higher Center if needed and if your patients progress light to the right of action line that means now some action has to be taken so over here they are saying right side of alert line indicates fru that means referral yes there is a four hours difference between alert line and Action Line yes each Square in a partogram is 30 minutes no each big Square in a partogram is 1 r partogram is plotted once the cervical dilatation reaches 4 centimeters yes this is because the this partogram which they are talking about is a modified who partogram and modified who partogram K according active phase began at four centimeters right so plotting began at four centimeters but suppose you get a question that it there is labor care guide so a midwife at phc is monitoring pregnancy and she's maintaining labor care guide of pregnancy progression at how much dilatation should partogram plotting be started to labor care guide labor care guide started at five centimeters right that was modified who partogram and wahape plotting began at four centimeters clear to all of you now now the next question which was there when a patient in labor presents to us for the first time where on partogram will you plot the dilation so when a patient comes to you for the first time please remember the first marking should be done on the alert line but if on the alert line is not given to you then you are going to say towards the left of alert line best answer for this question is on the alert line but if that is not given then to the left of alert line right then a 38 weeks primary gravida presented to the labor room with minimal labor pains and contraction on examination cervix is two centimeters dilated 50 percent phase heart rate normal hair BP normally what should be done two centimeters where patient is in latent phase so there is no role of you know inducing labor and specially there is no role of arm artificial rupture of membranes and oxytocin these are methods which are done in active phase Whenever there is a protracted active phase protracted active phase active phase is going very slowly protracted active phase so in protracted active phase management is arm and management is oxytocin but Yahoo patient latent phase latent phase May there is no role of oxytocin no role of arm then sedate the patient now why do I want to sedate the patient sedate the patient answer whenever it is a case of prolonged latent phase now this is not a case of prolonged latent phase so this is you are not going to sedate the patient simply you have to observe the patient and you have to wait for increase and uterine contractions right so all this we have done contraindications to breastfeeding we have done just quickly I want you to know what are postpartum Blues postpartum depression and postpartum psychosis postpartum blue is more common and postpartum blue May patient will have mild insomnia irritability fatigue she might cry and this happens between two to four days postpartum and it resolves within 10 days after delivery no treatment is needed for postpartum Blues postpartum depression is seen in 10 percent patients at a scene between two weeks to 12 months postpartum patient will have phobias she will have anxieties her symptoms are going to worsen more in the evening time and in postpartum psychosis which happens again two to three days postpartum and there's no time it will never resolve on its own patient will behave in a very uh you know she will have clouded sensorium she will be confused there will be attention deficit then that is postpartum psychosis right most common amongst them is postpartum Blues thankfully our orbs is over and in gyne I just have to tell you four or five things which are very important so you want me to continue Guinea now do you want me to continue Guinea or you want me to take it up some other day orbs is done whatever I wanted to tell you in orbs that is over 21st is your session for uh 21st I think is your session for image base session so what I am going to do is I will take your gyny quick revision on 20th is it okay with all of you right so if we do on 20th Feb if we do what are you saying yes you want me to do it on 20th continue okay just two minutes let me have some water I am continuing continuing don't worry I am continuing I'm just having water and we are continuing with gyne foreign one very important thing which you have to revise quickly is management of vulnerable cancer right so management of Volvo cancer May I'm giving you a flowchart just if you revise this much for management or valuable cancer that will be fine in management of a batch from Hyderabad missed ovarian and endometrial cancers oh okay so if you have missed ovarian and endometrial cancer uh let me connect to the Hyderabad team and maybe I take your endometrial cancer definitely I have to teach you full ovarian cancer is a very theoretical topic but endometrial cancer I am going to teach you so uh let me talk to them and if through a webinar I can connect with you I will take your complete endometrial cancer don't worry thank you for reminding me which was the batch which had missed endometrial cancer just mention it there okay now coming to Volvo cancer vulval cancer May uh whenever you are getting management of vulnerable cancer you have to see the stage and based on the stage we are going to do the management now stage of staging vessel cancer just for the management purpose we have to remember that stage 3 and stage four May management is chemo radiation and how do we come to know that it is th3 or stage four because in stage 3 or stage four lymph nodes are involved in stage 1 and Stage 2 lymph nodes are not involved so if lymph nodes are involved in vulval cancer and that means either it belongs to stage 3 or it belongs to stage four and whenever cancer belongs to stage 3 or stage 4 management is chemo radiation now when lymph nodes are not involved either it means it is stage 1 or it is stage two up stage one may we have one a one a commit that the size of the tumor is less than equal to two centimeters and the depth is less than equal to one millimeter stage one size of the tumor less than equal to two centimeters depth of invasion is less than equal to one millimeter stage one and Stage 2 May management is surgery stage 3 and stage 4 May management was chemo radiation stage 1 and stage 3 and Stage 4 The lymph nodes are involved now in stage one one a means that the size of the tumor is less than equal to two centimeters and depth of invasion is less than equal to one millimeters so the surgery which I am going to do in them will be a valvectomy in your options it can be given as partial radical vulvectomy or a total radical valvectomy right and there is no need for any lymph node dissection if it is stage 1A then comes stage 1B stage 1B means either the tumor is more than two centimeters in size or the tumors depth is more than one millimeter the depth of invasion is more than one millimeter now if it is stage 1p again the surgery is valvectomy radical vulvectomy or a partial vulvectomy and simultaneously you will have to do a lymph node dissection right then comes stage two vulval cancer stage 2 verbal cancer means any size of the tumor which involves lower one third of anus lower one third of urethra or lower one third of vagina so if there is any size of the tumor involving lower one third of vagina urethra or anus you you call it as stage two again in stage 2 I have to do valvectomy and I have to do lymph node dissection so in stage 1 a only one vector mean no lymph node dissection one b and 2 I have to do vulvectomy plus lymph node dissection most of the times the lymph node dissection which you have to do is bilateral inguinal femoral dissection bilateral inguinal femoral dissection there are only except few exceptions to this where you can go for a unilateral dissection so what are the conditions in which I can go for a unilateral dissection we can go for a unilateral dissection only if all these three conditions are fulfilled number one if the size of the tumor is less than two centimeters number two if location of the tumor is more than two centimeters from the midline and number three if local extension is absent so if all these three conditions are there then we go for unilateral inguinal femoral lymph node dissection so suppose you know now you are going to say Imam stage one become you are saying that the size of the tumor is more than two centimeters right and in one age is my size less than two centimeters we never do a lymph node dissection and now you are saying that unilateral lymph node dissection is done if size is less than two centimeters unilateral lymph node dissection we will never do now please understand one b means either the size is two centimeters or depth of invasion is more than one millimeter so suppose your question comes that there is a tumor which is one centimeter right and the depth of invasion is two millimeter now because depth of invasion is two millimeters you are going to put it in stage 1B right and when you put it in stage 1B your management becomes volvectomy plus lymph node dissection now if only this much information is given to you and they ask you whether you are going to do unilateral lymph node dissection or bilateral lymph node dissection because size of the tumor is one centimeter you will say I will do a unilateral lymph node dissection clear to all of you so this is how you decide bilateral lymph node dissection or unilateral lymph node dissection most of the times bilateral only if size of the tumor is less than two centimeters if it is more than two centimeters away from midline or if local extension is absent then you go for unilateral lymph node dissection clear to all of you the management of bulbal cancers yes there is no need to mug up this entire staging of vulval cancer in this flowchart Jitney stage that is important other than this you don't need to mug up the staging for valuable cancer what does it mean when they say no local extension so no local extension means this stage 2 disease stage 2 disease May the diseases locally extending to lower one-third of vagina lower one third of urethral lower one third of anus right that is what is no local extension had no local extension yes now next important thing in Guinea is they ask you the next step in management if they say next step in management and they ask you patient is having post-coital bleeding what is the next step now whenever they say patient is having post-coital bleeding and they ask you the next step next step is per speculum examination now if your question says patient is having post-coital bleeding and on per speculum examination a per speculum examination they have done on per speculum examination cervix is normal now what is the next step now next step is pap smear if they say on per speculum examination growth is seen so then the next step becomes punch biopsy now if they say that on per speculum examination cervix is Barrel shaped thick indurated and firm then in that case Again The Next Step because it is pointing towards cancer so the next step is biopsy plus endoservical curitage right so colposcopic call Pro biopsy plus endoservical curitage right whether you say colposcopy or whether you say corpo biopsy it's one and the same thing clear to all of you so this is the next step whenever they a patient comes to you with postcoital bleeding now next step if they give you some pap smear report and they ask you what is the next step please remember based on pap smear report we never go for management of cin based on pap smear report the next step is always biopsy right yep next step is some other investigation but you don't go for uh I'm going to do hysterectomy or I am going to manage a cig based on perhaps my report because pap smear is only a screening test so if they say that so I will not write management here because otherwise you get confused I will write Next Step now if they say on pap smear you are getting a s c u s what is AC ascus a typical squamous cells of unknown significance and they ask you what is the next step so this means the histopathologist or the cytologist is telling you that there are some atypical scholar cells but I don't know their significance in that case if age of the patient is less than 25 years you will repeat a pap smear after one year repeat a pap smear after one year but if age of the patient is more than equal to 25 years then you do HPV DNA testing and if HPV DNA testing is done after an abnormal pap smear report it is called as reflex HPV DNA testing now if report comes as l s i l low squamous intra-epithelial lesions and if age of the patient is less than 25 years next step is again pap smear this pap smear should be done between 6 months to one year if age of the patient is more than equal to 25 years then in that case copy right where they can write callposcopy they can write callposcopic guided biopsy they can write callpobiopsy all of them mean the same thing now if report is h s i l hsil means highest Commerce intraepithelial lesion then in all age groups no matter what is the age group the next step is called postcopy plus endocervical curitage similarly if the report is a s c h what is a s c h a typical squamous cells where hsil cannot be ruled out now wherever you get this word h the next step is that means it has high chances for cancers or it has high chances for uh cin2 and cin3 so the next step becomes callposcopy and endocervical curettage if report comes as a g u s a typical glandular cells of unknown significance now these glandular cells could come from endometrium so it can be an endometrial cancer which has spread to cervix or it could be a cancer of endocervix so in this case I am going to do colposcopy in this case I am going to do endocervical curitage and I am going to do endometrial biopsy all these three have to be done if it is a case of atypical glandular cells of unknown significance about HPV vaccination you should know what are the who Sage guidelines The Who Sage guidelines say that if the age of the patient is between 9 to 14 years then you have to give one dose of HPV vaccine if age group is between 15 to 20 years then either one or two doses and if age of the patient is more than equal to 21 years then you have to give two doses six months apart please remember the age group is 9 to 26 years for giving HPV vaccine but in high risk patients you can give from 27 to 45 years ideally HPV vaccine should be given before a female starts a sexual activity but then it can be given even after she has started her sexual activity HPV testing is not needed before giving this vaccine and screening should not be stopped after giving HPV vaccine if a patient is HIV positive then the doses which you have to give are three doses so this is who Sage guidelines for giving HPV vaccine according to who in a resource limited country like India the best screening test for cancer cervix is HPV plus Bia right if HPV plus via is not given in the options then the second best is HPV DNA testing and if that is also not given then v i a v i a is visual inspection with acetic acid according to who in India screening should begin at 30 years and it should end at 49 years right now next step next step if a patient comes to you with post menopausal bleeding if a patient comes to me with post menopausal bleeding then next step is I am going to do a TVs on TVs if endometrial thickness I am going to measure the endometrial thickness if endometrial thickness is less than four millimeters and my patient is having post menopausal bleeding that means her bleeding is happening due to atrophic endometrium a senile endometritis and so my next step becomes I am going to give her tranexamic acid if the bleeding persists then my next step is fractional curitage Plus hysteroscopy right but I am going to do fractional curitage and hysteroscopy only if the endometrial thickness was less than four millimeters I gave a tranexamic acid but bleeding persisted now suppose if endometrial thickness is more than equal to four millimeters in that case my next step is endometrial sampling this endometrial sampling can be done by endometrial aspiration cytology or it can be done by endometrial biopsy anything out of these things anything can be written right endometrial sampling and now sampling or endometrial biops and the report says present that means atypical cells are present there are there is endometrial hyperplasia with atypical cells so if atypical cells are present that means there is a high possibility of endometrial cancer and before I do hysterectomy in them endometrial cancer again I will do fractional hysteroscopy a fractional curitage Plus hysteroscopy so whenever there is endometrial hyperplasia with atypia and they ask you next step do not jump to hysterectomy next step is is fractional curitage plus hysteroscopy to rule out endometrial cancer already presents because if endometrial cancer is already present I will not just do hysterectomy right if after doing fractional curitage and hysteroscopy I know no endometrial cancer is present and they ask me what is the best management then best management is hysterectomy now someone is asking me what is the difference between endometrial sampling endometrial aspiration curitage endometrial biopsy no difference for you people just remember out of these three anything could be written and all three are right clear now if endometrial biopsy report says atypia is not present then what is the next step then the next step is you give progesterone foreign but if bleeding persists in spite of giving progesterone now I am worried that why there is bleeding in spite of giving progesterone so now I will do fractional curitage Plus hysteroscopy this means if someone asks you what is the investigation of choice for any endometrial lesion the investigation of choice for endometrial pathology is endometrial biopsy but the gold standard is fractional curettage Plus histro scopy right so these are all next steps which you have to remember very very important next steps right then uh just one more thing which I want to revise with you in case of gyne so in gyni whenever they say a patient is having primary amenorrhea right primary amenoria and uterus is absent now in this case there are two differential diagnoses which you have to keep in mind number one you have to keep in mind m r k h that is mullerian agenesis and number two which you have to keep in mind is Androgen insensitivity syndrome both of them in here the chromosome number is 46xx here it is 46 XY here the gonads are ovaries here the gonads are testes in case of mullerian a Genesis breast development will be stage 4 plus here also breast development will be stage 4 plus but in mullerian agenesis pubic hair and axillary hair will also be State they will be well developed stage four plus but in case of Androgen insensitivity pubic hair and axillary hair they will be stage one or stage two right in case of mullerian agenesis testosterone levels will be normal like a female level in case of Androgen incestry testosterone levels will be very very high in case of mullarian agenesis LH levels will be normal FSH levels will be normal in case of Androgen insensitivity FSH levels will be normal LH levels will be very high right because they are insensitive to testosterone so the negative feedback on LH is gone so the levels of LH will increase and because inhibin is secreted by sertoli cells enable is going to keep FSH under control right so this is the reason why sorry this is the reason why FSH is normal LH levels are high now here you are going to get renal anomalies here there will be no renal anomalies so this is how you differentiate between mrkh and androgen in Sensitivity Syndrome now if you get a question which says that there is primary amenorrhea and uterus is present in this case the differential diagnosis could be Turner's syndrome differential diagnosis could be Squires syndrome differential diagnosis could be Kalman syndrome and it could be cryptomenorrhea cryptomenorrhea now in all these cases the first thing which you should note is FSH levels and LH levels now LH and FSH levels will be high internal syndrome here the chromosome number is 45 XO so they have got a streak gonads and because they have streak gonads the estrogen is not there so the negative feedback on LH and FSH is gone in case of Swire Syndrome again FSH and level LH levels are high they are 46 XY individuals who have this genetic testes right in Calvin syndrome the levels of LH and FSH will be decreased because they have got decreased GN RH the problem is hypothalamic failure in case of cryptomenorrhea the levels of LH and FSH are going to be normal So based on LH and FSH levels you can come to know that which of these problems it is another thing in case of Turner's syndrome in case of Turner's syndrome you will have short Stitcher the patient is will have short stitches stature will be normal in Kalman syndrome in crypto menorrhea and in swires syndrome right inspires syndrome the uterus is present so in all these conditions uterus is present in or in case of Turner's syndromes wire syndrome and Calvin syndrome because estrogen is decreased that is why breast development is absent in Swire syndrome also there is no testosterone because of the dysgenetic testes so there is no estrogen so again breast development is absent in Kalman syndrome because there is decreased GnRH decrease LH decrease FSH so again breast development is absent but in crypto menorrhea breast will be present and it will be fully developed normal breast development right now internal syndrome the other thing which you have to remember is you will get Associated findings like webbing of neck like there will be cubitus valgus like there is going to be um low posterior hairline Shield shaped chest right so you are going to get Associated findings in case of Calvin syndrome there will be an osmia right so based on these findings you can come to know what is the problem in your patients so that is how you diagnose a patient with primary amenoria clear to all of you have you understood how to diagnose in your questions a case of primary amenorrhea now coming to secondary even area if you get a question on secondary amenoria and your question says that the levels of FSH are increased then it means they are talking about premature menopause the other name or the new name for premature menopause is primary ovarian insufficiency because ovaries are not functioning so there is decreased estrogen that is why the FSH levels are increased now if your question says FSH levels are normal or they are low right then what you have to see in your question what have they told you about progesterone withdrawal test right if bleeding is present after progesterone withdrawal test that means progesterone withdrawal test is positive then they are talking about p c o s please remember in PCOS levels of FSH are normal it is only the levels of LH which is increased right now if bleeding is absent that means progesterone withdrawal test is negative in that case you check the levels of estrogen if levels of estrogen are normal then it means it is a case of Asher man syndrome right if it is if they say estrogen is decreased then it means either the problem is in hypothalamus or problem is in pituitary problem in pituitary could be Sheehan syndrome or it could be a prolactinoma right now in order how am I going to come to know whether it is hypothalamus problem or pituitary problem I will do an MRI if on MRI I am getting empty cellar turcica it means it is she had if I am getting a space occupying Mass it means it is prolactinoma and if MRI is normal it is problem in hypothalamus clear so this secondary amenoriaka flowchart please memorize this properly secondary only one condition May FSH is raised that is premature menopause FSH normal to look at progesterone withdrawal test key report if your question says progesterone withdrawal test is positive what does that means that means it is a case of PCOS if bleeding is not present after giving progesterone then look at the levels of estrogen estrogen levels normally it it means it is asherman syndrome that means uterus May intrauterine additions are present and if estrogen levels are decreased problem hypothalamus and hypothalamus problem could be stress over exercise or it could be anxiety all that can lead to uh a secondary amenoria to differentiate between them you are going to do an MRI MRI empty salad space occupying prolactinoma everything is normal then it is hypothalamus clear to all of you please remember in case of Shihan patient comes to you with complain of failure of lactation plus secondary amenorrhea right and they can be features of other hormone deficiencies as well in prolactinoma patient comes to you with complain of secondary amenoria infertility and there is increased milk so there is a galactorrhea galactorrhea along with headache and visual disturbances right why is prolactinoma causing secondary amenorrhea because in prolactin has a negative feedback on GnRH so it leads to mnoria prolactin leads to milk secretions so it is leading to galactorrhea because prolactin is a pituitary tumor it is very near to optic chasma so it is leading to visual disturbances and headache clear to all of you so that's all what you need I mean you need to know more but this is if you do this much along with pyq session along with image based session I think this should solve your purpose so all the best to all of you keep studying and that with this I'm going to conclude today's session take care all of you