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Obstetric History Taking – OSCE Guide

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An obstetric history involves asking questions relevant to a patient’s current and previous pregnancies . Some of the questions are highly personal, therefore good communication skills and a respectful manner are absolutely essential.

Taking an obstetric history requires asking a lot of questions that are not part of the “standard” history taking format, therefore it’s important to understand what information you are expected to gather.

It’s also worth noting that before 18 weeks gestation, most obstetric conditions are unlikely, therefore your history should be gynaecology focussed (e.g. abdominal pain at 8 weeks gestation could be an ectopic pregnancy).

• Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role .

Confirm the patient’s name and date of birth .

Explain that you’d like to take a history from the patient.

Gain consent to proceed with history taking.

Key pregnancy details

It is useful to confirm the gestational age , gravidity and parity early on in the consultation, as this will assist you in determining which questions are most relevant and what conditions are most likely.

Gestational age, gravidity and parity should also be included at the beginning of your presentation of a patient’s history.

Gravidity (G)  is the number of times a woman has been pregnant, regardless of the outcome (e.g. G2).

Parity (P)  is the total number of times a woman has given birth to a child with a gestational age of 24 weeks or more, regardless of whether the child was born alive or not (stillbirth).

Example of gravidity and parity calculation

A patient is currently 26 weeks pregnant and already has two children of her own. She reports having had a miscarriage at 10 weeks and a stillbirth at 28 weeks:

• G5 : The patient’s gravidity is 5 because she has had 5 pregnancies in total.
• P3 : The patient’s parity would be 3 because she has had 3 pregnancies which resulted in the birth of a child with a gestational age of greater than 24 weeks (one of which was a stillbirth).

How does parity work for twins?

A British Journal of Gynaecology study suggests that a mother who has carried twins to a viable gestational age (greater than 24+0 weeks) should be defined as P1 .

However, in clinical practice, only 20% of UK Obstetricians and Midwives follow this definition, with the remaining 80% referring to twin pregnancy as P2 .

As a result, you should be aware that in clinical practice, a mother who has carried twins to a viable gestational age will often be referred to as P2, but from an academic perspective, they would be deemed P1.

General communication skills

It is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).

Some general communication skills which apply to all patient consultations include:

• Demonstrating empathy in response to patient cues: both verbal and non-verbal.
• Active listening: through body language and your verbal responses to what the patient has said.
• An appropriate level of eye contact throughout the consultation.
• Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
• Making sure not to interrupt the patient throughout the consultation.
• Establishing rapport (e.g. asking the patient how they are and offering them a seat).
• Signposting: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
• Summarising at regular intervals.
• Presenting complaint

Use  open questioning  to explore the patient’s  presenting   complaint :

• “What’s brought you in to see me today?”
• “Tell me about the issues you’ve been experiencing.”

Provide the patient with enough time to answer and avoid interrupting them.

Facilitate the patient to  expand  on their  presenting   complaint  if required:

• “Ok, can you tell me more about that?”
• “Can you explain what that pain was like?”

Open vs closed questions

History taking typically involves a combination of open and closed questions . Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis.

• History of presenting complaint

Once the patient has had time to communicate their presenting complaint, you should explore the issue with further open and closed questions.

The  SOCRATES acronym is a useful tool for exploring each of the patient’s presenting symptoms in more detail. It is most commonly used to explore pain, but it can be applied to other symptoms, although some of the elements of SOCRATES may not be relevant to all symptoms.

Ask about the location of the symptom:

• “Where is the pain?”
• “Can you point to where you experience the pain?”

Clarify how and when the symptom developed:

• “Did the pain come on suddenly or gradually?”
• “When did the pain first start?”
• “How long have you been experiencing the pain?”

Ask about the specific characteristics of the symptom:

• “How would you describe the pain?”  (e.g. dull ache, throbbing, sharp)
• “Is the pain constant or does it come and go?”

Ask if the symptom moves anywhere else:

• “Does the pain spread elsewhere?”

Associated symptoms

Ask if there are other symptoms which are associated with the primary symptom:

• “Are there any other symptoms that seem associated with the pain?” (e.g. shortness of breath in pulmonary embolism)

Time course

Clarify how the symptom has changed over time :

• “How has the pain changed over time?”

Exacerbating or relieving factors

Ask if anything makes the symptom worse or better :

• “Does anything make the pain worse?” (e.g. patients with symphysis pubis dysfunction may find going up or down the stairs makes things worse)
• “Does anything make the pain better?” (e.g. patients with gastro-oesophageal reflux may find that antacid medication helps with their symptoms)

Assess the severity of the symptom by asking the patient to grade it on a scale of 0-10:

• “On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve ever experienced?”

Obstetric symptoms

Once you have completed exploring the patient’s history of presenting complaint, you need to move on to more focused questioning relating to the  symptoms that may be relevant to pregnancy (if not already discussed). We have included a focused list of key symptoms to ask about when taking an obstetric history, followed by some background information on each, should you want to know a little more.

Summary of key obstetric symptoms

Key obstetric symptoms to ask about include:

• Nausea and vomiting : common in pregnancy and mild in most cases. Hyperemesis gravidarum represents a severe form of vomiting in pregnancy associated with electrolyte disturbance, weight loss and ketonuria.
• Reduced fetal movements : can be associated with fetal distress and absent fetal movements may indicate early fetal demise.
• Vaginal bleeding : causes include cervical bleeding (e.g. ectropium, cervical cancer ), placenta praevia and placental abruption (typically associated with abdominal pain).
• Abdominal pain : causes may include urinary tract infection, constipation, pelvic girdle pain and placental abruption.
• Vaginal discharge or loss of fluid : abnormal vaginal discharge may be caused by sexually transmitted infections such as gonorrhoea and the loss of fluid from the vagina indicates rupture of the amniotic membranes.
• Headache, visual disturbance, epigastric pain and oedema : these are typical clinical features of pre-eclampsia. Mild oedema is common and normal in the later stages of pregnancy.
• Pruritis : associated with obstetric cholestasis (typically affecting the palms and soles of the feet).
• Unilateral leg swelling : consider and rule out deep vein thrombosis .
• Chest pain and shortness of breath : pregnant women are at increased risk of developing pulmonary emboli.
• Systemic symptoms : fatigue (e.g. anaemia), fever (chorioamnionitis) and weight loss (e.g. hyperemesis gravidarum).

Nausea and vomiting

Nausea and vomiting are very common in pregnancy, but are typically mild, requiring only reassurance and basic hydration advice.

Nausea and vomiting typically begin between the fourth and seventh week  of gestation , then peak between the ninth and sixteenth week and resolve  by around the 20th week of pregnancy.

Persistent vomiting and severe nausea can progress to hyperemesis gravidarum . Hyperemesis gravidarum refers to persistent and severe vomiting leading to dehydration and electrolyte disturbance, weight loss and ketonuria. ¹

• Reduced fetal movements

Women typically start to feel fetal movements between 16 to 24 weeks gestation (primigravida women will often not feel fetal movements until after 20 weeks gestation). A mother will know what is the “usual” amount of fetal movements she experiences, therefore, if a reduction in fetal movements is reported, it should be taken very seriously .

Reduced fetal movements are associated with adverse pregnancy outcomes, including stillbirth , fetal growth restriction , placental insufficiency , and congenital malformations . ²

You should always ask about fetal movements once the patient is of the appropriate gestation to be able to feel them:

• “Have you noticed any change in the amount of your baby’s movement?”

Vaginal bleeding

Vaginal bleeding is an important symptom that can be relevant to a wide range of obstetric and gynaecological diseases.

It is important to ask about pain , associated trauma (including domestic violence), fever / malaise , recent ultrasound scan results (e.g. position of the placenta), cervical screening history , sexual history and past medical history to help narrow the differential diagnosis.

You should also ask about fatigue if anaemia is suspected and symptoms of hypovolaemic shock (e.g. pre-syncope/syncope).

Vaginal discharge

All healthy women will have some degree of regular vaginal discharge, so it is important to distinguish between normal and abnormal vaginal discharge when taking an obstetric history.

You should ask the patient if they have noticed any changes to the following characteristics of their vaginal discharge :

• Colour (e.g. green, yellow or blood-stained would suggest infection)
• Consistency (e.g. thickened or watery)
• Smell (e.g. fish-like smell in bacterial vaginosis)

Urinary symptoms

Urinary tract infections are common in pregnancy and need to be treated promptly. Untreated urinary tract infections in pregnancy have been associated with increased risk of fetal death, developmental delay and cerebral palsy .

Common symptoms of urinary tract infections include:

• Dysuria: pain whilst passing urine.
• Frequency: increased frequency of passing urine.
• Urgency: a sudden need to pass urine, with no earlier warning.

Headache, visual changes, epigastric pain, oedema

Pre-eclampsia is a relatively common condition in pregnancy which is characterised by maternal hypertension, proteinuria, oedema, fetal intrauterine growth restriction and premature birth. The condition can be life-threatening for the mother and the fetus. As a result, it is essential to ask about symptoms of pre-eclampsia as part of every patient review during pregnancy.

The key symptoms to ask about include:

• Headache (typically severe and frontal)
• Swelling of the hands, feet and face (oedema)
• Pain in the upper part of the abdomen (epigastric tenderness)
• Visual disturbance (blurring of vision or flashing lights)

Other symptoms

Fever is important to ask about when considering infectious pathology (e.g. urinary tract infections, cervical infections, chorioamnionitis).

Fatigue  is a non-specific symptom, but its presence may indicate anaemia or other systemic pathology.

Weight loss is a symptom of hyperemesis gravidarum and other significant conditions (e.g. malignancy, anorexia nervosa).

Pruritis in the context of pregnancy is suggestive of obstetric cholestasis (it typically affects the palms and soles of the feet).

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideas , concerns and expectations  (often referred to as ICE ) to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation.

The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues . This will help ensure your consultation is more natural , patient-centred and not overly formulaic.

It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below.

Explore the patient’s ideas about the current issue:

• “What do you think the problem is?”
• “What are your thoughts about what is happening?”
• “It’s clear that you’ve given this a lot of thought and it would be helpful to hear what you think might be going on.”

Explore the patient’s current concerns :

• “Is there anything, in particular, that’s worrying you?”
• “What’s your number one concern regarding this problem at the moment?”
• “What’s the worst thing you were thinking it might be?”

E xpectations

Ask what the patient hopes to gain from the consultation:

• “What were you hoping I’d be able to do for you today?”
• “What would ideally need to happen for you to feel today’s consultation was a success?”
• “What do you think might be the best plan of action?”
• Summarising

Summarise  what the patient has told you about their  presenting complaint . This allows you to  check your understanding of the patient’s history and provides an opportunity for the patient to correct  any  inaccurate information .

Once you have  summarised , ask the patient if there’s anything else that you’ve  overlooked . Continue to  periodically summarise  as you move through the rest of the history.

• Signposting

Signposting , in a history taking context, involves explicitly stating  what you have discussed so far  and  what you plan to discuss next . Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare  for what is coming next.

Signposting examples

Explain what you have covered so far : “Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”

What you plan to cover next : “Next I’d like to quickly screen for any other symptoms and then talk about your current pregnancy.”

• Systemic enquiry

A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint.

Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.

Some examples of symptoms you could screen for in each system include:

• Systemic : fatigue (e.g. anaemia), fever (e.g. chorioamnionitis, urinary tract infection), weight loss (e.g. hyperemesis gravidarum)
• Respiratory : dyspnoea (e.g. pulmonary embolism, anaemia), chest pain (e.g. pulmonary embolism)
• Gastrointestinal : abdominal pain (e.g. placental abruption), vomiting (e.g. hyperemesis gravidarum)
• Genitourinary : urinary frequency, dysuria and urgency (e.g. urinary tract infection), abnormal vaginal discharge (e.g. vaginal candidiasis, gonorrhoea)
• Neurological : visual changes, motor or sensory disturbances, headache (e.g. pre-eclampsia)
• Musculoskeletal : pelvic pain (e.g. symphysis pubis dysfunction)
• Dermatological : rashes, skin lesions, linea nigra
• Current pregnancy

Clarify the current gestational age of the pregnancy (e.g. 26 weeks and 5 days would be written as “26+5”).

Accurate estimation of gestation and estimated date of delivery (EDD) is performed using an ultrasound scan to measure the crown-rump length .

Scan results

Women are offered an ultrasound scan to check for fetal anomalies between 18+0 and 20+6 weeks . You should ask about the results of the scan (or check the medical records if the patient is unsure). The key findings to note include:

• Growth of the fetus: clarify if it was within normal limits for the current gestation.
• Placental position: if embedded in the lower third of the uterine cavity there is an increased risk of placenta praevia.
• Fetal anomalies: note any abnormalities identified.

There are several types of screening that women are offered during pregnancy:

• Down’s syndrome screening
• Rhesus status and the presence of any antibodies
• Hepatitis B, HIV and syphilis.

You should clarify if the patient has opted for screening and if so, what the results were.

Other details of the pregnancy

• Check if this is a singleton or multiple gestation .
• Clarify if the patient took folic acid prior to conception and during the first trimester.
• Explore the planned mode of delivery   (e.g. vaginal or Caesarean section ).
• Ask about any medical illness during pregnancy (clarify what type of illness and if the patient is still receiving any treatment).

Immunisation history

Check the patient is currently up to date with their vaccinations including:

• Flu vaccination
• Whooping cough vaccination
• Hepatitis B vaccination (if at risk)

Mental health history

Pregnancy can have a significant impact on maternal mental health , therefore it is essential that patients are screened for symptoms suggestive of psychiatric illness (e.g. depression, bipolar disorder, schizophrenia).

Ask about previous mental health diagnoses and any current thoughts of self-harm  and/or  suicide if relevant.

• Previous obstetric history

It is important to ask about a woman’s previous obstetric history, as this may help inform the assessment of risk in the current pregnancy and have implications for the mode of delivery.

Gravidity and parity

Gravidity is the number of times a woman has been pregnant, regardless of the outcome.

Parity is the total number of pregnancies carried over the threshold of viability (typically 24 + 0 weeks).

Term pregnancies (>24 weeks)

Gestation at delivery :

• Previous pre-term labour increases the risk of pre-term labour in later pregnancies.

Birth weight :

• A high birth weight in previous pregnancies raises the possibility of previous gestational diabetes.
• A low birth weight (small for gestational age) in a previous pregnancy increases the risk of a further small for gestational age baby.

Mode of delivery :

• Spontaneous vaginal delivery
• Assisted vaginal delivery (e.g. forceps)
• Caesarean section (will have implications for the choice of future mode of delivery)

Complications :

• Antenatal period: pre-eclampsia, gestational diabetes, gestational hypertension, placenta praevia and shoulder dystocia.
• Postnatal period: post-partum haemorrhage, perineal/rectal tears during delivery and retained products of conception.

Assisted reproduction :

• Clarify if IVF or other assisted reproductive techniques were used for any previous pregnancies.

As stated below, asking about stillbirths need to be done in a sensitive manner.

A  stillbirth  is when a baby is born dead after 24 completed weeks of pregnancy.

Sensitivity clarify the gestation of the stillbirth if this is not already documented.

Other pregnancies (<24 weeks)

Questions about miscarriage, terminations and ectopic pregnancies need to be asked in a sensitive manner in a private setting. It can be very difficult for women to discuss these topics. These questions should only be asked when relevant and by a person who is competent to do so.

Miscarriage

A  miscarriage  is the loss of a pregnancy before 24 weeks gestation.

Gestation :

• Clarify the trimester at which the miscarriage occurred (miscarriage is most common in the first trimester).

Other details :

• Clarify if medical or surgical management was required for the miscarriage and if any cause was identified for the miscarriage (e.g. genetic syndromes).

Termination of pregnancy

Termination of pregnancy  is the medical process of ending a pregnancy  so it doesn’t result in the birth of a baby. The pregnancy is ended either by taking medications or having a minor surgical procedure.

Clarify the gestation at which the termination of pregnancy was performed and the method of management (e.g. medical or surgical).

Ectopic pregnancy

An  ectopic pregnancy  is when a fertilised egg implants itself outside of the uterus , usually in one of the fallopian tubes.

Clarify the site of the ectopic pregnancy and how it was managed (e.g. expectant, medical, surgical).

• Gynaecological history

Cervical screening :

• Confirm the date and result of the last cervical screening test.
• Ask if the patient received any treatment if the cervical screening test was abnormal and check that follow up is in place.

Previous gynaecological conditions and treatments :

• Sexually transmitted infections
• Endometriosis
• Bartholin’s cyst
• Cervical ectropion
• Malignancy (e.g. cervical, endometrial, ovarian)

Past medical history

A patient’s past medical history is particularly relevant during pregnancy, as some medical conditions may worsen during pregnancy and/or have implications for the developing fetus.

Ask if the patient has any medical conditions :  

• “Do you have any medical conditions?”
• “Are you currently seeing a doctor or specialist regularly?”

If the patient does have a medical condition, you should gather more details to assess how   well   controlled  the disease is and what  treatment(s)  the patient is receiving. It is also important to ask about any  complications  associated with the condition including  hospital   admissions .

Ask the patient if they’ve previously undergone any surgery or procedures in the past such as:

• Abdominal or pelvic surgery: may influence decisions regarding delivery due to the presence of scar tissue and adhesions.
• Previous Caesarean section : increased risk of uterine rupture in subsequent pregnancies.
• Loop excision of the transitional zone (LETZ): increased risk of cervical incompetence.

It’s essential to clarify any allergies the patient may have and to document these clearly in the notes, including the type of allergic reaction the patient experienced.

Medical conditions which are particularly important to be aware of during pregnancy

Diabetes (type 1 or 2) : blood glucose control can deteriorate significantly during pregnancy resulting in poor maternal health and fetal complications (e.g. macrosomia).

Hypothyroidism : untreated or undertreated hypothyroidism can result in congenital hypothyroidism with significant neurodevelopmental impact.

Epilepsy : seizures during pregnancy pose a risk to both the mother and fetus (e.g. miscarriage) and many anti-epileptic drugs are teratogenic.

Previous venous thromboembolism (VTE) : pregnancy is a pro-thrombotic state, therefore, women who have previously developed a venous thromboembolism are at significantly increased risk of developing further VTEs without prophylactic treatment (e.g. low molecular weight heparin).

Blood-borne viruses :  HIV , hepatitis B, hepatitis C pose a risk to the fetus during childbirth (vertical transmission).

Genetic disease : it is important to identify any genetic diseases (e.g. cystic fibrosis, sickle-cell disease, thalassaemia) carried by both the mother and father as this may influence the management of the patient and their pregnancy (e.g. arranging input from the paediatric team immediately after delivery).

• Drug history

It is essential to gain an accurate overview of the medications the patient is currently and has previously taken during the pregnancy. The first trimester is when the fetus is most at risk of teratogenicity from drugs, as this is when organogenesis occurs.

Prescribed medications

Clarify the prescribed medications the patient has been taking since falling pregnant, noting which they are still taking and which they have now stopped (including drug name, dose and route).

• “Are you currently taking any prescribed medications or over-the-counter treatments?”
• “Have you stopped taking any prescribed medication since you became pregnant?”

Ask if the patient was using contraception prior to becoming pregnant and if so, clarify what method of contraception was being used. Check the patient has stopped their contraception or had their contraceptive device removed (e.g. coil, implant).

If the patient is taking prescribed or over the counter medications, document the medication name , dose , frequency , form and route .

Ask the patient if they’re currently experiencing any side effects from their medication:

• “Have you noticed any side effects from the medication you currently take?”

Teratogenic drugs

Some examples of drugs that are known to be teratogenic include:

• ACE inhibitors
• Sodium valproate
• Methotrexate
• Trimethoprim

Medications frequently used during pregnancy

Some medications are commonly used in pregnancy to both reduce the risk of fetal malformations and treat the symptoms of pregnancy.

Some examples of medications commonly used in pregnancy include:

• Folic acid (400μg): recommended daily for the first trimester of pregnancy to reduce the risk of neural tube defects in the developing fetus.
• Oral iron: frequently used in pregnancy to treat anaemia.
• Antiemetics: frequently used in pregnancy to manage nausea and vomiting (e.g. hyperemesis gravidarum).
• Antacids: frequently used to manage gastro-oesophageal reflux symptoms during pregnancy.
• Family history

Taking a brief family history can help to further assess the risk of adverse outcomes to the mother and fetus during pregnancy. This can also help inform discussions with parents about the risk of their child having a specific genetic disease (e.g. cystic fibrosis).

Some important medical conditions to ask about include:

• Inherited genetic conditions : such as cystic fibrosis and sickle cell disease.
• Type 2 diabetes : if first-degree relatives are affected there is an increased risk of gestational diabetes.
• Pre-eclampsia : most relevant if maternal mother or sister is affected as this is associated with an increased risk of developing pre-eclampsia.
• Social history

Understanding the social context of a patient is absolutely key to building a complete picture of their health. Social factors have a significant influence on a patient’s pregnancy.

General social context

Explore the patient’s general social context including:

• the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them (e.g. stairlift)
• who else the patient lives with and their personal support network
• what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework, food shopping)

Record the patient’s smoking history , including the type and amount of tobacco used.

Offer smoking cessation services (see our smoking cessation guide for more details).

Smoking increases the risk of a small for gestational age baby.

Record the frequency , type and volume of alcohol consumed on a weekly basis (see our alcohol history taking guide for more information).

Offer support services to assist the patient in reducing their alcohol intake.

Excess alcohol use during pregnancy can result in conditions such as fetal alcohol syndrome .

Recreational drug use

It is important to ask about recreational drug use , as these can have significant consequences on the mother and developing fetus (e.g. cocaine use increases the risk of placental abruption).

If recreational drug use is identified, patients can be offered input from drug cessation services .

Diet and weight

Ask if the patient what their diet looks like on an average day .

Ask about the patient’s current weight (obesity significantly increases the risk of venous thromboembolism, pre-eclampsia and gestational diabetes during pregnancy).

Ask about the patient’s current occupation and if there are plans in place for maternity leave.

Domestic abuse

It is important to privately ask all pregnant women if they are a victim of domestic abuse to provide an opportunity for them to seek help.

• Closing the consultation

Summarise  the  key   points back to the patient.

Ask the patient if they have any  questions  or  concerns that have not been addressed.

Thank the patient  for their time.

Dispose of PPE appropriately and wash your hands .

Dr Venkatesh Subramanian

Obstetrics & Gynaecology Registrar in London

• NICE. Clinical Knowledge Summary. Nausea/vomiting in pregnancy. Published: June 2017. Available from: [ LINK ].
• BMJ. Reduced fetal movements.  2018 ;  360. Published March 2018. Available from: [ LINK ] 
• MBRRACE-UK. Saving Lives, Improving Mother’s Care. Surveillance of maternal deaths in the UK 2011-13 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009. Available from: [ LINK ].

• Wash your hands and don PPE if appropriate
• Introduce yourself to the patient including your name and role
• Confirm the patient's name and date of birth
• Explain that you'd like to take a history from the patient
• Gain consent to proceed with taking a history
• Confirm gestational age, gravidity and parity early on in the consultation
• Use open questioning to explore the patient’s presenting complaint
• Site: ask where the symptom is (if relevant)
• Onset: clarify when the symptom first started and if it the onset was sudden or gradual
• Character: ask the patient to describe how the symptom feels
• Radiation: ask if the symptom moves anywhere else
• Associated symptoms: ask if there are any other associated symptoms
• Time course: ask how the symptom has changed over time
• Exacerbating or relieving factors: ask if anything makes the symptom worse or better
• Severity: ask how severe the symptom is on a scale of 0-10
• Screen for other key obstetric symptoms (e.g. nausea, vomiting, reduced fetal movements, vaginal bleeding, abdominal pain, vaginal discharge or fluid loss, headaches, visual disturbance, epigastric pain, oedema, pruritis, unilateral leg swelling, chest pain, shortness of breath, fatigue, fever, weight loss)
• Explore the patient's ideas, concerns and expectations
• Summarise the patient’s presenting complaint
• Screen for relevant symptoms in other body systems
• Clarify the current gestational age of the pregnancy (if not done already)
• Ask about recent scan results
• Ask about screening
• Ask about immunisations
• Ask about maternal mental health
• Clarify other details of the current pregnancy (e.g. singleton vs multiple gestation, use of folic acid, mode of delivery, medical illness during pregnancy)
• Clarify the patient’s gravidity and parity (if not done already)
• For term pregnancies (>24 weeks) clarify: gestation at delivery, birth weight, mode of delivery, complications, stillbirths, use of assisted reproductive techniques
• Ask sensitively about miscarriages, termination of pregnancy and ectopic pregnancy
• Ask about recent and previous cervical screening results
• Ask about previous gynaecological conditions and treatments
• Past medical history
• Ask if the patient has any medical conditions
• Ask the patient if they've previously undergone any surgery or procedures
• Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance
• Ask if the patient is currently taking any prescribed medications or over-the-counter remedies
• Ask if the patient was using contraception prior to falling pregnant and if this has stopped/removed (e.g. coil, implant)
• Ask if there is any family history of genetic conditions, type 2 diabetes or pre-eclampsia
• Explore the patient’s general social context (accommodation, who the patient lives with, support)
• Take a smoking history
• Take an alcohol history
• Ask about recreational drug use
• Ask about diet, weight and occupation
• Ask about domestic abuse
• Summarise the salient points of the history back to the patient and ask if they feel anything has been missed
• Thank the patient for their time
• Dispose of PPE appropriately and wash your hands
• Key communication skills
• Active listening

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• Preferences

Case scenario in obstetric emergencies for undergraduate - PowerPoint PPT Presentation

Case scenario in obstetric emergencies for undergraduate

Undergraduate course lectures in obstetrics &gynecology .faculty of medicine .zagazig university prepared by dr manal behery – powerpoint ppt presentation.

• CASE SECNARIO IN OBSTETRIC EMERGANCIES
• Life -or -death situation
• Infrequent, unanticipated, unpredictable nightmare
• Head delivers, then retracts
• tightly against the
• turtle sign
• C. Drop out apply for dermatology
• D. Be a Hero
• CALL FOR HELP!
• Stop Pushing!
• Suprapubic CPR
• Episiotomy?
• Roll patient
• Clavicle Fracture
• Symphysiotomy
• hyperflexion of maternal hips
• Increases intrauterine pressure
• (1,653mmHg - 3,262 mmHg)
• Increases amplitude of contractions
• (103mm Hg to 129mm Hg)
• Provides extra hand room for maneuvering.
• Does not help with the body impaction.
• 1. Rubin II
• 2. Ruben II
• 3. Reverse Woods Corkscrew
• Adduction of the most accessible shoulder
• Moves the fetus into an oblique position and decreases the biacromial diameter
• Abduct posterior shoulder exerting pressure on anterior surface of posterior shoulder
• grasp the posterior arm and
• sweep it across the anterior
• chest to deliver
• Roll Patient
• Can increase
• outlet by 20
• Apply downward traction to disimpact post shoulder
• direct posterior or oblique suprapubic
• cephalic replacement via reversal of the cardinal movements of labor
• Fracture the anterior clavicle by pushing it against the pubic ramus or using a closed pair of scissors
• 20 or 21 blade, cut till it opens
• Help obstetrician, pediatrician
• Legs elevate (McRoberts)
• Pressure - suprapubic
• Enter vagina Rubins and Woods screw
• Roll or Remove posterior arm
• Zavanelli, Clavicular , Symphysiotomy
• 22 years G1 at 34 wks, contractions every 5 min, and felt a gush of fluid immediately prior to arrival in ER.
• Cervix exam reveals 6cm dilation and a prolapsed umbilical cord.
• Malpresenations
• Prematurity
• Abnormal fetus
• Placenta previa
• Lift presenting part off the cord
• Relieve pressure
• Gently place cord in vagina
• (Cold air rough handling causes spasms)
• Gently palpate cord for pulsations
• Instruct NOT to push
• Knee chest Trendelenburg
• Full bladder
• Replacement of cord
• Tocolysis (ritodrine)
• Forceps (Cx fully dilated)
• Second twin internal podalic version and breech extraction
• Stat C-section
• Occult Aminoinfusion
• 24 years female G1 at 32 wks, SROM, in labor.
• Cervix is dilated to 7cm.
• You palpate feet.
• If not fully dilated,
• no pushing.
• Once scapulas show, help deliver arms
• Sweep arms over chest
• Rotating baby may help
• Deliver head (2-3 minute window)
• Mauriceau-Smellie-Veit maneuver
• Suprapubicpresure
• Using a towel
• Hooking the shoulders out
• Hand position during head delivery
• Didnt use suprapubic pressure
• Take your time, traction is bad
• Inversion Of The Uterus
• Mother in third stage of labour. Using the controlled cord traction, the midwife tries to deliver the placenta. Unfortunately, notices the descent of uterus instead of placenta.
• Most commen Causes
• Fundal attachment of placenta (75)
• uterine atony (40)
• Placenta accreta
• Excessive cord traction
• Treat hypovolumia
• Uterine relaxant(terbutaline 0.25 mg) iv followed by 2 g of mgso4 over 10 min)
• Repositioning
• Do not remove placenta
• 2.Replace uterus
• 3.Bimanual compression
• 4.Hydrostatic pressure
• 5.Start oxytocin
• 6.Laparotomy
• Rupture Uterus
• A mother in second stage of labour
• suddenly complains of persistent pain, and bleeding per vagina becomes profuse and the monitor shows decelerations in fetal heart rate.
• Incidence 1/2000 deliveries
• Dehiscense of
• Internal version
• Difficult forceps delivery
• Breech extraction
• Difficult manual removal of placenta
• Fetal anomaly
• Placenta increta / percreta
• Retroverted uterus (sacculation)
• Prolonged fetal decelerations (70.3)
• Bleeding (3.4) Pain (7.6)
• Monitor tracing demonstrating fetal heart rate decelerations, increase in uterine tone, and continuation of uterine contractions in a patient with uterine rupture monitored with an intrauterine pressure catheter.
• Simple repair
• Total Hysterectomy
• Sub total hysterectomy
• Mother has just delivered a male baby. You wait for 30 minutes But no signs of placental separation and descent is present. Manual removal fails.
• Incidence 1 in 2,562 deliveries
• Firm adherence of placenta to uterine wall
• Placenta increta Villi invade the myometrium
• Placenta percreta Villi penetrate myometrium
• placenta previa
• Previous cesearean scar
• uterine curettage
• Grand multiparity
• Abdominal exploration
• Uterine artery ligation
• Hysterectomy
• AMNIOTIC FLUID EMBOLISM
• A pregnant mother on oxytocin induction suddenly becomes short of breath and tachypneic. Vital signs drop and the patient goes into asystolic arrest.
• Incidence 1 in 3,500 to 1 in 80,000
• Amniotic fluid enters the maternal circulation and reaches pulmonary capillaries through a tear in amnion and chorion
• Opening in maternal circulation
• Increased intrauterine pressure
• Multiparity
• Large fetus
• Meconium in amniotic fluid
• Intrauterine fetal death
• Precipitate labour
• Placental abruption
• Intrauterine catheter
• Rupture of uterus
• Pulmonary vasospasm
• Hypotension
• Cardiovascular collapse
• Left ventricular failure
• Pulmonary edema
• Coagulation disorder
• Intubation Mechanical ventilation
• CVP monitoring
• Blood transfusion I.V. Fluids
• Dopamine 2-20mg/kg/min
• IV Digitalization (0.1 - 1.0mg)
• Prostaglandin
• Aminophylline
• Hydrocortisone
• Communicate
• Careful, sympathetic and
• optimal communication
• Avoid medical jargon
• Psychological support- one member - Touch
• Talking through the process
• Smile of reassurance
• Information and support to partners

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Introduction to Obstetrics &amp; Gynecology

Jul 15, 2012

1.64k likes | 7.7k Views

Introduction to Obstetrics &amp; Gynecology. Overview. Objectives. Match the terms r/t OB-GYN w/correct definitions Review female anatomy List purposes of OB-GYN surgery Discuss types of abortions Match common GYN complications with correct definitions

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• lithotomy position
• incontinence vaginal vault ob
• endometrial curettings
• urethrovaginal
• uterine ligaments
• pelvic exenteration

Presentation Transcript

Introduction to Obstetrics & Gynecology Overview

Objectives • Match the terms r/t OB-GYN w/correct definitions • Review female anatomy • List purposes of OB-GYN surgery • Discuss types of abortions • Match common GYN complications with correct definitions • Match diagnostic techniques w/correct definitions • Match abdominal procedures w/correct descriptions • Define and discuss vaginal procedures • Explain applications of lasers in GYN surgery

Objectives • Match the types of genital fistulas w/correct illustrations • Select true statements r/t special features of OB/GYN surgery • Match basic OB-GYN medications and solutions w/their uses • Identify specialized instruments for OB/GYN surgery • Discuss the steps of a D & C

Carcinoma in Situ Cervical Chromotubation Conization Cystocele Dilatation Dysplasia Endometriosis Enterocele Episiotomy Fibroma GIFT Insufflation Marsupilization Myoma Pneumoperitoneum Presentation Rectocele Stress Incontinence Vaginal Vault OB-GYN Terms

Female Reproductive System

Anatomy: Bony Pelvis/Girdle

Anatomy: External Genitalia • Vagina • Uterus • Cervix • Fallopian tubes/ovaries • External genitalia

Anatomy: Female Pelvis

Support of Female Pelvis

Uterus, Fallopian Tubes, Ovaries • Hollow, thick-walled • Situated between bladder and rectum • Lined with endometrium • Ligaments suspend the uterus

Female Reproductive System Concept Map

Why OB-GYN Surgery? • Dx abnormal symptoms • Tx abnormal conditions • Relieve pain • Electively prevent pregnancy • Assist infertile couples to conceive • Prevent Spontaneous abortion w/structural defects • Abdominally deliver an infant when vaginal delivery is contraindicated or not possible

Types of Abortions • Missed • Incomplete • Imminent • Spontaneous • Voluntary Interrupted

Common OB Complications • Dystocia • Placenta Previa • Abruptio Placenta • CPD • Abnormal presentations • Breech, Transverse, Footling, Vertex • Incompetent cervical os • Infertility • Ectopic pregnancy

Common GYN Complications • Menstrual abnormalities • Amenorrhea, dysmenorrhea, menorrhagia, metrorrhagia • Lesions • Weakened musculature • STDs

Colposcopy Colpotomy Conization of Cervix Culdocentesis Culdoscopy Hysterpsalpingography Hysteroscopy PAP smear Punch Biopsy Rubin’s test Schiller’s test Uterine curettage Diagnostics

Abdominal Procedures • Abdominal Hysterectomy • Cesarean Section • Laparoscopy • MMK Suspension • Microscopic Reconstructive Surgery of Fallopian Tubes • Myomectomy • Oophorectomy • Oophorocystectomy • Pelvic Exenteration • Salpingectomy/Salpingostomy • Tubal ligation

Fibroid tumors

Vaginal Procedures • Anterior & Posterior repair • Conization of cervix • Dilatation & Curettage • Hysteroscopy • LAVH • Colpocleisis • Marsupilization of Bartholin’ s duct cyst • Repair of fistula • Shirodkar or MacDonald cerclage • Simple vulvectomy • Suction curettage • Trachelorrhaphy • Vaginal Hysterectomy

Lasers in GYN • Most commonly used: Argon, CO2, Nd: YAG • Applications • Ablation • Eradication • Endometrial ablation • Transecting uterine ligaments & controlling bleeding

Genital Fistulas • Vesicovaginal • Ureterovaginal • Urethrovaginal • Rectovaginal

Special Features • Typically pt is catheterized • General or spinal • Important: antiembolic devices, ambulation • Drains • Lithotomy/Vaginal • Vaginal: Long instruments • Vaginal procedures: sponges/medicated packing • Use of catheters: ID of ureters • Order of procedures: vag/abd • Separate set-ups • Special equipment

Medications & Solutions • Oxytocics • Lugol’s solution • Acetic Acid 3 % • Anti-infective creams • Methylene blue • Solutions for hysteroscopic exams • Solutions for laser & cautery

Specialized Instruments • Abdominal Hysterectomy • Vaginal • Laparoscopic • Obstetrical • Adaptations for vag hyst • Adaptations for LAVH

ABD Hysterectomy

D & C Procedure Summary • Lithotomy position • Insert Weighted speculum • Grasp cervix w/ Tenaculum • Dilation using Graduated sound into cervix: depth & direction • Curette of choice for Endocervical curettings specimen • Endometrial curettings • Dilation using Hegar or Hanks uterine dilators • Curettings: Telfa strip for specimen • Dressing: perineal pad

Labor & Delivery Stages • Stage one: onset of labor • Stage two: complete dilatation of cervix • Stage three: birth of the infant • Stage four: after placenta is delivered

Objectives • Match the terms r/t OB-GYN w/correct definitions • List purposes of OB-GYN surgery • Discuss types of abortions • Match common GYN complications with correct definitions • Match diagnostic techniques w/correct definitions • Match abdominal procedures w/correct descriptions • Define and discuss vaginal procedures • Explain applications of lasers in GYN surgery • Match the types of genital fistulas w/correct illustrations

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• MSD careers

Evaluation of the Obstetric Patient

• Physical Examination |
• Symptoms and Signs |
• Diagnosis |
• Estimated Date of Delivery |
• Management |

Ideally, patients planning to become pregnant and their partners should see an obstetric clinician for a preconception visit. At the visit, the clinician reviews general preventive measures available prior to pregnancy. The clinician also reviews the medical, obstetric, and family histories of both the patient and partner (or the donor, if donor sperm will be used and medical history of the donor is available). The clinician advises the patient about managing chronic diseases or medications or receiving vaccinations prior to pregnancy. The patient and partner are referred to genetic counseling , if appropriate.

1 ). Folate reduces risk of neural tube defects . If women have had a fetus or infant with a neural tube defect, the recommended daily dose is 4000 mcg (4 mg).

Once pregnant, women should have routine prenatal care to monitor the pregnancy and detect or prevent maternal or fetal complications. Also, visits every 1 to 4 weeks are required to monitor for and evaluate symptoms and signs of illness.

Specific obstetric disorders and nonobstetric disorders in pregnant women are discussed elsewhere in THE MANUAL.

The initial routine prenatal visit should occur between 6 and 8 weeks gestation.

Follow-up visits usually occur at:

About 4-week intervals until 28 weeks

2-week intervals from 28 to 36 weeks

Weekly from 36 weeks to delivery

Prenatal visits may be scheduled more frequently if there is a high risk of obstetric complications.

Prenatal care includes:

Screening and management of general medical disorders, infectious diseases, and psychiatric disorders

Screening for social determinants of health

Discussion of previous history of obstetric disorders (eg, gestational diabetes, preeclampsia, preterm birth)

Offering screening for fetal chromosomal disorders

Taking measures to reduce fetal and maternal risks

Monitoring for new maternal disease or obstetric complications

Monitoring fetal growth and development

Health promotion and patient education

General reference

1. US Preventive Services Task Force

History Taking in the Obstetric Patient

During the initial visit, clinicians should obtain a full medical history, including:

Obstetric history, with the outcome of all previous pregnancies, including maternal and fetal complications (eg, gestational diabetes, preeclampsia, congenital malformations, stillbirth)

Medical history, including surgical and psychiatric history

Family history, to identify any potential genetic disorders

Medications (including over-the-counter), supplements, illicit drug use, and potential toxic exposures

Social determinants of health

Risk factors for complications of pregnancy

At the initial and subsequent visits, patients should be asked about symptoms of potential pregnancy complications (eg, vaginal bleeding, leakage of fluid, pelvic or abdominal pain, headache, changes in vision, edema of face or fingers, changes in frequency or intensity of fetal movement).

Gravidity and parity

The basic obstetric history is documented in a specific format, noting gravidity and parity.

Gravidity (G) is the number of confirmed pregnancies; a gravida is a term for a person who has had at least 1 pregnancy.

Parity (P) is the number of deliveries at ≥ 20 weeks of gestation. The numbers for parity are recorded along with other pregnancy outcomes:

Term deliveries (≥ 37 weeks)

Preterm deliveries (≥ 20 and < 37 weeks)

Abortions (including spontaneous pregnancy losses at induced abortions , ectopic pregnancies , or molar pregnancies )

Living children

Multifetal gestation is counted as 1 pregnancy in terms of gravidity and for all parity numbers, with the exception of living children (eg, for a woman who has had a singleton pregnancy and a twins pregnancy and all children are living, this is noted as 3).

In this documentation format, the numbers are recorded as:

G (gravidity number) P (parity number, noted as 4 numbers for term pregnancies, preterm pregnancies, abortions, and living children)

For example, the history of a patient who has had 1 term delivery, 1 set of twins born at 32 weeks, 1 spontaneous abortion, and 1 ectopic pregnancy is documented as G4 P1-1-2-3.

Physical Examination of the Obstetric Patient

A full general examination, including blood pressure (BP), height, and weight, is done first. BP and weight should be measured at each prenatal visit. A urine specimen is collected and checked with a dipstick for protein and findings consistent with infection.

In the initial obstetric examination, a complete pelvic examination is done to:

Estimate the gestational age based on uterine size

Check for uterine abnormalities (eg, leiomyoma) or tenderness

Check for lesions, discharge, or bleeding

Obtain cervical samples for testing

Pelvic examination is usually repeated only if symptoms (eg, vaginal bleeding or discharge, pelvic pain) are present. Starting at about 37 weeks, a sterile cervical digital examination may be done to check for cervical dilation and effacement.

Gestational age can be estimated on physical examination, although these estimates are imprecise and estimated delivery date should be determined based on last menstrual period and ultrasound measurements. The usual approach to is as follows:

1 ); precision may improve with clinical experience.

12 weeks: Uterine fundus is palpable at the level of the pubic symphysis.

16 weeks: Uterine fundus is at the midpoint between the level of the pubic symphysis and umbilicus.

20 weeks: Uterine fundus is at the level of the umbilicus.

> 20 weeks: Measurement from pubic symphysis to fundus in centimeters approximately correlates with gestational age.

Physical examination to estimate gestational age is not accurate if there are reasons for additional uterine enlargement, such as uterine leiomyoma or multiple gestation.

In late third trimester, palpation of the fetus through the abdomen is used to assess the fetal lie and estimate fetal weight (see figure Leopold Maneuver ).

Traditionally, clinical pelvimetry was performed to estimate pelvic capacity and describe pelvic type (gynecoid, android, anthropoid, or platypelloid), with the aim of predicting need for operative vaginal delivery or cesarean delivery. This was based on measurements of the pelvic inlet by pelvic examination, radiography, CT, or MRI. However, clinical pelvimetry is rarely used in current clinical practice because it has not be shown to be more effective than a trial of labor at predicting mode of delivery ( 2 ).

Fetal heart rate is measured at each visit.

Physical examination reference

1. Margulies R, Miller L . Fruit size as a model for teaching first trimester uterine sizing in bimanual examination.  Obstet Gynecol . 2001;98(2):341-344. doi:10.1016/s0029-7844(01)01406-5

2. Pattinson RC, Cuthbert A, Vannevel V : Pelvimetry for fetal cephalic presentations at or near term for deciding on mode of delivery.  Cochrane Database Syst Rev . 2017;3(3):CD000161. Published 2017 Mar 30. doi:10.1002/14651858.CD000161.pub2

Symptoms and Signs of Pregnancy

Pregnancy may cause breasts to enlarge and feel mildly tender because of increased levels of estrogen (primarily) and progesterone , similar to premenstrual breast enlargement.

Nausea and vomiting may occur because of increased secretion of estrogen Conception and Prenatal Development ). The corpus luteum in the ovary, stimulated by beta-hCG, continues secreting large amounts of estrogen and progesterone to maintain the pregnancy. Many women become fatigued at this time, and a few women notice abdominal bloating very early.

Women usually begin to feel fetal movement between 16 and 20 weeks.

During late pregnancy, lower-extremity edema and varicose veins are common; the main cause is compression of the inferior vena cava by the enlarged uterus.

Diagnosis of Pregnancy

Urine or serum beta-hCG test

Usually urine and occasionally blood tests are used to confirm or exclude pregnancy; results are typically accurate several days before a missed menstrual period and often as early as several days after conception.

Pregnancy may also be confirmed with other findings, including:

Presence of a gestational sac in the uterus, typically visible on ultrasound at about 4 to 5 weeks and typically corresponding to a serum beta-hCG level of about 1500 mIU/mL (a yolk sac can usually be seen in the gestational sac by 5 weeks)

Fetal heart motion visualized on ultrasound as early as 5 to 6 weeks

Fetal heart sounds, heard with a handheld Doppler ultrasound device, as early as 8 to 10 weeks if the uterus is accessible abdominally

Fetal movements felt by the examining physician after 20 weeks

Estimated Date of Delivery in Pregnancy

The estimated date of delivery (EDD) is based on the last menstrual period (LMP). One way to calculate the EDD is to subtract 3 months from the LMP and add 7 days (Naegele's rule). Other methods are: 

The date of conception + 266 days

The last menstrual period (LMP) + 280 days (40 weeks) for women with regular, 28-day menstrual cycles

The LMP + 280 days + (cycle length – 28 days) for women with regular menstrual cycles other than 28 days duration

Delivery up to 3 weeks earlier or 2 weeks later than the estimated date is considered normal. Delivery before 37 weeks gestation is considered preterm ; delivery after 42 weeks gestation is considered postterm .

When periods are regular, the menstrual history is a relatively reliable method of determining EDD. When other information is lacking, first trimester ultrasound provides the most accurate estimate of gestational age. When the date of conception is unknown and menstrual cycles are irregular or information about them is not available, ultrasound may be the sole source of the EDD.

If there is uncertainty about menstrual dating, the gestational age based on the last menstrual period and based on the first fetal ultrasound in the current pregnancy are compared. If these age estimates are inconsistent, the EDD (and, thus, the estimated gestational age) may be changed, depending on the number of weeks and the degree of inconsistency. The American College of Obstetricians and Gynecologists (ACOG) (see Methods for Estimating Due Date ) recommends using the date based on ultrasonographic measurements if it differs from the menstrual date by:

At ≥ 8 6/7 weeks of gestation: > 5 days

At 9 to 15 6/7 weeks of gestation: > 7 days

At 16 to 21 6/7 weeks of gestation: > 10 days

At 22 to 27 6/7 weeks of gestation: > 14 days

At ≥ 28 weeks of gestation: > 21 days

Reconciling the menstrual and ultrasonographic dates is done only after the first ultrasound in the current pregnancy—EDD is not changed based on subsequent ultrasounds. Because ultrasonographic estimates are less accurate later in pregnancy, second and third trimester ultrasonographic results should rarely be used to change estimated gestational age, and, if changing the estimated date of delivery is considered, a specialist in fetal ultrasonography should be consulted.

Testing in the Obstetric Patient

Laboratory testing.

Prenatal evaluation involves blood tests, urine tests, cervical specimens, ultrasound, and sometimes other tests. Initial laboratory evaluation is thorough; some tests are repeated during follow-up visits (see table Routine Prenatal Evaluation Schedule ).

Routine Prenatal Evaluation Schedule

Routine testing evaluates for anemia, proteinuria, and infectious diseases that may affect fetal development or maternal health. Proteinuria before 20 weeks gestation suggests kidney disease. Proteinuria after 20 weeks gestation may indicate preeclampsia . Patients with any colony count of Group B streptococcus (GBS) in a urine culture at any time during pregnancy (which suggests heavy vaginal–rectal colonization) should be given antibiotic prophylaxis at the time of delivery ( 1 ).

Blood type and alloantibodies are checked because women with Rh-negative blood are at risk of developing Rh(D) antibodies (if previously exposed to Rh-positive blood). If the father has Rh-positive blood, the fetus may also be Rh-positive, and maternal anti-Rh(D) antibodies can cross the placenta and cause hemolytic disease of the fetus . Rh(D) antibody levels should be measured in pregnant women at the initial prenatal visit and, in those with Rh-negative blood, again at about 28 weeks.

Generally, women are routinely screened for gestational diabetes between 24 and 28 weeks using an oral glucose tolerance test . However, if women have significant risk factors for undiagnosed type 2 diabetes, they are screened during the first trimester with a random or fasting serum glucose and HbA1C. These risk factors include a combination of obesity and one or more of the following risk factors ( 2 ):

Physical inactivity

First-degree relative with diabetes

Race or ethnicity associated with increased risk (eg, African American, Latino, Native American, Asian American, Pacific Islander)

Gestational diabetes or a macrosomic neonate (weight ≥ 4,000 g) in a previous pregnancy

Hypertension (140/90 mmHg or on therapy for hypertension)

High-density lipoprotein cholesterol level 250 mg/dL (2.82 mmol/L)

Polycystic ovary syndrome

HbA1C ≥ 5.7%, impaired glucose tolerance, or impaired fasting glucose on previous testing

2 , acanthosis nigricans)

History of cardiovascular disease

If the first-trimester test is normal, patients are screened for gestational diabetes at 24 to 28 weeks.

If either potential parent has a known or suspected genetic abnormality, the couple should be referred for genetic counseling and testing . Pregnant patients should also be counseled about options for noninvasive screening or diagnostic testing for fetal aneuploidy. The American College of Obstetricians and Gynecologists recommends that all women be offered diagnostic testing, irrespective of baseline risk or maternal age, including non-invasive prenatal testing (NIPT) or cell free DNA testing ( 3 ).

Blood tests to screen for or monitor thyroid disorders (measurement of thyroid-stimulating hormone [TSH]) are done in women with one or more of the following ( 4 ):

Symptoms or other reasons for clinical suspicion of disease

Thyroid disease or family history of thyroid disease

Type 1 diabetes

Evaluation for other disorders (eg, lead level, measles, bacterial vaginosis, Zika virus infection, Chagas disease, and others) are done depending on medical history, risk factors, symptoms, and recent exposures.

Ultrasonography

Most obstetricians recommend at least one ultrasound examination during each pregnancy, ideally between 16 and 20 weeks. Earlier ultrasound may be done if there is uncertainty about the estimated delivery date (EDD) or if a patient has symptoms (eg, vaginal bleeding, pelvic pain).

Specific indications for ultrasound examination include:

Detection of multifetal gestation, hydatidiform mole , ectopic pregnancy

Investigation of fetal abnormalities (eg, indicated by abnormal results of noninvasive maternal screening tests or uterus size not consistent with estimated gestational age)

Nuchal translucency measurement as a component of noninvasive aneuploidy screening tests

Detailed assessment of fetal anatomy (usually at about 16 to 20 weeks)

Possibly fetal echocardiography at 20 weeks if risk of congenital heart defects is high (eg, in women who have type 1 diabetes or have had a child with a congenital heart defect)

Determination of placental location, polyhydramnios , or oligohydramnios

Determination of fetal position and size

Ultrasound is also used for needle guidance during chorionic villus sampling , amniocentesis , and fetal transfusion.

If an ultrasound is needed during the first trimester (eg, to evaluate pain, bleeding, or viability of pregnancy), use of an endovaginal transducer maximizes diagnostic accuracy; evidence of an intrauterine pregnancy (gestational sac or fetal pole) can be seen as early as 4 to 5 weeks and is seen at 7 to 8 weeks in > 95% of cases. Fetal movements and heart motion can be directly observed on ultrasound as early as 5 to 6 weeks.

Other imaging

Medically necessary radiographs or other imaging should not be postponed because of pregnancy. However, elective abdominal radiographs are postponed until after pregnancy.

The risk of exposure to the fetus of ionizing radiation from imaging studies depends upon gestational age and radiation dose. The effects and threshold dose for various gestational ages include ( 5 ):

2 to 3 weeks (fertilization to implantation): Death of embryo or no effect (50 to100 milligray [mGy])

4 to 10 weeks (during organogenesis): Congenital anomalies (200 mGy); growth restriction (200 to 250 mGy)

8 to 15 weeks: High risk of severe intellectual disability (60 to 310 mGy); microcephaly (200 mGy)

16 to 25 weeks: Low risk of severe intellectual disability (250 to 280 mGy)

Imaging studies can be categorized by dose of radiation to the fetus ( 5 ):

Very low dose (

Low to moderate dose (0.1 to 10 mGy): Radiographs of the abdomen or spine; intravenous pyelography; double-contrast barium enema; chest CT; nuclear medicine scans (eg, low-dose scintigraphy or angiography)

Higher dose (10 to 50 mGy): Abdominal or pelvic CT

Thus, reproductive-aged women should be asked about the possibility of a current pregnancy (and a pregnancy test should be done, if indicated) before radiographs or CTs are performed. Abdominal or pelvic CT is sometimes used during pregnancy if it is the standard and most effective imaging modality for a particular diagnostic indication. In this case, the patient should be counseled about risks and benefits and informed consent should be obtained.

MRI does not emit radiation and may be used throughout pregnancy without concern for pregnancy-associated risks.

In addition, contrast agents are often used to enhance imaging modalities. Contrast agents for CT imaging have not been associated with teratogenic effects. Conversely, gadolinium-containing contrast commonly used for MRI imaging is controversial based on animal model data suggesting teratogenicity, but this has not been confirmed in humans. Thus, contrast use in MRI is reserved for specific situations in which clinical management may be changed or the condition is considered life threatening to the pregnant individual ( 5 ).

Testing references

1.  American College of Obstetricians and Gynecologists (ACOG) : Prevention of Group B Streptococcal Early-Onset Disease in Newborns: ACOG Committee Opinion, Number 797 [published correction appears in Obstet Gynecol . 2020 Apr;135(4):978-979].  Obstet Gynecol . 2020;135(2):e51-e72. doi:10.1097/AOG.0000000000003668

2. ACOG Committee on Practice Bulletins : ACOG Practice Bulletin No. 190: Gestational Diabetes Mellitus.  Obstet Gynecol . 2018;131(2):e49-e64. doi:10.1097/AOG.0000000000002501

3. ACOG Committee on Practice Bulletins—Obstetrics; Committee on Genetics; Society for Maternal-Fetal Medicine : Screening for Fetal Chromosomal Abnormalities: ACOG Practice Bulletin, Number 226.  Obstet Gynecol . 2020;136(4):e48-e69. doi:10.1097/AOG.0000000000004084

4. ACOG Committee on Practice Bulletins—Obstetrics : Thyroid Disease in Pregnancy: ACOG Practice Bulletin, Number 223.  Obstet Gynecol . 2020;135(6):e261-e274. doi:10.1097/AOG.0000000000003893

5. ACOG Committee on Obstetric Practice : Opinion No. 723: Guidelines for Diagnostic Imaging During Pregnancy and Lactation [published correction appears in Obstet Gynecol . 2018 Sep; 132(3):786. doi: 10.1097/AOG.0000000000002858].  Obstet Gynecol . 2017 (reaffirmed 2021);130(4):e210-e216. doi:10.1097/AOG.0000000000002355

Management of the Obstetric Patient

Preexisting maternal disease or risk factors for obstetric complications or maternal or fetal issues that present during pregnancy are managed, as appropriate. Prenatal care also includes counseling about health promotion and anticipatory guidance to prepare patients for labor, delivery, and newborn care. Couples are encouraged to attend childbirth classes.

High-risk pregnancies require close monitoring, specialized care, and a multidisciplinary medical team, and sometimes referral to a perinatal center. Perinatal centers offer many specialty and subspecialty services provided by maternal, fetal, and neonatal specialists. Close monitoring throughout the pregnancy may involve management of chronic diseases and increased frequency of prenatal visits, blood tests, and ultrasonography and other types of fetal monitoring. Communication with the pregnant woman and her family is essential to involve the patient in shared decision-making, develop a care plan, and provide emotional support.

Symptoms requiring evaluation

Patients are counseled about normal pregnancy changes, sensations, and fetal movement, diet, weight gain, mental health, recommended preventive measures, and health promotion. They are also counseled about concerning symptoms for which they should contact their obstetric clinician, including vaginal bleeding, persistent uterine contractions, leakage of fluid, fever, dysuria, urinary frequency, urinary urgency, decreased fetal movement, severe persistent pain (headache, pain in the pelvic, abdomen, back, calves), faintness or dizziness, shortness of breath, edema of the face, hands, or asymmetric edema of the calves, and visual changes.

Multiparous women with a history of rapid labor should notify the physician at the first symptom of labor.

Diet and supplements

To provide nutrition for the fetus, the average number of additional calories pregnant patients who begin pregnancy with a body mass index (BMI) in the normal range require varies by trimester: first trimester, no additional calories; second trimester, approximately 340 kcal extra daily; third trimester, approximately 450 kcal extra daily. See Eat Healthy During Pregnancy: Quick Tips . Most calories should come from protein. If maternal weight gain is excessive ( > 1.4 kg/month during the early months) or inadequate ( < 0.9 kg/month), diet must be modified further.

1 ). Women who have had a fetus with spina bifida should take 4 mg once a day, starting 3 months before conception and continuing through 12 weeks of gestation ( 2 ).

Most prenatal vitamins contain the recommended daily allowance of ferrous iron during pregnancy (27 mg) ( 3 ). In patients with iron deficiency anemia, a higher dose is needed (eg, 325 mg ferrous sulfate [65 mg elemental iron]). Iron is usually taken daily but may be taken every other day if a patient has bothersome gastrointestinal effects, especially constipation.

Pregnant patients should also be counseled on safe food handling practices, including avoiding certain seafood with high mercury levels and foods with a high risk of contamination by Listeria , such as:

Raw or rare fish, shellfish, meat, poultry, or eggs

Unpasteurized juice, milk, or cheese

Lunch or deli meats, smoked seafood, and hot dogs (unless heated to a steaming hot temperature)

Prepared meat or seafood salads like ham salad, chicken salad, or tuna salad

Raw sprouts, including alfalfa, clover, radish, and mung bean sprouts

Weight gain

Women are counseled about exercise and diet and advised to follow the Institute of Medicine guidelines for weight gain, which are based on prepregnancy body mass index (BMI—see table Guidelines for Weight Gain During Pregnancy ). Weight-loss dieting during pregnancy is not recommended, even for women with severe obesity.

Guidelines for Weight Gain During Pregnancy*

Physical activity

Exercise during pregnancy has minimal risks and has demonstrated benefits for most pregnant women, including maintenance or improvement of physical fitness, control of gestational weight gain, reduction in low back pain, and possibly a reduction in risk of developing gestational diabetes or preeclampsia ( 4 ). Moderate exercise is not a direct cause of any adverse pregnancy outcome; however, pregnant women may be at greater risk of injuries to joints, falling, and abdominal trauma. Abdominal trauma can result in placental abruption , which can lead to fetal morbidity or death.

Sexual activity can be continued throughout pregnancy unless vaginal bleeding, pelvic or vaginal pain, vaginal discharge, leakage of amniotic fluid, or uterine contractions occur.

Medications, substance use, and toxic exposures

Clinicians should review the patient's medications and nutritional supplements to address drug safety in pregnancy and determine if any medications or supplements need to be discontinued, adjusted, or changed.

Consuming  caffeine  in small amounts (eg, 1 cup of coffee a day) appears to pose little or no risk to the fetus.

Pregnant patients should not use alcohol , tobacco (and should avoid exposure to secondhand smoke), cannabis, or illicit drugs. Patients with substance use disorders should be managed by a multidisciplinary team with appropriate expertise, including an obstetrician, addiction specialist, and pediatrician.

Pregnant patients should also avoid the following:

Direct handling of cat litter (due to risk of toxoplasmosis )

Prolonged temperature elevation (eg, in a hot tub or sauna)

Exposure to people with active viral infections (eg, rubella , erythema infectiosum [fifth disease], varicella )

Exposure to toxic environmental agents during pregnancy has been associated with adverse reproductive and developmental health outcomes, including infertility, miscarriage, preterm birth, low birth weight, neurodevelopmental delay, and childhood cancer ( 5 ). The risk of adverse outcome depends on the toxin and extent of the exposure. Obstetric clinicians should include questions about environmental health as part of the medical history.

Patients should be advised to avoid or minimize exposure to specific agents, such as lead, pesticides, solvents, and phthalates. Personal care products used during pregnancy should have no phthalates, parabens, oxybenzone, or triclosan. Cosmetic and personal care products labeled "fragrance-free" are less likely to contain toxins than those labelled "unscented." 

Immunizations

Vaccines during pregnancy  are as effective in women who are pregnant as in those who are not.

Live-virus vaccines, such as those for rubella or varicella, should not be used during pregnancy.

The following vaccines are recommended for all or selected pregnant women by the American College of Obstetricians and Gynecologists (ACOG) (see ACOG: Maternal Immunization ):

Influenza vaccine : All pregnant women during influenza season.

COVID-19 vaccine : People 5 years and older, including people who are pregnant, breastfeeding, trying to get pregnant, or might become pregnant in the future (see also Centers for Disease Control and Prevention (CDC): COVID-19 Vaccines While Pregnant or Breastfeeding )

Tetanus-diphtheria-pertussis (Tdap) vaccine : Pregnant patients during the third trimester ( 6 )

Respiratory syncytial virus (RSV) vaccine : Pregnant patients between 32 0/7 and 36 6/7 weeks of gestation, using seasonal administration, to prevent RSV lower respiratory tract infection in infants (for most of the United States, RSV season occurs from September through January) (see CDC: Healthcare Providers: RSV Vaccination for Pregnant People and ACOG: Maternal Respiratory Syncytial Virus Vaccination)

Other vaccines should be reserved for situations in which the woman or fetus is at significant risk of exposure to a hazardous infection and/or are at increased risk of complications, and the risk of adverse effects from the vaccine is low. Pneumococcal vaccination is recommended for pregnant patients at increased risk of severe pneumococcal disease. Vaccinations for cholera , hepatitis A , hepatitis B , measles, mumps, plague, poliomyelitis , rabies , typhoid , and yellow fever may be given during pregnancy if risk of infection is substantial.

Prevention of perinatal complications

For pregnant patients with a Rh-negative blood type, Rho(D) immune globulin is given to prevent alloimmunization, which could result in hemolytic disease of the fetus and neonate. Rho(D) immune globulin is given at 28 weeks, before any episode or procedure that may cause fetal-maternal hemorrhage, and after delivery.

For pregnant patients with increased risk of preeclampsia

Psychosocial issues

Screening for depression and anxiety should be done at the first prenatal visit and repeated in third trimester and postpartum. Screening should also be done for intimate partner violence .

Patients should be asked about barriers to accessing care or that require support or accommodations (eg, physical or cognitive disabilities, language barriers, personal, family, social, religious, or financial issues). Clinicians should give patients information and help patients access available resources.

There is no absolute contraindication to travel at any time during pregnancy. Pregnant women should wear seat belts regardless of gestational age and type of vehicle.

Travel on airplanes is allowed by most airlines until 36 weeks gestation, because of the risk of going into labor and delivering during the flight.

During any kind of travel, pregnant women should stretch and straighten their legs and ankles periodically to prevent venous stasis and the possibility of thrombosis. For example, on long flights, they should walk or stretch every 2 to 3 hours. In some cases, clinicians may recommend thromboprophylaxis for prolonged travel.

Treatment references

1. US Preventive Services Task Force, Barry MJ, Nicholson WK, et al JAMA . 2023; 330(5):454-459. doi:10.1001/jama.2023.12876

2. American College of Obstetricians and Gynecologists' Committee on Practice Bulletins : Practice Bulletin, Number 187, Neural Tube Defects.  Obstet Gynecol . 2017 (reaffirmed 2021);130(6):e279-e290. doi:10.1097/AOG.0000000000002412

3. American College of Obstetricians and Gynecologists' Committee on Practice Bulletins : Practice Bulletin, Number 233, Anemia in Pregnancy.  Obstet Gynecol . 2021;138(2):e55-e64. doi:10.1097/AOG.0000000000004477

4. Syed H, Slayman T, Thoma KD: ACOG Committee Opinion No. 804 : Physical activity and exercise during pregnancy and the postpartum period. 2020. PMID: 33481513. doi: 10.1097/AOG.0000000000004266

5. ACOG Committee on Obstetric Practice : Reducing Prenatal Exposure to Toxic Environmental Agents: ACOG Committee Opinion, Number 832.  Obstet Gynecol . 2021;138(1):e40-e54. doi:10.1097/AOG.0000000000004449

6. Committee Opinion No. 718 : Update on Immunization and Pregnancy: Tetanus, Diphtheria, and Pertussis Vaccination.  Obstet Gynecol . 2017;130(3):e153-e157. doi:10.1097/AOG.0000000000002301

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• CASE REPORTS

Wilson’s Disease Diagnosed Postnatally Due to Neurological Manifestation

Pregnancy and its outcome in a rare case of combined protein c and protein s deficiency with severe adenomyosis case, spontaneous ohss in a young adolescent: a diagnostic dilemma, laparoscopic approach for recurrent huge vulval mass, pregnancy in a persistent vegetative state: a management dilemma. case report, literature review and ethical concerns.

Sujata Siwatch 1 • Minakshi Rohilla 1 • Apinderpreet Singh 2 • Chirag Ahuja 3 • Kajal Jain 4 • Vanita Jain 1

A woman who developed a persistent vegetative state in the late first trimester after an arterio-venous fistula (AVF) bleed in the brain presented at 12 weeks period of gestation. The difficult clinical and ethical management issues faced include whether to continue pregnancy, antenatal care and planning for delivery. Multidisciplinary team management along with a family centred approach helped in planning and continuing the pregnancy that resulted in a successful fetal outcome.

Keywords: Pregnancy • Persistent vegetative state • Coma • Ethical issues

Abbreviations:

AV arterio-venous ICH intracranial hemorrhage ECA external carotid artery ICA internal carotid artery MCA middle cerebral artery DSA digital subtraction angiography PVS persistent vegetative state

Inflammatory Myofibroblastic Tumour at Episiotomy Site: A Rare Case Report with Review of Literature

Meenal Bhati 1 • Meenakshi Gothwal 2 • Pratibha Singh 3 • Garima Yadav 2

An inflammatory myofibroblastic tumour (IMT) is a rare mesenchymal neoplasm which was earlier considered under the broad category of inflammatory pseudotumor. It can arise from various anatomic location, out of all lung is the most common site. In our case a 27 years old female presented in our OPD with a mass arising from the episiotomy scar site in the vagina. The histopathological examination showed spindle-shaped cells in fascicles with inflamed granulation tissue with dense mixed inflammation. Immunohistochemistry test showed immunoreactivity for Smooth muscle actin (SMA) and are focally immunoreactive for Bcl2 and Desmin, negative for CK, CD34 and S100 protein. We framed our diagnosis of an inflammatory myofibroblastic tumour of the episiotomy site. However, female genital tract IMT's are rare; to the best of our knowledge, there are no reported cases of IMT involving episiotomy site.

Pancreatitis in Pregnancy: Case Series for 5 Years

Chandrakala Magudapathi 1 • Sudha Shanthi 2 • R. Palanisamy 3

Background To study the course of pancreatitis in pregnant women and demonstrate that early diagnosis and conservative management leads to good maternal and perinatal outcome.

Methods: This article is a retrospective case series study. Six patients with acute pancreatitis during pregnancy were seen in a tertiary referral based obstetric practice at our department in the last 5 years. One of them had gallstones, one hyperlipidemia, one Diabetes and one miliary tuberculosis on ATT . Conservative treatment was instituted for pancreatitis. All of them were followed at least six weeks post-partum.

Results: There was no maternal mortality and perinatal mortality. Acute pancreatitis occurred in both primipara and multipara patients. Preterm labor was a complication in most of our cases complicated by acute pancreatitis. Most patients experienced relief from the pancreatitis soon after delivery. One patient underwent cesarean section due to fetal distress all the other 5 patients had vaginal delivery. One patient had Pseudopancreatic cyst and had a morbid postpartum period.

Conclusion: Pancreatitis is a rare event in pregnancy, approximately 3 in 10,000 pregnancies. It is most often acute and related to gallstones but nonbiliary causes should be sought because they are associated with worse outcomes. Although acute pancreatitis is a rare complication of pregnancy with 50% maternal and 70 % perinatal mortality early and appropriate treatment is of utmost importance to improve the outcome.

Ovarian Follicle: Twirling Microfilaria’s New Abode

Sachin Khanduri 1 · Namrata Nigam 2 · Mazhar Khan 1 · Anvisha Shukla 1 · Ekta Tyagi 1 · Tariq Ahmad Imam 1 · Shobha Khanduri 3

Filariasis is parasitic disease with significant morbidity and socio-economic implications. Its uncommon presentation in female genital organs and rarer presentation in ovarian follicles pose a major diagnostic problem even in endemic regions.As in recent times, there is increase in travel and immigration ,physicians need to be familiar with cases not only endemic to their region but to non endemic diseases as well.Herein ,we report a case of a 26 year old female patient who presented with chronic pelvic pain and polymenorrhoea. Transvaginal ultrasonography revealed microfilariae in ovarian follicular fluid which led to correct diagnosis. This case report sheds light on uncommon presentation of filariasis which needs to be considered for correct diagnosis in endemic as well as non-endemic regions.

Effective Management of Early Cervical Pregnancy with Bilateral Uterine Artery Embolization Followed by Immediate Evacuation and Curettage: A Case Report

Pregnancy in a rare case of intracranial rosai dorfman disease (rdd).

Shashikala Ksheerasagar 1,2 · N. Venkatesh 1 · Niti Raizada 1 · K. M. Prathima 1 · Ravindra B. Kamble 1 · K. Srinivas 1 · M. A. Suzi Jacklin 1 · B. A. Chandramouli 1

We report an extremely rare case of spontaneous pregnancy in a 38 year women following chemotherapy for Rosai-Dorfman Disease (Rosai-dorfman Disease). What made the case more interesting was the challenges that obstetric team faced managing the patient in the presence of co-morbidities like Gestational Diabetes Mellitus , anemia , sub clinical hypothyroidism , allergic bronchitis , progressive symptoms of Rosai-Dorfman Disease like diplopia and cerebellar ataxia

Granulosa Cell Tumor of the Ovary Accompanying with Ollier’s Disease: First Case of Contralateral Presentations

Amirmohsen Jalaeefar 1 · Mohammad Shirkhoda 1 · Amirsina Sharifi 2 · Mohsen Sfandbod 3

Objective: Granulosa cell tumor (GCT) is a rare entity of ovarian malignancies. Juvenile GCT is considered a malignant tumor with an indolent course and tendency toward late recurrence. However, the association of this tumor and multiple enchondromas has been reported.

Case Presentation: A 17-year-old female with abnormal uterine bleeding was referred to our center. Ultrasonographic evaluation revealed a mass with origin in right ovary. Patient was worked up to undergo salpingo-oophorectomy, she felt a dull pain in her left lower limb. X-ray imaging was indicative for Ollier’s disease at the distal part of femur and proximal part of tibia. Postoperative pathological review was compatible with juvenile granulosa tumor of the right ovary.

Conclusion: This case was the first of its kind that ovarian tumor was contralateral to the side involved by enchondromatosis.

Ogilvie Syndrome with Caecal Perforation After Caesarean Section

Osseous metaplasia of the vaginal vault: a case report, heterotopic quadruplet pregnancy after icsi conception.

Background : Heterotopic pregnancy (HP) is a condition characterized by the coexistence of multiple fetuses at two or more implantation sites. It occurs in 1% of pregnancies after assisted reproductive techniques (ART). Presence of triplet intrauterine pregnancy with ectopic gestational sac is one of the rarest forms of HP. Ectopic pregnancy is implanted in the ampullary segment of the fallopian tube in 80% of cases. Most of the patients present with acute abdominal symptoms due to rupture of the tube. Case Presentation This article reports a case of quadruplet heterotopic pregnancy after intracytoplasmic sperm injection (ICSI) with an ampullary ectopic pregnancy and intrauterine triplet pregnancies. The ruptured ampullary pregnancy was emergently managed by right salpingectomy. This was followed by embryo reduction at 12 ? 6 weeks and successful outcome of intrauterine twin pregnancy.

A Rare Case of Adenoma Malignum: Preparing for the Unforeseen

Gayathri Dinesh Kamath 1 • Aditi Bhatt 1 • Veena Ramaswamy 1

Gonadal Vein Graft for Maintaining Renal Circulation After a Complication During Para-Aortic Nodal Dissection: A Case Report

Pesona Grace Lucksom 1 • Jaydip Bhaumik 1 • Gautam Biswas 2 • Sujoy Gupta 3 • Basumita Chakraborti 1

A 39 year old female underwent staging laparotomy for carcinoma endometrium. During para aortic node dissection the left renal vein (LRV) was accidentally injured. The patency of the LRV after rent repair was not adequate for functioning of the left kidney. Nepherectomy was considered but plans for saving the kidney was discussed by the joint team of surgeons. The venous blood of the left kidney was diverted through an anastomosis of the left gonadal vein with the venacava. Patency of the anastomosis was checked and was found to be adequate for keeping the left kidney functional. Doppler of the renal veins done on post-operative day three was normal and she was fit for discharge on day four.

Benign Ovarian Edema Masquerading as Malignancy: A Case Report

Shalini Singh 1 • Kameswari Surampudi 1 • Meenakshi Swain 2

Solid ovarian masses in young age can pose significant diagnostic and therapeutic challenges to the clinician. A young 16 year old girl presented with irregular cycles, pain abdomen and reportedly bulky ovaries with calcifications. Examination was unremarkable. Ultrasound scan revealed bilateral complex ovarian masses suggestive of neoplasm. MRI confirmed a solid right ovarian mass with normal left ovary. Tumour markers were normal. Option of frozen section followed by complete surgery if malignant or two stage procedure including staging laparotomy and if necessary a second surgery were discussed. Parents opted for the latter. At midline laparotomy, free fluid from abdomen was sent for cytology. Right ovary was irregular and enlarged measuring 10 x 8 cm with unruptured white capsule and no torsion. Left ovary was normal. Right salpingo-oophorectomy with omental and peritoneal biopsies were performed. Cytology was benign and histopathology showed massive ovarian edema which was a surprise and relief. Massive ovarian edema is a unique condition with tumour like enlargement of the ovary mimicking neoplasm on imaging leading to overtreatment of patients. Knowledge of this condition allows for fertility sparing procedures.

Maternal Near-Miss: A Perimortem Caesarean Section Resulting in a Remarkable Foetomaternal Recovery in a Rural Tertiary Care Centre in Eastern India

Leiomyoma of urinary bladder in middle-aged female.

Bhushan Dodia 1 • Abhay Mahajan 1 • Dhruti Amlani 1 • Sandeep Bathe 1

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