GYNAECOLOGY

 THE MENSTRUAL CYCLE

It is the cyclical bleeding from the female genital tract which is due to the cyclical changes during endometrium due to the secretion of ovarian hormones. A cycle is counted from the first day of the menstrual bleeding to the first day of next menstrual bleeding.

Menstrual cycle can be divided into four phases.

1. Menstrual Phase- if the ovum is not fertilized, then menstrual bleeding occurs which lasts for about 3-5 days. There is bleeding and shedding of uterine endometrium. An average of 50-200 ml of blood is lost during each menstrual bleeding.

2. Proliferative phase -  here damaged endometrial lining is restored. From day 5 to 14, the endometrium thickens and proliferates. Proliferation occurs in the glands, stroma , blood vessels and superficial epithelium. Thickness of uterine endometrium reaches about 4 mm by about 14^th day.

3. Ovulatory phase -  ovulation occurs about the 14^th day. Cervical mucus secretion increases and it becomes thinner which helps the penetration of sperms.

4. Secretory phase /  Luteal phase/ progestational phase – in this phase, the uterine endometrium further thickens,glands increase in length, spiral arteries become coiled and dilated, cervical secretions become thick and tenacious in preparation for implantation of fertilized ovum. These changes end about 28^th day of the cycle with the onset of menstruation if the ovum is not fertilized.

Hormonal Control of the Menstrual cycle

            The menstrual cycle is regulated by the hormones from the hypothalamus, pituitary and ovaries. The hypothalamus releases gonadotropin releasing hormone which stmulates the synthesis and release of gonadotropins ,FSH and LH. Increase FSH helps in the development of ovarian follicles and stimulates the secretion of oestrogen from ovarian follicles. Increase oestrogen levels causes the changes in the proliferative phase. Serum oestrogen levels becomes peak at about 12 to 13^th day. (oestrogen surge) which has a positive feedback on the hypothalamus resulting in increased gonadotropin releasing hormone. This in turn induces a burst of LH secretion (LH surge) from the anterior pituitary which is the cause of rupture of mature graffian follicles to cause ovulation. After ovulation serum LH and FSH decreases in concentration.

            The corpus luteum formed from the ruptured follicle secretes progesterone. During the secretory phase, the serum progesterone and oestrogen level rises which reduces the secretion of FSH and LH from the anterior pituitary. Progesterone causes the main changes during secretory phase.  If pregnancy occurs, corpus luteum persists and continue to secrete progesterone and oestrogen. But if fertilization does not occur, the corpus luteum regresses into corpus albicans and serum oestrogen and progesterone level decreases which causes the menstrual bleeding.

MENSTRUAL DISORDERS

1.      Amenorrhoea – is the absence of menstruation which may be primary or secondary.PRIMARY amenorrhoea is the condition where menstruation fails to begin by the age of 16 years. Seconday amenorrhoea is the amenorrhoea in a woman after menstruation has been established.(cryptomenorrhoea is where menstrual bleeding occurs but remains concealed due to vaginal occlusion by a congenital septum or atresia)

amenorrhoea can also be classified as physiological and pathological.

Physiological amenorrhoea

1.      Amenorrhoea before puberty

2.      Amenorrhoea during pregnancy

3.      During lactation

4.      After menopause

Pathological Amenorrhoea

A.    Defects in the genital tract

1.      Vaginal atresia

2.      Imperforate hymen

3.      Transverse vaginal septum

4.      Cervical atresia

5.      Genital tuberculosis

6.      Ashermann’s syndrome(amenorrhoea secondary to the trauma of the endometrium due to vigorous curettage during procedures like abortion and MTP.

B.     Defects in the ovaries

1.      Ovarian dysgenesis

2.      PCOD (Stein –Leventhal syndrome)

3.      Premature menopause

4.      Surgical removal of both ovaries

C.     Chromosomal defects

1.      Turner’s syndrome

D.    Pituitory disorders

1.      Pituitory tumors

2.      pituitary infantilism

3.      Hyper prolactinoma

4.      Sheehan’s syndrome(post partal pituitary necrosis due to thrombosis of pituitary blood vessels following post partum haemorrhage)

E.     Gonadotropin releasing hormone deficiency causes hypothalamic amenorrhoea.

F.      Disorders of adrenal glands

1.      Adrenogenital syndrome (caused by a tumor or hyperplasia of adrenal cortex resulting in excessive androgen production. )

2.      Cushing’s syndrome (Cortico steroid hormones are in excess which causes osteoporosis, hirsutism, obesity and amenorrhoea.

3.      Addison’s disease.

G.    Thyroid disorders

H.    Nutritional factors

1.      Starvation,

2.      Extreme obesity

3.      Anorexia nervosa

I.       Drugs

1.      Oral contraceptives

2.      Prostaglandin inhibitors

Management:

            Depends upon the underlying causes

DYSMENORRHOEA

It is the painful menstruation incapacitating the women in day today activities.

1.   Spasmodic dysmenorrhoea (primary dysmenorrhoea)

here there is no identifiable  pelvic pathology. May be due to cervical obstruction, psychological factors like low pain threshold, endocrine factors like low progesterone level, intrauterine contraceptive devices and muscular spasms. The pain begins a few hours before or just after the onset of menstruation may last upto 12 hours and accompanied by constitutional symptoms like chills nausea, vomiting and fainting.

2.   Congestive dysmenorrhoea (secondary dysmenorrhoea)

Causes:

1.      Uterine fibroid

2.      Chocolate cyst of ovary

3.      Pelvic endometriosis

4.      Adenomyosis

5.      PID

6.      Salpingoophrites

Here the pain starts 3 to 5 days before menstruation and is relived by the flow..

3.      Membraneous dysmenorrhoea

It is a variety of primary dysmenorrhoea characterized by shedding of large endometrial casts during menses.

PMT

It is a condition where women suffer from excessive premenstrual symptoms which are experienced for 7 to 10 days before the onset of menstruation.

Symptoms:

Irritability, lassitude, sleepiness, headache, nausea, constipation, frequency of micturition , weight gain, oedema of legs, fullness and tenderness of breast etc. though the exact aetiology is not known, the PMT is said to be due to excess of oestrogen in relation to the progesterone.

MENORRHAGIA

            Is excessive menstrual blood loss both in amount and duration.

Casuses:

Pelvic causes:

1.      Uterine fibroid

2.      Adenomyosis

3.      Ovarian tumors

4.      Pelvic endometriosis

5.      PID

6.      Genital TB

Endocrine causes:

1.      Hypo and hyper thyroidism

2.      General diseases

3.      Chronic HTN

4.      CCF

5.      Leukaemia and purpureas

6.      Liver dysfunction

IUCD (Intra Uterine Contraceptive Devices)

METRORRHAGIA

            It is acyclical intermenstrual irregular uterine bleeding.

Causes:

1. Uterine fibroid

2. Uterine polyps

3. Ca cervix

4. Ca endometrium

5. Cervical erosion

6. Cervical polyp

POLYMENORRHOEA (EPIMENORRHOEA)

            It is the frequent menstruation at regular intervals of 2 or 3 weeks due to the shortening of the cycle. If it is associated with prolonged bleeding, it is called Epimenorrhagia.

Dysfunctional Uterine Bleeding

            This is abnormal uterine bleeding where no organic cause can be detected and occur at any age between menarche and menopause.

Metropathica haemorrhagica- it is irregualar anovulatory prolonged bleeding which may last for many weeks and is painless due to the failure of ovarian response to gonadotropins.

VAGINAL DISCHARGE

A.    Physiological :

In healthy women the vagina contains a small amount of watery secretion which contains mucus, desquamated epithelial cells, doderllains bacilli and lactic acid. It is usually colorless.

B .Pathological”

            To investigate the pathology behind the vaginal discharge, it is necessary to know the colour, quantity, duration of time it has been present,smell, irritating or not and if it is blood stained or not. An irritating discharge may be due to infection by the trichomonas vaginalis or candida albicans. Yellow discharge may be due to bacterial infections, infected cervical polyp or erosion, acute gonorrhoea, puerperal sepsis or pyometra.Offensive vaginal discharge is characteristic of necrotic lesion of genital tract, carcinoma  of vagina, foreign bodies retained in the vagina. Blood stained discharges occur with oestrogen deficiency, carcinoma of cervix, any ulcerated lesions and in intra uterine pregnancies. 

INFERTILITY

Is defined as failure to conceive even after one year of regular unprotected intercourse. (Sterility is an absolute state of inability to conceive where as infertility is only a relative state)

Infertility can be primary and secondary.

Causes of infertility

Faults in the Male

1.      Defective spermatogenesis

2.      Obstruction in the efferent duct

3.      Sperm motility

4.      Failure in depositing the sperm.

Faults in the Female:

1.      Vaginal factors

a.       Vaginal atresia

b.      Narrow introitus

c.       Transverse vaginal septum

d.      Vaginal stenosis

e.       Vaginismus

2.      Cervical factors

1.      Elongation of cervical canal

2.      Obstruction of cervical canal

3.      Uterine prolapse

4.      Thick cervical mucus

5.      Chronic cervicitis

6.      Presence of antisperm antibody in cervical mucus

3.      UTERINE FACTORS

1.      Congenital malformations of uterus

2.      Uterine fibroid

3.      Adenomyosis

4.      Uterine tuberculosis

5.      Tubal factors

1.      Tubal occlusion

2.      Tubal additions

3.      Loss of celia

4.      Congenital tubal defects

5.      Tuberculosis

6.      Salpingitis

6.      Ovarian factors

1.      Anovulatory cycles

2.      Ovarian tumors

3.      PCOD

7.      Endocrinal factors

1.      Thyroid disturbances

2.      Hypogonadotrophism

3.      Corpus luteum insufficiency

4.      Hyperprolactinaemia

INVESTIGATIONS OF INFERTILITY

MALE

1.      Local examinations of genitals

2.      Semen analysis

3.      Serum hormone levels

4.      Testicular biopsy

5.      Chromosomal test

6.      Immunological test

FEMALE

1.      Detailed history taking

2.      General systemic and gynaecological examinations

3.      Special investigations to assess tubal, cervical, peritoneal and ovarian functions.

URINARY PROBLEMS IN GYNAECOLOGY

            Retention of Urine:- the condition where urine collects in the urinary bladder but fails to be voided out leading to stasis of urine in the bladder.

            Causes:

1. Postoperative retention

it may be due to oedema, reflex spasm of bladder sphincter, or denervation of bladder.

2. Obstructive conditions like stenosis, cancer of bladder neck retention durine Puerperal period.

3. Pelvic tumors

4. Retroverted gravid uterus

DYSURIA

            Causes:

1. Cystitis

2. Urethritis

3. Urethral caruncle

4. Carcinoma of urethral meatus

5. Trauma to the urethra

6. Postoperative

7. Vesical calculi

8. Following catheterization

9. Radiation cystitis

INCREASED FREQUENCY OF MICTURITION

            Causes:

1. Cystitits

2. Pregnancy

3. Ca Cervix or Vagina

4. Trauma during catheterization

5. Diabetes

STRESS INCONTINENCE

            It is the involuntary escape of urine when there is sudden increase in the Intraandominal pressure

Causes:

1. Incompetent urinary sphincter

2. Post menopausal atrophy

3. Lowered urethral pressure

4. Neurological causes

5. Trauma to the pelvic floor

URGE INCONTINENCE

            In this condition , the women experience a sudden desire to pass urine which is unable to control.

Causes

1. Cystitis

2. Trigonitis

3. Bladder stone or foreign body

4. Pelvic tumor

5. Neurological causes

UTI

            It is more common in female because of the shorter urethra, proximity of the external urethral meatus to the vaginal and anal openings, sexual intercourse, stasis or urine during pregnancy and peurperium.

            e-coli is the most common causative agent

UTERINE FIBROIDS (FIBROMYOMA/LEIOMYOMA)

Causes:

Exact aetiology is not known. But there is substantial evidence that oestrogen plays an important role in myomas.

Types:

1. Intra mural fibroid (interstitial)

2. Subserous fibroid

3. Submucus fibroid

Clinical features

Majority are asymptomatic. Symptoms may depend upon the size of the tumor. Abdominal lump. Pressure symptoms, pain, menstrual abnormalities and infertility may be the presenting features.    

Diseases of the New born

RDS (Respiratory Distress Syndrome)

            Aetiology : the basic abnormality is deficiency in pulmonary surfactant. In the absence of surfactant, the surface tension increases and alveoli collapse during expiration.

            RDS appears within 6 hours of life characterized by tachyapnoea, chest retraction and cyanosis.

            Diagnosis can be confirmed by X-ray which shows ground glass mottling.

Meconeum aspiration Syndrome

            Meconeum aspiration causes chemical pneumonitis or blockage of various airways. This is common in small for date and post mature babies. They develop respiratory distress in the first 24 hours of life.

HAEMOLYTIC DISEASE OF THE NEWBORN

            The disease is characterized by excessive haemolysis of the foetal RBC. It is mostly due to incompatibility of the foetal and maternal blood groups. They include Rh incompatibility, ABO group incompatibility  and other antigen incompatibilities.

CARCINOMAS

Ca of Female Genital Organs

Ca of Vulva

Ca of vulva contributes about 4.8% of total carcinomas of female genital organs. 3 clinical types are there

The cauliflower growth, the flat indurations and the excavated ulcer. Pruritus is a very common complaint. Diagnosis is made by lump, pruritus and cytology.

Carcinoma Vagina

It contributes about 1.9% of all genital carcinomas. Usually seen in the upper 1/3^rd of the posterior vaginal wall as cauliflower growth or indurated ulcer.

Symptoms are pain, bleeding after coitus and later blood stained offensive discharge.

Ca Cervix

            It is the most frequent of all genital tract cancers (about 30%). Occurs frequently in multiparous women. Average age incidence is between 39 and 57. usually presents as cauliflower like growths or excavated ulcers which causes profuse bleeding on even slightest touch. The four main symptoms of Ca Cervix are

1. haemorrhage

2. discharge

3. cachexia

4. pain.

Ca fallopian tube

            This is the rarest type of gynaecological cancer and can be managed by means of radical surgery.

Ovarian carcinoma

            This is extremely common and usually metastatic. (Krukenberg tumor- these are bilateral ovarian tumors which have smooth and slightly bossed surfaces and are freely movable in the pelvis.). Ovarian carcinomas usually present with pain and tender swelling.

MEDICAL TERMINATION OF PREGNANCY (ABORTION ACT OF 1067)

According to abortion act of 1967, the circumstances in which abortion may be carried out are as follows.

1. two registered medical practitioners must form in good faith about the abortion.(section 1(1))

2. the continuance of pregnancy would involve risk to the pregnant woman (section 1 (1-a))

3. if cause injury to the physical or mental health of the pregnant woman (section 1 (1-a)

4. if it would cause injury to the physical or mental health of any existing children of the pregnant woman’s family. (section 1 (1-a)

5. the child that is to be born would suffer from severe physical or mental abnormalities. (section 1(1-b)

Consent:

      A written consent of the patient should be obtained before conducting the MTP. If the patient is an unmarried girl between the ages of 16to18, the patient consent is a must rather than the parent’s consent.

      If the patient is under 16, her parents should always be consulted even if the patient forbids it. Still if the patient’s consent is not obtained MTP should not be carried out.

 CARCINOMAS

Ca of Female Genital Organs

Ca of Vulva

Ca of vulva contributes about 4.8% of total carcinomas of female genital organs. 3 clinical types are there

The cauliflower growth, the flat indurations and the excavated ulcer. Pruritus is a very common complaint. Diagnosis is made by lump, pruritus and cytology.

Carcinoma Vagina

It contributes about 1.9% of all genital carcinomas. Usually seen in the upper 1/3^rd of the posterior vaginal wall as cauliflower growth or indurated ulcer.

Symptoms are pain, bleeding after coitus and later blood stained offensive discharge.

Ca Cervix

            It is the most frequent of all genital tract cancers (about 30%). Occurs frequently in multiparous women. Average age incidence is between 39 and 57. usually presents as cauliflower like growths or excavated ulcers which causes profuse bleeding on even slightest touch. The four main symptoms of Ca Cervix are

5. haemorrhage

6. discharge

7. cachexia

8. pain.

Ca fallopian tube

            This is the rarest type of gynaecological cancer and can be managed by means of radical surgery.

Ovarian carcinoma

            This is extremely common and usually metastatic. (Krukenberg tumor- these are bilateral ovarian tumors which have smooth and slightly bossed surfaces and are freely movable in the pelvis.). Ovarian carcinomas usually present with pain and tender swelling.

MEDICAL TERMINATION OF PREGNANCY (ABORTION ACT OF 1067)

According to abortion act of 1967, the circumstances in which abortion may be carried out are as follows.

6. two registered medical practitioners must form in good faith about the abortion.(section 1(1))

7. the continuance of pregnancy would involve risk to the pregnant woman (section 1 (1-a))

8. if cause injury to the physical or mental health of the pregnant woman (section 1 (1-a)

9. if it would cause injury to the physical or mental health of any existing children of the pregnant woman’s family. (section 1 (1-a)

10. the child that is to be born would suffer from severe physical or mental abnormalities. (section 1(1-b)

Consent:

      A written consent of the patient should be obtained before conducting the MTP. If the patient is an unmarried girl between the ages of 16to18, the patient consent is a must rather than the parent’s consent.

      If the patient is under 16, her parents should always be consulted even if the patient forbids it. Still if the patient’s consent is not obtained MTP should not be carried out.

 Endometriosis

Is the presence of ectopic endometrium in any situation other than it normal location. Endometriosis is confirmed when

-          Lining epithelium rescembles, should have typical endometrial stroma, should respond to oestrogen, the contents of endometrial glands is dark altered tarry blood

-          The disease is one adult sexual life- peak 30-40 years of age

-          Divided into internal endometriosis or adenomyosis or external endometriosis .eg. ovaries , uterosacral ligament, abdominal scars, umbilicus, bladder etc

symptoms of adenomyosis

            Menorrhagia in fairly high degree

            Infertility

            Large uterus

            Feeling of weight in the pelvis

CYSTS OF OTHE OVARIES

1.   Chocolate cyst of the ovaries – the important site of extra uterine endometriosis, affected ovary enlarge, outer surface white and thickened. Ovary and fallopian tubes prolapsed and fixed to the pelvis. Rupture is common with chocolate sauce like blood as content.

Symptoms-

-          Pain

-          Dysmenorrhoea

-          Dyspareunia

-          Infertility

-          Bowel and bladder symptoms

2.     Retention cyst of graffian follicle

Incase of excess hCG

3.     Follicular cyst

Regarded as pathological if it is more than one inch diameter.

SCLEROCYSTIC DISEASES OF OVARY (PCOD) Stein-leventhal syndrome

Virilising syndrome in young women characterized with infertility obesity hirsutism and acne

Kruckenberg tumour

May be primary or seconday . invariably bilateral. Smooth bossed surface with additions.

Clinical features- abdominal swelling pain , alteration in menstrual cycle, ascites, post menopausal bleeding, fixity indicated malignancy.

ABORTION

            Classification-

1.     degree

a.     threatened

b.     inevitable

c.     incomplete

d.     complete

e.     missed

2.     cause

a.     spontaneous

b.     habitual

c.     criminal- legal and illegal

3.     infections

a.     septic

b.     non septic

Abortion may occur due to

a.     abnormalities of foetus

b.     abnormalities of placental membrane e.g. hydatidiform mole

c.     disease of the mother. E.g. measles, cholera, syphilis,

d.     chronic disease like HTN, nephritis

e.     local abnormalities in mother.e.g. cervical incompetence, genital hyperplasia

f.      drugs

g.     endocrine factors

h.     psychiatric disturbance

i.      faults in the male like law quality sperm

HYDATIDIFORM MOLE (vesicular mole)

            Chorionic villi distended with fluid forming translucent vesicles . usually abortion may occur between 4-6^th month.

Symptoms- abdominal pain, vaginal bleeding or watery dirty discharge. Complication may follow as haemorrhage, sepsis, perforations ,chorione epithelioma which is pre malignant.

PROLAPSE UTERUS

            Normal position of uterus is one of universal anteversion and antiflexion with body of the uterus tilted forward.

 First degree prolapse descent of cervix in vagina

Second degree to the introitus

Third degree – out side the introitus

Fourth degree or procidentia – uterus completely out side

ASPHYXIA NEONATORUM

            Here heart continues to beat but respiration not established. Diagnosed by APGAR Scoring carried out every one and five minute after birth.

APGAR scoring

-          heart rate

-          respiratory effort

-          muscle tone

-          reflex irritability

-          pallor of the skin

cephal haematoma- may not present in birth but develop within two to three days. Limited by a suture to a particular bone. Soft and elastic. Does not pit on pressure. Gradually increases in size and takes week or months to disappear.

Caput succidenum present at birth not well circumscribed . maximum at birth and gets smaller.

CARCINOMAS

Ca of Female Genital Organs

Ca of Vulva

Ca of vulva contributes about 4.8% of total carcinomas of female genital organs. 3 clinical types are there

The cauliflower growth, the flat indurations and the excavated ulcer. Pruritus is a very common complaint. Diagnosis is made by lump, pruritus and cytology.

Carcinoma Vagina

It contributes about 1.9% of all genital carcinomas. Usually seen in the upper 1/3^rd of the posterior vaginal wall as cauliflower growth or indurated ulcer.

Symptoms are pain, bleeding after coitus and later blood stained offensive discharge.

Ca Cervix

            It is the most frequent of all genital tract cancers (about 30%). Occurs frequently in multiparous women. Average age incidence is between 39 and 57. usually presents as cauliflower like growths or excavated ulcers which causes profuse bleeding on even slightest touch. The four main symptoms of Ca Cervix are

9.     haemorrhage

10.  discharge

11.  cachexia

12.  pain.

Ca fallopian tube

            This is the rarest type of gynaecological cancer and can be managed by means of radical surgery.

Ovarian carcinoma

            This is extremely common and usually metastatic. (Krukenberg tumor- these are bilateral ovarian tumors which have smooth and slightly bossed surfaces and are freely movable in the pelvis.). Ovarian carcinomas usually present with pain and tender swelling.

MEDICAL TERMINATION OF PREGNANCY (ABORTION ACT OF 1067)

According to abortion act of 1967, the circumstances in which abortion may be carried out are as follows.

11.  two registered medical practitioners must form in good faith about the abortion.(section 1(1))

12.  the continuance of pregnancy would involve risk to the pregnant woman (section 1 (1-a))

13.  if cause injury to the physical or mental health of the pregnant woman (section 1 (1-a)

14.  if it would cause injury to the physical or mental health of any existing children of the pregnant woman’s family. (section 1 (1-a)

15.  the child that is to be born would suffer from severe physical or mental abnormalities. (section 1(1-b)

Consent:

      A written consent of the patient should be obtained before conducting the MTP. If the patient is an unmarried girl between the ages of 16to18, the patient consent is a must rather than the parent’s consent.

      If the patient is under 16, her parents should always be consulted even if the patient forbids it. Still if the patient’s consent is not obtained MTP should not be carried out.

MCQs 

1. ------------------ type pelvis is the type with accepted with female sex characteristics

2. The uterus grows out of the pelvis by --------- week

3. Alphafoeto proteins are synthesized in the -------------- and ----------- .

4. The bluish discolouration of the vagina during pregnancy is called ----------- .

5. Hegar’s sign is --------------

6. The soft murmur heard rarely synchronous with the foetal heart beat is called ------

7. Aschheim and zondek test detects ----------

8. The retention of menstrual fluid in the cavity of uterus leads to ---------------

9. The most common presentation of the foetus is ---------------

10. Peurperium is a period following the delivery lasting up to ---------------

11.  Elderly primi is a woman above ----------- years of age

12. Vagina is lined by --------------- epithelium

13. Vaginal ph is acidic due to the presence of --------------

14. Commonest malignancy in women in india is --------------------

15. Quickening appears at ----------- weeks

16. The most common cause of postpartum haemorrhage is------------

17. The weight of non pregnant uterus is -----------

18. The involution of uterus is completed by ------------ days

19. Other than pre-eclampsic symptoms, eclampsia is characterized by --------

20. The disease due to cystic degeneration of chorionic villi is ---------

21. The normal amount of liquor amni at term is ---------

22. ---------------- is the placenta in which the cord is attached to the margin of the placenta.

23. The normal length of the umbilical cord is----------

24. False knots in the umbilical cord are the result of local increase of the ----------

25. A  woman is said to be habitual aborter if she has undergone ---------consecutive abortions

26. The overlapping of skull bone seen in the x-ray in intrauterine death of foetus is called -------------- sign

27. The most common site of ectopic pregnancy is ---------

28. The most common form of multiple pregnancy is -------------

29. Excessive traction in the delivery of the shoulder results in ---------------

30. The characteristic oedema in the haemolytic disease of the new born is called-----

31. ‘Islands of bones in a sea of membranes’ is a particular feature of ---------

32. Umbilical cord contains ---------- arteries and ----------- veins

33. The best speculum for pelvic examination is ------------------- .

34. The glands of both sexes present in the same individual is called ----------------

35. The condition , in which the urethra opens below the phallus is -------------

36. In turner’s syndrome the nucleus has ------- chromosomes

37. Cyclic recurrent ulceration of vulva and mouth with uveitis is called --------------

38. Mittelschmers refers to ------------

39. The usual position of uterus is ----------- and ----------------

40. The commonest type of fibroid uterus is -------------

41. Sharp dorsiflexion of the foot which elicit pain in deep phlebothrombosis is called-------

42. A baby weighing less than ---------- gms at birth is classed as premature according to the international standards

43. ‘Phlegmasia alba dolans’ is usually associated with -------------------

44. Snuffles in infants is an important and early sign of ---------------------

45. Formation of an opaque tissue behind the lens of the eyes, a few months after birth especially in premature babies is called---------------------

46. The normal foetal heart rate is ------------

47. The commonest reason for post partem mortality is ------------

48. The basic cause of placenta accrete is ----------------

49. The bimanual examination done to assess the cephalopelvic disproportion is called----

50. The study of nature pf uterine contraction is called ---------------

51. The most common maternal disease which is associated with hydramnios is --------

52. The colostrums is rich in immunoglobulin ---------

53. The most common type of episiotomy applied is -----------------

54. In cephalic presentation maximum intensity of foetal heart sound is heard ---------

55. It is estimated that the mature milk flow is about ------------- ml/day

56. The diameter of engagement in a vertex presentation is ---------------------------

57. Mac Donald’s rule calculates the EDC  from calculating the -----------------

58. Calculate the EDC by Nagetes rule- LMP July 17^th

59. In a nulliparous woman the external os of the uterus is ----------

60. Active foetal movements are felt during --------- trimester of pregnancy

61. The normal ph of vagina during reproductive period is -----------------

62. The pouch of peritoneum which separates the bladder from the uterus is --------

63. After ovulation, the ruptured follicle develops in to --------------

64. The hormone liberated by graffian follicle is -----------

65. Corpus luteum secretes the hormone ---------------

66. The menstrual blood does not clot, though it contains calcium, because it does not contain ------------

67. Excessive menstrual loss with preservation of the normal cycle is --------------

68. In turner’s  syndrome the chromosome structure is -----------

69. Hyperplasia of adrenal cortex leads to ---------------------

70. A frothy discharge from vagina is the indication of --------------------

71. The basophil adenoma of the anterior pituitary leads to ---------------

72. The most frequent type of all genital tract cancer is ----------

73. Complete prolapse of the uterus is called--------

74. Relaxin secreted by the ---------------

75. Presence of ecto endometrium in any site outside normal location is -----------

Answers

1. Gynaecoid type

2. 12^th week

3. foetal liver and yolk sac

4. Chadwick sign

5. Softening and

6. funic soufflé

7. HCG

8. Haematoma

9. Vertex

10. 6-8 weeks

11. 40 years

12. simple squamous

13. Doderlein’s bacilli

14. Carcinoma breast

15. 16^th week

16. Uterine atony

17. 50 gms

18. 12 days

19. Convulsions

20. Hydatidiform mole

21. 100 ml

22. Battle dore placenta

23. 50-60 cm

24. Wharton’s jelly

25. 3 or more

26. Splading’s sign

27. Tubal

28. Twin pregnancy

29. Erb’s palsy

30. Hydrops foetalis

31. Hydrocephalus

32. 2 arteries and 1 vein

33. Bivalve speculum of cusco

34. True hermaphroditism

35. Hypospadiasis

36. 45 chromosomes

37. Behcet’s syndrome

38. Ovulation pain

39. Anteversion and anteflexion

40. Intramural

41. Homan’s sign

42. 2500 gms

43. Thromobophlebitis

44. Congenital syphillis

45. Retrocentral fibroplasias

46. 150/minute

47. Shock

48.  Decidual deficiency

49. Munro – Kerr-Muller method

50. Tocography

51. Diabetes mellitus

52. A

53. Mediolateral

54. Below the  umbilicus

55.850 ml/day 

56. Subocciputo bregmatic presentation

57. height of the fundus

58. April 24

59. Circular

60. Last / Third

61. 4.5

62. Uterovesical pouch

63. Corpus luteum

64. Oestrogen

65. Progesterone

66. Prothrombin

67. Menorrhagia

68. 44+ X0

69. Adernogenital syndrome

70. Trichomoniasis

71. Cushing’s disease

72. Ca Cervix

73. Procidencia

74. Ovaries

75. Endometriosis