Ms W is 33 years teacher and at 18 weeks gestation of her second pregnancy .

she experienced heavy vaginal bleeding with the passage of . -products of conception . her blood group is O What are the blood groups of the fetus and the father to expect Rh.1 ? incompatibility ? Mention two other events that may lead to Rh sensitization.2 Mention two factors that the rhesus antibodies development depend on.3 ? them By which test we can determine the proportion of fetal cells in the mother.4 ? circulation By which test we can determine the amount of the prophylactic dose of.5 ? anti D ? By which test we can determine if the mother is sensitized or not.6 ? What is the prophylactic dose of anti D for this patient.7 : ANSWERS ." +any blood group with the rhesus factor positive "O.1 a- delivery b- antepartum hemorrhage .2 a-inborn ability to respond b- ABO compatibility .3 Kleihauer-Betke test .4 Kleihauer-Betke test .5 direct or indirect coomb,s test .6 " half of the standard dose " 250 IU .7 A primigravida deliver her full term baby weighting 3 Kg . her blood group is A.+and the infant blood group is A ? When to give her the prophylactic anti-D dose.1 ?What is the prophylactic dose of anti D for her.2 ? Does rhesus disease affect the first pregnancy.3 : ANSWERS . Within 72 hours after delivery.1 A- the British school , standard doses of 500 IU are given subsequently.2 . according to Kleihauer-Betke test B the American school , a booster dose of 1500 IU is given in all . cases rhesus disease dose not affect the first pregnancy unless the mother.3 was sensitized before the first pregnancy by receiving an Rh- positive . blood transfusion

A 30 years housewife and at 32 weeks gestation in her fourth pregnancy .her blood group is B- , her first child was full term and 3.5 Kg and his blood group is AB+ ,and she did not take anti D prophylactic dose , the second child born with jaundice and anemia , in the third pregnancy there was intrauterine fetal death . at 34 weeks gestation ? is there a role for the use of Anti-D injection.1 what could be done if isoimmunization was discovered before 20.2 ? weeks of gestation ? when to do amniocentesis.3

dose the level of bilirubin in amniotic fluid correlate with the.4 ? severity of fetal anemia other than amniocentesis how the severity of fetal anemia can be.5 ? predicted , ? according to Whitefield s action line what will be done.6 ? mention three prognostic factors.7 ? what will be done for the infant after delivery.8 : ANSWERS there is NO role for the use of Anti-D injection.1 plasmaphoresis to wash all the maternal antibodies and it can be done.2 as early as 12 weeks at 20 weeks gestation when the antibody titer more than 5 IU.3 yes it correlate roughly with the degree of hemolysis and thus indirectly.4 predicts the severity of fetal anemia ,mild moderate or sever according to Liley,s chart by Doppler study for the fetal middle cerebral artery.5 if bilirubin is in Liley,s third zone and as it less than 34 weeks then.6 intrauterine fetal transfusion is done. until 34 weeks then the fetus will be delivered a- paternal genotype b- maternal history of blood transfusion c-.7 antibody titer a- mild cases can be treated with phototherapy and correction of.8 acidosis b- sever cases may need exchange transfusion Ectopic pregnancy female pregnant at 8 week of gestational age presented with sever abdominal 32 pain of 6 hours duration and history of small amount vaginal bleeding after half . hour from starting of the pain

(Diagnosis : ectopic pregnancy(acute rupture Risk factors: -salpingitis intra uterine devicetubal or abdominal surgeryPID(Ddx: abortion(but remember in case of abortion bleeding then pain (More sensitive investigation: -- -HCG level (blood sample vaginal ultrasound

definitive diagnosis by laprascopy :Treatment : surgery salpingectomy by: laparoscopy or laparotomy) or)salpingstomy or.salpingtomyOvary

(Diagnosis :Mature Teratoma( dermoid cyst Component: hair, bone, cartilage, teeth ,Sign and symptoms: pelvic mass , abdominal pain if twisted , urinary symptoms Peak incidence: second decade of life :Treatment cystectomy-1 atypical in older age group we consider oophrectomy -2

This picture for a 57 years female presented with abdominal distention and and .feeling pressure in her pelvis since 4 months Diagnosis : Serous cystadenocarcinoma (cystic appearance while mucinous multicystic usually) ? Before diagnosis how to approach taking hx-1 ( examination (abdominal and pelvic -2 ( invistigation( us , ct scan , mri, ,tumor marker-3 (Risk factors :(nulliparitry ,family hx , fertility drug like clomiphene citrate ( Protective factors : ( number of pregnancy , occp , tubal ligation Staging workup :1- BUN ,craetinine level . electrolyte for renalmets LFT for liver mets-2 chest X-ray for lung or mediastinal involvement-3

Treatment: surgery and chemotherapy Follow up : repeated physical exam. And estimation of tumor marker like CA125 ..Level and do ct scan when we suspect recurance

-1

The arrows show tiny brown active patches presenting with adhesions (ball-* .ending arrow), which are consistent with endometriosal lesions -2

The second picture shows a red flame lesion on the small bowel area .(! which is mostly also an endometriosal lesion (endometriosis -3

.This is also a peritoneal dark endometriosal lesion

-4

:From the previous pictures answer the following questions

?What are the different lesions shown in the previous pictures-A (Endometriosis. ( Endometrial Lesions

?B-Define the Endometriosis Is the presence of endometrial glands and stroma outside the endometrial cavity, proliferating during the menstrual cycle, braking down & bleeding, causing local inflammatory reaction which may be followed after prolonged period by fibrosis & .distortion of the tissue affected with dense scarring and adhesions C-What are the differences between the ectopic endometrial tissues and the ?normal endometrium .The degree of response to ovarian hormones-1 .They do not have an ordered blood supply, but there is an in-growth of new capillaries -2 .(They are outside the normal site (endometrium of the uterus-3

?(D-What is the prevalence of the disease (epiedemiology .Estimates about its prevalence vary but 5-15% is a reasonable number

?E-What are the two main categories in which patients manifest with (Infertility (20%-30%-1 (Chronic Pelvic Pain ( In lec. Written 80%, in books 20%-2

?F-What are the risk factors for endometriosis .Family hx (first-degree >>mother or sisters) 7 times more to have the disease -1 .(Having some autoimmune disorders (eg. Lupus-2 .More in whites than blacks-3

?G-What are the theories about its etiology (Retrograde menstruation (Sampson theory -1 (Coelomic metaplasia (Mayer theory -2 (Lymphatic & vascular dissemination (Halban Theory -3 Genetic predisposition -4 ?H-What are the ages that usually we dont see the disease Before puberty-1 After menopaus-2 Why? Endometriosis depends on estrogen so during those periods we dont have estrogen .as in the reproductive age

I-What are the different laproscopical or during- laparotomy appearances of the ?lesions Red flame lesions, these lesions are active, looks like tiny hemorrhages in the peritoneal -1 surface Yellowish brown patches -2 (matchstick heads (small dots on the peritoneal surface -3 Adhesions especially between the ovaries and the ovarian fossa -4 .Circular peritoneal defects with sharp edges -5 On the ovaries, endometriosis might cause endometrioma or the chocolate cyst -6

?What is the main pathology which appears in the previous 4 pictures* .These are called endometriomas/choclate cysts/ovarian endometriosal cysts ?How are these cysts formed* On the ovaries, endometriosis might cause endometrioma or the chocolate cyst, this cyst will be filled with menstrual blood every month and with time it will accumulate and will resemble brown melted chocolate or even becomes hard and form what looks like small .stones ?If you do histopathological study, what do you suspect to see* :We have 2 cases .In Early lesions: Endometrial glands and stroma-1

.In Advanced disease: Blood filled cyst formation & fibrosis-2 .(macrophages filled with RBCs underneath it)

?(Where do you suspect to have the lesions? (Distribution* The OVARIES are the most common sites; they .are involved in 50% of the cases The posterior surface of the broad ligaments .and the uterus .Utero-sacral ligaments Uterine cul-de-sac the area behind the uterus .and in front of the rectum Implants may involve the bladder, ureters, .bowel, cervix and the posterior vaginal fornex May occur in wounds contaminated by endometrial tissue; e.g. following C-section the patient will complain of pain and enlargement .of the wound area during her period Distant tissues; brain, lungs & kidneys may be .involved

?What are the clinical features of the disease*

.The usual history patients having endometriosis is dysmenorrhea (pain) and infertility*

The symptoms of pelvic endometriosis depend on the site and the activity of the disease and the most frequent

:Pain-1
CONGESTIVE DYSMENORRHOEA (Secondary) begins with or few days before .menstruation .It is felt in the pelvis and lowers back .OVULATION PAIN is sometimes severe in mid-cycle DYSPAREUNIA is felt deep in the pelvis due to pressing on the uterosacral ligaments and rectovaginal septum during coitus and is worse in the luteal phase .when the implants most active PAIN AND BLEEDING WITH URINATION OR DEFECATION usually at the time of the .periods, occurs when the disease has involved the rectum or the bladder (?Infertility: (Mention 4 causes for Infertility-2 .FIBROSIS, ovulation occurring into closed off areas of fibrosis .DAMAGE TO TUBAL FIMBRIA .KINKING OF TUBES by adhesions .BLOCKAGE OF TUBE by deposits of endometriosis in the wall :Disturbances of menstruation -3 Menorrhagia .(If deposits are in the myometrium (Adenomyosis.Shorter cycles and episodes of prolonged bleedingIrregular menstrual spottingPolymenorrhoea:(Other less common symptoms (According to the SITE and ACTIVITY-4 .Haematuria .Bleeding from the umbilicus .Dysuria .Intestinal obstruction .Pain on defecation Occasionally a chocolate cyst may rupture causing chemical peritonitis, leading to .symptoms and signs of an acute abdomen A 35 years high socioeconomic patient, having 5 children, presented to you with* menorrhagea and spasmodic dysmenorrheal. You examined her, and you found a bulky big uterus, with tenderness on palpation and irregularities on its surface. ?Whats the most diagnosis you suspect of .Adenomyosis

You examined a patient with Endometriosis, what clinical findings you suspect to* ??find May be nil or marked depending mainly on location and tissue reaction to a -1 .chronic inflammatory process and NOT on the total mass of the diseased tissue The most typical clinical picture is that of FIXED RETROVERSION -2 .Enlarged, tender ovaries -3 Deposits in the uterosacral ligaments may be palpable as tender nodules -4 ((beading Pigmented cervical and/or vaginal lesions -5 Pelvic mass which could be asymptomatic might be noticed during -6 .examination ?Give 6 differential diagnoses in relation to the clinical features* .Pelvic inflammatory disease .Ovarian tumors .Adenomyosis .Pelvic congestion syndrome .Acute appendicitis .Ectopic pregnancy Ca-colon or rectum ?How you can definitely diagnose endometriosis* Definite diagnosis is by VISUALIZATION, LAPAROSCOPY remains the key diagnostic .tool and BIOPSY of the lesion confirms the diagnosis ?What are the modalities of treatment of that disorder

Medical-1 Surgical-2 :Medical-1 A- Non-steroidal anti-inflammatory drugs: are only used to relive the pain of dysmenorrhea and are NOT going to prevent the progression of the disease Hormone Therapy: to induce atrophy in the ectopic endometrium and avoid complications associated with it, bleeding, adhesions, etc. once stopped .symptoms will reoccur ?What are the hormonal drugs used to treat the disease* Ovarian hormones -1 Danazol -2 Gestrinone -3 Megestrol acetate-4 LHRH analogues -5 :Surgical-2 A- (Highly Invasive): TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPINGO-OOPHORECTOMY :(B-Minimally invasive surgery (Endoscopic surgery THERMO COAGULATION Endoscopically directed LASER surgery ENDOSCOPIC EXCISION :Now these are additional pictures on the topic -1

The thickened and spongy appearing myometrial wall of this sectioned uterus is typical of adenomyosis, a condition in which endometrial glands with stroma are .located within the myometrium -2

.This is taken from the myometrium>>>Adenomiosis -3

This is taken from the fallopian tube>>>Endometriosis -4

.Pouch of Douglas Endometriosal deposits -5

Endometriosis deposits .Case (1) : 16 year old girl come to u complaining of absent menses till now She also complains of cyclic lower abdominal pain, recurring every month & urine .retention .Examination revealed a well-developed breast .PR revealed a cystic swelling anterior to the rectum ?what do u call this-1 ?what is the cause of this cystic swelling-2 ?what is the Dx-3 ?mention other findings u expect to c-4 ?what is the tt-5 ?mention other DDx-6 :ANSWERS .(primary amenorrhea(cryptomenorrhea-1 .hematocolpos-2 .imperforated hymen-3

.pelvic abdominal mass*-4 .bulging at the introitus* .(accumulation of the blood in the vagina (hematocolpos* .(accumulation of the blood in uterus (hematometrium* under GA, a cruciate incision is done in the hymen, the edges r excised &-5 .sutured to avoid re-closure \.(Transverse vaginal septum (results from failure of recanalisation of the vagina-6 :(Case (2 .year old female complains of absent menses till now 16 Examination shows normal female external genitalia, well-developed .breast, scanty pubic & axillary hair US shows NO uterus,fallopian tubes,Or proximal (upper) vagina ?what do u call this-1 ?what investigations u want to do-2 ?what is the Dx-3 ?what is the tt-4 :ANSWERS .primary amenorrhea-1 chromosomal analysis /karyotyping-2 (androgen insensitivity syndrome. (46 xy-3 (creation of a new vagina (Mc Indoe or William operation *-4 .(removal of the ovaries (30 % risk of malignancy* :(Case (3 .year old female complains of absent menses till now 16 Examination revealed short stature, webbing of the neck,widely spaced .nipples,&coarctation of aorta .Karyotyping: 45XO ?what is the Dx-1 ?what do u expect the levels of FSH & estrogen-2 ?what is the tt-3 :ANSWERS .Turner syndrome-1 .FSH > 40 mIU/ml & low estrogen-2 .estrogen is given to induce breast development & prevent osteoporosis-3 .Progestron is added to prevent endometrial CA .N.B : tt is delayed to prevent premature closure of epiphysis .If the genotype is mosaic XO/XY the gonads should be removed to avoid CA :(Case (4 .year old female complain of absent menses till now 16 .Also she complains of stress & anosmia .Primary amenorrhea .(Dx: Kallman syndrome (def in GnRH-2 ?Why anosmia occur Bcz olfactory bulbs either failed to form or have hypoplasia as it is closely related .embryologically to the hypothalamus :(Case (5 year old married female, complaining from missing her period for 8 months, 30 .she has a hx of severe PPH & failure of lactation Now she has constipation,cold intolerance,bradycardia,hypotension,& loss of .weight

?What do u call this-1 ?what is ur Dx-2 ?what is the underlying cause in this case-3 ?what's the cause of bradycardia,constipation & cold intolerance-4 ?what's the cause of hypotension & weight loss-5 ?what investigations you'll do to her-6 ?what is the tt-7 :ANSWERS .secondary amenorrhea-1 .sheehan syndrome-2 .PPH-3 .hypothyroidism-4 .decrease ACTH-5 prolactin-6 FSH/LH TSH ACTH :replacement therapy-7 .cortisone & thyroxine for life.HMG for induction of ovulation if pregnancy is desired:(Case (6 year old married female, complaining from missing her period for 7 months, 35 .she also has galactorrhea,headache, & visual problems ?what is ur Dx-1 ?what visual problem could happen to her-2 ?what is the tt-3 ?what drugs u should exclude taking by the patient-4 prolactinoma-1 .bitemporal hemianopia-2 bromocriptine-3 .Surgical removal of the tumor if it's drug resistant or cause field changes :U should exclude .tranquilizers-1 .tricyclic anti depressant-2 .narcotics-3 .combined oral contraceptives-4 :(Case (7 year old married female, obese, has amenorrhea since 6 months, hirsuitism, & 35 .recurrent miscarriage

what is ur Dx? PCOS-1 ?investigations -2

.US .Free testosterone level (LH:FSH (>3:1 .Fasting insulin level :(Case (8 year old female, has amenorrhea since 8 months, has hx of vigorous uterine 36 .curettage ?What is the cause of amenorrhea in this case .Asherman's syndrome :N.B :Primary amenorrhea with absent breast development* .Kallman syndrome.pituitary infantilism.Turner syndrome.the commonest cause of secondary amenorrhea is PREGNANCY** Antepartum Hemorrhage year old female, 3o weeks of gestation, came to your office of a chief complain 29 .of vaginal bleeding ?What is Antepartum Hemorrhage (! Vaginal bleeding in the 3rd trimester of pregnancy, or after age of validity, with % Incidence = 4 ?Differential diagnosis (! .Placenta Previa Placenta Abruption* .Marginal separation= bleeding from the edge of normally implanted placenta* .Show= blood stained mucus blug at onset of labor* .local causes= cervical cancer, cervical polyp, varicosity of external genitalia* .vasa previa= bleeding from ruptured fetal vessels* :Compare between Placenta previa and Placenta abruption (! Placenta Previa Placenta Abruption Bleeding from separation of abnormally Premature separation of normal situated placenta in the lower uterine situated placenta before delivery of the .segment .fetus Etiology: abnormal vascularization Etiology: bleeding into decidua basils, leading to abnormal placement of the leading to premature separation and .placenta .bleeding Symptoms of: Painless recurrent Symptoms of: Painful bleeding, normal bleeding, malpresentation alive well the lie and presentation of the fetus, fetus fetus, soft non tender uterus, risk is on is on distress, titanic and tender uterus, .maternal side .risk on fetus and mother Predisposing factors: Multiparity, Predisposing factors: Multiparity, HTN, multiple gestation, previous placenta previous placental abruption, trauma, previa, increase maternal age, previous PROM, smoking, short cord, idiopathic, cesarean section, uterine anomalies or .cocaine .fibroids :Classification :Classification Grade 1> low lying placenta Mild , moderate, sever Grade 2> anterior marginal placenta .Concealed and revealed Grade 3> posterior marginal placenta .Grade 0> Asymptomatic Grade 4> partially covering the cervical Grade 1> vaginal bleeding, uterine os tetany and tenderness, no maternal

Grade 5> central, completely covering the os

Perinatal mortality: Hypoxia and prematurity Diagnosis: Abdominal or Vaginal US speculum examination digital exam is .contraindication Management: - assessment and .resuscitation Cesarean section irrespective of .gestational age in severe bleeding Expectant management in non severe bleeding, and give steroid, correct anemia, cross matched blood should be .ready at any time

.shock or fetal distress Grade 2> vaginal bleeding??, uterine tetany and tenderness, no maternal .shock, fetal distress Grade 3> vaginal bleeding??, uterine tetany and tenderness, maternal shock, fetal distress or death, coagulopathy Perinatal mortality: prematurity Diagnosis: digital Vaginal examination .and rupturing the membrane Management: - assessment and .resuscitation Cross matched blood should be.prepared .Vaginal deliverymanage bleeding, shock, DIC,.newborn

female pregnant at 8 week of gestational age presented with sever abdominal pain of 6 hours 32 .duration and history of small amount vaginal bleeding after half hour from starting of the pain (Diagnosis : ectopic pregnancy(acute rupture Risk factors: -salpingitis intra uterine devicetubal or abdominal surgery PID(Ddx: abortion(but remember in case of abortion bleeding then pain (More sensitive investigation: -- -HCG level (blood sample vaginal ultrasound --

:Treatment (surgery (salpingectomy by: laparoscopy or laparotomy?Q What causes the pain in the first stage of labor, which nerves (Uterine contractions (T10-L1 (Cervical dilatation (S2-S4 ?QWhat causes pain in the 2nd stage of labor Uterine contraction , Pressure on pelvic floor , Vulvar orifice stretching QIn case of opioid toxicity during labor your tt of choice is naloxone :QWhich is true about petidine a- Usually given SQ b- Doesnt cross placenta C- Doesnt inhibit uterine contraction d- T 1/2 = 12 hours QMention 3 side effects of opioids Nausea , vomiting , constipation, delayed gastric emptying

QThe most commonly used inhalational analgesic is entonox QThe best analgesia used for labor pain in the 1st and 2nd stage is lumbar epidural analgesia Q 3 contraindications for epidural analgesia Patient refusal, coagulation disorders, local or systemic sepsis,lack of trained staff QThe main immediate complications for epidural analgesia are: hypotension, total spinal block ? QMention 2 indications for spinal anesthesia Any operation below the umbilicus Ciscerean section -:QCompare between spinal (S)and epidural (E) according to .Level of injection: (S) below L2, (E) any level of V.COnset of action: (S) rapid, (E) slowHow to know correct injection: (S) CSF leakage(E) loss of resistenceHeadache and hypotension: (S) more, rapid(E) not common, slow(Easier technique : (S) easier than (EPelvic Inflammatory disease year old female, came to your office of a chief complain of suprapubic 20 * .bilateral abdominal pain, fever and foully smelling vaginal discharge *Appendicitis *Abortion ?What is your differential diagnosis (1 *Endometriosis *Ectopic Pregnancy * UTI PID*

?What investigations you do (2 .CBC, CRP, Urine analysis .High vaginal and Endocervical swab .US >> differentiate adnexal mass, ectopic pregnancy, tubo-overian-abcess (Laparoscopy (definitive diagnostic method .BhCG pregnancy test (No hysteroscopy >> (no duct visualize, spread inf., bleeding, rupture ectopic ?What is PID? Route of infection? Etiology M.O (3 It is upper genital tract infection that involves (endometritis, salpingitis, tubooverian-abcess, and peritonitis) .. With ascending M.O from vagina or direct spread, or blood born M.O < Sexually transmitted: Nisseria gonorrhea, Clamedia .Trachomatis, E-coli, and Bacteroids ?What are the risk factors for PID (4 .Young age group .Sexual active female .Previous PID .(Menstruation (alkaline blood .Cupper releasing IUCD Combined Contraceptive pills, condoms, Progesterone releasing IUCD are .protective ?What symptoms and signs PID patient may have (5 .Suprapubic bilateral pain and tenderness increase by walking .Dysparunea. Abnormal foully vaginal discharge - Adnexal mass. Cervical motion tenderness on .examination

Fever

?What is your treatment (6 Mild cases: outpatient treatment > Doxycyclin 100gm/twice daily/14 days .Metrondizole 400 mg/twice daily/5 days > Ciprofloxacin in Gonocoacal inf < :Hospitalization in Uncertain diagnosis, Tubo-overian-abcess, pregnancy, no response to oral) antibiotics for 24-48 h) IV antibiotics 2nd and 3rd generation cephalosporin and .Metrondizole :Surgery laparoscopy or laparotomy (Confirm diagnosis, drain Tubo-overian-abcess or pelvic abscess) ?What complications patient may have (7 .Tubo-overian-abcess .Tubal damage > infertility > Ectopic pregnancy .Recurrence .Chronic IPD .Fitz-Hugh-Curtis-Syndrome: perihepatic inflammation A 27 years old pregnant female, presents to the ER on 15.8.2009 at 2 -1 AM, with a chief complain of sever lower abdominal pain since 3 hours PTA, preceded by vaginal bleeding which was mixed with abnormal tissue and without .other symptoms Her LMP was on 15.5.2009, and she married since 3 years ago with P1 before 2 .year She has used oral contraceptive drugs since 1:5 years ago but not regularly. By abdominal examination, she has softer abdomen and spots of bleeding in her .lower outer genital tract .She referred to obstetric ward for further investigation and treatment for this patient, what is the next step that u must do in order to-1 ?confirm your diagnosis The results of your investigation was-(the cervix was dilated and the -2 uterus size was small for date)--what is the most deferential diagnosis? .Give 2 ?How you can treat this patient-3 :Answer first thing I do vaginal examination, in order to determine if the cervix is dilated-1 .or not, and assess the uterine size to determine if it's adequate with GA or not Then I ask for ULS to see if the fetus is alive or not, and to look for any present of .RPOC a. Inevitable abortion -2 .b. Incomplete abortion .First of all I insert two large canulas -3 b- I take blood sample for CBC, blood grouping, cross matching and for .coagulation profile c- Resuscitate the patient by IV fluid and blood transfusion d- Administer uterotonic drugs (oxytocine or ergometrine) to induce uterine .contraction .e- Evacuation and curettage .(f- Post abortion management. (Support and counseling A 20 years old pregnant female, married sine 1 year ago, this is the first -2 ,gravida .She is in 20 weeks of GA; the ANC was regular, once every 4 weeks In her last visit to ANC, she tells the doctor that the vomiting and the frequency of urination that she was complaining of before, now she is

free from it. Also she mentions that in the last 2 days she didnt feel her .baby movement, but ignored any pain or vaginal bleeding .By ULS the doctor notices that there is no fetal heart activity ?What is the most deferential diagnosis in this case -1 What is the most important thing in the history of this patient that -2 ?give u a hint about the diagnosis ?How you can treat this patient -3 :Answer .Missed abortion -1 .Regression of early symptoms of pregnancy -2 .First of all wee resuscitate the patient with IV fluid -3 .do CBC, cross matching and blood grouping .Three options for treatment .(a- conservative treatment,(which has bad result .(b- Surgical evacuation, by doing D & C (mostly in the first trimester of abortion (c- Medical termination by using uterotonic drugs( misoprostol (PGE1) OR oxytocin followed by surgical evacuation in case of RPOC A 35 years old pregnant female, married sine 10 years ago, she has G5P1+ (3 -3 .(MISCARRIAGE She is in 14 weeks of GA; the ANC was regular, her GA was compatible with the .ULS result at the booking visit She was admitted to ER complaining of sever vaginal bleeding (10socked pads .per day) since 1 day PTA followed with high fever and chills since 2 hours PTA .By general examination her TM was 38.5, BP 140/90, HR 110 By abdominal examination her uterus was small for date and her pelvic was .tender By vaginal exam her cervix was slightly dilated, and there was spotting of blood at .its inner surface By past obstetric HX the patient has 3 miscarriages at 12 weeks which was .spontaneous ?According to this short HX, what is your DD -1 What the next steps that u must do to this patient in order to confirm -2 ?your diagnosis What is the management for this patient, and mention the name of -3 ?one drug ?What are the most organisms that lead to this type of abortion -4 ?give five common causes that lead to abortion in general -5 :Answer The DD for this case is septic abortion and in the same time it's a recurrent -1 .abortion .I ask for investigation and ULS -2 .Hb, blood grouping and cross matching for resuscitation -1 .Cervical swab (not vaginal) for culture and sensitivity -2 .Blood culture and coagulation profile-3 .(We ask about ULS to determine our diagnosis (if the fetus exist or not -4 We start by resuscitate the patient by IV fluid and in case of needing blood we -3 give b- We give antibiotics IV (CEPHALOSPORIN + METRONIDAZOLE) 3 times bu .injection then orally .-c- surgical evacuation of the uterus- 12 hour after antibiotics therapy .(d- post abortion management ( support and counseling ;the most type of organisms that lead to septic abortion are -4

.Gram (-): E.coli, streptococcus & staphylococcus -1 .Anaerobics: Bacteroids -2 .(Clostridium tetani (very rare -3 a) fetal chromosomal abnormalities. b) Uterine disorders. c) Endocrine -5 disorder. d) Infection (torch infection). e) Autoimmunity disorders .((thrombophilia ,A 24 years old pregnant female, married sine 3 years ago, has G2P1-4 Her LMP was on 13.12.2009, was regular, she ignored using any OCP and she .(+)wasn't in lactation. Her BG IS O(-), and her husband O She referred from outpatient clink on 1.3.2010 complaining of mild vaginal .bleeding followed by slightly lower abdominal discomfort .By abdominal exam the uterus size was correct with date .By vaginal exam the cervix was closed .And there are no other associated symptoms According to the above information, what is the most DD that reflect -1 ?the case ?By ULS (according to your DD) what can u see in her uterus -2 ?According to her LMP what is the EDD and the GA now -3 ?What is the management for this patient -4 :Answer The HX and general exam go with THREATENED ABORTION, because she -1 complain of mild vaginal bleeding with slightly abdominal pain ,her cervix was .closed and her uterus size correct with date .By ULS I can see normal heart beat and alive baby -2 .EDD is 20.9.2010, and GA now is 11 weeks -3 ;For this patient I do the following to safe her pregnancy -4 .a- admitted her to obstetric ward for one day .b- Do fetal and maternal assessment for 24 hours .c- Give her anti D .(d- Inject progesterone and hCG to support her pregnancy (one dose weekly e- Advice her to decrease physical activity and avoid intercourse during the first .and second trimester f- We consider this case as high risk pregnancy and advice her to visit ANC .weekly weeks pregnant, presented with fatigue, weakness ,shortness of 32 breath ,lightheadedness , palpitations, no history of vaginal bleeding or bleeding from any other site. Her Hb at booking visit was 11.0g/dl, but now it is found to be .9.5 g/dl. Indices of RBCs was otherwise normal ?What is the diagnosis ?Why Hb fall down to this value ?When the drop is most significant ?What are the expected changes on the indices Answer (1):- Physiological anemia. The most common type of anemia in pregnancy Answer (2):- in pregnancy, there is increase in both plasma volume and red cell mass, but the increase in plasma exceeds that of the red cell mass so, the red .blood cells dilute

Answer (3):- at 32 weeks gestation because plasma volume increase until the 32nd week of gestation, then it stops while red cell mass increases all through the .pregnancy .Answer (4):- Nothing. They are normal weeks pregnant, presented with vaginal bleeding for 2 days, large in amount, 14 also complained of chest pain, dizziness, and palpitations. On examination she have tachycardia, cold skin and heart murmur. Her HB is 9 g/dl. Low MCV and low ..MCHC ?What is the diagnosis ? What are other possible presentations could be ?What are the treatment options What is the treatment if the gestational age was advanced, 32 for example, what ?are the possible side effects ?what investigations you do to diagnose the case Answer (1):- Iron deficiency anemia. The commonest pathological and 2nd .commonest of anemia in pregnancy Answer (2):- *get pregnant immediately after the previous pregnancy and now is .lactating Menorrhagia before getting pregnant, * poor intake as in heavy tea drinkers * malabsorption disease * chronic illnesses such as liver disease or renal * .disease .chronic blood loss *hemolysis as in sickle cell disease * Answer (3):- iron supplementation and a single 60mg tablet daily should suffice. If the woman is unable to tolerate this because of common side effects, including nausea and constipation, different iron preparations are available, including liquid .formula Answer (4) :- blood transfusion, there is a small risk of antibody production and .transfusion reaction Answer (5) :- *decrease in MCV and MCHC *decrease serum iron increase total iron binding capacity *decrease ferritin source* weeks pregnant, presented with Fatigue, weakness ,shortness of breath, 14 lightheadedness, palpitations. Her HB is 9 g/dl. High MCV but normal MCHC. .Every thing otherwise is normal. She is currently taking anticonvulsant therapy ?what is the diagnosis.1 ?why.2 ?Mention other possibilities that can cause folic acid deficiency anemia .3 ?what is the treatment and what is the benefit.4 ?what is the commonest cause of raised MCV worldwide .5 mention another cause of macrocytic anemia and what is the incidence in .6 ?pregnancy, and what is the treatment ?what investigations you do to diagnose the case.7 Answer (1):- Folic acid deficiency anemia Answer (2):- because of high MCV and because she is taking anticonvulsant .therapy which interferes with folate consumption Answer (3) :- methotrexate (anti folate), hemolytic anemia Answer (4) :- all women considering pregnancy should be encouraged to use folate supplementation (0.4 mg daily) as it has been shown to reduce the .incidence of neural tube defects Additional supplements (5g daily) are required in women receiving anticonvulsant .medication .Answer(5) :- alcohol consumption

Answer (6) :- Vitamin B12 deficiency (pernicious anemia), unlikely to present in pregnancy, as sever cases are associated with infertility. Diagnosed cases should .continue vitamin B12 injections throughout gestation Answer (7) :- * increase MCV *decrease in serum folic acid decrease red cell folate sometimes better because serum folate could be falsely* .high A 53 years old G0 complain of vaginal bleeding occurs every 6 months although she had gone into menopause at the age of 51 , since menopause she has been taking an estrogen supplement to relieve the hot flashes There is no pain and she deny any vaginal dryness She do pap smear 3 years ago and was normal BMI 35 On exam :well looking vaginal mucosa without sign of atrophy and cervix appears normal how you proceed .1 Patient has many risk factor for endometrial CA so you have to do transVaginal US to check for endometrium (endometrial biopsy(if biopsy cant be done bcos of stenosis or others do D&C pap smear endocrine evaluation TSH,FSH,prolactin what is the risk factor for endometrial CA that patient have .2 Nulliparity , obesity , unopposed estrogen use what is other risk factor .3 Obesity (Chronic anovulation (eg PCOS Nulliparity Late menopause and early menarche Exogenous estrogen without progesterone HTN DM (Tamoxifen use(selective serotonin reuptake inhibitor used in breast CA CA of breast ,ovary ,colon Family hx of endometrial CA SO ITS RELATED TO ESTROGEN ANYTHING INCREASE ESTROGEN WILL INCREASE THE RISK What is the most common affected age group.4 Its mainly affect postmenopause Average age 61 years PRESENTATION.5 (Abnormal vaginal bleeding(menorrhagia ,metrorrhagia,even oligorrhagia Postmenopausal bleding Non bloody vaginal discharge (Pelvic pain ,pelvic mass ,wt loss (only in advanced stage PROGNOSIS.6 IS GOOD bcos it cause bleeding (symptomatic)so early diagnosis (And bcos its mostly of type 1 (80% management.7 (Surgery(total abdominal hysterectomy and bilateral salpingo-oopherectomy If in advanced stage surgery combined with L.N dissection and radiotherapy In recurrent CA: chemotherapy and high dose progestine can be given

: types .8 Type1 : 80% Estrogrn dependent Well differentiated Good prognosis Start as atypical hyperplasia

Type2 : 20% Estrogen independent Older thin women Less differentiated : Also it could be (endometrioid adenocarcinoma(80% -1 others less common but more serious as mucinous CA , clear cell CA, papillary-2 serous CA,squamous CA SO MOSTLY FOUND IN EARLY STAGEAND OVERALL PROGNOSIS IS GOOD DD .9 Fibroid ,endometrial polyp, adenomyosis , endometrial hyperplasia, ovarian cyst,atrophic vaginitis, cervical CA First picture: US pic for a 40 years old patient known to have SLE ,she is 14 :weeks pregnant presented with mild vaginal bleeding ? What is your diagnosis Give 2 signs in the physical exam Give 2 risk factors for this patient ( Second picture: CTG ( there were many early decelerations ?Is she in labor ?What is the baseline ?What is the most prominent abnormality in the CTG ?What is the cause of this abnormality ?When it happens Third : pic of placenta for a lady para 6 presented with vaginal bleeding of 2 hours duration and abdominal pain and the fetus was dead ?Give 2 risks factors-1 ?Give two causes -2

Fourth : a pic of uterine fibroid , a 30 year old single lady presented with acute abdomen ? What is this-1 What is the gynecological cause foe this-2 ? patient ?Give 2 symptoms related to menstruation-3 What is the most serious change that might-4 ?happen

Fifth : a pic for endometriosis cant remember the case exactly but I guess she was married but infertile ? Give two causes for infertility in this patient-1 ?Give two physiological conditions that stop it-2

Sixth : 36 year old ,para 1 was delivered at 34 weeks because the mother complained of eclampsia . the patient is 32 weeks now presented with BP of (140/90 and 500 proteinuria : (no picture for this question ? What is your diagnosis ?Give two symptoms of the severe case ?Give two risk factors for this patient ? Give two signs in the physical exam Seventh : pregnant lady known to have chronic diabetes presented at 32 weeks of (gestation to the ANC ( no picture for this question ? Give 3 investigation you do for her other than glucose ? Give 2 signs for bad control Eighth : picture of uterine prolapse for 53 year old patient P8 ?What is this-1 What is the main complaint-2 ?What is the main cause for this case-3 Mention 2 ligaments support the uterus-4