OG Short Cases

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Short Cases in OBGY

Wong Wen hao & Low Qin Jian
Special thanks to Ng Chee Guan
Dr Win Win Than

Dr Helen
Dr Win Win Min
3nd Edition
Wong & Low O & G Short Cases Record

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Our Aim : Made it easy to do it right!
Cases Compiled
Gynaecology
1. Uterine fibroid
2. Ovarian cyst
Obstetric
1. Uterus Larger than Date
2. Uterus Smaller than Date
3. Breech Presentation
4. Unstable Lie
5. Previous LSCS Scar
6. Multiple Pregnancy
7. Pregnancy Induced Hypertension
8. Gestational Diabetes Mellitus
Common Questions & Answers
th
Date of Publication: 17 June, 2012
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Short Case Record for uterine mass (Fibroid)
Sir, this patient is a middle age Malay lady who appears to be well. She has a normal body built.
(Prof SA : add She appears to be alert, conscious, orientated, not in pain or respiratory distress)
In the peripheral examination, there is no clubbing, palmar pallor, pulse rate is 80bpm. She has no
conjunctiva pallor or sclera icterus. No palpable cervical LN. No pedal edema.
In the abdomen examination, abdomen is distended at the suprapubic region. There are no cutaneous
stigmata of pregnancy, surgical scars or superficial veins noted. Umblicus is central & inverted. Hernia
orifices are intact.
On palpation, abdomen is soft, non-tender. The suprapubic mass corresponds to 14 weeks pregnancy size.
It is globular in shape, firm in consistency, smooth surface, regular margin, non-tender, mobile sideways
but not up & down, cannot get below the mass & scoop up sign negative (Prof SA). There is no sense of
urgency when pressure is applied over the mass. Both iliac fossa are empty. There is no other mass felt in
the abdomen. Liver & Spleen are not palpable. Kidneys are not ballotable. Percussion over the mass
reveal dullness. No flank dullness. No palpable inguinal lymph nodes!
On auscultation, I can hear normal bowel sounds, no bruit heard over the mass.
I would like to complete my examination by doing a vaginal examination : Speculum & bimanual
examination.
In the speculum examination, I would like to look for any bleeding, local lesions on the cervix, and do a
Pap’s smear if the patient had not had one before.
In the bimanual examination, I would like to confirm the origin of the mass. If it’s a uterine mass, when
the mass is moved upwards, the cervix will move away along with the mass from the examining finger. If
it’s an ovarian mass, when the mass is moved upwards, the cervix will not move. I would also like to feel
at the adnexae for any mass, POD for bogginess as it suggests presence of fluid or nodularity which
suggest malignant infiltration.
In summary, I think the suprapubic mass is uterine in origin and most likely a fibroid (or leiomyoma). She
is clinically not anemic.
My differentials for this mass are:

Adenomyosis. Others are uterine sarcoma, tubo-ovarian inflammatory mass, ovarian neoplasm, pelvic
kidney, diverticular or inflammatory bowel mass & cancer of colon.
Differential diagnoses (depends on symptoms)

Menstrual symptoms: DUB, endometrial polyps, endometrial ca, endometriosis, chronic PID.
Mass: Ovarian tumour, pregnancy, adenomyosis, uterine sarcoma, tubo-ovarian abscess, others: tumour of
large bowel, appendix abscess, diverticular abscess.

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What are the investigations you would like to do?

To confirm my diagnosis, I would like to do an ultrasound imaging to distinguish between a fibroid from
an ovarian mass. I would like to determine the site, type, number & size of the fibroid. Also, I would like
to exclude hydronephrosis from pressure over ureters.
Besides, I would also like to do a UPT and hysteroscopy with biopsy (endometrial sampling).
To assess the general wellbeing of my patient, I would like to do FBC (Hb, platelet).
How would you manage her?

If the fibroid is small, not influencing her general health, lifestyle, she is asymptomatic or she is near
menopause, I would like to manage her conservatively/expectantly by routine surveillance 6-12 monthly,
monitor FBC & the growth of the mass.
Appropriate medical management with Mefenamic acid & Tranexamic acid should be offered for
menorrhagia along with hematinic. Heavy & prolonged menses can be controlled by oral contraception
(COC) or danazol. Levonorgestrel releasing intrauterine system (mirena) is effective in reducing fibroid
related menorrhagia provided the uterine cavity is not distorted. It can cause shrinkage of the fibroid as
well. Progesterone receptor modulators (asoprisnil) or progesterone receptor antagonist (mifeprostone)
may also be used.
If medical treatment fails, symptomatic menorrhagia, reproductive failure problem, rapidly growing
fibroids (12-14 weeks uterus), if it is subserous and pedunculated (prone to torsion), if it is likely to
complicate a future pregnancy, if tere is doubt about its nature, then surgery will be offered. The options
for surgery will be myomectomy or hysterectomy. Hysterectomy option will depend on her age & need
for fertility. I will counsel her about the advantages & possible complications of the surgery (like
hemorrhage, infection, recurrence). If she wants to preserve her fertility, myomectomy may be an option
if the number & size of the fibroids is limited. If there is uncontrolled bleeding during myomectomy, she
might need to undergo hysterectomy.
Submucosal fibroids may be resected hysteroscopically. Pedunculated, subserosal myomas can be

resected laparoscopically (usually asymptomatic, so can treat conservatively). If she has completed her
family, hysterectomy provides a definitive cure.
GnRH analogues have high adverse effects & should not be use > 6/12 as it can cause a pseudo-
menopausal state which can lead to osteoporosis. They can be used selectively to reduce the fibroid size,
less bleeding intra-operatively & enable a suprapubic incision rather than a midline abdominal incision.
What are the new methods for treating fibroid?

Medical – progesterone receptor modulators.
Surgical – Bilateral uterine artery embolisation, uterine artery ligation, high intensity focused ultrasound,
MRI guided laser ablation, laparoscopic myolysis, high intensity focused ultrasound (HIFU), laser
photocoagulation.
What is the incidence of uterine fibroids?

It is the commonest tumor of the female genital tract, being present in > 20% of women > 35 years old.
Peak age of incidence of symptoms is between 35-45 years old.
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What is the risk of malignant change? (please refer 10 teachers)

Traditionally, has been stated up to 0.5%. There is also opinion based on cytogenetic evidences stated that
the malignant change of fbroid is unlikely and conincidental.
What are the sites of origin?

(a) Intramural – Within uterine wall.
(b) Subserous – Projecting from the peritoneal surface of the uterus. Can be pedunculated.
(c) Intraligamentary – Between the layers of broad ligament.
(d) Submucous – Indenting the uterine cavity. Can be polypoidal.
(e) Cervical
What are the clinical features of leiomyoma?

Mostly asymptomatic. Pelvic pressure/congestion/bloating, feeling of heaviness in lower abdomen, lower
back pain. Pressure symptoms like frequency of urination (urinary retention).
Prolonged or heavy menses associated with intramural or submucosal myoma.
Intermenstrual bleeding may occasionally occur with submucous myomas ulcerating through endometrial
lining. Excessive bleeding may lead to anemia, weakness & dyspnea.
Generally no pain, but severe pain (may be due to uterine colic to abort the myoma, torsion of its pedicle,
degeneration, sarcomatous change, adhesion to other organs associated endometriosis) associated with red
degeneration. Submucosal myoma are associated with infertility because the tumour interferes with
implantation of the fertilized ovum, it hinders the ascent of the spermatozoa by distorting uterus and tubes.
What are the risk factors of developing fibroids?

Increase age during reproductive age (40% more than 40 y/0), ethnicity (African 3x > White ), nulliparity,
family history, high BMI, excessive estrogen stimulation.
What are the protective factors of developing fibroids?

Oral contraceptive pills & pregnancy.
What are the complications of fibroids?

Torsion of pedicle, infection, hemorrhage, red/hyaline/cystic degeneration, calcification, malignant
change (leiomyosarcoma) in 1:200 cases or less.
What the potential effects of fibroids on pregnancy?

Antenatal : Subfertility, miscarriage, preterm labour, malpresentation, red degeneration.,
Intrapartum : Cord prolapsed / obstructed labour (rare), third stage problems (uterine inertia).
Postpartum : Delayed involution postpartum, PPH.
What are the common associated conditions?

Follicular cysts of the ovary, endometrial hyperplasia, endometrial carcinoma, endometriosis
What is the rare association with fibroids?

Fibroids is rarely associated with polycythaemia. Cervical fibroid can cause acute retention of urine.
Broad ligament fibroid can cause hydroureter.

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What is the pathogenesis of leiomyomas?

Leiomyomas have increased levels of estrogen & progesterone receptors compared with other smooth
muscle cells. Estrogen stimulates proliferation of smooth muscle cells, whereas progesterone increases the
production of protein that interferes with apoptosis. Leiomyomas also has higher levels of growth factors
that stimulate production of fibronectin & collagen, major components of extracellular matrix that
characterizes these lesions.
Given a 14 weeks size suprapubic mass, how would you differentiate it between a bladder,
pregnancy or myoma?
Bladder : Cystic consistency, urge to urinate upon pressure.
Pregnancy : Cutaneous stigmata of pregnancy, fetal poles, external ballottement.
Myoma : Firm consistency.
How do you differentiate myoma from adenomyosis?
Myoma Adenomyosis
Epidemiology Commonest benign uterine tumor. Less common.
Age group 30-40 years old 40-50 years old (uptodate)
Clinical manifestation Menorrhagia Dysmenorrhea
Size Any size < 14 weeks size
Tenderness Non tender mass Usually tender mass

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Facts about GNRH analogue
Mechanism of action These drugs work by initially increasing the release of gonadotropins,
followed by desensitization and downregulation to a
hypogonadotropic, hypogonadal state that clinically resembles
menopause.
Routes of administration Goserelin acetate (3.6 mg/month subcutaneously or 10.6 mg

subcutaneous implant every three months) Leuprolide acetate depot
(intramuscularly 3.75 mg/month or 11.25 mg/three months).
Ornafarelin acetate (administered as a twice daily intranasal spray).
Benefits Reduce fibroid size, less bleeding intra-operatively.

Enable a suprapubic incision rather than a midline abdominal incision
or facilitate vaginal rather than abdominal hysterectomy (Rapid
recovery & less post-operative complications).
Side effects Severe hypoestrogenism like hot flashes, sleep disturbance, vaginal
dryness, myalgias, arthralgias, possible impairment of mood &
cognition. Osteoporosis.
10 teachers : Obscure tissue planes around fibroids making surgery

more difficult.

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Short Case Ovarian Cyst Record
Sir, my patient is a middle-aged lady lying supine comfortably on the bed supported by one pillow. She is
not wasted/cachexic/emaciated, pale or jaundiced. There is also no facial flushing.
On peripheral examination, there are no stigmata of chronic liver disease, pulse rate is 80 beats/minute
with regular rhythm, no cervical lymphadenopathy and no pedal oedema. I would like to measure her
blood pressure.
Abdomen:
On inspection, the right/left iliac fossa is distended (sometimes maybe suprapubic). Otherwise, the
abdominal wall moves with respiration, umbilicus is centrally located and inverted, no superficially
dilated veins, hernial orifices are intact and no visible peristalsis or pulsation seen.
On palpation, the abdomen is soft and non-tender. A mass can be appreciated at the right/left iliac fossa,
which measures 5cm X 6cm, oval in shape, has a smooth surface, cystic in consistency, has a well-defined
margin, mobile vertically and horizontally. I am able to get below the mass. I could not appreciate any
other mass at the contralateral side. There are no hepatomegaly, splenomegaly or ballotable kidneys. No
palpable inguinal lymph nodes.
On percussion, there is dullness over the mass. No signs of free fluid.
On auscultation, there is no bruit heard over the mass. Bowel sounds are present.
To complete my examination, I would like to examine the breast, inguinal and supraclavicular lymph
nodes and perform a bimanual examination. In the bimanual examination, if it is ovarian in origin the
cervix will not move along with the mass. Cleft sign can also be appreciated.
Discussion
Diagnosis
Based on the clinical findings, my impression is that the mass is of ovarian origin and it is benign. (if
elderly, malignant ovarian tumour (MOT) after considering signs of MOT). The reason I think is ovarian
in origin is because of the location of the mass, I can get below the mass & it is mobile in all direction. I
think it is benign because the general condition of the patient looks fit, not lethargic or cachexic, the mass
is well defined, single, unilateral, patient age, no hepatomegaly or ascites.
Since my patient is young, my differential diagnoses include benign functional (follicular, corpus luteal,
theca luteal), inflammatory (tubo-ovarian abscess, endometrioma – which are not freely mobile) and germ
cell (benign teratoma) tumours.
Since she is an elderly lady, my differential diagnoses include benign epithelial (serous cystadenoma,
mucinous cystadenoma, Brenner tumour) and sex cord stromal (fibroma, thecoma) tumours.
However, I would also like to consider the possibility of malignancy by calculating the risk of malignancy
index (RMI) score, which is the product of ultrasound scan score, menopausal status and Ca125 level.
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My differential diagnosis are pedunculated fibroid, appendicular mass, tumor arising from GIT especially
terminal ileum & rectum and bladder/kidney mass.
Investigations:
To confirm my diagnosis, I would like to proceed with transabdominal and transvaginal ultrasound scan,
which my yield information about the origin and nature (benign or malignant) of the mass. Besides, I
would also like to check the tumour marker levels, which include Ca125, Ca19-9, Inhibin, B-HCG and
AFP. Both USG and ca125 level will be used in the scoring of RMI.
To provide baseline data, I would like to do renal and liver function tests. Renal function may be impaired
if the tumour has caused obstruction urinary flow obstruction. Liver function may be deranged if there is
secondary metastasis.
Management
Since my patient is young and the tumour size is < 5 cm in diameter, I will manage her conservatively. If
the tumor is > 5cm I will also treat her conservatively if there is no signs or symptoms of malignancy.
I will re-examine in 12 weeks for diminution in size. If persists, she will be scheduled for follow-up
6monthly with USG and CA125 levels. However, if the tumour enlarges further evaluation may need to
be done by laparoscopy or laparotomy. If she becomes symptomatic, such as an acute painful episode,
emergency laparotomy/laparoscopy is indicated.
Since she is an elderly lady and the tumour size measures more than 5 cm, she should be offered surgical
management (TAHBSO).
What are the complications of ovarian cyst? THIN RIM
• Torsion, haemorrhage, infection, necrosis, rupture, intestinal obstruction, malignant change
Differentiate mass between ovarian and myoma
Ovarian Uterine
RIF/LIF Suprapubic
Cystic Firm
Mobile vertically/horizontally Mobile horizontally
Can get below Cannot get below
Cervix doesn’t move with mass Cervix moves with mass
Exception: Exception:
• Endometriosis causing adhesions • Pedunculated fiboid
Scoop up sign positive
Cleft sign positive

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Differentiate between benign and malignant ovarian tumor based on clinical features
Malignant:
• General: Elderly, Cachectic, pale

• Mass: pain and tenderness of mass, rapidity of growth, 75% are bilateral, consistency is party
solid-cystic, solid, nodular, irregular shape, poorly defined margin, irregular surface, limited
mobility
• Ascites: peritoneal metastases or ovarian capsule perforated. (in benign, fibroma and cystadenoma)
• Palpable liver, ballotable kidneys, inguinal lymph nodes enlargement
• Pleural effusion
• Oedema of the legs and vulva or evidence of venous obstruction
• Supraclavicular lymph nodes
• Irregular deposits in POD
Differentiate between benign and malignant ovarian tumour based on laparotomy findings
Malignant:
• Bloody ascitic fluid

• Mass: bilateral, consistency is solid or party solid-cystic, fungation through capsule, large vessel
on tumor, poorly defined margin, irregular surface, limited mobility (adhesion).
• Retroperitoneal nodes enlargement
• Omental cake
• Liver metastasis
How do you differentiate benign from malignant ovarian tumor through ultrasound?
Benign Malignant
Unilateral lesion Bilateral lesion
Thin wall Thick wall/septum, Breaching capsule
Simple cyst Solid tumor / Mixed solid & cystic mass
No loculations Multilocular cyst
Internal papillary projections
Ascites
Evidence of metastasis
Increased vascularity on Doppler

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Uterus Larger than Date
In summary, the SFH is > 37 cm, >3cm greater than the gestational age of 34 weeks. Clinically, amniotic
fluid is adequate. No pelvic mass felt.
To complete my examination, I would like to take a detailed history (LMP, EDD, GDM, Anomaly scan),
through examination (BMI) & relevant investigations to find the possible cause. I would also like to
arrange for an ultrasound to look for evidence of multiple pregnancies, pelvic mass, AFI, EFW, evidence
of placenta abnormality.
What are the causes for uterus larger than date?

Mother : Wrong date, wrong SFH measurement, obesity, pelvic mass, maternal diabetes.
Fetus : Macrosomia, multiple gestations, polyhydramnios, normal large-for-gestation.
Placenta : Choriangioma, AVM.
How would you manage this case?

I will like to manage according to the underlying cause. I will treat the patient conservatively if she is
asymptomatic & no pressure symptoms. If she is symptomatic, there is a role for medical treatment (*
Indomethacin 50-200mg od till 35 weeks can be use in Polyhydramnios; COX 2 inhibitor) or serial
amniocentesis.

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Uterus Smaller than date
SFH is 3cm less than the gestational age in weeks.
Management
Dear Sir, my patient has uterus smaller than date. First of all, I would like to rule out wrong dates. Then, I
will proceed to look for the cause. Serial USG should be done and growth parameters plotted on growth
charts for the detection of IUGR. IUGR may be suspected if there is a single measurement below the 5th
centile. Besides, an USG may also yield information about the liquor amount, as oligohydramnios may
also cause uterus smaller than date. A detailed fetal anomaly scan can also be done to detect congenital
anomalies, such as renal agenesis. Doppler study of the umbilical arterial flow maybe be done to detect
placental insufficiency as a cause of IUGR.
Other tests which may be valuable are urine dipstick for glycosuria and proteinuria, MOGTT and FBC.
GDM is associated with congenital anomalies (renal agenesis) and IUGR, if there is nephropathy and
vasculopathy. PIH and Pre-eclampsia is also associated with IUGR. Furthermore, anaemia in pregnancy is
associated with IUGR.
Once the cause is found, management is tailored accordingly to treat the cause.
FAQs
What are the causes of uterus smaller than date?
• Mother: wrong dates, post dates, NSAIDs, oligohydramnios, missed miscarriage, IUD, PPROM.
• Fetus: IUGR (placental insufficiency, congenital infections), congenital anomalies (renal agenesis
– Potter’s sequence, multicystic kidney disease.)
What do you understand by the term symmetrical and asymmetrical IUGR? What are the causes?
Symmetrical IUGR is less common, begins early in pregnancy, manifested as generalized growth
restriction. Causes of symmetrical IUGR include:
• idiopathic
• chromosomal abnormalities
• TORCH infections
• maternal smoking
• maternal alcohol/opiate abuse
• chronic maternal nutritional deficiency
• ionising radiation
• sickle cell disease
Asymmetrical IUGR is more common, usually begins late in pregnancy, manifested as restriction of
weight followed by length, but the head continues to grow at normal or near-normal rates.
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Causes of asymmetrical IUGR include:
• Idiopathic
• Uteroplacental insufficiency: pre-eclampsia, maternal renal or cardiac disease, multiple gestation,
anemia.
What are the complications of FGR?

Antenatal: fetal hypoxia IUFD
In labour: intrauterine hypoxia/asphyxia stillbirth
Neonate:
• hypoxic-ischaemic encephalopathy (HIE) including seizures, multiorgan damage in neonate
• neonatal hypothermia, hypoglycaemia, infection
• necrotizing enterocolitis
• cerebral palsy
Adult life:
• CVS complications (hypertension and ischaemic heart disease)
• Metabolic disorders (non-insulin dependent diabetes)

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Breech Presentation
In summary, SFH is … weeks. This is a singleton fetus in longitudinal lie, breech presentation, fetal back
on maternal left side. FHR 150 bpm, strong & regular. Amniotic fluid is clinically adequate. Estimated
fetal weight is 3kg.
Discuss management options for a breech presentation at 38 weeks.

I would like to counsel her regarding the presentation, various options for delivery & allow her to make
an informed consent. Recent Us (after 36 weeks) should be checked to confirm presentation, rule out
placenta praevia, fetal malformation.
I would like to offer her ECV by trained professionals at 38 weeks. Before that, I would exclude the
contraindications of ECV. It should be performed on the labor ward near facilities for emergency delivery.
Us guidance is helpful. CTG prior & after ECV reconfirms fetal wellbeing. Tocolysis is effective. ECV
carries a success rate of 50% and halves the rate of C-sections done for breech presentation. < 1% require
emergency C-section for fetal distress, placenta abruption, vaginal bleeding.
Postural management to promote cephalic version include knee chest position, elevation of pelvis using
cushion, moxibustion.
(No more Trial of vaginal breech delivery except for breech delivery of second twin!)
Elective C-section at 39 weeks is now the safest mode of delivery (Term breech trial). However, there is
inherent risk of a surgical procedure like thromboembolism, bleeding & infection. If spontaneous labour
start before scheduled surgery, EMLSCS maybe required which carries higher morbidity.
Finally, I would like to document meticulously the counseling & women’s decision in her case records.
What is the incidence of breech presentation?

4% of all term singleton pregnancies.
What are classifications of breech presentation at term?

Extented/frank breech (65%), Flexed/complete breech (25%), Footling/incomplete breech (10%).
What are the etiology of breech presentation?

Mother : Uterine anomaly (bicornuate uterus), CPD, pelvic tumors obstructing birth canal,
polyhydramnios/oligohydramnios.
Fetus/placenta : IUGR, congenital anomalies, extended legs preventing spontaneous version, prematurity,
multiple gestations, placenta praevia, IUD.
What are breech presentation associated with?

Fetal anomaly (hydrocephalus, anencephaly), preterm, multiple pregnancy.
What are the hazards of ECV?

PROM, transplacental haemorrhage, Preterm labour, placenta abruption, cord accident, uterine rupture
(previous scar), fetal distress, fetal bradycardia, rupture membrane cord prolapsed.

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What are the contraindications to ECV?

Absolute CI : Multiple pregnancy, significant fetal anomaly, ruptured membranes, oligohydramnios, APH,
placenta praevia, caesarean section indicated for other reasons.
Relative CI : Mother (hypertension, rhesus iso-immunization, obesity), Previous C-section, FGR, anterior
placenta, polyhydramnios.
What are the prerequisites for ECV?

The gestation should be > 36 weeks. Recent ultrasound to confirm presentation, normal fetus, rule out
placenta praevia, adequate liquor volume. Reactive CTG. Informed consent of mother. Facilities for rapid
progression to C-section. If necessary, rhesus –ve women must be given anti-D Ig.
How are you going to monitor the mother post successful ECV?
My aim is to monitor both maternal & fetal wellbeing. For the maternal wellbeing, I will monitor her BP,
PR 4 hourly, ask her for any signs/symptoms of labour, per vaginal bleeding, unusual abdominal pain,
increased contraction pain. If mother is rhesus negative, I would like to give anti-D prophylaxis. For fetal
monitoring, I will do a post ECV CTG, measure the fetal heart rate by pinard stestoscope, fetal kick chart,
and look for contractions.
Which type of breech presentation is associated with the highest ECV success?
Flexed/Complete breech.
What are the prerequisites for breech vaginal delivery? (Singleton Vaginal breech delivery is no
longer practiced)
Type of breech (Flexed or extended, footling not allowed), Normal uterus with no scars or abnormalities,
no placenta praevia, fetal weight 2.5-3.5Kg, no hyper-extended head.
What are the possible complications of vaginal breech delivery? (Singleton Vaginal breech delivery
is no longer practiced)
Prolonged labour, fetal distress, entrapment of head (preterm head), maternal/fetal injury.
Which type of breech presentation is favorable for vaginal delivery? (Singleton Vaginal breech
delivery is no longer practiced)
Frank or extended breech.
What are the possible complications of breech vaginal delivery?

Umbilical cord prolapsed, head entrapment, intracranial hemorhage, birth asphyxia, birth trauma (Erb’s
palsy, fracture of bones, soft tissue injury of abdomen).
RCOG : How should delayed second stage of labour with breech presentation be managed?
Caesarean section should be considered if there is delay in the descent of the breech at any stage in the
second stage of labour.

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RCOG : How should delayed engagement in the pelvis of the aftercoming head be managed?
Suprapubic pressure by an assistant should be used to assist flexion of the head. The Mauriceau-Smellie-
Veit manoeuvre should be considered, if necessary, displacing the head upwards and rotating to the
oblique diameter to facilitate engagement.
RCOG : How should the aftercoming head be delivered?

The aftercoming head may be delivered with forceps, the Mariceau-Smellie-Veit manoeuvre or the Burns-
Marshall method (rare).

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Unstable Lie
In summary, SFH is … cm. This is a singleton fetus in transverse lie, with its head at the right
hypochondrium and back facing downwards. Amniotic fluid is adequate and estimated fetal weight is
3.0kg. Fetal heart rate is 142 bpm, strong and regular.
How would you manage this patient if the lie is changing everyday and she is currently at 36 weeks
of gestation?
My diagnosis for this condition is unstable lie. Antenatally, she should be managed expectantly, as 85 %
of fetal lies will become longitudinal before rupture of the membranes or labour. The causes for unstable
lie should be sought, such as wrong dates, mechanical causes like polyhydramnios, placenta praevia,
fibroids, multiple pregancnies; and pelvic size and shape may be assessed by pelvic examination. If no
abnormalities are detected, she should be reassessed at 37 weeks. If unstable lie persists, she should be
admitted to hospital until delivery. Fetal lie should then be monitored using a lie chart daily. She can be
discharged if there is longitudinal lie for 3 days. My patient should also be informed of need for prompt
admission to hospital if membranes rupture or when labour starts.
Immediate clinical assistance should be given if membranes rupture or there are signs of labour.
Intrapartumly, vaginal and pelvic assessment should be done to establish presentation, exclude cord
presentation and assess cervical dilatation. If the lie is longitudinal, it can be managed normally. If the lie
is not longitudinal, ECV may be considered early in labour and ARM done with caution. If the lie is not
longitudinal and cannot be corrected, Caesarean section should be done.
Alternatively, a stabilizing induction can be done at 38 weeks, if the cervix is favourable according to
bishop score.
FAQs
What is lie?
Relationship between the longitudinal axis of the fetus to the longitudinal axis of the mother.
What is the definition of unstable lie?

Fetal lie and presentation repeatedly change at beyond 36weeks of gestation.
What is the incidence of unstable lie?

At 26weeks is 40%, at 30week is 20%, at term is 3%.
What are the causes of unstable lie?
• Prematurity
• Prevention of head descending: Cephalopelvic disproportion, cervical fibroid, Placenta praevia,
Uterine surgery, Multiple gestation, Fetal abnormality (anencephaly), Fetal neuromuscular
disorder
• Condition that permit free fetal movement: Polyhydramnios, Uterine laxation (multipara)

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What are the possible complications of unstable lie?
• Cord prolapsed leading to fetal hypoxia/ fetal death.

• Compound presentation
• Uterine rupture
How are you going to manage an unstable lie case?

I would like to rule out causes of unstable lie like placenta praevia, polyhydramnios & pelvic tumors. If
the patient has reached term, I would like to put her on daily lie chart. If the fetus turns into cephalic
presentation, I would like to do stabilization induction if there are no contraindications to vaginal delivery.
I would also like to counsel the mother on the mode of delivery, if the fetus is not in longitudinal lie
LSCS will be offered.

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Previous LSCS Scar
In summary, SFH is 37 cm, there is a singleton fetus in longitudinal lie, cephalic presentation, fetal back
on maternal right side. FHR is 150 bpm, strong & regular. Clinically, amniotic fluid is adequate. EFW is
3kg. There is presence of a transverse suprapubic scar, measuring ?cm, healed by primary/secondary
intention, no scar tenderness or incisional hernia. (if new or recent scar comment on signs of
inflammation, infection, induration, tenderness.
To complete my examination, I would like to know the type of C-section, indication (emergency or
elective), how many times she had a scar, last scar date (>2 years for good healing), any complications
from previous C-section, any medical conditions complicating this pregnancy & the current baby
condition.
I would like to do an ultrasound to locate the placenta (r/o placenta praevia), confirm number of
pregnancy, lie/presentation of fetus, AFI, growth parameters, EFW.
Where and how would you manage her during labour?
Delivery should be conducted in suitably staffed and equipped delivery suit, with continuous
intrapartum care and monitoring, available resources for immediate CS and advance neonatal
resuscitation facilities.
During the first stage of labour, I will monitor her vital signs closely & do continuous electronic fetal
monitoring (CTG), monitoring progress with partogram. I will provide adequate analgesia. I would be
extra caution & vigilance in monitoring for evidence of scar dehiscence & rupture. I would do 4 hourly VE
to look for OS dilatation & fetus position. I would also prepare her as if she is going for OT (in case she
needs to go for emergency C-section when there is scar rupture (rare) or fetal / maternal complications)
by by monitoring her vital signs, insert 2 large bore cannula, GSH 4 units blood + FBC (hb), NBM (good
hydration), counsel & take consent.
In the second stage of labour, my aim is to monitor vigilantly. (2-3 fold increased risk of uterine rupture
and 1.5 fold increased CS rate in induced and augmented labour than spontaneous labour.)
IOL wit prostin in patient with previous LSCS is extremely high risk, need to carefully monitor patient.
I would like to actively manage the third stage of labour by giving IM syntocinon after the anterior
shoulder is out, early cord clamping, rubbing of uterine fundus & CCT ( = Active management of 3rd
stage). I would watch actively for signs of PPH by monitoring her vital signs.
If during any stage of labour there is scar dehiscence or rupture, I would like to manage the patient in
the OT by doing laparotomy.
What are the possible complications of vaginal birth with previous scar?
Uterine rupture (disrupt uterine serosa), uterine dehiscence (intact uterine serosa).

20
What are the signs of scar dehiscence?

Mother : Suprapubic pain asynchronous with contraction with PV bleeding & Sudden cessation of
contraction, loss of sensation of the presenting part.
Fetus : Loss of fetal heart sound, Fetal distress seen on CTG
What are the signs of scar rupture?

Mother : Pale, tachycardia, hypotension, shock, chest pain/shoulder tip pain, sudden SOB.
Sudden cessation of contraction, loss of sensation of the presenting part easily palpable fetal part,
uterus separated from baby.
Abdominal distension/tender free fluid in peritoneum cavity, hematuria, PV bleed,
Also, post-delivery maternal collapse. Diagnosis is confirmed at laparotomy.
Fetus : Loss of fetal heart sound, fetal distress on CTG.
What are the indications for repeat LCSC?

Elective LSCS : CPD, 2 previous scar, breech/malpresentation, IUGR, placenta praevia, pelvic tumor.
Emergency LSCS : Fetal distress, cord prolapsed, placenta abruption.
Non- recurrent causes : Breech, Placenta praevia, secondary arrest, fetal distress, eclampsia.
Recurrent cause : Gross CPD
RCOG : What are the success rate of VBAC?

Women considering their options for birth after a single previous caesarean should be informed that,
overall, the chances of successful planned VBAC are 75-80 %.
RCOG : What is the single best predictor for successful VBAC?

Previous vaginal birth (VBAC).
RCOG : What are the risk factors for unsuccessful VBAC?

Induced labour, no previous vaginal birth, BMI > 30, previous Caesarean section for dystocia.
VBAC at or after 41 weeks, birth weight > 4kg, no epidural anaesthesia, previous preterm caesarean
section, cervical dilatation at admission < 4cm, < 2 years from previous caesarean birth, advanced
maternal age, non-white ethinicity, male infant, short stature.
Indications / Option for VBAC?
• Women with prior history of one uncomplicated LSCS

• Women with an otherwise uncomplicated pregnancy at term
• Women with no contraindication to vaginal birth

21
Final decision for mode of delivery

Should be agreed between women and her obstetrician before planned delivery date (ideally by 36
weeks of gestation.
Counseling
Should include maternal and perinatal risk and benefits of planned VBAC versus elective LSCS.
Risk factors for unsuccessful VBAC

Induced labour, no previous vaginal birth, BMI >30, previous CS for dystocia (49% success rate)
Contraindications to VBAC
• Women with a prior history of one classical CS (200-900/10000 risk of uterine rupture)
• Previous uterine rupture (risk is unknown)
• 3 or more previous CS (risk is unknown)
Rupture rates
• Inverted T or J incision (190/10,000 risk)
• Low vertical incision (200/10,000 risk)
• LSCS (22-74/10,000 risk)
Caution in VBAC (uncertainty in safety)

• Twins
• Macrosomia
• Short interdelivery interval

22
Multiple Pregnancy Record
In summary, the SFH is …cm. There are 2 fetuses, both in longitudinal lie. The leading twin is in cephalic
presentation, whereas the second twin is non-cephalic. The head of the leading twin is 3/5 palpable, hence
not engaged. Estimated fetal weight of the individual twins is 2.0kg. The liquor amount is adequate. Fetal
heart rate of the leading twin is … bpm, whereas the second twin is …bpm (at least 10 bpm difference,
different intensity, audible at 2 different areas)
Remark : In a twin pregnancy, both fetal back will be at the maternal sides.
How would you manage a case of twin pregnancy?
A twin pregnancy should ideally be managed by 1 consultant or specialist.
Antenatally, regular clinic attendance is strongly advised because all the major hazards of pregnancy are
increased. Maternal complications such as anaemia, pregnancy-induced hypertension or pre-eclampsia,
gestational diabetes mellitus, preterm prelabour rupture of membranes and placentae praevia should be
identified, monitored and treated appropriately. Iron and folic acid supplementation from the 1st trimester
is recommended. I also like to monitor for fetal growth and well-being. (As for the fetus, an early dating
scan, ideally in the 1st trimester should be done and chorionicity determined.) A monochorionic twin
require much greater surveillance as the perinatal mortality is 5 times greater than dichorionic twins. A
detailed anomaly scan should be done at 20 weeks of gestation. Serial growth scans should also be done,
2 weekly for monochorionic and 4 weekly for dichorionic, as fetal growth restriction complicates 30% of
twin pregnancies. Complications such as TTTS, TRAP, IUGR and IUD should be identified. Fetal well-
being should also be monitored regularly, in the form of fetal kick counts, fetal heart rate and
cardiotocography. My patient should counseled that if pain, contractions and leaking of liquor occur, she
should seek medical attention immediately. If it is preterm, corticosteroids should be given.
If no complications arise, the timing of delivery should be at 38 weeks. The mode of delivery of choice is
vaginal delivery, as the leading twin is in cephalic presentation.
Intrapartumly, 2 neonatologists, 2 senior obstetricians, 1 midwife and 2 neonatal resuscitation trolleys

should be present. Continuous CTG monitoring of both the fetuses is indicated. The leading twin should
be delivered normally. The second twin’s lie and presentation should be assess thereafter, and stabilized
in longitudinal lie. Amniotomy can be performed when the presenting part descended to stimulate or
augment uterine contraction. Watch out for cord prolapsed. The second twin can be delivered as cephalic
or breech. For abnormal lie of the second twin, ECV, IPV can be done. If complications arise, second
twin may be delivered by CS. After delivery of the second twin, syntometrine can be given, provided
there is no undiagnosed triplet. Third stage should be managed actively.

23
FAQs
What is the role of ultrasound in multiple pregnancy?

Early : Number of fetus, chorionicity (first trimester), sac.
18-20 weeks : Fetal anomaly scan
Third trimester : Lie, presentation, monitor fetal growth & wellbeing (discordant growth/IUGR),
placenta localization, AFI (high risk of polyhydramnios), , TTTS, TRAP
What is Hellin’s rule? Expected incidence in twins is 1:80, triplets is 1:802, and so on.
What are the complications of multiple pregnancy?
Mother Fetus
Antepartum • Excessive symptoms of • Miscarriage
(Divide into pregnancy • Unexplained IUD
1st, 2nd, 3rd o Hyperemesis gravidarum • IUGR
trimesters) o Backache, abd discomfort • Congenital malformations
o Varicose veins, haemorrhoids • TTTS
o Edema • TRAP
• Anaemia • Prematurity
• PIH/PE (5-10x more common)
• PPROM/PROM
• APH (Placenta praevia)
• Compressive symptoms (e.g.
dyspnea)
Intrapartum • Prolonged labour • Preterm labour
• Increased likelihood for • Malpresentation
operative delivery (instrumental, • Fetal hypoxia/distress
LSCS) • Cord prolapsed
• Uterine rupture (due to internal • Retained 2nd twin
podalic version, prolonged • Fetal trauma
labour) • Difficulty in monitoring 2 fetus
Postpartum • PPH, Retained placenta, delayed • Prematurity associated problems
uterus involution. (RDS, sepsis, jaundice, hypothermia
• Puerperium infection. • Cerebral palsy
• Highest risk of pre-eclampsia in
48 hours.
• Social, financial, personal
problems (breastfeeding and
care for 2 babies)

24
Types of multiple pregnancy : Monozygotic and dizygotic (MCMA, MCDA, DCDA)
Why is there higher risk of PPH in multiple gestation?

Larger placenta site & uterine over-distension.
What are the causes of morbidity & mortality in twins?

RDS, birth trauma, cerebral hemorrhage, birth asphyxia/anoxia, congenital anomalies, still births,
prematurity.
Before discharge, what are you going to counsel her?

I would like to talk about contraception & benefits of family planning to her. Arrange follow-up to
monitor maternal & fetal wellbeing. Provide reading pamphlets & contact details of local multiple
pregnancy support group.

25
Long Case : Pregnancy Induced Hypertension
In summary, she has PIH diagnosed at 30 weeks POA. BP is 130/80mmHg & there is no signs &
symptoms of IE.
I would like to complete my examination by measuring her weight, performing a complete examination of
the cardiovascular system, neurological examination to look for neurological deficits, clonus,
hyperreflexia; fundoscopy do look for hypertensive retinopathy & dipstick urine for proteinuria.
When will you deliver her (sole PIH case)?

Delivery is considered when prolonging the pregnancy offers no benefit to mother & fetus and there is
increasing risk of deterioration of both parties after through investigations.
In an uncomplicated asymptomatic PIH case with no evidence of fetal/maternal compromise, I would like
to manage conservatively until 40 weeks but do not allow post date (risk of placenta insufficiency
Sudden IUD).
If she is on anti-hypertensive & BP well controlled, no evidence of fetal/maternal compromise, there is a
role of managing her expectantly till 38 weeks.
If she develops severe PE, eclampsia or any evidence of fetal/maternal compromise, I will like to deliver
her immediately regardless of POA.
How will you monitor her during labor?

Intrapartum monitoring includes continuous electronic fetal monitoring, monitor labor by partogram,
anti-hypertensive medications continued. I will also establish IV line, keep NBM & provide adequate
analgesia as pain can increase BP. I will monitor her BP/PR every 15 minutes. In the second stage of
labor, I will try to assist her to shorten this stage. In the third stage of labor, I will give her syntocinon
after the delivery of the baby. I will monitor closely her urine output by strict I/O charting. Restriction of
fluids to < 1 liter following delivery of women with severe PE reduces risk of pulmonary oedema.
I will request an experience pediatrician to b there at delivery room.
How would you manage her if she develops eclampsia?

I will like to resuscitate her according to airway, breathing, circulation (ABC).
I will place her in left lateral position & secure airway, give O2. I will also insert an urinary catheter to
monitor urine output. I will like to check for disorders of electrolyte imbalance & DIC. To control the
convulsions, MgSO4 is the drug of choice as it reduces neuromuscular irritability & cerebral vasopasm.
A suggested regime is a loading dose of slow bolus of 4g iv over 5-10 minutes followed by iv infusion of
1g for 24 hours. Treat recurrent seizures with further iv bolus of 2g over 5 minutes. If seizure persists
despite on MgSO4, I would consider giving diazepam or thiopentone under anaesthetic guidance. If BP >
160/110 mmHg, I will consider staring hypertensive crisis regime. Finally, when eclampsia is under
control, I will like to deliver her immediately by C-section if vaginal delivery is unfavorable. If she is in
labour, delivery may be possible.
What are the predisposing factors for hypertensive disorders during pregnancy?
Primigravida, genetic (mother & fetal), predisposing factors medically (essential hypertension,
thrombophilia, migraines, DM), socioeconomy (Poor maternal nutrition).

26
What is the strong association with hypertensive disorders during pregnancy?

Multiple pregnancy (particularly monochorionic twins), fetal triploidy/trisomy 13, hydatidiform mole,
placenta hydrops.
What is the timing of eclampsia seizures?

38% antenatally, 18% intrapartum, 44% postpartum.
What are the sign & symptoms of impending eclampsia?

Symptom : Epigastric pain, nausea & vomiting, frontal headache.
Signs : Severe hypertension & proteinuria. Papilloedema, retinal oedema/hemorrhages.
What are the signs of MgSO4 toxicity?

Respiratory suppression (<16 bpm), urine output (< 25ml/hr), absence knee jerks.
What is the antidote for MgSO4 overdose?

IV Calcium gluconate 1g over 10 minutes.
What is the proposed etiology of pre-eclampsia?

Genetic predisposition Abnormal immunological response Deficient trophoblast invasion
Hypoperfused placenta Circulating factors released Vascular endothelial cell activation Clinical
manifestation of disease.
Why pre-eclamptic / eclamptic patient who goes for emergency LSCS bleeds more?
Hypertension & Thrombocytopenia (HEELP).

27
Long Case : Gestational Diabetes Mellitus
Management
Since my patient has GDM, I would like to manage her by a multidisciplinary team, which consists of
obstetricians, physicians and dieticians. Antenatally, the aims of my management are to achieve a good
blood glucose control and to prevent complications. To control the blood sugar level, a strict diet
control should be adopted. This can be achieved by taking high fibre diet with correct calorific intake as
advised by the dietician. If indicated, an insulin therapy may be initiated. The usual insulin treatment is
combined soluble intermittent soluble insulin with each meal and an intermediate-acting insulin in the
evening. If my patient is on insulin, she should be instructed on the use of glucagon for hypoglycaemic
attacks. To assess her blood glucose control, blood sugar profile monitoring should be done for 2-3 times
per week. Ideal pre and post-prandial levels are <5.0 and <7.0 respectively. Urinalysis should also be
done at each visit for glycosuria and evidence of UTI (leucocyte esterase, nitrites). HbA1c or
fructosamine tests may also be done regularly to assess blood glucose control.
For maternal health, her weight, optic fundi, blood pressure and renal function should be monitored
regularly. Fetal monitoring, on the other hand, consists of fetal well-being and growth. This can be done
by counting of fetal movements by the mother and recording it on a fetal kick chart (>10 in 12 hours),
symphysiofundal height, fetal heart rate and CTG should be done at each follow up. Serial USG should
also be done fortnightly to assess for fetal growth, as GDM is associated with macrosomia. Liquor
amount should also be assessed as GDM is associated with polyhydramnios. A detailed anomaly scan
should be done at 20 weeks, as there is associated increase in incidence of congenital anomalies (e.g.
cardiac and cranio-spinal defects) in DM mothers.
For labour and delivery, if diabetes is well-controlled and pregnancy is uncomplicated, the timing of
delivery should be at 38 weeks, by induction of labour. The mode of delivery of choice is normal vaginal
delivery, unless contraindicated. During labour, close control of blood glucose is achieved by a continous
infusion of soluble insulin using a sliding scale, and a separate infusion of dextrose and KCl. Regular
blood glucose control monitoring should be undertaken (hourly DXT) and the insulin infusion titrated to
keep levels between 5-7 mmol/L. If a syntocinon infusion is needed, should be made up using normal
saline. Continous electronic fetal monitoring should be done.
If my patient is going for ELSCS, keep her NBM from 12 midnight. Baseline U&E and RBS should be sent
at 6am. Morning dose of insulin is omitted. DXT to be monitored regularly. Close control of blood
glucose is achieved by hourly assessment of BS level, a continuous infusion of soluble insulin using a
sliding scale, and a separate infusion of dextrose and KCl.
Shoulder dystocia and fetal distress should be anticipated.
During the post partum period, following the delivery of placenta, insulin infusion should be discontinued.
DXT for both mother and baby to be checked before transferred out to post-natal ward. Mother should be
encouraged to commence breast feeding early. Blood glucose level should be maintained at 4-10mmol/L.
Contraception should be advised.

28
FAQs
What are the risk factors for the development of DM in pregnancy?
• Increasing age
• Certain ethnic groups (Asian, African Americans, Hispanic/Latino Americans and Pima Indians)
• High BMI before pregnancy (three-fold risk for obese women compared to non-obese women)
• Smoking - it doubles the risk of GDM
• Change in weight between pregnancies - an inter-pregnancy gain of more than three units (of BMI)
doubles the risk of GDM
• Short interval between pregnancies
• Previous unexplained stillbirth
• Previous congenital anomaly
• Previous macrosomia
• Family history of type 2 diabetes or GDM - more relevant in nulliparous than parous women
What are the effects of pregnancy on diabetes?
• Change in eating pattern

• Increase in insulin dose requirements
• Greater importance of tight glucose control
• Increased risk of sever hypoglycaemia
• Risk of deterioration of pre-existing retinopathy
• Risk of deterioration of established nephropathy
What are the effects of diabetes on pregnancy?
• Increased risk of miscarriage

• Risk of congenital malformation
• Risk of macrosomia
• Increased risk of pre-eclmpsia
• Increased risk of still birth
• Increased risk of infection
• Increased operative delivery rate
Factors associated with poor pregnancy outcomes in diabetes
• Maternal social deprivation

• No folic acid intake pre-pregnancy
• Suboptimal approach of the woman to managing her diabetes
• Suboptimal pre-conception care
• Suboptimal glycaemic control at any stage
• Suboptimal maternity care during pregnancy
• Suboptimal fetal surveillance of big babies
29
Who to be screened for GDM? (Carol)
• Age > 25 years old

• BMI >27 kg/m2
• Glycosuria @ 1st antenatal / booking visit
• Previous macrosomic baby (≥4kg) or LGA
• Previous GDM
• First-degree relative with diabetes
• Family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle
Eastern)
• Previous unexplained stillbirths, recurrent abortions, birth defects
• Current obstetric problems – polyhydramnios, current use of steroids, persistent glycosuria.
How would you screen for GDM in a pregnancy?

In the presence of GDM risk factors but gestation < 12 weeks, I will perform a RBS.
If GDM risks present but gestation is > 12 weeks but patient has hyperemesis, I will deter OGTT till later.
If gestation is > 12 weeks & she has no hyperemesis, I will do OGTT.
I would like to repeat OGTT at 24-28 weeks if the first OGTT is normal.
How you diagnose GDM?

MOGTT : FBS ≥5.6 and / or 2nd hr ≥ RBS 7.8

30
Common Q & A
What is the definition of labour?

Labour is defined as the presence of regular contractions with increasing intensity & frequency associated
with progressive dilatation & effacement of the cervix with descent of the presenting part.
What are the features of normal labour?

Spontaneous onset; single cephalic presentation, 37-42 weeks; no artificial interventions; unassisted
spontaneous vaginal delivery; dilatation ≥ 1cm/2 hours in active first stage; active second stage < 2 hours
in primiparous, < 1 hour in multiparous; third satge < 30 minutes with active management.
How to differentiate true from false labour pain?

In false labour, the cervix remains undilated & uterine contractions remain impalpable or infrequent.
What is the evidence of obstructed labour?

Secondary arrest of cervical dilatation & descent of presenting part, large caput, third degree moulding,
cervix poorly applied to presenting part, oedemtous cervix, ballooning of lower uterine segment,
formation of retraction band, maternal/fetal distress. Thick meconium stained liquor.
What are the signs of separation of the placenta?

Lengthening of the cord, small gush of blood, rising of uterine fundus to above umbilicus, fundus become
hard & globular compared to soft & broad prior to separation.
How are you going to present a vaginal examination finding?

Vulva & Vaginal no abnormalities detected. Os 2cm. Cervix canal length 2cm, station -1, medium
consistency, membrane intact, no cord felt, vertex presentation. (0/5 = +2cm, 1/5 = +1cm, 2/5 = 0cm (this
is a little controversial) @ischial spine; head engaged, 3/5 = -1 cm, 4/5 = -2cm, 5/5 = -3cm)
Where would you place your Pinard stethoscope?

Anterior shoulder. (Prof SA : Fetal back, identify the anterior shoulder then move 3.75 cm (1.5-2 inch)
laterally).
If mother complained of reduced fetal movement, what will you do?

I will take a complete history & PE. I will use a pinard stestescope to measure fetal heart rate.
Next, I will like to proceed to US to look at fetal heart activity, measure the growth parameter (BPD, AC,
FL, AFI and weight), lie & presentation, biophysical profile. I will also like to do a Doppler US to look
for reversed diastolic flow, CTG, and ask the mother to plot a fetal kick chart.
What is a biophysical profile? Score 0-10

A biophysical profile is a long US scan (30 minutes) which identify antenatal hypoxia. It takes into
account of a non-stress CTG, fetal breathing movements, fetal body movements, fetal tone & amniotic
fluid volume.

31
What is a modified biophysical profile?

The modified biophysical profile combines the non-stress test (CTG) with the amniotic fluid index.
The modified biophysical profile is considered normal if the nonstress test is reactive and the amniotic
fluid index is greater than 5 cm and abnormal if the nonstress test is nonreactive or the amniotic fluid
index is 5 cm or less.
What is Bishop score? Score 0-13

Dilatation of cervix, consistency of cervix, length of cervical canal, position, station of presenting part.
How do you determine fetal well being?

By CTG & Biophysical profile.
What is active management of third stage of labour?

Syntocinon, controlled cord traction, early clamping of cord, uterine massage.
What are the indications of doing a emergency LSCS in a major placenta praevia case?
Major bleeding, in labour, fetal distress, placenta abruption.
What are the complications of post date?

IUFD secondary to placenta insufficiency, fetal hypothermia or hypoglycemia, fetal distress during labour,
increase risk of caesarean section, meconium stained liquor.
Prof SA : What should be excise in hysterectomy?

Broad ligament, round ligament, cardinal ligament/paracervical & vaginal vault.
Mnemonics in Obstetrics & Gynaecoogy
Prerequisites for instrumental delivery : FORCEPS

Fully dilated cervix (8cm for ventouse)
OA/OP
Ruptured membranes
C – No CPD, catheterize patient, contraction satisfactory.
Episiotomy, Engage (0/5)
Pain relief, position( (Lithotomy)
Supervision, sterility, skill

32
Some Important Obstetrics Definitions

By Ng Chee Guan
a) Term:
37 + 0 weeks to 41 + 6 weeks
b) Pre-term:
24 +0 weeks to 36 +6
weeks
c) Normal labour:
Process by which regular painful uterine contraction which brings about effacement and
dilatation of the cervix and descent of the presenting part ultimately leading to the expulsion of
the fetus and placenta from mother
d) Lie:
Relationship between the longitudinal axis of the fetus to the longitudinal axis of the mother
e) Presentation:
Lowest pole of the fetus that presents to the lower uterine segment and the cervix
f) Attitude:
The degree of flexion and extension of the upper cervical spine (fetus)
g) Engaged head:
2/5 or less fetal head is palpable

33
By Ng Chee Guan
Example of presentation on abdominal findings for obstetrics short case (need to be modified based
on various scenarios such as singleton pregnancy, twins pregnancy & abnormal lie and etc)
Inspection:
Abdomen is grossly / symmetrical / asymmetrical distended by gravid uterus as evidence by
linea nigra and striae gravidarum (may or may not present). There are also striae albicans (may or may
not present). Umbilicus is centrally located / deviated and inverted / flat / everted (describe what you see).
Dilated veins (may or may not present) are seen on both flanks. Suprapubic transverse scar is present
(describe everything about the scar if presents such as length, healed by primary union / hypertrophied
scar / keloid, any incisional hernia and any scar tenderness etc). Hernia orifices are intact. I can
appreciate fetal movement (may or may not present) on inspection.
Palpation:
Clinical fundal height corresponds to ____ weeks while symphysio-fundal height measures
____ cm. (this may or may not correspond with gestation age – uterus smaller / larger than date). There is
a singleton fetus (no. of fetus), in longitudinal lie (lie: transverse, oblique, longitudinal), cephalic
presentation (presentation: breech, cephalic and etc), fetal back is at maternal left while fetal limb is at
maternal right. Estimated fetal weight is ___ kg and liquor volume seems to be adequate (excess may
indicate polyhydramnios while reduce may indicate oligohydramnios).
Auscultation using pinard stethoscope:

Fetal heart sound is heard at right iliac fossa (depending on where you heard it) which is
120bpm, strong and regular.
I would like to complete my examination by doing ____ (depends on the case).
*** Sometimes may need to present general & peripheral examination findings depending on the case
and stem given by examiners
Summary
In summary, this lady, 28 years old (age), G2P1 (GxPy), is having __________ at ______ weeks
of POG/POA.

OG Short Cases

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Short Cases in OBGY

Dr Win Win Than

Wong & Low O & G Short Cases Record

Our Aim : Made it easy to do it right!

Common Questions & Answers

Short Case Record for uterine mass (Fibroid)

My differentials for this mass are:

Differential diagnoses (depends on symptoms)

Wong & Low O & G Short Cases Record

What are the investigations you would like to do?

How would you manage her?

Submucosal fibroids may be resected hysteroscopically. Pedunculated, subserosal myomas can be

What are the new methods for treating fibroid?

What is the incidence of uterine fibroids?

What is the risk of malignant change? (please refer 10 teachers)

What are the sites of origin?

What are the clinical features of leiomyoma?

What are the risk factors of developing fibroids?

What are the protective factors of developing fibroids?

What are the complications of fibroids?

What the potential effects of fibroids on pregnancy?

What are the common associated conditions?

What is the rare association with fibroids?

Wong & Low O & G Short Cases Record

What is the pathogenesis of leiomyomas?

How do you differentiate myoma from adenomyosis?

Epidemiology Commonest benign uterine tumor. Less common.

Age group 30-40 years old 40-50 years old (uptodate)

Clinical manifestation Menorrhagia Dysmenorrhea

Size Any size < 14 weeks size

Tenderness Non tender mass Usually tender mass

Wong & Low O & G Short Cases Record

Facts about GNRH analogue

Routes of administration Goserelin acetate (3.6 mg/month subcutaneously or 10.6 mg

Benefits Reduce fibroid size, less bleeding intra-operatively.

10 teachers : Obscure tissue planes around fibroids making surgery

Wong & Low O & G Short Cases Record

Short Case Ovarian Cyst Record

On percussion, there is dullness over the mass. No signs of free fluid.

What are the complications of ovarian cyst? THIN RIM

• Torsion, haemorrhage, infection, necrosis, rupture, intestinal obstruction, malignant change

Differentiate mass between ovarian and myoma

Wong & Low O & G Short Cases Record

• General: Elderly, Cachectic, pale

• Bloody ascitic fluid

Wong & Low O & G Short Cases Record

Uterus Larger than Date

What are the causes for uterus larger than date?

How would you manage this case?

Wong & Low O & G Short Cases Record

Uterus Smaller than date

SFH is 3cm less than the gestational age in weeks.

What are the causes of uterus smaller than date?

Causes of asymmetrical IUGR include:

What are the complications of FGR?

Wong & Low O & G Short Cases Record

Discuss management options for a breech presentation at 38 weeks.

What is the incidence of breech presentation?

What are classifications of breech presentation at term?

What are the etiology of breech presentation?

What are breech presentation associated with?

What are the hazards of ECV?

Wong & Low O & G Short Cases Record