Textbook for MrCoG-1. Basic Sciences in Obstetrics and Gynaecology by Richa Saxena

438 Textbook for MRCOG-1

is likely to cause urethral obstruction resulting in urinary treatment of infection), steroids, etc. Vitamin E can help
retention. Since the retained blood is usually sterile, counter oxidative stress, which is associated with sperm
development of infection usually does not occur. DNA damage. A hormone-antioxidant combination may
improve sperm count and motility. Phosphodiesterase
Infertility Type 5 inhibitors, e.g. sildenafil, can be used in the
patients with ejaculatory sexual dysfunction. Drug
Infertility is defined as the inability to conceive even after therapy has limited benefit, apart from bromocriptine,
trying with unprotected intercourse for a period of 1 year for used for treating raised prolactin levels. Nonetheless,
couples in which the woman is under 35 years and 6 months gonadotropins, clomiphene, androgens, etc. have all
of trying for couples in which the woman is over 35 years been used.
of age. In nearly 30% of cases, the cause can be attributed TT Caverject: Caverject (intracavernosal alprostadil) is an
to the male partner. effective therapy for impotence and is generally used
following failure of oral phosphodiesterase inhibitors.
Male Infertility TT Squeeze technique: The squeeze technique where the
penile shaft is firmly squeezed during intercourse
Introduction can help in the treatment of premature ejaculation.
Fluoxetine [a selective serotonin reuptake inhibitor
Nearly 30% cases of infertility are due to the male factor. (SSRI)] amongst others such as clomipramine can be a
Table 14.7 lists the causes of male infertility. useful treatment for premature ejaculation.
TT Surgical therapy: Surgery may be employed for treatment
Treatment of conditions, such as duct obstruction, varicocoeles,
undescended testes, etc. Modern microsurgical
TT Lifestyle modification: The patient must be advised to techniques can also prove to be useful for procedures
discontinue smoking, stop consumption of excessive such as vasectomy reversal and tubal re-canalisation.
alcohol and/or intake of drugs, such as bodybuilding TT Assisted reproductive techniques: This includes
steroids and illicit drugs, wear loose fitting underwear procedures, such as sperm washing/capacitation,
and cool clothes and avoid high temperature baths like intrauterine insemination, gamete intra-fallopian
saunas, etc. Coital frequency should be increased in transfer, in vitro fertilisation (IVF) and micromanipula­
order to improve the chances of conception. tion [intra-cytoplasmic sperm injection (ICSI)]. ICSI
involves injection of sperm directly into an ovum,
TT Medical therapy: Some of these include clomiphene followed by IVF. It is a successful technique even with
citrate, tamoxifen, gonadotropins, antibiotics (for very low counts. This process cannot work if there are
no sperms. After successful vasectomy, one would get
Table 14.7 Causes of male infertility azoospermia, but sperm could still be retrieved from
• Idiopathic: No obvious cause of infertility can be found. the testicle and used for ICSI. Even precursors of sperm
• Varicocoele have been used successfully. ICSI has been found to
• Infections (may be suspected clinically on rectal examination with result in successful pregnancies in men with Klinefelter’s
syndrome.
tenderness of the prostate or seminal vesicles) TT Incurable cases: In cases where none of the treatment
–– STDs: Chlamydia, gonorrhoea and syphilis modalities seem to work, the only options may be donor
–– Acute systemic infections: Smallpox, mumps, other viral infections, etc. insemination or adoption.
–– Chronic systemic infections: TB, leprosy, filariasis, prostatitis, renal,
Diagnosis
hepatic diseases, diabetic neuropathy, etc.
General Physical Examination
• Undescended testes (cryptorchidism)
• Genetic and endocrine disorders: Klinefelter’s syndrome, androgen These include examination of the patient for development
of male secondary sex characteristics, gynaecomastia or
insensitivity syndrome, disorders of pituitary and adrenal glands, hirsutism. The complete physical examination also includes
adrenal hyperplasia, etc. a digital rectal examination.

• Substance abuse (excessive intake of alcohol and/or drugs) Examination of Male External Genitalia
• Testicular factors: Torsion, undescended testes, damage to the testis due
TT Scrotum: This must be evaluated for the presence
to exercise or heat, tumours (seminoma), hydrocele, etc. of congenital abnormalities, such as hypospadias,
cryptorchidism, absence of vas deferens (unilateral or
• Long-term use of drugs: Anti-hypertensive drugs such as reserpine, bilateral), etc.

methyldopa, guanethidine, cimetidine, spironolactone, propranolol,
corticosteroids, anabolic steroids, antipsychotics and certain anti-
cancer drugs

• Environmental factors: Exposure to chemicals, such as lead, nickel,

mercury, anaesthetic agents, pesticides, tobacco smoking, excessive
alcohol intake, etc.

• Previous surgery: Inguinal, scrotal, retroperitoneal, bladder neck,

vasectomy, hernia repair, etc.

• Sexual dysfunctions: ejaculatory disturbances, impotence, etc.

mebooksfree.com

•Chapter 14    Gynaecology 439

TT Testis: This involves assessment of testicular size, Polycystic Ovarian Syndrome
presence of tenderness on palpation of testicles and
presence of any associated mass, such as an inguinal The condition, polycystic ovarian syndrome, also known as
hernia or varicocoele (bag of worms appearance). PCOS, is a relatively common endocrine disorder amongst
women of reproductive age group. It is characterised by the
Investigations presence of many minute cysts in the ovaries and excessive
production of androgens. According to the American Society
The main test used for investigation of male infertility is of Reproductive Medicine (ASRM) and the European
semen analysis. Society of Human Reproduction and Embryology (ESHRE)
joint consensus meeting in November 2003, the diagnosis
Semen analysis
Table 14.9 Abnormalities associated with abnormal
The primary values that are evaluated at the time of semen sperm count in the semen
analysis include the volume of the ejaculate, sperm motility,
total sperm concentration, sperm morphology, motility Semen abnormality Definition
and viability.
Oligozoospermia Less than 20 million spermatozoa per mL
After 3 days of abstinence, a specimen of semen should
be collected in a suitably sized sterile plastic container by Azoospermia No spermatozoa in the semen
masturbation and examined generally within 2 hours. A
normal semen analysis usually shows the values described Teratozoospermia Excess of abnormally formed spermatozoa
in Table 14.8. Some commonly encountered abnormalities
associated with abnormal sperm count are described in Table 14.10 Causes of female infertility
Table 14.9.
Cervical factor infertility
Female Infertility
• Abnormalities of the mucus-sperm interaction
Various causes of female infertility are illustrated in Figure • Narrowing of the cervical canal due to cervical stenosis
14.1 and Table 14.10.
Uterine factor infertility
Impaired fertility may be associated with the following
conditions: • Total absence of the uterus and vagina (Rokitansky-Küster-Hauser
TT Previous ectopic pregnancy
TT Previous pelvic infection  syndrome)
TT Cystic fibrosis (in a male)
TT Reversal of vasectomy (in a male) • DES-induced uterine malformations
• Asherman’s syndrome, endometritis (due to tuberculosis)
Table 14.8 Normal parameters for semen analysis (World • Leiomyomas
Health Organization, 4th Edition, 1999)
Ovarian factor infertility
Parameter Normal reference value
• Polycystic ovarian syndrome
Volume 2–5 mL
Tubal factors

• PID associated with gonorrhoeal and chlamydial infection

Peritoneal factors

• Infection
• Adhesions and adnexal masses
• Endometriosis

Abbreviations: DES, diethylstilbestrol; PID, pelvic inflammatory disease

Liquefaction Complete in 30 minutes

Sperm density >20 million spermatozoa per mL or more

Total sperm 40 million spermatozoa per ejaculate or more
number

Motility 50%, forward progression; 50% or more motile (grades
a* and b**) or 25% or more with progressive motility
(grade a) within 60 minutes of ejaculation

Sperm >50% normal (WHO, 1987, 2nd Edition)
morphology >30% normal (WHO, 1992, 3rd Edition)
>14% normal (WHO, 1999, 4th Edition)

White blood cells <1 million/mL

Immunobead <20% spermatozoa with adherent particles
test

SpermMar test <10% spermatozoa with adherent particles

* Grade a: Rapid progressive motility (sperm moving swiftly, usually in a straight line) Fig. 14.1: Female causes of infertility
** Grade b: Slow or sluggish progressive motility (sperms may be less linear in their
progression)

mebooksfree.com

440 Textbook for MRCOG-1

of PCOS should be made, when two of the following three Medical Treatment
criteria are met:
1. Infrequent or absent ovulation TT Lifestyle changes: Exercise to maintain a normal body
2. Clinical or biochemical features of hyperandrogenism, mass index

such as excessive hair growth, acne, raised LH and raised TT Ovulation induction drugs: The treatment of choice
androgen levels in patients with PCOS is ovulation induction with
3. Morphologically, there is bilateral ovarian enlargement, clomiphene citrate, which is associated with nearly 70%
thickened ovarian capsule, multiple follicular cysts rate of ovulation after the first treatment cycle.
(usually ranging between 2 mm to 8 mm in diameter)
and an increased amount of stroma. TT Metformin: Metformin has now become the first line of
management in cases of clomiphene citrate-resistant
Clinical Features women with PCOS.

Polycystic ovarian syndrome is characterised by the Surgical Management
following features:
TT Hirsutism Laparoscopic ovarian drilling (LOD) is sometimes used
TT Oligomenorrhoea (usually with normal oestrogen for women with PCOS, who do not respond to first-line
treatment options, such as weight loss and use of medicines.
concentrations) In LOD, different techniques, such as electro-cauterisation,
TT Infrequent or absent ovulation laser, electro-coagulation, biopsy, etc. are used for destroying
TT Obesity ovarian follicles.
TT The risk of endometrial hyperplasia and carcinoma may
Ovarian Hyperstimulation Syndrome
be increased.
TT Miscarriage and infertility. Ovarian hyperstimulation syndrome is an iatrogenic
condition that occurs in patients undergoing ovulation
Diagnosis induction with clomiphene or human menopausal
gonadotropin (hMG) or controlled ovarian hyperstimulation
Diagnosis of PCOS is established by ultrasound examination for assisted reproductive technologies. The pathophysiology
and serum hormonal assay. of the disease is not well understood but is associated with
TT Blood hormone levels: Various endocrinological massive extravascular accumulation of fluid. This causes
severe depletion of the intravascular volume resulting
abnormalities encountered in cases of PCOS are in dehydration, haemoconcentration, and electrolyte
enumerated in Table 14.11. FSH levels are low or normal imbalance (i.e. hyponatraemia, hyperkalaemia, etc.).
and LH levels are often raised, resulting in a raised LH/ Ovaries become dramatically enlarged by the presence of
FSH ratio. The levels of androgens and testosterone may cystic follicles, ascites of varying degrees follows, and in the
also be raised. most severe cases, pleural effusion, hypovolaemia with an
TT Ultrasound examination: Features of polycystic ovarian increased tendency to thrombosis and emboli, and even
morphology on ultrasound scan are as follows (Fig. 14.2):
• Greater than 12 follicles measuring between 2 mm

and 9 mm in diameter, located peripherally, resulting
in a pearl necklace appearance
• Increased echogenicity of ovarian stroma and/or
ovarian volume greater than 10 mL.

Progesterone levels in excess of 30 nmol/litre indicate
ovulation. If there is evidence of ovulation, there is no
point in prescribing clomiphene, unless ovulation and
menstruation are very infrequent.

Table 14.11 Endocrinological abnormalities in cases of Fig. 14.2: Ultrasound features of polycystic ovarian morphology
polycystic ovarian syndrome

• Increased oestrone levels
• low SHBG
• Increased free testosterone levels
• Increased LH and decreased FSH levels. An LH:FSH ratio greater than

2.5 or 3 is used to diagnose polycystic ovary syndrome

• Androgen levels: Increased production from ovaries and adrenals
• Hyperinsulinaemia
• Hyperprolactinaemia (low to moderate levels <2,500 mu/L)

Abbreviations: SHBG, sex hormone-binding globulin; LH, luteinising hormone; FSH,
follicle-stimulating hormone

mebooksfree.com

•Chapter 14    Gynaecology 441

renal failure and death can occur. Ovarian hyperstimulation Table 14.12 Causes of dyspareunia
syndrome can be classified as mild, moderate or severe.
Although this condition is idiosyncratic, it is more common • Superficial vulvovaginitis (especially infection by Trichomonas or
in presence of the following conditions:
TT When there are many follicles (say more than 15) Candida)
TT When the plasma oestrogen level has exceeded 2,500
• Vaginal cysts
pg/mL on the day of hCG administration • Infection of Bartholin’s gland
TT Where pregnancy has occurred. • Post-menopausal shrinkage
• Thick hymen (rarely)
It is thus sensible for the hMG regime to be used only in • Deep retroverted uterus with prolapsed ovaries (the “ovarian
cases where there are appropriate facilities for monitoring
and for taking care of the complications related to ovarian entrapment” syndrome)
hyperstimulation syndrome.
• Chronic pelvic infection
• Endometriosis/adenomyosis
• Pelvic tumours including ectopic pregnancy

Asherman’s Syndrome ultrasonographically, but occlusion of the tube and fimbrial
end clubbing cannot be diagnosed by this means.
Asherman’s syndrome is characterised by development of
intrauterine adhesions, occurring in women who have had Tubal occlusion is surprisingly uncommon even in the
endometrial trauma associated with vigorous curettage, presence of moderately severe pelvic endometriosis. On the
especially following abortion or delivery. The incidence other hand, appendicitis can result in considerable tubal
becomes even more pronounced if a pre-existing or post- damage, both from the local pelvic inflammatory reaction
operational infection occurs. These adhesions may cause and the associated surgery.
amenorrhoea, repeated miscarriages, infertility and ectopic
pregnancy. Diagnosis of Asherman’s syndrome can be Test for Tubal Patency 
reached by doing tests like hysteroscopy and transvaginal
ultrasound examination. Treatment involves hysteroscopic The injection of a radio-opaque aqueous solution
surgery to cut and remove the adhesions or scar tissue. through the cervix under radiographic control is a useful
After the removal of scar tissue, the uterine cavity must be investigation for assessment of tubal patency and uterine
kept open. Over the years, many surgical adjuncts have shape. Laparoscopic examination of the uterus and
been tested in an attempt to prevent the reformation of fallopian tubes has presently become the method of choice
adhesions. Some of these surgical adjuncts include IUDs for investigating tubal patency. The procedure is generally
(inert), intrauterine Foley’s catheters, anti-adhesion combined with injection of a dilute solution of methylene
barriers, amnion grafts, hormonal therapy, antibiotic blue or indigo carmine dye through a tightly fitting cannula
therapy, etc. Post-operative evaluation for reformation placed in the cervical canal. If the tubes are patent, they fill
of adhesions in form of hysterosalpingography (HSG) or with dye that then can be seen spilling from the distal ends.
hysteroscopy should be considered mandatory. Following
the treatment of Asherman’s syndrome, the rate of fertility Dyspareunia
restoration is high, but not 100%.
Dyspareunia can be defined as difficult or painful sexual
Fallopian Tube Occlusion intercourse. As a result, dyspareunia is often related
with sexual dysfunction and infertility. Some causes of
Pelvic inflammatory disease (PID) is the most important dyspareunia are summarised in Table 14.12.
cause of fallopian tube obstruction. PID is typically
associated with gonorrhoeal and chlamydial infection. Genital Tract Fistulae
Chlamydial infection, which may be asymptomatic, can
cause considerable tubal damage. It is more common Urogenital fistulas (UGFs) can be defined as abnormal
than gonorrhoea as the infection responsible for causing communication tracts (lined with epithelium) between the
fallopian tube occlusion. However, the mechanism by genital tract and the urinary tract or the alimentary tract or
which infection ascends through the cervical canal and both. UGFs can be classified as follows (Fig. 14.3):
reaches the fallopian tubes is still unknown. TT Urethrovaginal
TT Vesical fistula [vesicovaginal fistula (VVF) or vesico-
Formation of peritoneal adhesions secondary to PID
can compromise the motility of the fallopian tubes. cervical]
Furthermore, obstruction of the distal end of the fallopian TT Ureterovaginal
tubes results in accumulation of the normally secreted tubal TT Rectovaginal.
fluid, creating distention of the tube. This subsequently
causes damage to the epithelial cilia and may result in Vesicovaginal fistula is an abnormal fistulous tract
development of hydrosalpinx. A hydrosalpinx may be seen extending between the bladder and the vagina that allows
the continuous involuntary discharge of urine into the
vaginal vault.

mebooksfree.com

442 Textbook for MRCOG-1

Fistula Repair

Fresh injuries may be repaired immediately. However, in
cases where the fistula is noticed some days after the injury,
the timing of the surgery is important. Several weeks may be
required to allow any urinary tract infection (UTI) or local
inflammation to be eliminated. Most vesicovaginal fistulae
can be closed by surgery via the vaginal route. The principle
of the surgery is to separate the bladder mucosa from the
vaginal skin. The mucosa is then carefully closed in one or
two layers, without tension, using polyglycolic acid sutures.

Pelvic Prolapse

Fig. 14.3: Types of genitourinary fistulas Uterine prolapse can be described as a descent or herniation
Abbreviations: A, uterovesical fistula; B, cervicovesical fistula; C, midvaginal VVF; of the uterus into or beyond the vagina. Weakness of the
D, VVF involving the bladder neck; E, urethrovaginal fistula anterior compartment results in cystocoele and urethrocoele,
whereas that of the middle compartment in the descent
of uterine vault or uterine prolapse and enterocoele. The
weakness of the posterior compartment results in rectocoele.

Causes Symptoms

TT Obstetric injury: Most rectovaginal fistulae are the result Symptoms produced as a result of pelvic prolapse include
of unrepaired third degree lacerations of the perineum the following:
and posterior vaginal wall, or repairs that have broken TT Local discomfort: There may be vaginal discomfort,
down, so that an opening is left from the rectum into
the vagina. Obstructed labour is an important cause dragging and the sensation of “something coming
for development of VVF in developing countries. In down” the vagina, sensation of lump in the vagina, a
cases of obstructed labour, disproportion between the feeling of pelvic insecurity and low backache. Sensation
size of the pelvic opening and the foetal head results of “something coming down the vagina” results due
in prolonged labour, causing compression of the to the bulging of prolapsed part into the vagina and
bladder base between the foetal head and the pubic eventually protrusion through the vaginal opening.
bone, leading to avascular necrosis of the bladder. TT Backache: Backache due to prolapse is worse on
This commonly results in development of a VVF. The standing and is relieved when the patient lies down. In
diagnosis of VVF is generally obvious from the history the majority of women with prolapse, backache may be
of urinary incontinence and a constant leakage of urine due to some other cause.
from the vagina. The fistula can be visualised through TT Urinary symptoms: Urinary symptoms, such as difficulty
the direct inspection of the anterior vaginal wall, using in passing urine and recurrent UTIs, may be associated
a Sim’s speculum. with cystocoele and cystourethrocoele.
TT Bowel symptoms: A patient with a rectocoele may have
TT Surgery: The bladder may be opened during the course difficulty passing stool; manual manipulation may be
of obstetric and gynaecological operations, especially required for complete defecation.
during caesarean section and abdominal or vaginal TT Ulceration and bleeding: Blood stained vaginal discharge
hysterectomy. may be present in the cases of procidentia and decubitus
ulcerations.
TT Complication of radiotherapy: They are most likely TT Dyspareunia.
to occur during the treatment of advanced growths,
especially if the radiation dose is excessive. The sensation of prolapse is increased on coughing,
standing or exertion and is relieved by lying down. Some­
TT Neoplastic growths: Carcinoma of the cervix may times, the apparent uterine prolapse may be due to a
invade the bladder and eventually cause a fistula. significant elongation of the cervix.
Advanced carcinoma of rectum or vagina may give rise
to colovaginal fistulae, which may result from rupture Supports of the Uterus
of a pericolic abscess into the posterior vaginal fornix;
the abscess is usually secondary to acute diverticulitis. The uterus and vagina are held in the pelvis by the
cardinal and uterosacral ligaments and by the pelvic floor

mebooksfree.com

•Chapter 14    Gynaecology 443

Fig. 14.4: Ligaments of the pelvic floor Fig. 14.5: Muscles of the pelvic floor

Table 14.13 Different levels of support for vaginal tissue Each levator ani muscle consists of three main divisions:
(1) pubococcygeus, (2) iliococcygeus and (3) ischiococ-
Different levels of support of vagina Support elements cygeus. The levator ani muscle creates a hammock-like
structure, by extending from the left tendinous arch to the
Level I (for proximal one-third of Cardinal and the uterosacral right tendinous arch. The muscle has openings, through
vagina) ligaments which the vagina, rectum and urethra traverse. Contraction
of the levator muscles tends to pull the rectum and vagina
Level II (for middle one-third of vagina) Paravaginal fascia inwards towards the pubic symphysis. This causes narrow-
ing and kinking of both vagina and rectum. The origin of
Level III (for distal one-third of vagina Levator ani and perineal muscles levator ani muscles is fixed on the anterior end, because
and the introitus) the muscle arises anteriorly either from the bone or from
the fascia, which is attached to the bone. As a result, the an-
musculature, mainly the levator ani muscles. Different levels terior attachment of the muscle largely remains immobile.
of support for vaginal tissue are described in Table 14.13. On the other hand, the levator ani muscles posteriorly get
inserted into the anococcygeal raphe or into the coccyx,
Important ligaments supporting the uterus are described both of which are movable. Thus, the contraction of levator
in Figure 14.4. The most important ligaments supporting ani muscles tends to pull the posterior attachment towards
the uterus are the transverse cervical or cardinal ligaments the pubic symphysis. The main nerve supply of the levator
that attach the cervix and vaginal vault to the sidewalls ani muscles comes from the third and fourth sacral nerves.
of the pelvis. Cardinal ligaments fan out laterally from The uterus does not rest on the levator muscles but is held
the vaginal vault and attach to the anterior border of the in place at a higher level by the ligaments and connective
greater sciatic foramen and ischial spines and the parietal tissues of the pelvic fascia.
fascia of the obturator internus and piriformis muscles. The
cardinal ligaments contain the uterine arteries and provide The periurethral levator ani is under voluntary control
attachment of uterus to the pelvic side walls. and actively contracts during abdominal straining. As
soon as the bladder fills to its functional capacity, a signal
Other important ligaments, which help in supporting the from within the detrusor muscle receptors is sent to higher
uterus are the uterosacral ligaments, which pass upwards cortical centres in the brain to initiate the emptying phase.
and backwards from the cervix and vaginal vault to blend Normal voiding occurs when urethral muscles relax
with the fascia covering the front of the second and third before the detrusor muscle contracts. The voiding process
sacral segments. begins with the inhibition of both sympathetic relaxation
of the detrusor muscle and of sympathetic contraction
The round ligaments help to keep the uterus anteverted, of the proximal urethral sphincter. This is followed
but have little or no supporting function. Similarly, the by the inhibition of the pudendal and sacral efferent
broad ligament is not a ligament but a peritoneal fold, and nerves, resulting in the relaxation of the external urethral
it does not support the uterus. sphincter and levator ani muscles. Finally, parasympathetic
stimulation via the interaction of released acetylcholine
Muscles of the Pelvic Floor: Levator Ani and cholinergic receptors causes the detrusor muscle to
contract, thereby emptying bladder contents.
The levator ani muscle, the most important muscle of
the pelvic floor (Fig. 14.5), consists of a pair of broad, flat
muscles, the fibres of which pass medially, downwards and
inwards. Together with its fellow on the opposite side, the
two muscles constitute the pelvic diaphragm.

mebooksfree.com

444 Textbook for MRCOG-1

Rectal distention stimulates relaxation of internal anal
sphincter and the sampling reflex. If defecation is to be
delayed, voluntary contraction of the external anal sphincter
and levator ani muscles occurs. Accommodation refers to
the relaxation of the rectal ampulla after an initial increase
in pressure. At the appropriate time for defecation or when
rectal pressure is high, the levator ani muscle, puborectalis
muscle and external anal sphincter relax.

Relaxation of the pelvic floor, along with a squatting
position, straightens the anorectal angle. An increase
in abdominal pressure along with colonic and rectal
contractions allows expulsion of a faecal bolus.

Perineal Body Fig. 14.6: Attachments of perineal body

The perineal body, a pyramid-shaped fibro-muscular Table 14.14 Indications for various surgeries performed
structure lying at the centre of perineum (midpoint between for uterine prolapse
the vagina and the anus), assumes importance in providing
support to the pelvic organs as it provides attachment to the Hysterectomy
following eight muscles of the pelvic floor: superficial and
deep transverse perineal muscles; levator ani muscles of • Removal of a non-functioning organ in postmenopausal women
both the sides; bulbocavernosus anteriorly and the external • Concomitant uterine or cervical pathology (e.g. large fibroid uterus,
anal sphincter posteriorly (Fig. 14.6). It lies in front of the
anal canal, and behind the posterior border of the perineal endometrial carcinoma, etc.)
membrane.
• Patient desires removal of the uterus
Management
Anterior Colporrhaphy
The only definitive cure for prolapse is surgery. Indications
for various surgeries performed for uterine prolapse are • Presence of cystocoele, urethrocoele or a cystourethrocoele
described in Table 14.14. In patients unfit for surgery, • Repair of anterior defects
non-surgical management approaches are sometimes
used. Non-surgical management must be primarily used in Posterior Colpoperineorrhaphy
cases with mild degree of uterovaginal prolapse with no or
minimal symptoms. The current mainstays of non-surgical • Presence of a rectocoele
management of patients with uterine prolapse consist of • Repair of posterior defects
expectant management including the pelvic floor exercises
(Kegel exercises) and pessaries. Manchester Operation

Ring Pessary • Childbearing function is not required.
• Malignancy of the endometrium has been ruled out.
Pessaries are a non-surgical method for supporting the • Absence of UTI
uterine and vaginal structures.Various indications for using • Presence of a small cystocoele with only a first- or second-degree
a pessary are described in Table 14.15.
prolapse
Manchester Repair
• Absence of an enterocoele
Manchester repair is performed in those cases where • Symptoms of prolapse are largely due to cervical elongation.
removal of the uterus is not required. Indications of • Patient requires preservation of menstrual function.
Manchester operation are described as follows:
TT Childbearing function is not required. Le Fort Colpocleisis
TT Malignancy of the endometrium has been ruled out by
• No sexual activity at present or no plans for sexual activity in future
performing a dilatation and curettage. • Patient is medically fragile.
TT Absence of UTI
TT Presence of a small cystocoele with only first- or second- Table 14.15 Current indications for using a pessary
• A young woman planning a pregnancy in future
degree prolapse • During early pregnancy, immediately after delivery and during lactation
TT Absence of an enterocoele • Temporary use while clearing infection and decubitus ulcer prior to

the actual surgery

• Women unfit for surgery (patient is unfit for an anaesthetic)
• Women who do not desire surgery
• The patient refuses surgery or whilst awaiting surgery.

mebooksfree.com

•Chapter 14    Gynaecology 445

TT Symptoms of prolapse are largely due to cervical elon- share the common goal of stabilising the bladder neck
gation. Patient requires preservation of the menstrual and proximal urethra. Various procedures available
function. for urinary incontinence are retropubic bladder neck
This surgery involves amputation of the cervix after suspension procedures or colposuspension; transvaginal
urethropexies/needle suspension procedures/Pereyra’s
exposing, clamping and cutting the Mackenrodt’s (cardinal) procedure; and sub-urethral sling procedures and peri-
ligaments. These are shortened and sutured back onto the urethral injections.
anterior surface of cervical stump. As the cardinal ligaments
run from the cervix to the sidewalls of the pelvis, this process Retropubic Bladder Neck Suspension Procedures or
helps lift up the uterus. Anterior colporrhaphy is almost Colposuspension
always done as well, with posterior colporrhaphy and repair
of enterocoele if present. All these procedures are performed through lower
abdominal (transverse supra-pubic) incision and involve
Patients should not become pregnant after this surgery the attachment of peri-urethral and peri-vesical endopelvic
because it carries a significant risk of premature labour fascia to some other supporting structure in the anterior
and prolapse recurrence. Caesarean section needs to be pelvis (Table 14.17 and Fig. 14.7). Nowadays, some of
considered in these cases to reduce the risk of prolapse these procedures are performed through laparoscopic and
recurrence, though pregnancy itself increases this. robotic surgery.

Incontinence Colposuspension mainly deals with stress incontinence
and this operation is superior to vaginal surgery in the form
Urinary incontinence can be defined as an involuntary loss of anterior colporrhaphy, except in cases with significant
of urine, which is a social or hygienic problem and can be degrees of prolapse. Exactly how this restores continence is a
demonstrated with objective means. There are two main matter of debate, but the operation is effective in about 80%.
types of urinary incontinence: stress incontinence and urge One theory is that the bladder neck is lifted above the pelvic
incontinence. floor. In this location, the bladder and proximal urethra are
subject to the same external pressures, e.g. from coughing
Stress Urinary Incontinence sneezing, etc. So long as the “urethral closing pressure”,
from the intrinsic tone of its musculature and the effect of
Stress urinary incontinence (SUI) can be defined as surrounding tissues, is higher than the pressure inside the
involuntary leakage of urine during conditions causing an
increase in intra-abdominal pressure (exertion, sneezing, Table 14.16 Normal urodynamic findings in the adult
coughing or exercise) which causes the intra-vesical female
pressure to rise higher than that which the urethral closure
mechanisms can withstand (in the absence of detrusor Parameter Normal value
contractions). Urine loss is instantaneous and is often
described as a “squirt” of urine. SUI is often associated with Voiding pressure 45–70 cm H2O
other pelvic relaxation problems, for example, cystocoele, Residual urine 50 mL
rectocoele and uterine prolapse.
First sensation of bladder filling 150–200 mL
Bladder Urodynamic Studies
Maximum voiding pressure 70 cm H2O (some people consider 60–
Urodynamic studies are a method for assessing the Bladder capacity 70 cm H2O as borderline for obstruction)
pressure-flow relationship between the bladder and the 400–600 mL
urethra. This helps in defining functional status of the
lower urinary tract, which ultimately helps in correctly Intra-vesical pressure rise during Less than 10 cm H2O
diagnosing the type of urinary incontinence based on the early filling
pathophysiology. Urodynamic investigation of bladder
function involves an investigation of bladder movements Maximum urine flow rate 60 mL per second
and tensions during different levels of filling, and includes
measurement of bladder activity (cystometry) and urethral Voiding volume 250 mL
flow (uroflowmetry). The cystometry is a fundamental test of
bladder function and measures changes in bladder pressure Residual volume Less than 10 mL
with changes in bladder volume. Normal urodynamic
findings in an adult female are described in Table 14.16. Table 14.17 Various supporting structures in different
types of retropubic procedures
Management
Name of surgical procedure Supporting structure in the anterior pelvis
Surgery forms the mainstay of treatment for cases of stress
incontinence. Various procedures for stress incontinence Paravaginal procedure Arcus tendineus

Modified Marshall- Back of pubic symphysis

Marchetti-Krantz procedure

Burch colposuspension Iliopectineal ligament (Cooper’s ligament)

Turner-Warwick vaginal Fascia over obturator internus
obturator shelf procedure

mebooksfree.com

446 Textbook for MRCOG-1

and is carried down to the rectus fascia. Anterior repair
elevates the bladder neck from below and, whilst there is
a recurrence rate, is useful in the elderly or the physically
frail. Bladder neck suspension elevates the bladder from
above and below. It also elongates the urethra preventing
pressure transmission to the posterior urethra.

Fig. 14.7: Point of attachment of endopelvic fascia during bladder neck Sub-urethral Sling Procedures and Peri-urethral Injections
suspension procedures
Abbreviations: A, arcus tendinous; B, periosteum of the pubic symphysis; C, iliopectineal These methods are used for stress incontinence resulting
ligament (Cooper’s ligament); D, obturator internus fascia from intrinsic sphincteric damage or weakness. Peri-
urethral injections increase urethral resistance and
bladder, continence will exist, regardless of various types of are particularly useful in the old patients or those who
stress (e.g. coughing, etc.). If the bladder neck is below the have failed surgery previously. Both these methods
pelvic floor, coughing pressures are not transmitted through work by compressing the urethral lumen at the level of
the pelvic floor to the urethra, but continue to affect the bladder neck to compensate for a faulty urethral closure
bladder. This can increase intra-vesical pressure above the mechanism. Various materials have been used for making
“urethral closing pressure” and may result in incontinence. slings such as synthetic materials, cadaveric donor fascia,
endogenous rectus fascia, fascia lata, etc. Sling operations
It is important to counsel patients that a small percentage can be performed using a combined vaginal and abdominal
can develop detrusor instability or voiding difficulty after approach and involve mid-urethral placement of mesh.
the operation. Also, the surgery does not resolve uterine
descent or posterior wall prolapse, with the latter often Peri-urethral injections are performed under local
being more pronounced after the operation. Frequency, anaesthesia and involve administration of various types of
nocturia, and urgency usually indicate bladder dysfunction, materials around the peri-urethral tissues to facilitate their
which is treated with a combination of behavioural and coaptation under conditions of increased intra-abdominal
medical treatments. pressure. Various bulking agents have been used including
collagen; carbon-coated zirconium; ethylene vinyl alcohol;
Most patients who used to have colposuspension are polydimethylsiloxane; polytetrafluoroethylene and
now having transvaginal tape (TVT), transobturator tape glutaraldehyde cross-linked bovine collagen (contigen).
(TOT) or equivalent. In TVT, a tape is inserted underneath
the urethra with the ends being passed up each side of the Urge Incontinence
urethra behind the pubic bone. It thus forms a “U” shape
and provides support to the bladder neck and proximal Urge urinary incontinence can be defined as involuntary
urethra during increased intra-abdominal pressure. It seems leakage of urine accompanied by or immediately preceded
to be roughly as effective and durable as colposuspension, by urgency. The corresponding urodynamic term is detrusor
with similar incidences of bladder instability and urinary overactivity, which is evident in the form of involuntary
retention. It is an easy and quick procedure and the patient detrusor contractions at the time of filling cystometry. Urge
can be discharged home earlier, usually within 24 hours. incontinence is caused by uninhibited contractions of the
TVT was the first of such procedures on the market, but is detrusor muscle. Urge incontinence is worse in the night
now being challenged by alternatives like TOT, which is a because of bladder filling. Generally, urine volume is less
technically easier surgery. than 2 litres daily.

Transvaginal Urethropexies/Needle Suspension Management of Detrusor Overactivity
Procedures/Pereyra’s Procedure
Management options for urge incontinence are enumerated
This involves passage of sutures between the vagina and in Table 14.18 and are described next in details.
anterior abdominal wall using an especially designed
long needle carrier, which is inserted through the vaginal Table 14.18 Treatment of urge incontinence
incision made at the level of bladder neck. The other end Treatment option Kind of treatment
of the suture passes through a small abdominal incision First-line
which is made transversely just above the pubic bone treatment Behavioural therapies such as bladder training and
bladder drill help in establishing or re-establishing
Second-line cortical control over a hyperactive micturition reflex
treatment
Third-line Medical treatment: Anti-cholinergic drugs oxybutynin
treatment (Ditropan) or imipramine (Tofranil)

Surgical procedures (rarely used)

mebooksfree.com

•Chapter 14    Gynaecology 447

Medical Treatment Another term, which can be confused with hirsutism,
is hypertrichosis that refers to excess growth of fine hair in
Pharmacological management options for urge incontinence males and females.
include the following:
TT Anticholinergic agents: Propantheline bromide is an Investigations

anticholinergic agent which is commonly prescribed Investigation of a case of hirsutism involves taking a detailed
in the dosage of 15–30 mg every 4–6 hours. history and performing a complete clinical examination.
TT Tricyclic antidepressants: They possess both central This involves elicitation of the risk factors for significant
and peripheral anti-cholinergic effect as well as alpha- disease as enlisted in Table 14.20.
adrenergic agonist effect and central sedative effect. The
resultant clinical effect is bladder muscle relaxation and Investigations
increased urethral sphincter tone.
TT Musculotropic relaxants: The main smooth muscle Management of hirsutism is described in Figure 14.8. The
relaxant used in these cases is oxybutynin in the dosage following investigations must be ordered:
of 5 mg, 2–4 times per day. TT An ultrasound scan of the pelvis: This helps in diagnosis
TT Behaviour modification: Behavioural interventions help
in establishing or re-establishing cortical control over a of conditions such as polycystic ovary syndrome,
hyperactive micturition reflex. ovarian tumours, etc.
TT Intermittent catheterisation: This type of management
is most appropriate for patients with detrusor hyper- Table 14.19 Causes of hirsutism
reflexia and functional obstruction. • Polycystic ovary syndrome (up to 80% of all cases)
TT Vaginal prosthetic devices: A disposable vaginal device • Idiopathic hirsutism (up to 15% of all cases)
made of polyurethane has been found to be moderately • Other causes:
effective in patients with detrusor overactivity.
–– Conditions associated with raised androgen levels:
Surgical Treatment -- HAIR-AN syndrome [hyperandrogenism (HA), insulin resistance
(IR), and acanthosis nigricans (AN)]
Surgical therapy should be considered only in severe and -- Late-onset congenital adrenal hyperplasia
refractory cases of urge incontinence and include bladder -- Androgen-secreting tumours (adrenal and ovarian)
augmentation procedures, denervation procedures, urinary -- Cushing’s syndrome
diversion, sacral neuromodulation, etc. -- Hypothyroidism (increased concentration of SHBG, resulting in
high levels of free testosterone)
Hirsutism
–– Conditions associated with normal androgen levels:
Hirsutism is defined as the presence of coarse, dark, -- Acromegaly
terminal hair in a male pattern in a woman. The commonest -- Drugs (Androgenic agents: danazol, 19-nortestosterone derived
areas, where increased hair growth is apparent are upper progestogens e.g.“Primolut-N”, norethisterone, anabolic steroids,
lips, chin, side burns, upper abdomen, back, breasts, etc. and non-androgenic agents: methyldopa, metoclopramide,
inner thighs, chest and linea alba of abdomen. Hirsutism phenothiazines, phenytoin, valproate, etc.)
only affects women. Excessive hair in cases of hirsutism
is “terminal” hair, coarse and pigmented as opposed to Abbreviation: SHBG, sex hormone binding globulin
“vellus” hair, the fine hair that covers much of the body.
Hirsutism can be scored using the modified Ferriman- Table 14.20 Risk factors for significant hirsutism to be
Gallwey system. A score of greater than 8 is considered as elicited at the time of taking history and
diagnostic. Various causes of hirsutism are summarised performing clinical examination
in Table 14.19. Hirsutism is more likely to have a serious
underlying cause if it is severe, of sudden onset or pre- • Recent onset
pubertal, associated with signs of virilisation or associated • Rapid progression
with amenorrhoea. • Severe hirsutism
• Signs of acromegaly or Cushing’s disease
Hirsutism is in contrast to virilisation, which reflects very • Signs of virilisation
high levels of androgens and manifests in form of features
such as deepening of the voice; enlargement of the clitoris; –– Deepening of the voice
male pattern hair loss, e.g. temporal recession; breast –– Enlargement of the clitoris
atrophy; increased muscle mass, etc. Women with virilism –– Reduction in breast volume
will have hirsutism, but vice versa is usually not true. –– Hair loss
–– Acne

• Family history of hirsutism
• Ethnicity (hair distribution is associated with huge racial variation)
• Drugs

mebooksfree.com

448 Textbook for MRCOG-1

Fig 14.8: Management of hirsutism
Abbreviations: DHEA, dehydroepiandrosterone sulphate; CT, computed tomography

TT A basic hormone profile: frequencies suitable for destroying the hair follicle are
• Total and free testosterone (total testosterone levels those that melanin absorbs. It works best for dark hair.
>5 mmol/litre indicate possible adrenal disease) TT Drug treatment: This can include hormonal and non-
• 17-hydroxyprogesterone (OHP) levels (this is raised hormonal treatment.
in cases of congenital adrenal hyperplasia)
• Other investigations might be added on an individual Hormonal Treatment
basis (e.g. tests for acromegaly, Cushing’s disease,
etc.) TT Oral contraceptive: All of the combined oral contracep-
tives will have an effect by reducing LH production. They
Treatment also increase SHBG, thereby reducing the levels of free
testosterone. The treatment may take months to produce
TT Counselling or psychotherapy significant improvement.
TT Weight loss: This is one of the most effective approaches,
TT Dianette: This is an oral contraceptive with 35 µg of
which is particularly useful for women having obesity ethinyl oestradiol and 2 mg of cyproterone acetate.
and PCOS. It increases SHBG, thereby reducing the level For further details related to dianette and cyroterone
of androgens. It can help restore ovulatory cycles and acetate, kindly refer to Chapter 12.
fertility in the absence of any other treatment.
TT Physical treatment: These include several methods TT Yasmin : This is the trade name of an oral contraceptive
such as shaving, depilatory creams, waxing, bleaching, pill comprising 30 µg ethinyl oestradiol and 3 mg
electrolysis, thermolysis, laser treatment, etc. The laser drospirenone. Drospirenone is a derivative of spirono­
lactone and has similar anti-androgenic properties.

mebooksfree.com

•Chapter 14    Gynaecology 449

It binds to testosterone receptors, thereby producing heavy; so they are particularly likely to undergo torsion. It
anti-androgenic effects. is estimated that about 1% of these tumours may undergo
TT Progestogenic agents: Some progestogens have malignant degeneration in the elderly.
androgenic effects, e.g. norethisterone. So, preparations
with non-androgenic progestogens should be chosen, e.g. Uterine Retroversion
medroxyprogesterone. However, medroxyprogesterone
(Depo-Provera) has to be administered for months to Normal uterine position is that of anteversion and
be able to produce effective results. Depo-Provera has anteflexion, i.e. the uterine body is bent forward at the utero-
also been linked to the loss of bone marrow density. cervical junction over the bladder (Fig. 14.9A). Retroversion
Therefore, its use is contraindicated for adolescents is a type of uterine displacement in which the uterine
whose bones are still maturing. body is displaced backwards at the utero-cervical junction
TT GnRH agonists: Initial administration of GnRH agonists (Fig. 14.9B). Retroversion could be either fixed or mobile.
stimulates the release of FSH and LH. This is followed Mobile retroversion, which is uncomplicated by pelvic
by the eventual downregulation of pituitary gland, disease is of little clinical significance. Fixed retroversion
thereby producing a hypogonadotropic-hypogonadic could be related to conditions such as PID (salpingo-
state. These drugs are effective in hirsutism because oophoritis), pelvic tumours, chocolate cysts of the ovary
of the “downregulation” of FSH and LH production. and pelvic endometriosis. Diagnosis is mainly established
The limiting factors are its high cost, and risks of long- on the basis of findings of pelvic examination. On bimanual
term treatment (e.g. loss of bone mass, etc.). However, examination, a mass is felt in the pouch of Douglas. Since
they can be used with “add back” therapy, e.g. the oral this mass moves with the cervix, it can be considered a part
contraceptives or just oestrogen. For further details of the uterus. Uterus may be tender to touch. Retroversion
related to GnRH agonists, kindly refer to Chapter 12. is recognised on bimanual pelvic examination when the
cervix is found to be directed forwards. With the examining
Non-hormonal Drugs fingers in the posterior vaginal fornix, the body of the uterus
can be felt.
TT Metformin: Insulin increases androgen production and
reduces SHBG. Metformin reduces insulin levels and If pregnancy occurs in case of retroverted uterus, the
counteracts this. Therefore, this is particularly useful in uterus nearly always rises up into the abdomen in the
women with PCOS. normal way at about the 12th week and after delivery, it
resumes its retroverted position. The uterus is sometimes
TT Spironolactone: This is an aldosterone antagonist having discovered to be retroverted in the puerperium or at a
a beneficial effect on hirsutism.
Fig. 14.9A: Uterus in the position of anteversion and anteflexion
TT Finasteride: 5α-reductase is an enzyme, which converts
testosterone into its more active metabolite dihydrotes-
tosterone. The enzyme 5α-reductase has two forms,
type 1 and type 2, which are present in different amounts
in different tissues. Finasteride is a synthetic chemical
that inhibits (type 2) 5α-reductase.

TT Flutamide: This is an anti-androgen that binds to
androgen receptors. There are some concerns about
its hepatotoxicity.

TT Eflornithine: Polyamines are critical components
of hair. A key enzyme involved in their synthesis is
ornithine decarboxylase. Eflornithine inhibits ornithine
decarboxylase. It is applied as a cream and is effective in
reducing hair growth. It may cause side effects such as
skin irritation and acne in a small number of patients.

Ovarian Masses

Dermoid Cysts of the Ovary Fig. 14.9B: Retroverted uterus: long axis of the uterus is directed backward

Dermoid cysts of the ovary are also known as benign cystic
teratomas. They are the commonest ovarian tumour in
pregnancy. Dermoids are bilateral in 10−20% of cases. These
mostly occur in women of reproductive age; so they form
the likeliest diagnosis in pregnancy. Dermoids are relatively

mebooksfree.com

450 Textbook for MRCOG-1

postnatal examination. Most of these cases are merely distortion of the uterus and damage to the tubes or from
instances of pre-existing retroversion in which the uterus consequent infection. Although sub-serosal and interstitial
has returned to its usual position. fibromyomatas are commonly associated with pregnancy,
sub-mucosal tumours may rarely present with some
Management problems due to sub-fertility.

In asymptomatic cases of mobile retroversion, no treatment Management
is required. Insertion of a pessary may be required in
symptomatic cases, where the uterus is bimanually replaced Various treatment options for a patient with uterine fibroids
and a Hodge pessary is inserted inside to keep the uterus are described in Figure 14.10. Women with asymptomatic
in an anteverted position. The Hodge pessary was designed uterine fibroids do not require any treatment. Small
for insertion into the vagina in such a way as to maintain a asymptomatic tumours, however, should be re-examined
uterus in the anteverted position once the retroversion had regularly so that treatment can be immediately administered
been manually corrected. It is usually retained for 3 months if the tumour increases in size or symptoms arise. Presently,
in position and then removed. the main modality of curative treatment in a patient with
leiomyoma is surgery and acts as a definitive cure.
Surgical Treatment
Options for surgical treatment include abdominal
Surgical treatment may be required in the cases of fixed myomectomy, vaginal myomectomy, endoscopic
retroversion and comprises of the following options: myomectomy, abdominal hysterectomy and vaginal
TT Modified Gillam’s ventrosuspension: This is the most hysterectomy. Myomectomy of the fibroids should not be
undertaken in pregnancy due to the risk of haemorrhage.
commonly used surgical option in which the round The exception to this may be presence of symptomatic
ligaments are anchored to the anterior rectus sheath sub-serous fibroids on a pedicle less than 5 cm thick.
TT Plication of the round ligaments If the woman has completed her family and does not
TT Baldy-Webster’s operation: This surgery involves wish to preserve her uterus, hysterectomy can be done.
shortening of the round ligaments. Round ligaments Myomectomy is an option for women who desire future
are anchored to the posterior surface of the uterus by pregnancy or wish to preserve their uterus. Various
passing them through the anterior and posterior leaves indications for surgical treatment are listed in Table 14.21.
of the broad ligament.
Myomectomy
Fibromyomata
Surgical removal of myomas from the uterine cavity is
Uterine leiomyomas (uterine myomas, fibromyomas termed as myomectomy. Although myomectomy allows
or fibroids) are well-circumscribed benign tumours preservation of the uterus, present evidence indicates
developing from uterine myometrium, most commonly a higher risk of blood loss and greater operative time
encountered amongst women of reproductive age group with myomectomy in comparison to hysterectomy.
(30–44 years). There are three types of fibroids: intramural Numerous techniques are used nowadays for performing
or interstitial fibroids (which are present within the uterine myomectomy. These include the following: performing
myometrium), sub-mucosal fibroids (which grow beneath a myomectomy through an abdominal incision, vaginal
the uterine endometrial lining) and sub-serosal fibroids incision, with the help of a laparoscope or a hysteroscope.
(which grow beneath the uterine serosa). Of these various Though abdominal myomectomy is nowadays uncommonly
types of fibroids, the commonest are the intramural fibroids. performed, removal of fibroids, especially hysteroscopically
Most fibroids are asymptomatic, but the symptoms which and laparoscopically, has become more popular in recent
they can commonly cause, include bleeding, pressure years. Nowadays, myomectomy is mainly useful for the
symptoms (e.g. urinary symptoms, low backache, rectal pedunculated fibroids. A pedunculated sub-mucosal fibroid
tenesmus and constipation), anaemia (due to excessive can be removed through hysteroscopic myomectomy. The
bleeding) and less commonly pain. The pattern of bleeding
is usually excessive or prolonged menses (menorrhagia). Table 14.21 Indications for surgical treatment of fibroids
Other causes of abnormal uterine bleeding must be ruled
out by endometrial sampling in these cases. • Heavy or prolonged bleeding
• Large tumours (14-week pregnancy), even if these are not causing
Pain is a rare symptom, which may occur as a result
of degeneration or torsion of the fibromyomata. Severe symptoms
cramping may be due to uterine contractions as the
uterus attempts to pass a sub-mucosal tumour out from • Possible malignant change (for example, growth of the tumour after
the uterine cavity. Fibroids are usually not responsible
for causing infertility. Infertility might ensue from menopause)

• Retention of urine (acute retention of urine rarely occurs)
• Tumours which obstruct labour
• Tumours which have undergone torsion

mebooksfree.com

•Chapter 14    Gynaecology 451

Fig 14.10: Treatment options for a patient diagnosed with fibroid uterus
Abbreviations: NSAIDs, non-steroidal anti-inflammatory drugs; GnRH, gonadotropin releasing hormone; OCPs, oral contraceptive pills; UAE, uterine artery
embolisation, MR, magnetic resonance

pedunculated sub-serous type of fibroid, which bulges out iliac and uterine vessels have to be cannulated, and there
from the uterus into the peritoneal cavity can be removed may be infection and bleeding after the procedure. There
via laparoscopic myomectomy. Indeed, there is always a was concern about pregnancy after the procedure, but
risk with myomectomy that the bleeding may be as severe several successful pregnancies have been reported to occur.
as to require a hysterectomy.
Pregnancy in Presence of Fibroids
Hysterectomy would be more likely to provide relief from
symptoms such as bleeding, pain and pressure symptoms. In case of pregnancy with fibroids, the patient should be
There is not a lot of evidence that myomectomy achieves a allowed to go to term, and, if there appears to be a chance
lot of symptomatic improvement, especially with regard to that the fibromyoma may be pulled up, labour may be
infertility and menorrhagia. However, caesarean section is allowed to begin. However, if it becomes evident that
not always necessary after myomectomy. The risk of scar normal delivery is impossible, caesarean section should
dehiscence at the time of caesarean delivery is greatest if be performed. It is occasionally possible to perform
the whole thickness of the myometrium has been involved myomectomy at the same time as caesarean section, but
and the surgery was particularly extensive. it is usually safer to leave this until later because of the risk
of haemorrhage. In the case of a patient who is unlikely to
Uterine Artery Embolisation become pregnant again, caesarean hysterectomy may be
the best treatment.
Uterine artery embolisation (UAE) is a relatively new, novel
technique for treatment of uterine fibroids, which was first Degenerative Changes in the Fibromyomatas
performed by Ravina, a French gynaecologist in 1995. UAE
is a non-hysterectomy surgical technique, which helps in Certain degenerative changes can occur in a fibroid, which
reducing the size of the uterine fibroids by shrinking them, can cause an interference with capsular circulation. As a
without actually removing them. The procedure involves result of circulatory disturbances, the tumour becomes
injection of an embolising agent [gelatin microspheres painful, tender, softened and enlarged. Some such
(trisacryl gelatin) or polyvinyl alcohol] via a cannula inserted degenerative changes taking place in the fibroids are
through the femoral artery into the internal iliac and the described below:
uterine vessels, which helps in blocking both the uterine TT Atrophy: Shrinkage of the fibroid can occur as a result of
arteries, thereby cutting off the blood supply to the fibroid.
Embolisation is mainly performed to provide symptomatic reduced blood supply to the fibroid, usually following
relief and is effective in a reasonable proportion of cases. menopause.
However, the procedure is not without hazard because the TT Hyaline degeneration: This is the commonest type
of degeneration in which the fibrous tissue cells are

mebooksfree.com

452 Textbook for MRCOG-1

replaced by a homogeneous substance that stains shock. The uterus is “woody” hard and tender all over;
pink with eosin. The bundles of muscle fibres become foetal parts are difficult to feel and localise; and foetal
isolated and die off causing large areas of the tumour heart activity cannot be usually detected.
to become structureless. Eventually, the liquefaction of TT Sarcomatous change: Occurrence of malignant changes
hyaline material occurs, leaving behind ragged cavities in a leiomyoma is an extremely rare occurrence.
filled with colourless or bloodstained fluid.
TT Calcification: This type of degeneration may initially Primary Dysmenorrhoea
occur with the presence of fatty deposits within the
leiomyomas. At a later stage in this process, there is Dysmenorrhoea has been defined by the ACOG as a
deposition of phosphates and carbonates of calcium gynaecological medical condition characterised by presence
along the course of blood vessels. Calcification usually of pain during the menstrual phase. The first thing is to
begins at the periphery of the fibroid and can be reassure the patient and her mother that there is no serious
identified with the help of radiography. At a later pathology. Dysmenorrhoea can be of two types: primary
stage, there may be widespread deposition of calcium (spasmodic or the 1st day pain) and secondary (congestive
throughout the tumour resulting in “womb stone” type). Dysmenorrhoea is labelled as primary in the absence
appearance or a peripheral distribution resulting in an of underlying medical disease/pathology. Secondary
“egg shell” appearance. dysmenorrhoea on the other hand, is associated with an
TT Myxomatous/cystic degeneration underlying medical disease/pathology. An ultrasound
TT Red/carneous degeneration: This type of degeneration scan is useful for this purpose. The mainstay for treatment
of uterine fibroid usually develops during pregnancy. of primary dysmenorrhoea is the NSAIDs with or without
It may be associated with constitutional symptoms like the oral contraceptive pills. Cervical dilatation used to be
malaise, nausea, vomiting, fever and severe abdominal popular, but it was ineffective and was associated with the
pain. The myoma may become soft and necrotic in the risk of cervical incompetence in subsequent pregnancies.
centre and is diffusely stained red or salmon pink in Division of the utero-sacral ligaments has also been tried
colour. Though the pathogenesis of the condition is but has largely been abandoned in the present times. Use
not yet clear, it is believed that the purple-red colour of GnRH analogues as the second-line option may prove to
of the myoma is probably due to the thrombosis of be effective in cases not responding to the first-line therapy.
blood vessels supplying the tumour. The myoma may However, the GnRH analogues, through abolition of ovarian
also develop a peculiar fishy odour due to infection by function may produce bone loss, so they do not serve as a
the coliform organisms. The fibroid outgrows its blood very practical option.
supply and central haemorrhagic breakdown occurs.
 Although the patient may develop mild leucocytosis Pre-menstrual Syndrome
and a raised erythrocyte sedimentation rate (ESR),
the condition is essentially an aseptic one. It needs Pre-menstrual syndrome (PMS) or pre-menstrual tension
to be differentiated from other conditions including includes a combination of physical, psychological and
appendicitis, twisted ovarian cyst, accidental emotional symptoms, which the women experience for a
haemorrhage, etc. Good history taking, clinical few days (usually 7–10 days) preceding menstruation. Some
examination and ultrasound examination usually helps of the symptoms, which are commonly observed, include
in establishing the correct diagnosis. On ultrasound the following: abdominal bloating, breast tenderness,
examination, the tumour shows a mixed echo-dense and headache, sleeplessness, fatigue, emotional liability and
echo-lucent appearance. Red degeneration occurring emotional outbursts, mood swings, depression, irritability,
during pregnancy must be managed conservatively. lassitude, insomnia, fluid retention, increase in appetite,
The patient must be advised bed rest and prescribed craving for sweet foods, intestinal distention, colonic spasm,
analgesics to relieve the pain. The acute symptoms spasmodic dysmenorrhoea, etc.
subside gradually within the course of 3–10 days and
pregnancy then proceeds uneventfully. Uterine Malformations
  The major hazard associated with red degeneration is
the risk of unnecessary caesarean section (with possible Congenital uterine anomalies may arise from malformations
prematurity) due to a mistaken diagnosis of placental at any step of the Müllerian developmental process. The
abruption. The key of establishing the correct diagnosis classification of Müllerian abnormalities as proposed by the
is taking a good history and conducting a proper American Society for Reproductive Medicine is described
clinical examination. In “red degeneration”, there is no in Figure 14.11 and Table 14.22.
bleeding; the area of pain and tenderness is localised to
the fibroid; the rest of the uterus is soft; the foetal heart Bicornuate Uterus
rate is normal. On the other hand, in cases of abruption,
bleeding is usually present. There may be an evidence of Bicornuate uterus occurs due to abnormality of the fusion
process in the upper parts of Müllerian ducts. As a result,

mebooksfree.com

•Chapter 14    Gynaecology 453

but in more than 10% of those with recurrent miscarriage.
It is still a matter of debate whether uterine anomalies
have any role in the pathogenesis of recurrent miscarriage.
Nevertheless, it is not thought to be the major cause. Surgery
can be done but would only be considered in extreme cases
such as recurrent second trimester miscarriage.

The genital and urinary tracts develop hand in hand;
abnormality in one is associated with an increased risk of
malformation in the other. Therefore, bicornuate uterus may
be associated with simultaneous presence of urinary tract
abnormalities. Bicornuate uterus is often associated with
premature labour, and a persistent abnormal lie, usually
breech, but possibly transverse.

Fig. 14.11: Classification of the uterine anomalies Uterus Didelphys
* Uterus may be normal or take a variety of abnormal forms; ** May have two distinct
cervices Incomplete fusion of the Müllerian or paramesonephric
Source: The American Fertility Society classifications of adnexal adhesions, distal tubal ducts results in the commonest types of uterine malforma­
occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, Müllerian tion. Complete failure of the fusion of Müllerian ducts
anomalies and intrauterine adhesions. Fertil Steril. 1988;49(6):944-55. results in uterus didelphys, which is an extremely rare
condition, characterised by the following:
Table 14.22 American Society for Reproductive Medicine TT Double vagina
classification of congenital uterine anomalies TT Double cervix
TT Entirely double uterus, that is, two single-horned uteruses
Classification Clinical finding Description
I Segmental or complete Endometriosis
Müllerian agenesis or • Vaginal
II hypoplasia • Cervical Endometriosis is characterised by occurrence of endometrial
• Fundal stroma and glands outside the uterus in the pelvic cavity,
Unicornuate uterus • Tubal including all the reproductive organs as well as on the
with or without a • Combined bladder, bowel, intestines, colon, appendix and rectum (Fig.
rudimentary horn • With a communicating 14.12). The ectopic endometrial tissues, both the glands and
the stroma, are capable of responding to cyclical hormonal
rudimentary horn stimulation and have the tendency to invade the normal
surrounding tissues. The pathogenesis of endometriosis is
• With a non- yet not clear. Some likely mechanisms for its pathogenesis
are as follows:
communicating TT Retrograde menstruation: Retrograde menstrual flux

rudimentary horn can be considered as an essential element in the
pathogenesis of endometriosis.
III Didelphys uterus Characterised by complete TT Theory of coelomic metaplasia: Peritoneal epithelium
can get “transformed” into endometrial tissue under the
or partial duplication of the influence of some unknown stimulus.
TT Metastatic theory of lymphatic and vascular spread:
vagina, cervix and uterus Metastatic deposition of endometrial tissues at ectopic
sites can occur via lymphatic and vascular routes.
IV Complete or partial • Complete TT Immunological defects and genetic factors.
• Partial
bicornuate uterus Classically, endometriosis causes dysmenorrhoea,
particularly pain that starts days before the onset of
V Complete or partial • Complete bleeding. Cramping pain that starts with the bleeding is
• Partial typical of spasmodic dysmenorrhoea. Deep dyspareunia is
septate uterus also a typical feature of endometriosis. Other features can be
chocolate cysts of the ovaries (due to collection of old blood/
VI Arcuate uterus A small septate indentation clotted blood) and fixed retroversion of the uterus. Rarely,
bowel symptoms may be present.
is present at the fundus

VII Diethylstilbestrol-related Presence of a T-shaped

abnormalities uterine cavity with or

without dilated horns

there is a single cervical canal in the lower part, but the upper
part is bifurcated, having two horns. Significant uterine
malformation is said to occur in less than 1% of women,

mebooksfree.com

454 Textbook for MRCOG-1

Fig. 14.12: Common sites of endometriotic lesions

Table 14.23 Diagnostic features of the commonest causes of vaginitis

Basis of Bacterial vaginosis Vulvovaginal candidiasis Trichomoniasis
diagnosis

Signs and Thin, greyish to off-white coloured discharge; Thick, white (curd-like) Copious, malodorous, yellow-green (or discoloured)
symptoms unpleasant “fishy” odour especially increas­ discharge, with no odour discharge, pruritus, and vaginal irritation, dysuria,
ing after sexual intercourse. The discharge or asymptomatic in many cases
is usually homogeneous and adheres to
vaginal walls.

Physical Normal appearance of vaginal tissues; Vulvar and vaginal erythema, Vulvar and vaginal oedema and erythema,
examination greyish white-coloured discharge may be oedema and fissures; thick white “strawberry” cervix
adherent to the vaginal walls. discharge that adheres to in up to 25% of affected women; frothy purulent
the vaginal walls discharge

Vaginal pH Elevated (> 4.5) Normal Elevated (> 4.5)

Microscopic “Clue cells” (vaginal epithelial cells coated Pseudo-hyphae, mycelial tangles or Motile trichomonads, many polymorphonuclear
examination with coccobacilli), few lactobacilli, occasional budding yeast cells cells
of wet-mount motile, curved rods, belonging to prepara-
and KOH tions of Mobiluncus species
preparations
of the vaginal
discharge

“Whiff” test Positive Negative Can be positive
(Normal = no
odour)

Additional Amsel’s criteria is positive in nearly 90% of KOH microscopy, gram stain, DNA probe tests: Sensitivity of 90% and specificity
tests
affected women with bacterial vaginosis culture of 99.8%

Culture: Sensitivity of 98% and specificity of 100%.

Vaginal Discharge bacterial vaginitis. However, later it was discovered that
the condition was primarily caused due to the alteration
Diagnostic features of the commonest causes of vaginitis of normal vaginal flora, rather than due to any specific
are described in Table 14.23. infection. Due to the absence of inflammation, the term
“vaginosis” rather than “vaginitis” is now being preferred.
Bacterial Vaginosis The normal vaginal epithelium contains numerous bacteria
called L. acidophilus. These bacteria release hydrogen
Bacterial vaginosis (BV) is one of the most important peroxide, which is toxic to other aerobic and anaerobic
causes of vulvovaginitis. Initially, this was termed as bacteria. BV typically is associated with a reduction in

mebooksfree.com

•Chapter 14    Gynaecology 455

the number of the normal hydrogen peroxide-producing 80% of women with “thrush”, with other forms of Candida
Lactobacilli in the vagina. The resultant change in pH causing the rest. It is a fungus and mycelia may be seen on
allows proliferation of organisms that are normally microscopy. It is not a sexually transmitted disease (STD).
suppressed such as Haemophilus vaginalis, Gardnerella Maturity onset diabetes may present with monilial infection,
mobiluncus, Mycoplasma hominis, Gardnerella vaginalis, often of the vulva and vagina. But, the juvenile variety will
Peptostreptococcus species, etc. These organisms may usually present with the classical clinical features such as
produce metabolic byproducts, such as amines, that further polyuria, polydypsia, etc. It is said that it can be found in
increase the vaginal pH and cause exfoliation of vaginal the vagina in more than 25% of asymptomatic women.
epithelial cells. These amines are also responsible for The drug of choice for treatment of candidal infections is
the characteristic malodorous discharge in BV. Bacterial fluconazole.Fluconazole (Diflucan) is available to the public
vaginosis is not dangerous, but it can cause disturbing in a 150 mg single-dose preparation. It is not known to be a
symptoms. Certain factors have been identified that teratogen but is avoided in pregnancy, as its safety has not
increase the chances of developing BV. These include yet been established.
multiple or new sexual partners, vaginal douching and
cigarette smoking. However, the role of sexual activity in The clinician would only remove an IUD if there was
the development of the condition is not fully understood a significant risk of ascending infection or signs of it, e.g.
and BV can still develop in women who have not had sexual pelvic tenderness. The common infections, due to Candida
intercourse. Risk factors include Afro-Caribbean race, use and Trichomonas, are not grounds. Actinomyces is a rare
of douches, smoking, and presence of an IUD. It is not cause of ascending infection. It is not uncommonly reported
regarded as sexually transmitted and can occur in those on routine cervical smears in asymptomatic patients. There
who are not sexually active. It is linked to an increased risk is an increased risk of ascending infection in this situation,
of preterm premature rupture of membranes (PPROM) and which has led to advice that the IUD be removed.
preterm labour. Diagnosis can be clinical or using laboratory
tests. Amsel’s diagnostic criteria for BV are as follows: Trichomonas vaginalis is a flagellate protozoan and is
TT Thin, homogeneous discharge transmitted by sexual intercourse.
TT Positive “Whiff test”
TT Presence of “clue cells” on microscopic examination Sexually Transmitted Infections
TT Vaginal pH greater than 4.5
Various causes of genital ulcers are listed in Table 14.24.
Treatment
Gonorrhoea
TT Metronidazole: A 7-day course of oral metronidazole,
400 mg TDS or vaginal metronidazole gel (metrogel) is Gonorrhoea is a STD, which is derived from the Greek words
an effective treatment. gonos (seed) and rhoia (flow) implying “flow of seeds”
and is caused by the bacterium Neisseria gonorrhoeae.
TT Tinidazole: Tinidazole is an antibiotic that appears to The bacterium causing gonorrhoea is a Gram-negative
have fewer side effects than metronidazole and is also intracellular diplococcus. It is detected on cervical and
effective in treating BV. urethral swabs. The disease is characterised by adhesion
of the gonococci to the surface of urethra or other mucosal
TT Ornidazole: Ornidazole, 500 mg vaginal tablet daily for surfaces. Gonorrhoea spreads through contact with the
7 days, is another effective option. penis, vagina, mouth or anus. Gonorrhoea can also spread
from mother to baby at the time of delivery.
TT Ampicillin: Ampicillin 500 mg TDS or cephalosporin 500
mg BID for 7 days is also effective. Symptoms

TT Tetracyclines: Tetracycline 500 mg, four times a day or TT The commonest clinical presentation of the disease
doxycycline 100 mg twice daily for 7 days may also be in men is acute urethritis resulting in dysuria and a
used. purulent penile discharge. The majority of gonococcal-
infected men develop urethritis, dysuria and urethral
TT Lincosamides: Vaginal clindamycin cream 2% (cleocin) discharge.
or oral clindamycin 300 mg daily for 7 days is also
effective. Table 14.24 Causes for genital ulcers

TT Clindamycin: The treatment of choice in pregnancy for Painless genital ulcers Painful genital ulcers
BV is clindamycin, which has been shown to reduce the
risk of pre-term delivery. Metronidazole is also an option. • Circinate balanitis • Herpes simplex/zoster and genital herpes
• Granuloma inguinale • Behçet’s disease
Monilial Infection • Primary syphilis • Reiter’s syndrome
• Chancroid
Monilial infection is most commonly caused by the • Gonococcal disease
organisms belonging to the genus candida (Monilia).
Candida albicans is the infecting organism in more than

mebooksfree.com

456 Textbook for MRCOG-1

TT Symptomatic women commonly experience vaginal TT Evidence of inflammation: Raised ESR, C-reactive
discharge, dysuria and abdominal pain. protein and white cell count.

TT The infection, if untreated, may extend to Bartholin’s Apparently, it is also a common finding in pelvic tuber­
glands, endometrium and fallopian tubes. The culosis. As it is secondary to pelvic infection, it is often
gonococci can typically ascend to the fallopian tubes at associated with impaired fertility. Treatment is with
the time of menstruation or after instrumentation (for appropriate antibiotic therapy. A similar phenomenon can
MTP) giving rise to acute salpingitis. also occur around the appendix.

TT Systemic manifestations, peri-hepatitis and septicaemia Bartholin’s Abscess
can all be caused by gonococcal infection.
The Bartholin’s glands are situated at the level of the
Investigations introitus within the labia majora. The cause for development
of cysts and abscesses in the Bartholin’s glands largely
The swabs are usually taken from the endocervix and remains unknown; it could be related to the blockage of
urethra. In some circumstances, throat and rectal swabs ducts, but the explanation of this remains obscure. The
should be considered. The bacterium is difficult to grow infection may be due to the gonococcus. Treatment is by
and successful culture requires rapid transport to the “marsupialisation”, in which the cyst is effectively de-roofed
laboratory and special culture media (e.g. chocolate agar). to allow drainage.
The investigations performed on these samples include:
TT Culture and sensitivity Genital Warts
TT DNA probes.
Genital warts are caused by different strains of human
Medical Management papilloma virus, especially HPV types 6, 11, 16 and 18.

Treatment comprises of using the following antibiotics: Additional cervical screening for detecting genital warts
Ceftriaxone 125 mg IM, cefixime 400 mg, ciprofloxacin 500 is not justified. The incidence of genital warts is increasing
mg PO or ofloxacin 400 mg PO. This is followed by: at present. The mean incubation period is about 3 months.
However, it is quite variable and may range from 3 weeks
Doxycycline 100 mg BID × 7 days or azithromycin 1 g to 8 months. There is debate about the role of Caesarean
PO (single dose). section for patients with active herpes, but not for patients
with warts.
Complications
Podophyllin in spirit is the standard treatment in cases of
The infection may extend along the urethra to the prostate, genital warts, but can be toxic in pregnancy; so, it is not to be
seminal vesicles and epididymis, resulting in complications used. If podophyllin cannot be used or fails to produce positive
such as epididymitis, prostatitis, peri-urethral abscesses results, the warts can be frozen or treated with diathermy.
and chronic urethritis. The infection may spread to the
peri-urethral tissues, resulting in formation of abscesses and Genital Herpes Infection
multiple discharging sinuses (watercan perineum). Acute
salpingitis may be followed by PID. This may be associated Genital herpes is one of the commonest sexually transmitted
with a high probability of sterility if not treated adequately. diseases worldwide and is a viral infection caused by the
Peritoneal spread occasionally occurs and may produce a herpes simplex virus (most commonly HSV-II), which is
peri-hepatic inflammation, resulting in Fitz-Hugh-Curtis transmitted through sexual contact. Genital herpes spreads
syndrome. Gonococcal infection can result in neonatal eye only by direct person-to-person contact. The virus enters
infection and can cause substantial damage if not treated through the mucous membrane of the genital tract via
promptly. In America, the neonate is given prophylactic microscopic tears. From there, the virus travels to the nerve
antibiotic eye drops to prevent such infection. Gonococcal roots near the spinal cord and settles down permanently.
ophthalmia neonatorum can lead to severe conjunctivitis,
keratitis and blindness if not promptly treated. Symptoms

Fitz-Hugh-Curtis Syndrome The primary infection may be associated with constitutional
symptoms like fever, malaise, vulval paraesthesia, itching
It is related to peri-hepatic infection with formation of fine or tingling sensation on the vulva and vagina followed by
adhesions known as the “violin string” secondary to pelvic redness of skin. Eventually, there is formation of blisters and
infection. The clinical presentation is similar to that of vesicles on the vulva, vagina, cervix, perianal area or inner
cholecystitis. Previously, the commonest infecting organism thigh, which ultimately develop into shallow and painful
was the gonococcus, but nowadays, the commonest ulcers within a period of 2–6 weeks. They are frequently
organism is Chlamydia. Most patients will have the accompanied by itching and mucoid vaginal discharge.
following clinical features: Swollen and tender lymph nodes may occur in the groin
TT Right upper quadrant pain region.
TT Evidence of chlamydial infection

mebooksfree.com

•Chapter 14    Gynaecology 457

Investigations Urinary Tract Infections

Diagnosis is usually based on clinical examination. Genital Escherichia coli accounts for 80% of UTIs. Enterobacter
herpes is suspected when multiple painful blisters are and Klebsiella spp. tend to be hospital-acquired infections.
present on the external genitalia. The various investigations Pseudomonas and Candida spp. are opportunistic
which can be performed are as follows: infections, which affect immunosuppressed patients.
TT Cytological tests: The blister fluid may be sent to Proteus spp. are often associated with urinary calculi.
Chlamydia rarely causes UTIs but is associated with PID.
the laboratory for culturing the virus. However, it is
associated with a high false negative rate of nearly Asymptomatic Bacteruria
50%.
TT Immunological tests: These tests are specific for HSV-I Asymptomatic bacteruria (ASB) occurs in about 5% of
or HSV-II and may be able to demonstrate that a women, irrespective of whether they are pregnant or not.
person has been infected at some point in time with The infecting organism is usually a coliform. A significant
the virus. bacterial count is 100,000 organisms per mL, i.e. 105.
TT Other diagnostic tests: These include tests such as Many hospitals screen for the infection via microscopy
polymerase chain reaction and rapid fluorescent and culture. However, nowadays, use of dipsticks for
antibody screening tests. screening is increasingly becoming popular. Some
TT Biopsy: The Tzanck smear is a rapid, fairly sensitive research evidence suggests that dipsticks are less effective
and inexpensive method for diagnosing HSV infection. than formal microscopy and culture for initial screening
Smears are preferably prepared from the base of purposes. Microscopy and culture is still useful for the
the lesions and stained with 1% aqueous solution of patient admitted later in pregnancy with UTI, premature
toluidine blue “O” for 15 seconds. Positive smear is labour, etc. The importance of ASB in pregnancy is related
indicated by the presence of multi-nucleated giant cells to its predisposition for ascending infection. This is
with faceted nuclei and homogeneously stained “ground probably due to urinary stasis from dilatation of ureters
glass” chromatin (Tzanck cells). due to progesterone. Another factor could be related to
the compression of ureters at the pelvic brim by the gravid
Medical Management uterus. Dextrorotation of the uterus may cause more
compression on the right ureter and a tendency for the
There is still no curative medicine available for genital condition to occur more commonly on the right side. ASB
herpes, and the antiviral drugs only help in reducing the has been linked with an increased risk for preterm delivery;
severity of symptoms and duration of outbreaks. this may be due to the increased risk of pyelonephritis.
Treatment involves nursing measures to lower the
TT Oral antiviral medications, such as acyclovir, (Zovirax), temperature, rehydration and antibiotic therapy.
famciclovir (Famvir) or valacyclovir (Valtrex), which
prevent the multiplication of the virus, are commonly Non-gonococcal Urethritis
used. For the treatment of primary outbreaks, oral
acyclovir is prescribed in the dosage of 200 mg five times Mostly non-gonococcal urethritis (NGU) is due to Chla-
a day for 5 days. mydia, and more rarely due to Mycoplasma, Ureaplasma,
Trichomonas or meningococcal disease. These may occur
TT Local application of acyclovir provides local relief and together.
accelerates the process of healing.
Non-gonococcal urethritis is also part of Reiter’s
TT In severe cases, acyclovir can be administered intra­ syndrome (reactive arthritis, conjunctivitis, urethritis). This
venously in the dosage of 5 mg/kg body weight every 8 can be caused by gonococcus and Campylobacter.
hourly for 5 days.
Complications of NGU: Salpingitis, peri-hepatitis,
TT The couple is advised to abstain from intercourse conjunctivitis, sterility.
starting right from time of experiencing prodromal
symptoms until total re-epithelialisation of the lesions Treatment of NGU: Doxycycline or erythromycin.
occurs.
Pelvic Abscess
TT Pregnant women with active herpetic lesion must be
preferably delivered by caesarean section. Pelvic abscess is the commonest variety of intra-peritoneal
abscess. Pus can track down the peritoneal cavity to form
Herpes can be spread from one part of the body to a pelvic abscess. The abscess can irritate the bladder
another during an outbreak. Thorough handwashing is causing urinary frequency/nocturia. If an abscess drains
a must during outbreaks in order to prevent the spread spontaneously via the rectum, it rarely requires any further
of infection. Couples who want to minimise the risk of treatment. Ultrasound imaging requires a full urinary bladder
transmission should always use condoms if a partner is to identify the pelvic organs and any abscesses present.
infected. Such couples must be instructed to avoid all kinds
of sexual activity, including kissing, during an outbreak of
herpes.

mebooksfree.com

458 Textbook for MRCOG-1

Choose the Single Best Answer (Sba)

Q 1. Which of the following statement regarding Q 7. Which of the following organisms is not a common
endometriosis is correct? cause of urinary tract infection?
A. Does not usually affect the ovaries A. Candida
B. Effective drug therapy significantly improves B. Chlamydia
potential fertility C. Enterobacter
C. May be a cause of fixed retroversion of the uterus D. Klebsiella
D. Classically causes superficial dyspareunia E. Proteus
E. tubal damage is common and occurs early in the
progression of the disease Q 8. Which of the following is true regarding asympto-
matic bacteriuria (ASB)?
Q 2. Which of the following is true regarding bacterial A. Should be investigated postpartum by IVP
vaginosis? B. Ascending infection occurs in about 30% of
A. Is associated with a purulent, green discharge pregnant women with ASB
B. Is associated with pre-term labour C. A significant count is more than 106  organisms per
C. Is associated with intense vaginitis mL of urine
D. Is associated with a cheesy smell D. Is usually due to chlamydia
E. Is best treated with tetracycline E. Screening should be by microscopy and culture of
a “clean catch” urine specimen, not dipsticks
Q 3. Which of the following is true regarding Fitz-Hugh-
Curtis syndrome? Q 9. In cases of non-gonococcal urethritis (NGU), which
A. Presents with the features of appendicitis of the following statement is correct?
B. Is frequently due to tuberculosis A. Association with septic arthritis is common
C. Is associated with sub-fertility B. Chlamydia trachomatis is the commonest organism
D. Is best treated by laparotomy C. Chronic conjunctivitis is not a recognised sequel
E. Is due to allergy to violin strings D. Cystitis is typical
E. It is usually treated with Septrin
Q 4. Which of the following is not true regarding syphilis
infection? Q 10. Which of the following is not correct concerning
A. Syphilitic chancre is a firm painless nodule pelvic abscess?
B. Chancre usually appears on the genital region 2–4 A. Is a common cause of intra-abdominal abscess
weeks after infection. B. Can be associated with a perforated peptic ulcer
C. The Wasserman reaction is a non-specific test. C. Can only be identified on CT if there is a full bladder
D. Aortitis is a feature of secondary syphilis. D. Commonly present with nocturia
E. Is caused by a spirochaete. E. Frequently drain spontaneously into the rectum

Q 5. Which of the following is true regarding Bartholin’s Q 11. Which of the following statement is true regarding
abscess? monilial infection?
A. Is located on the cervix uteri A. Is due to a flagellate organism.
B. May be associated with gonococcal infection. B. Responds to metronidazole.
C. Results from poor repair of tears sustained in C. Is a common presenting feature in juvenile diabetes.
childbirth. D. The organisms are commonly present in asympto-
D. Is normally treated by excision of the gland. matic women.
E. Is usually bilateral. E. Fluconazole is of proven safety in pregnancy.

Q 6. Which of the following is true concerning genital Q 12. Which of the following is not true concerning
herpes infection? bacterial vaginosis?
A. Can be responsible for pre-term delivery A. Can be diagnosed by the finding of clue cells on
B. Is always symptomatic microscopy
C. Tender inguinal lymphadenopathy frequently occurs B. Cannot be detected by Gram staining
D. First attack is milder than subsequent attacks C. Causes a rise in the pH of vaginal secretions
E. Has an incubation period of 2 months D. Is often asymptomatic
E. Should be treated in pregnancy with clindamycin to
help prevent late miscarriage and pre-term birth

1. C 2. B 3. C 4. D 5. B 6. C 7. B 8. B 9. B 10. C 11. D 12. B

mebooksfree.com

•Chapter 14    Gynaecology 459

Q 13. Which of the following is not true regarding genital C. A luteal phase progesterone is essential.
warts? D. IMB may be associated with ovulation.
A. They are always sexually transmitted E. IMB is a feature of cervical intra-epithelial neoplasia.
B. Additional cervical screening is not justified,
provided that the woman has had a screening test Q 20. Which of the following is not true regarding submu-
within the previous 3–5 years cous uterine fibroids?
C. Podophyllin paint cannot be used with safety during
pregnancy A. Can become infected
D. Condom usage with regular sex partners has not B. Frequently cause infertility
been shown to affect the treatment outcome C. May become polypoidal
E. All treatments have significant failure and relapse rates D. May protrude through the cervix
E. Often present with menorrhagia
Q 14. Gonococcus can be found in which of the following
tissues? Q 21. Which of the following is true regarding uterine
A. Anus fibroids?
B. Endocervix
C. Endometrium A. Undergo malignant degeneration in 5% of cases
D. Epididymis B. If present in pregnancy, myomectomy should be
E. All the above
performed at 14 weeks to prevent“red degeneration”
Q 15. Which of the following viruses cannot be sexually later in pregnancy
transmitted? C. Can be effectively treated with an LH-RH analogue
A. Echovirus D. Commonly co-exist with endometriosis
B. Hepatitis B E. Are a common cause of acute retention of urine
C. Herpes simplex virus
D. Papovavirus Q 22. Which of the following symptoms is characteristically
E. None of the above associated with uterine fibromyomata?

Q 16. Which of the following is true regarding bicornuate A. Abdominal pain
uterus? B. Dysmenorrhoea
A. Is the commonest cause of unstable lie C. Dyspareunia
B. Should be treated surgically if pregnancy has D. Menorrhagia
resulted in premature delivery E. Vaginal discharge
C. Is associated with premature labour
D. Is a proven cause of recurrent miscarriage Q 23. Which of the following is true regarding myomec-
E. is associated with placental abruption tomy?

Q 17. A 16-year-old girl has primary dysmenorrhoea. A. Is an underused alternative to hysterectomy
Which is the most suitable treatment in this case? B. Is useful in the management of infertility
A. D&C C. Is useful in managing menorrhagia
B. Paracervical block D. Makes Caesarean section obligatory in subsequent
C. Non-steroidal anti-inflammatory drugs
D. GnRH analogue pregnancy
E. Laser ablation of the endometrium E. None of the above

Q 18. Which of the following procedures does not help Q 24. Which of the following is true regarding colposus-
correct retroversion of the uterus? pension for treatment of uterine retroversion?
A. Hodge pessary
B. A laparoscopic procedure A. Effectively treats dyspareunia
C. A sling operation B. Effectively treats frequency of micuturition
D. Pelvic floor repair C. Is an appropriate treatment for enterocoele
E. Gilliam’s operation D. Is associated with a need to treat rectocoele
E. Is usually performed vaginally
Q 19. Which of the following is true concerning intermen-
strual bleeding (IMB)? Q 25. Which of the following statement is not correct
A. IMB occurs in about 10% of normal menstrual cycles. regarding the mobile retroversion of the uterus?
B. Laparoscopy should be included as part of the
investigation. A. It is suspected when the cervix points anteriorly on
speculum examination

B. Is usually asymptomatic
C. Occurs at 20 weeks gestation
D. May occur in 20% of women
E. Occurs in the puerperium

13. A 14. E 15. A 16. C 17. C 18. D 19. D 20. B 21. D 22. D 23. E 24. D 25. C

mebooksfree.com

460 Textbook for MRCOG-1

Q 26. Which of the following changes does not commonly C. Is worse during the night than at day
occur in uterine leiomyomata? D. Results in the daily passage of larger volumes of
A. Atrophy
B. Calcification urine than normal
C. Hyaline degeneration E. Urodynamic studies in upper motor neuronal
D. Squamous metaplasia
E. Sarcomatous change diseases (for example, multiple sclerosis) show an
increased bladder capacity
Q 27. Which of the following is not correct regarding the
masses of ovarian origin? Q 34. Which of the following is acceptable surgical opera-
A. Include benign teratomas tion for the treatment of stress incontinence?
B. Those of germ cell origin may secrete hormones A. Anterior colporrhaphy
C. Are always malignant in the presence of ascites B. Colposuspension
D. May be confused with developmental abnormalities C. Marshall-Marchetti-Kranz operation
of the renal tract D. All the above
E. Careful surgical staging is essential to determine the E. None of the above
appropriate subsequent management
Q 35. Which of the following is true regarding colposus-
Q 28. Which of the following is true regarding central pension?
parenteral nutrition? A. Is normally done as a vaginal procedure
A. Does not cause derangement of liver function tests B. Is effective in relieving urge incontinence.
B. Is a hypo-osmolar solution C. Is effective in relieving dyspareunia
C. Is not associated with any metabolic disturbance D. Is associated with an increased incidence of posterior
D. Typically contains about 250 g glucose vaginal wall prolapse
E. Typically contains 14–16 g nitrogen as D-amino acids E. cannot be done via the laparoscope

Q 29. Which of the following is true regarding hirsutism? Q 36. Treatment with a ring pessary for vaginal prolapse is
A. Is synonymous with virilisation generally indicated in which of the following
B. Is pathological in most cases patients?
C. Is a side effect of cyproterone A. As the primary therapy when the patient is over
D. Androgensinwomenareproducedsolelyintheadrenal 75-years-old who is unfit for surgery
E. May be due to an ovarian tumour B. Who refuse operation
C. Wishing to become pregnant
Q 30. Dyspareunia may result from which of the following? D. Patient awaiting surgery
A. Adenomyosis E. All the above
B. The climacteric
C. Superficial vulvovaginitis Q 37. Which of the following is true regarding male infer-
D. All the above tility?
E. None of the above A. Is the primary cause in 10% of couples who fail to
conceive
Q 31. Which of the following is suggestive of genuine B. Always occurs after vasectomy
stress incontinence (GSI)? C. May be due to genital tract infection
A. Constant wetness D. Normal semen analysis involves a count > 20 million
B. Prolapse per ejaculate
C. Dysuria E. Azoospermia can be treated with ICSI.
D. Haematuria
E. Passage of large amounts of urine Q 38. Which of the following is true regarding a normal
semen specimen?
Q 32. Incontinence of urine in the female is investigated A. Contain 10 million white blood cells per ml
by which of the following tests? B. Have a sperm count of more than 20 million/mL
A. Cystometry C. Have a volume of more than 5 mL
B. Intravenous urography D. Have at least 80% motility
C. Urodynamic investigations E. Liquefy within 3 minutes
D. All the above
E. None of the above Q 39. Which of the following does not cause secondary
amenorrhoea?
Q 33. Which of the following is true regarding urge incon- A. Asherman’s syndrome
tinence in the female? B. Virilising ovarian tumours
A. Is improved greatly by an anterior repair procedure C. Endometriosis
B. Is improved by bladder drill and re-education D. Hyperprolactinaemia
E. Congenital hypothroidism

26. D 27. C 28. D 29. E 30. D 31. B 32. D 33. B 34. D 35. D 36. E 37. C 38. B 39. C

mebooksfree.com

•Chapter 14    Gynaecology 461

Q 40. A 30-year-old woman recently had amenorrhoea and Q 46. A 39-year-old smoker with two healthy children asks
galactorrhoea. Which of the following investigation for contraceptive advice. In these circumstances,
is not required? which of the following contraceptive advice must
A. Prolactin not be given?
B. Oestradiol A. A progesterone-only oral contraceptive
C. Luteinising hormone (LH) and follicle stimulating B. An IUD
hormone (FSH) C. Barrier methods
D. Pregnancy test D. Sterilisation
E. X-ray skull E. Combined oral contraceptive pills

Q 41. Which of the following statements concerning the Q 47. Which of the following statement regarding sterilisa-
hyperstimulation syndrome associated with the use tion is not correct?
of ovulation inducing agents is correct? A. In men has a failure rate of about 1 in 300 cases
A. It occurs with clomiphene B. Prevents pregnancy in a similar order of magnitude
B. It may be avoided by withholding the mid cycle to the Mirena levonorgestrel intrauterine system
injection of HCG in the presence of high oestrogen C. When it fails, it can be associated with an ectopic
levels pregnancy
C. Patients with polycystic ovaries before treatment are D. In women cause no change in the volume of
more likely to develop the syndrome menstrual bleeding loss
D. The incidence can be reduced by ultrasonic E. In women can be successfully reversed if clips were
examination used for the original operation in approximately 80%
E. All the above of cases.

Q 42. Which of the following regarding crytomenorrhoea Q 48. Which of the following statement is true concerning
is correct? copper-containing IUDs?
A. Is associated with the failure of development of the A. Do not cause menorrhagia
mesonephric system B. Have a higher incidence of actinomycosis
B. May be associated with Turner’s syndrome colonisation than plastic devices
C. There is failure of development of secondary sexual C. Have not been implicated as a cause of fatal infection
characteristics in pregnancies
D. May be associated with acute retention of urine D. Cause a relative increase in ectopic pregnancies
E. May have a karyotype 47 XXX E. Should be changed every year

Q 43. Which of the following concerning post-coital Q 49. Which of the following methods is used to locate a
contraception is correct? lost IUD?
A. The progesterone-only pill can be used. A. Ultrasound
B. Oral methods should be administered within 24 B. MRI
hours. C. Hysteroscopy
C. It is available only through prescription of the GP. D. Colpotomy
D. The intrauterine device has a role. E. None of the above
E. Follow-up of individuals who have used post-coital
contraception is not worthwhile. Q 50. Which of the following statement is not correct
regarding the progesterone-only pill?
Q 44. Use of the combined oral contraceptive pills A. Is a recognised cause of secondary amenorrhoea
is associated with an increased risk of which of the B. Can be safely given to lactating women and before
following? recommencing menstruation
A. Breast carcinoma C. Should not be prescribed to an individual with a
B. Endometrial carcinoma history of a deep venous thrombosis
C. Ovarian carcinoma D. Acts mainly by thickening the cervical mucus
D. None of the above E. Decreases tubal motility.
E. All the above
Q 51. Progestogen-only pills work as contraceptive agent
Q 45. Which of the following is a typical adverse effect of by which of the following mechanism?
combined oral contraceptive preparations? A. Acting as a spermicide
A. Breast tenderness B. Altering the cervical mucus
B. Hyperprolactinaemia C. Producing endometrial hyperplasia
C. Loss of libido D. Reducing libido
D. All the above E. Suppressing ovulation in all cases
E. None of the above

40. E 41. E 42. D 43. D 44. A 45. A 46. E 47. E 48. D 49. A 50. C 51. B

mebooksfree.com

462 Textbook for MRCOG-1

Q 52. Whichofthefollowingistrueregardingprogestogen- Q 58. Which of the following statement regarding contra-
only contraception? ceptive use is correct?
A. Are contraindicated in mild hypertension A. Oral testosterone is effective in the treatment of
B. Cannot be taken during the period of lactation male hypogonadism.
C. Causes HDL levels to rise B. Ovulation is inhibited by medroxyprogesterone
D. Has a lesser effect on hepatic function than the acetate.
combined oral contraceptive pill C. Intra-uterine device insertion is less effective than
E. Produces headaches more commonly than the the hormonal methods of emergency contraception.
combined oral contraceptive D. The oral contraceptive pill is free from central
nervous system side effects.
Q 53. Which of the following is true regarding injectable E. Combined oral contraceptives increase the risk of
progestogens used for contraceptive purposes? ovarian and endometrial cancers.
A. Carry a risk of venous thrombosis
B. Cause amenorrhoea in approximately 30% of patients Q 59. Which of the following statement regarding cypro-
C. Cause hypertension terone acetate is correct?
D. Can cause irregular vaginal bleeding A. Is an agonist of the beta oestrogen receptor
E. They have an effect on blood coagulation B. Is associated with visual disturbance as a recognised
side effect
Q 54. Which of the following instruction is appropriate C. Is used in the treatment of acne hirsutism
when advising on the use of the diaphragm? D. Its administration has no correlation with the day of
A. Always use a spermicide. menstrual cycle
B. Sterilise the diaphragm prior to insertion. E. Has androgenic properties
C. The diaphragm cannot be used at the same time as
the sheath. Q 60. Which of the following statement regarding the use
D. Refitting the diaphragm is not required after childbirth. of combined oral contraception is correct?
E. The diaphragm must be immediately removed A. The effectiveness of the combined oral contraceptive
following intercourse pill is increased by rifampicin.
B. Combined oral contraceptives increase the incidence
Q 55. Regarding condoms, which of the following state- of premenstrual tension.
ment is correct? C. Spironolactone, an aldosterone antagonist which is
A. Has the highest failure rate when used alone used as a diuretic, is also an antiandrogen.
B. Is the most effective contraceptive measure D. Previous venous thrombosis is a relative contra-
C. Should be put on just before ejaculation indication to the use of combined oral contraceptives.
D. Can reduce the transmission of sexually transmitted E. Cyproterone acetate can cause hirsutism.
diseases
E. Should be used in conjunction with spermicides Q 62. Which of the following statement is true regarding
the various types of hormonal contraception?
Q 56. Which of the following is a recognised risk associated A. Mifepristone is progestogenic.
with the use of combined oral contraceptive (COC) B. Cyproterone acetate leads to increased levels of
pills? cortisol in the blood.
A. Increased incidence of endometrial carcinoma C. Thyroid-binding globulin plasma concentration
B. Pelvic inflammatory disease is decreased in women using the combined oral
C. Benign ovarian cysts contraceptive pill.
D. Hypertension D. Regular menstrual cycles and fertility return to
E. Increased risk of ovarian carcinoma. normal within 6 months of the last progestogen
injection (Depo-Provera R).
Q 57. Which of the following statement regarding contra- E. Progestogens are not contra-indicated in patients
ception is correct? with porphyria.
A. There is an increased incidence of ovarian cancer in
the users of the combined oral contraceptive pill. Q 62. Which of the following statement is not true regard-
B. Conversion of cholesterol to pregnenolone is the ing the surgical wound infections?
rate-limiting step in the production of sex steroid A. Anaerobic organisms exert their lethal effects by
hormones. producing endo- and exotoxins
C. The combined oral contraceptive pill contains B. MRSA wound infection is usually the result of wound
between 10 to 100 μg of ethinyl oestradiol. contamination by hospital staff
D. Progesterones have a major role in the treatment of C. Necrotising fasciitis is commoner in carriers of MRSA
threatened abortion. D. Staphylococcus aureus is the commonest organism
E. Contraceptive implants (e.g. Implanon) provide up to infect the surgical wound
to 5 years of continuous contraceptive efficacy. E. With opportunistic organisms, they are the result of
a patient’s increased immune defence

52. D 53. D 54. A 55. D 56. D 57. B 58. B 59. C 60. C 61. D 62. D.

mebooksfree.com

•Chapter 14    Gynaecology 463

Q 63. Which of the following is true regarding Asherman’s B. Creatine phosphokinase (CPK) is a myocardial
syndrome? specific isoenzyme

A. Is associated with obstetric complications including C. Heart failure can be classified into four groups
post partum haemorrhage according to the NYHA classification system

B. Is characterised by menorrhagia D. Peri-operative myocardial infarction has a mortality
C. May be treated by forceps of approximately 10%.
D. May be treated by a Foley catheter
E. None of the above E. Risk of perioperative heart failure is approximately
47% if there is a pre-operative cardiovascular history
Q 64. Which of the following statement is not true regard­
ing fallopian tube occlusion? Q 69. Hypertension 1 hour following a laparotomy can be
due to all the below except which of the following?
A. may be caused by chlamydial infection A. Hypocapnia
B. Tubal occlusion is surprisingly uncommon even in the B. Hypoxia
C. Inadequate analgesia
presence of moderately severe pelvic endometriosis D. Malignant hyperpyrexia
C. When caused by infection most commonly ascends E. Urinary retention

from the lower genital tract Q 70. Following a major surgery in a normal person, which
D. May follow appendicitis of the following is observed?
E. Can be assessed using transvaginal ultrasound. A. Decreased heart rate
B. Decreased metabolic rate
Q 65. Which of the following drugs used in conventional C. Fall in blood glucose concentration
doses would be an effective pre-operative antiemetic D. Fluid retention
agent? E. Potassium retention

A. Atropine Q 71. Which of the following is not a risk factor for post-
B. Lorazepam operative wound infection?
C. Metoclopramide A. Chronic obstructive airways disease
D. Midazolam B. Diabetes mellitus
E. Ondansetron C. Haematoma formation
D. Incorporation of a synthetic mesh
Q 66. Which of the following is true regarding high-risk E. None of the above
patients?
Q 72. Which of the following is a predisposing factor for
A. Higk-risk patients must be placed at the end of an the development of keloid scars?
operating list to avoid infecting any subsequent A. Patients of Afro-Caribbean origin with dark complex-
patients ion
B. Secondary wound closure
B. The hepatitis B virus can be transmitted by splash C. Steroid therapy
contamination of the conjunctiva D. Use of local bupivacaine
E. Triamcinolone injection
C. Theskiniscleanedatleastfourtimeswithchlorhexidine
D. When double gloving it is usual to wear the inner Q 73. Does failure of wound healing in a surgical wound
does not result in which of the following?
glove a half-size larger than the surgeon’s usual size A. Cicatrisation
E. None of the above B. Hypertrophic scarring
C. Incisional hernia
Q 67. Which of the following is not true regarding skin D. Superficial wound disruption
preparation before surgery? E. Wound dehiscence

A. Alcohol pooled in the umbilicus must be removed Q 74. Which of the following is caused by the total paren-
B. Application of alcoholic solutions chlorhexidine teral nutrition?
A. Fatty acid deficiency
gluconate or povidone-iodine gives better disinfec­ B. Hypercarbia
tion C. Hyperglycaemia
C. Chorhexidine and cetrimide (Savlon) is advised D. Hypoglycaemia
when disinfecting the vagina and perineum E. All the above
D. Chlorhexidine gluconate 4% w/v is a clear solution
E. Povidone-iodine has a broader spectrum and
persists longer than chlorhexidine gluconate

Q 68. With regard to cardiac disorders in surgical patients,
which of the following is true?

A. 60% of patients will re-infarct if operated on within
3 months of a myocardial infarction

63. D 64. E 65. E 66. B 67. E 68. C 69. A 70. D 71. D 72. A 73. B 74. E.

mebooksfree.com

Index

Page numbers followed by ‘f ’ and ‘t’ indicate figures and tables respectively.

A Adrenal glands Amphibolic role of the citric acid cycle 133
blood supply 50 Amyloid material 163
Abdominal aorta, branches of 20f embryological origin 50 Amyloidosis 163
Abdominal cavity, contents of 20 lymphatic drainage 50 Anabolic steroids 438
Abdominal wall, see anatomy of nerve supply 50 Anaesthesia in pregnancy 409
Abnormalities of acid-base balance pathway for the synthesis of steroid complications 410
metabolic acidosis 75 adverse effect on the first stage of labour
metabolic alkalosis 76 hormones 330f
respiratory acidosis 75 venous drainage 50 410
respiratory alkalosis 76 Adrenal hormones aspiration of gastric contents 411
Absorption of glucose, see tubular reabsorption diseases due to the abnormality of 331 delayed respiratory depression with
Acetyl CoA molecules, see ketone bodies disorders of adrenal medulla 332
Achondroplasia, see autosomal dominant glucocorticoids 331 hydrophilic opioids 411
effect on carbohydrate metabolism 331 evidence of myocardial ischaemia on the
pattern of inheritance effect on fat metabolism 331
Acid-base balance 74 effect on protein metabolism 331 electrocardiograph 411
anion gap 75 mineralocorticoids 330 hypotension 410
determination of acid-base status 74 sex steroids 331 increased incidence of malpositions 410
Henderson-Hasselbalch equation 74 Adrenergic agents postural headache 411
compensatory mechanisms 74 beta-sympathomimetic drugs, side effects 345 risk of bleeding 410
regulation of acid-base balance 74 clonidine, side effects 345 venous air embolism 411
types of buffer system Adrenocorticotrophic hormone 329 entonox 411
bicarbonate buffer system 74 Adrenocorticotropin 153 epidural anaesthesia in labour 409
phosphate buffer system 74 Adrenogenital syndrome 258 indications 409
protein buffer system 74 Adult polycystic kidney disease 259t method of administration 410
Acromegaly, see sweating 274 Aerobacter aerogenes 174 pethidine analgesia in labour 411
Actinomyces, Actinomyces israelii 194 Aerobic conditions 131 Anaesthetic drugs
Actinomycosis 164, 165, 194, 435 Aetiopathogenesis of circulatory shock 174f characteristics of local anaesthetic agents 363t
Active immunisation 203 Akathisia, extrapyramidal side effects 345 classification of general anaesthetic agents
Acute Alanine, non-essential amino acids 149t
adrenal insufficiency 332 Alanine transaminase 102 364t
encephalitis 198 Alcohol consumption during pregnancy general anaesthesia 363
infectious hepatitis 198 foetal effects 368t lidocaine, side effects 363
inflammation maternal effects 368t local anaesthesia 363
cellular events 162 Alkylating agents, different types of 357t neuromuscular blocking agents 364
vascular events 162 Allergy to egg 218 regional anaesthesia 364
lymphoblastic leukaemia 279 Allograft 215 Anal canal
meningitis 198 Allosteric regulation 136 interior of the anal canal 39
poliomyelitis 198 Alpha carbon atom 147 musculature 40
respiratory distress syndrome 173 Alpha-fetoproteins 263 relations of the anal canal 40
Adaptive disorders Alpha-ketoglutarate 151 Anal triangle 55
atrophy 167 Alpha 1-antitrypsin deficiency 258 Analgesic drugs 346
dysplasia 168 Alpha thalassaemia 258 classification of 346t
heteroplasia 168 Alzheimer’s disease 259 morphine 347
hyperplasia 167 Ambiguous external genitalia 273 infants of opiate-abusing mothers 347
hypertrophy 167 Ambisexual period of development 243 nalorphine 347
metaplasia 167 Amenorrhoea causes of Anastomosis 17, 19, 21
Addison’s disease 332 primary amenorrhoea 437t Anatomy of 10-58
Adductor canal secondary amenorrhoea 437t abdominal cavity 20
boundaries 52 American Society of Reproductive Medicine 439 abdominal wall 15
contents of the canal 52 Amino acid female breast 13
Adenocarcinoma 177, 201 basic structure of 147f female pelvis 25
Adequate sterilisation and disinfection 198 in the body various structure of 148f foetus 55
Adhesive glycoproteins 166 various types of 149t inguinal region 23
thigh 50
thorax 10
urinary tract 45

mebooksfree.com

466 Textbook for MRCOG-1

Andersen’s disease, see glycogen storage angiotensin-converting-enzyme inhibitors Becker’s muscular dystrophy 259
diseases 139t 359 Benign and malignant tumours 169t
Benzodiazepines 428
Androgens in women 313 beta-adrenoceptor blocking drugs 360 Beta blockers propranolol 345
Androstenedione 313 calcium antagonists 360 Beta-hydroxybutyrate 145
Angiogenesis 164 different types of 359t Beta-lactam antibiotics 352
Angiotensin converting enzyme 330 labetalol 360 Beta-oxidation of unsaturated fatty acids 144
Ani muscles 443 phenytoin 361 Beta thalassaemia 258
Anococcygeal raphe 443 sodium valproate 361 Bias 292
Anovulation 322 Antimicrobial drugs 351 observer/responder bias 293
Antenatal period Anti-Müllerian hormone 179 selection bias 292
antiretroviral therapy during pregnancy 206 Antinuclear antibody estimation 385 Bicornuate uterus 452
invasive therapy 206 Antiphospholipid syndrome 214 Biguanides 347
monitoring for drug toxicity 206 Antipsychotic drugs, classification of Bimastoid diameter 57
screening for foetal anomalies 206 atypical antipsychotics 346t Biochemistry 124-160
screening for genital infections 206 butyrophenones 346t Biochemistry and nutrition 124
Anterior abdominal cutaneous branches of phenothiazines 346t Biochemistry of vitamins 153
thioxanthenes 346t Biophysics 278-286
thoracoabdominal nerves 18 Antiviral drugs acyclovir 356 Biparietal diameter 57
Anterior colporrhaphy 444t Antiviral drugs Bipolar diathermy 283
Anterior sagittal plane 28 amantadine 356 Bitemporal
Anthrax 195, 198 interferon 356 diameter 57
Antiamoebic drug metronidazole 355 zidovudine 356 hemianopia 306
Antibiotics Anxiolytic 428 Blastocyst 236
be avoided during pregnancy APGAR score 418 Blood coagulation
aminoglycosides 367 Apoptotic bodies 169 coagulation pathway 70
chloramphenicol 367 Appendectomy 96 platelets 70
ciprofloxacin 367 Arcus tendineus 445 tests of coagulation 71
co-trimoxazole 367 Arginine 149 activated partial thromboplastin time 72
erythromycin 367 Aromatisation of androgens 314 bleeding time 71
metronidazole 367 Arterial blood gas analysis 173 clotting time 72
nitrofurantoin 367 Arteries of the anterolateral abdominal wall 17f prothrombin time 72
tetracycline 367 Asherman’s syndrome 178, 439, 441 Blood pressure regulation 87
trimethoprim 367 Ashkenazi jews 272 Blood supply to the
classification of 352t Asparagine 149 anterior abdominal wall 17
mechanism of action of 352t Aspartate transaminase 102 brain 10
Anticancer agents Aspartic acid 149 Body fluids 72
alkylating agents 356 Assisted reproductive techniques 438 Bolam 4
antibiotics 357 Atheroma 172 Borrelia 194
antimetabolites 357 Atherosclerosis, mechanism of 171f Botulism 198
platinum derivatives 356 Atrophy 451 Bowel symptoms 442
spindle poisons 357 Attachments of perineal body 444f Bradykinin 87, 161
Anticoagulants Audit Branchial muscles and artery 246
heparin 357 cycle 5f Braxton hicks contractions 99
warfarin 358 definition 5 Breakdown of erythrocytes in the body 68
Antidepressant drugs steps of an audit cycle Breastfeeding 207
first-line drugs for treatment of depression data collection 5 Breech presentation
identification of standards 5 cord prolapse
346 initial needs assessment 5 diagnosis 415
atypical antidepressants 346 re-audit 5 management 415
selective serotonin reuptake inhibitors recommendations 5 external cephalic version 415
Autism 273 Bromocriptine and cabergoline 371
(SSRIs) 346 Autograft 215 Brucellosis 198
serotonin and noradrenaline reuptake Autoimmunity 213 Budd-Chiari syndrome 162
Autosomal dominant pattern of inheritance 259t Bulbospongiosus 44
inhibitors (SNRIs) 346 Autosomal recessive Bulbourethral glands 244
monoamine oxidase inhibitors 346 disorder 262f Burkholderia cepacia 272
reversible inhibitors of MAO-A 346 pattern of inheritance 258 Burkitt’s lymphoma 201
side effects 346 Axon 4
tricyclic antidepressants 346 Azoospermia 272 C
Anti-diuretic hormone 431
Antiemetic agents B Cadaveric donor fascia 446
classification of 348t Caesarean section 416
domperidone 348 Bacillus proteus 174 Café au lait spots 269
metoclopramide 348 Bacteria Calcification 452
ondansetron 348 anaerobic 185t Calcium ions 153
Antifungal drugs common forms of 183t Campylobacter 195
antibiotics 356 Bacterial toxins 196t Campylobacter coli 195
antimetabolite 356 Basal metabolic rate 155 Campylobacter jejuni 195
azoles 356 Basement membrane of cytotrophoblast 241
ketoconazole 356
Antigens 212
Anti-hypertensive agents
alpha-methyldopa 359

mebooksfree.com

Index 467

Cancers Children exposed in utero to X-ray irradiation Complications of diathermy
risk 267 279 operator error 284
specific markers for different types of 171t thermal injury 284
types of 170t Chlamydia 192 Concentration of disinfectant 197
Candidiasis Chlamydia trachomatis 192 Conditions specific to pregnancy 401
Candida albicans 207 Frei’s test 192 Confidential enquiries into
systemic candidiasis 207 genital chlamydiasis 192 maternal and child health 5
vulvovaginal candidiasis 207 infections of the genital tract 192 maternal deaths 5
Capillary endothelium 88 Chlorhexidine 428 maternal morbidity 5
Carbohydrate metabolism 130 Cholecystectomy 96 Congenital
Cardiac Cholera 198 anomalies 267
cycle 84f Chorda tympani 246 cytomegalovirus infection 200
disease during pregnancy 396 Chorionic villi formation 239 rubella 204
disorders in surgical patients 429 Chromophil cells 313 Congestive cardiac failure 173
Cardinal signs of inflammation 161 Chromophobe adenoma 306 Connective tissue capsule 177
Cardiovascular changes during normal Chromosomal Consent
abnormalities 268 components of 3
pregnancy 101t disorder 261t exceptions to the informed consent 2
Carneous degeneration 452 Chromosome informed consent 2
Carriers of genetic information basic structure of 256 types of consent
deoxyribonucleic acid 128 different types of 257f implied consent 2
methods of DNA analysis 129 Chronic inflammation 163 verbal consent 2
structure of DNA 128 Chronic osteomyelitis 430 written consent 3
Catabolism of Cicatrisation 430 Constituents of branchial arches 246f
proteinogenic amino acids 151 Cimetidine 438 Contraception
purine nucleotides 147 Circle of Willis 10 barrier contraception
Catecholamines 153 Classification of viruses cervical cap 433
Causative virus 170 RNA-containing viruses 199t diaphragm 432
Caverject 438 DNA-containing viruses 199t female condom 432
Cell division Cleavage division and formation of Morula 235 male condom 432
meiosis 231 Clinical spermicides 433
mitosis 230 evaluation of disturbances in acid-base combined oral contraceptives 435
Cell membrane 124 emergency contraception
Cell signalling and second messengers 151 status—anion gap 75 complications 437
Cells and humoral elements of acquired negligence scheme for trusts 6 indications 436
pharmacy management 436
immunity T cells 209 adverse drug reactions 344 intrauterine contraceptives complications
Cells of drug combinations 344 bleeding 435
cytotrophoblast 241 drug interactions 344 difficulties at the time of insertion 435
the gastric glands 91f trials expulsion 435
Cellular response to injury different types of 293 functional ovarian cysts 435
apoptosis 168 double-blind trial 293 infection 435
tissue necrosis 168 randomised controlled trials 293 pain or dysmenorrhoea 435
Centre for Maternal and Child Enquiries 5 single-blind trial 293 systemic hormonal side effects 435
Centrifuged blood 68t Clomiphene 438 uterine perforation 435
Centrosome and centrioles 125, 126 Clostridia progestogen-only contraceptive methods
Cerebral circulation C. botulinum 190 depo-provera 434
anterior 10 C. difficile 190 injectable progestogens 434
posterior 10 C. perfringens 190 progestogen-only pill 433
Cerebral gliomas 279 C. tetani 190 Coomb’s test 219f, 220
Cervagem (gemeprost) 385 Clostridium 190 direct Coomb’s test 219f
Cervical Clostridium perfringens 191 indirect Coomb’s test 219f
cancer 170, 176 Clostridium tetani 191 Cooper’s ligament 445
factor infertility 439 Cocaine and pregnancy 367 Cordocentesis 201
intraepithelial neoplasia 176 Co-dominant inheritance 259 Cori’s cycle 138, 140f
Chadwick’s or Jacquemier’s sign 98 Codons code 254 Coronal suture 55
Characteristic phenotype 267 Cognitive and behavioural disturbances 370 Corpus
Chediak-Higashi syndrome 213 Colectomy 96 atreticum 234
Chemical Colposuspension 445 luteum 315
agents Columnar metaplasia 167 Corynebacterium 190
heavy metals 197 Comparison between fatty acid oxidation and Cri du chat syndrome 261
oxidising agents 197 Crohn’s disease 376
phenol derivatives 197 synthesis 145 Cryptomenorrhoea 437
surface-active agents 197 Complement activation pathway 216 Cuboidal cells of endoderm 238
mediators of inflammation 162t Complete hydatidiform mole Cushing syndrome 332
structure of hormones aetiology 385 Cyanosis 430
amino acid hormones 300 clinical presentation 386 Cyclic adenosine monophosphate 314
peptide hormones 300 general physical examination 386 Cysteine 149
steroid hormones 300 investigations 387 Cystic
Chemoreceptors 79t obstetric management 387
Chiasmal compression 306 per abdominal examination 386
vaginal examination 386

mebooksfree.com

468 Textbook for MRCOG-1

degeneration 452 Diathermy/electrosurgery 283 tetracycline 371
fibrosis 258 Diazepam 345 thiazide diuretics 371
clinical features 271 Different types of for inducing and inhibiting vomiting 348
treatment 272 blood cells 69f for thyroid abnormalities antithyroid drugs
Cytomegalovirus 199, 200 epidemiological studies
Cytoplasm 124 case-control study 294 365
Cytoplasmic organelles without limiting cohort studies 294 for treating galactorrhoea
cross-sectional studies 294 bromocriptine 362
membrane 125t, 127, 128 meta-analysis 294 cabergoline 362
Cytosine-thymine-guanine 260 open study 294 in gynaecology
Cytotrophoblastic shell 240 Diffusion hypoxia 429 clomiphene citrate
Digestive system contraindications 372
D mouth/saliva 91 dosage 372
pancreas 92 indications 372
Dead cells 163 small intestine 93 mechanism of action 372
Decidua basalis 239 stomach 91 side effects 372
Deep perineal pouch 55 Dihydrotestosterone 244, 313 cyproterone acetate
Deep vein thrombosis 173, 214, 294 Diphtheria 198 contraindications 375
aetiology 416 Diploid 258 dosage 375
clinical presentation 416 Disease causation mechanism of action 375
investigations 416 analogy 288 side effects 376
management 417 biological gradient 288 danazol
risk factors for 416 coherence 288 contraindications 374
Defective wound healing 430 consistency 288 dosage 374
Dehydroepiandrostenedione 313 experiment 288 indications 374
Dendritic cells 211 plausibility 288 mechanism of action 374
Denominator 58 specificity 288 side effects 374
Deoxygenated blood 249 strength 288 LHRH analogues
Deoxyribonucleic acid 254 temporality 288 contraindications 373
Derivative of pharyngeal pouches 247 Diseases caused by spirochetes 193t dosage 373
Dermoid cysts of the ovary 449 Diseases of indications 373
Development of (embryology) blood vessels mechanism of action 373
central nervous system 247 atherosclerosis 171 route of administration 373
external genitalia 244, 245 berry aneurysms 172 side effects 373
foetal heart 248 embolus 173 other drugs used commonly 376
genitourinary system 243 pulmonary embolism 173 interfering with glucose metabolism drugs,
gonads 243 thrombosis 172
human embryo 235 lymph nodes 175 causing hyperglycaemia
human placenta 238 Disorders of thyroid gland 307 corticosteroids 347
internal genitalia 243 Disorders related to nutrition 155 glucagon 347
neural tube 248 Distal convoluted tubule 88 thiazide diuretics 347
pharyngeal arches in the region of hindbrain Disturbances in respiration aspirin 347
bronchial asthma 83 atenolol 347
246f chronic respiratory failure 83 ethanol 347
urinary tract 245 cough reflex 83 gliclazide 347
vagina 245 cyanosis 83 likely to have deleterious effects during
Diabetes 430 Diuretics
Diabetes in pregnancy 396 loop diuretics 347 lactation 371t
antenatal care 397 osmotic diuretics 348 secreted in breast milk drugs which reach the
management 396 potassium sparing diuretics 348
pre-pregnancy advice 397 thiazide diuretics 348 baby in
screening for diabetes 397 Diurnal variation 300 insignificant amounts 371
Diabetes mellitus DNA-histone complex 127 sufficient amounts 371
characteristic features of diabetes Doderlein’s bacilli 32, 314, 320 undetectable in the baby 371
Domperidone 306 Drugs
ketoacidosis 312t Dopamine antagonists 306t which can be used during breastfeeding
classification of diabetes ketoacidosis 312t Doppler ultrasound 282 antihypertensive agents 371
complications of diabetes 311 Dorsal nerve of the clitoris 44 metronidazole 371
diagnosis 311 Down syndrome propranolol 371
difference between type I and type II diabetes clinical features 263 ranitidine 371
screening of 263 warfarin 371
mellitus 311 Drugs Duchenne muscular dystrophy 259, 269
Diacylglycerol 153 acting on the uterus 349 Ductulus aberrans
Diameters of contraindicated during lactation 371 inferior 244
foetal skull 57 androgens 371 superior 244
pelvic outlet 28 bromocriptine and cabergoline 371 Ductus
the pelvic inlet 27 labetalol 371 arteriosus 250
Diaphragm methyldopa 371 venosus 249, 250
apertures in the diaphragm 11 sulphonamides 371 Dysfunction of the growth hormone 305
attachments of the diaphragm 11 Dyspareunia, causes of 441t
blood supply 12 Dysplasias
embryology 12 mild dysplasia 176
nerve supply 12

mebooksfree.com

Index 469

moderate 176 Endometriosis 439, 453 Evidence-based medicine 1
severe 176 Endometriotic lesions 454 grading criteria 1t
Dystrophia myotonica 259 Endopelvic fascia 446f grading of recommendations 1t
Endoplasmic reticulum 124, 125 levels of evidence 1t
E Endoplasmic reticulum, structure of 125f pyramid various levels of evidence 1f
Endothelial Excitation 279f
Early pregnancy gaps 162 Exons 255
care 384 injury 172 External genital primordia 244
loss 384 Endothelium and basement membrane 241 External
investigations 385 Energy released by different food products 155 iliac artery 43
medical termination of pregnancy 385 Enteric fever 184, 198 pudendal artery 42
miscarriage at 10 weeks 384 Enterobacteriaceae 192 Extracellular matrix 166
treatment 385 Enzyme guanylyl cyclase 153 Extraembryonic mesoderm 241
Echogenic bowel 200 Epidemiology 287 Extravascular space 162
Eclampsia confidence interval 289 Exudation of leucocytes in cases of acute
complications confounding factor 288
foetal 407 disease causation 288 inflammation 162f
maternal 407 analogy 288
obstetric management 406 biological gradient 288 F
symptoms 406 coherence 288
Ectopic pregnancy 390, 435 experiment 288 Facioscapulohumeral muscular dystrophy 260
aetiology 390 plausibility 288 Factors influencing wound healing
clinical examination 390 specificity 288 local factors
heterotopic pregnancy 391 strength 288 amount of tissue separation in the wound
investigations 391 temporality 288
symptoms 390 evaluation of a clinical test 287 166
Edward’s syndrome 261, 263 negative predictive value 288 exposure to ionising radiation 166
Electrolyte imbalance positive predictive value 288 exposure to ultraviolet light 166
hyperkalaemia 77 sensitivity 287 foreign bodies 166
hypernatraemia 76 specificity 287 infection 166
hypocalcaemia 77 incidence 287 lymph drainage 166
hypokalaemia 76 null hypothesis 289 movement 166
hyponatraemia 76 percentile 288 necrosis 166
Electron transport system pathway 133 power 289 type, size and location of injury 166
Embden-Meyerhof pathway 130, 131 prevalence 287 vascularity 166
Embryology 230 probability 289 systemic factors
Emetic drugs relative risk 288 administration of glucocorticoids 167
apomorphine 348 reliability 288 age 167
contraindications 349 screening program 288 diabetic patients 167
ipecacuanha 349 variables haematologic abnormalities 167
Empty sac 384 continuous variable 288 nutrition 167
Endocrine anomalies 268 discrete variable 288 systemic infection 167
Endocrinology 298-343 Epidermal ingrowth 164 temperature 167
female reproductive system 343 Epilepsy and pregnancy 395 Fallopian tube 32, 441
general endocrinology 298 Epithelial metaplasia, example of 167t Familial
hormones produced by the gonads 299t Epstein-Barr virus (diagnosis test) 201 adenomatous polyposis 259
hormones produced in the body by the DNA probe 201 breast and ovarian cancer 259
ELISA 201 hypercholesterolaemia 258, 259
endocrine glands 299t Monospot test 201 mediterranean fever 258
major endocrine glands in the body 298f Paul-Bunnell test 201 Fate of
maternal-foetal placental unit 299f PCR and virus isolation 201 acute inflammation 163f
principles of parathyroid 327 Western blot 201 of germ layers 242t
puberty and adolescence 348 Erythema Female
understanding of adrenal structure and chronicum migrans 175 breast
induratum 175 anatomy of 13
function 329 infectiosum 175 blood supply 14
understanding of pancreas 309 marginatum 175 embryology 13
understanding of sex hormones 342 multiforme 175 lymphatic drainage of the breasts 14
Endocrinology of lactation 418 nodosum 175 nerve supply 15
Endodermal 244 Erythrocyte sedimentation rate infertility
Endodermal cells 238 increased ESR 68 causes of female infertility 439t
Endogenous pyrogens 196 reduced ESR 68 clinical features 440
Endometrial Escherichia coli 174 diagnosis 440
biopsy 317 Eukaryotic cells 254, 255 medical treatment 440
cancer 323 Evaluation of a clinical test polycystic ovarian syndrome 439
cavity 317 negative predictive value 288 surgical management 440
changes 317 positive predictive value 288 internal genitalia 31
glands 315 sensitivity 287 pelvis anatomy of 25
hyperplasia 325 specificity 287 urethra 49
receptors 325 Femoral
stroma 315 artery 52

mebooksfree.com

470 Textbook for MRCOG-1

branch of the genitofemoral nerve 51 Forbe’s or Cori’s disease 139 Gillick’s competence 3
ring 52 Formation of Glassware 197
sheath 51 acetyl CoA and the citrate shuttle 142 Glomerular filtration rate 90
triangle blastocyst 235 Glomerulonephritis 88
boundaries 50 foetal blood cells 250 Glomerulus 88
contents of the femoral triangle 50 malonyl CoA 142 Glucagon and adrenaline 144
femoral nerve 50 malonyltransferase by fatty acid synthetase Gluconeogenesis 138
Fertilised ovum 237f Glucose transporters 89
Fetomaternal haemorrhage 219 using acetyl CoA 142 Glucose tubular transport maximum 90
Fibrin 163 pharyngeal arches 246 Glucose-6-phosphate dehydrogenase deficiency
Fibrofatty plaques 171 Fragile x syndrome 255, 259, 273
Fibroids, different types of 177f Frank’s dilators 179 270
Fibromyomas 177 Fraser guidelines 3 Glutamic acid 149
Fibromyomata Friedreich’s ataxia 258 Glutamine 149
degenerative changes in the fibromyomatas Fructose metabolism Glycine 149
liver 140 Glycogen
451 muscle and adipose tissues 140 storage diseases, various types of 139t
indications for surgical treatment of fibroids Functional closure of structure of 135f
ductus venosus 250 Glycogenesis
(t) 450 ductus arteriosus 250 regulation of glycogenesis 136
management 450 steps 135
myomectomy 450 G Glycogenolysis 136
pregnancy in presence of fibroids 451 Glycolysis 131
uterine artery embolisation 451 Galactorrhoea 306 Glycosylated haemoglobin 385
Fibroplasia 164 Galactosaemia 258 Golgi
Filtration 197 Galactose metabolism apparatus 125
Fistula repair 442 cerebrosides 140 complex, structure of 126f
Five-alfa reductase deficiency chondromucoids 140 Gonadotropin-releasing hormone 306, 312
clinical features 266 Gametogenesis 231 Gonococcus 189
treatment 267 Gamma-aminobutyric acid 153, 345 Gonocytes 243
Flap closure of foramen ovale 250 Gartner’s duct 244 Graft-versus-host (GVH) reaction 215
Foetal alcohol spectrum disorders 368 Gastrectomy 95 Granuloma formation mechanism of 164
category 1 Gastric adenocarcinoma 170 Granulomatous type chronic inflammation 164
confirmed maternal alcohol exposure 368 Gastrinomas 333 Granulosa cells 315
dysmorphia 369 Gastrointestinal symptoms Great saphenous vein 53
category 2 bowel obstruction 272 Growth hormone 304, 431
FAS without confirmed maternal alcohol damage to the pancreas 272 Guanethidine 438
gastrointestinal abnormalities 272 Guanine and uracil 254
exposure 370 rectal prolapse 272 Gynaecoid pelvis 29
category 3 Gaucher’s disease 258 Gynaecologic cancer 177
growth restriction 370 Gene 255 Gynaecological abnormalities
neurodevelopmental and behavioural or Genetic aetiopathogenesis 178
and endocrine disorders, causes of male pathology of
cognitive abnormalities 370 common congenital abnormalities 179
partial FAS 370 infertility 438t miscarriage 178
category 4 anticipation 260 Gynaecology 428-463
alcohol-related birth defects 370 carriers 261 contraception 431
category 5 Genital gynaecological abnormalities 437
cognitive and behavioural disturbances herpes infection surgical skills 428
investigations 457
370 medical management 457 H
neurodevelopmental anomalies 370 symptoms 456
Foetal tract fistulae 441 Haematocrit
blood 250 tubercle 244 value 68
circulation 248 ulcers, causes of 455t blood 67
adult circulation 248 warts 456 erythrocyte sedimentation rate 68
just before birth 249 Genitofemoral nerve 51 haematocrit value 68
outside the uterine cavity 250 Gestational trophoblastic increased ESR 68
denominators 58t disease 385 red blood cells (erythrocytes) 67
distress indicators of foetal distress 414 neoplasia reduced ESR 68
distress management 414 advice related to contraception 389 white blood cells 68
intrauterine death 7 clinical presentation 388 basophils 69
definition 8 hormone replacement therapy 389 classification of 69
diagnosis 8 invasive mole 390 eosinophils 69
management 8 investigations 388 lymphocytes 70
Foetal skull 56 management of twin pregnancy with monocytes 69
Folic acid 154 neutrophils 69
Follicle-stimulating hormone 153, 274 molar gestation 389 Haemophilia A 72, 268
Follicular phase 315 persistent gestational trophoblastic Haemophilus influenza 272
Food poisoning
infective type 198 disease and choriocarcinoma 389
infective-toxic type 198 placental site trophoblastic tumour 390
toxic type 198

mebooksfree.com

Index 471

Haemorrhage Human Immediate effects of surgery in normal person
and necrosis 173 herpesvirus 1 199 429
gastroenteropathy 174 herpesvirus 2 199
Haemorrhagic shock 174 herpesvirus 6 to 8 201 Immune response 208
Half-life of hormone 299 herpesviruses, classification of Immunisation for haemophilus influenzae 216
Hamburger’s phenomenon 81 alpha herpesvirinae 200 Immunodeficiency 213
Healing by beta herpesvirinae 200 Immunogenetics and principles of antigen
first intention (primary union) 164 gamma herpesvirinae 200
second intention (secondary union) 166 immunodeficiency virus 205 recognition 212
Hearing loss 200 leucocyte antigens 124 Immunoglobulins
Hegar’s sign 99 papillomavirus 175, 201 immunoglobulin A 213
Hemochromatosis 258 placenta 240 immunoglobulin E 213
Hepatitis viruses placental lactogen 96 immunoglobulin G 213
A virus 202 sex chromosomes immunoglobulin M 213
B core antigen 202 Lyon hypothesis 257 Immunological problems in pregnancy 214
B e-antigen 202 x chromosome 257 Immunology 208-220
B surface antigen 202 y chromosome 258 Immunology of transplantation 214
B virus, structure of 202f Huntington’s chorea 255, 259 Impact on obstetricians’ lives 7
C virus 203 Hurler’s syndrome 258 Important landmarks of foetal skull 57f
D virus 204 Hyaline degeneration 451 Inadequate analgesic effect 429
E virus 204 Hydatidiform mole 258 Incisional hernias 430
G virus 204 Hydramnios Incontinence 445
Her’s disease 139 abdominal examination 403 Incurable cases 438
Hereditary non-polyposis colon cancer 259 aetiology 403 Infection
Hermaphroditism 274 clinical presentations 403 determinants of virulence 195
Herpes group of viruses 199 complications foetal 404 disease causation 195
Hexose monophosphate shunt pathway 133 complications maternal 404 febrile response: a mediator of infection 196
non-oxidative phase 134 investigations 403 modes of transmission of infection 195
oxidative phase 134 management 403 sources of infection 195
significance of hexose monophosphate shunt management foetal treatment 404 toxins 196
management maternal treatment 404 zoonotic diseases 195
pathway 134 Hypercapnia 429, 430 Inferior
Hirsutism Hyperemesis gravidarum 407 epigastric vessel 17
causes of 447t Hyperkalaemia 430 haemorrhoidal 44
hormonal treatment 448 Hyperparathyroidism vena cava 248
investigations 447 primary hyperparathyroidism 328 Infertility 438
management of 448f secondary hyperparathyroidism 328 Inflammation in response to injury 161f
non-hormonal drugs tertiary hyperparathyroidism 328 Influenza vaccine 6
eflornithine 449 Hyperprolactinaemia due to prolactinoma 306 Inguinal canal
finasteride 449 Hypersensitivity boundaries 23
flutamide 449 type i reaction 215 contents of females 24
metformin 449 type ii reactions 215 contents of males 24
spironolactone 449 type iii reactions 215 ligament 24
risk factors for 447t type iv reactions 215 Inhibin 313, 315
treatment 448 Hypertension 268 Innate and acquired immunity
Histamine 161 Hyperthermia 430 acquired immunity 209
Histidine 149 Hyperthyroidism 309 active immunity 209
HIV and pregnancy 205 Hypertrophic cardiomyopathy 259 passive immunity 209
Hodgkin’s disease 201 Hypnotics, sedatives and anxiolytics B lymphocytes 211
Homeostasis and the fluid balance 72 long-acting hypnotics 345 natural killer cells 211
Homocystinuria 258 short-acting hypnotics 345 phagocytic cells 211
Hormonal regulation 136 Hypogastric Inositol triphosphate 153
Hormone receptors 301 arteries 249, 250 Insulin 144
Hormone-mediated regulation of glycogenolysis plexus 43 Insulinomas 333
Hypoglycaemia 274 Intelligence, typical feature of Turner’s syndrome
138 Hypoparathyroidism 328
Hormones posterior pituitary Hypopituitarism 306 267
oxytocin 307 Hypothalamic secretion of dopamine 306 Intermediate cutaneous nerve of the thigh 51
vasopressin 307 Hypothalamus Internal iliac artery, branches of 42
Hormones produced by anatomy 302 Interpretation of anti-cytomegalovirus
other organs 299 embryology 302
the gonads 299 Hypothyroidism 309 antibodies in the serum 201
Hormones regulating tubular reabsorption 89f Hysterectomy 444t Intra-abdominal pus
Hot flushes 324 actinomyces 430
Human chorionic gonadotropin 239, 263, 315 I bacillus 430
Human chromosomes bacteroides 430
acrocentric chromosomes 257 Iliococcygeus 443 clostridia 430
metacentric chromosomes 256 Iliohypogastric and ilioinguinal nerves 18 enterococci 430
submetacentric chromosomes 257 escherichia coli 430
telocentric chromosomes 257 klebsiella spp 430
peptostreptococci 430
proteus 430

mebooksfree.com

472 Textbook for MRCOG-1

Intracellular signal transduction 152 Klinefelter’s syndrome 261, 264, 313, 438 hypogastric group 45
Intracranial calcification 200 Korotkoff sounds inguinal group 44
Intra-cytoplasmic sperm injection 272, 438 fifth phase 87 internal iliac group 45
Intrauterine first phase 87 lumbar group 45
foetal death, causes of 7t fourth phase 87 pararectal group of lymph nodes 45
growth restriction 200 second phase 87 sacral group 45
foetal 395 third phase 87 Lymphadenopathy 175
maternal 395 Kreb’s Lymphatic drainage of the anterior abdominal
Intrinsic sphincteric damage 446 cycle 130, 131
Inulin clearance 90 pathway 131 wall 18
Ionisation and excitation 279 Lyon’s hypothesis 258, 273
Ionising radiation L Lysine 149
alpha particle 278 Lysosome 125, 126
beta particles 278 Labioscrotal folds 244
gamma rays 278 Labour and delivery M
positron 278 corticosteroids 207
X-rays 278 mode of delivery 207 Male and female pelvis difference 29t
Iron deficiency anaemia precautions during delivery 207 Male infertility
aetiology 392 role of caesarean section 207 causes of 438
causes of iron deficiency anaemia 393t Lambdoid suture 55 diagnosis 438
classification of anaemia based on the blood Landouzy-Dejerine disease 260 investigations 439
Langhan’s giant cells 164 treatment
values 393t Lasers lifestyle modification 438
clinical symptoms 392 classes of 284 medical therapy 438
complications due to anaemia 394 principle of 284 Male internal genitalia 38
general physical examination 393 safety precautions at the time of using lasers Malignant
investigations 393 hyperpyrexia 429
management in the antenatal period 394 285 neuroleptic syndrome 345
sickle cell disorders in pregnancy 395 Lateral cutaneous Malonyl CoA as a substrate 142
Ischial tuberosities 54 branches 18 Manchester operation 444t
Ischiocavernosus 44 nerve of the thigh 51 Manchester repair 444
Ischiococcygeus 443 Le Fort colpocleisis 444t Mast cells 211
Ischiopubic rami 54 Leber’s hereditary optic neuropathy 256 Maternal
Isograft 215 Leigh syndrome 256 and foetal complications associated with
Isolation 198 Leiomyomas 439
Isoleucine 149 Leishmaniasis 208 alcohol consumption during pregnancy
Leptospira 194 368t
J Leucine 149 characteristics 7
Leucocytic 162 infection 200
Japanese B encephalitis 199t Levator ani muscle 443 pelvis anterior view of 26f
Jaundice Leydig cells 244 side of the placenta 241f
characteristics of different types of 95t Lifespan of different types of white blood cells Mayer-Rokitansky-Küster-Hauser syndrome 179
in newborn 419 McArdle’s disease 139
causes related to increased haemolysis 69t McCune-Albright syndrome 269
Ligaments of the pelvic floor 443f Mechanism of action of hormones
420 Ligamentum arteriosum 250 situation of the hormone receptors 301
drugs 420 Lipid digestion and absorption 95f protein hormone receptor 302
management Listeria monocytogenes 188 steroid hormone receptors 301
exchange transfusion 420 Liver in the regulation of blood glucose levels Medial
phototherapy 420 cutaneous nerve of the thigh 51
Job’s syndrome 213 141 view of maternal pelvis 27
Juxtaglomerular apparatus 330 Loop of henle 88 Median sacral artery 42
Juxtamedullary tubules 88 Lorazepam 428 Mediators of acute inflammation 163
Lumbosacral plexus 54 Medical disorders during pregnancy 392
K Lung capacities Meigs’ syndrome 162
forced Menopause
Kallmann’s syndrome 259 expiratory volume 78 changes in the levels of various hormones
Kaposi’s sarcoma 201, 205 vital capacity 78 323
Karyorrhexis 169 functional residual capacity 78 symptoms 323
Karyotype inspiratory capacity 77 various effects related to menopause 324t
abnormalities in some common total lung capacity 78 Menstrual fluid 317t
vital capacity 78 Mental Capacity Act 2005, powers of attorney 4
chromosomal disorders 261t Lung volumes Mesenchymal cords 240
46xx 386 expiratory reserve volume 77 Mesoderm 241
Kearns-Sayre syndrome 256 inspiratory reserve volume 77 Mesonephric ducts 246
Keloid scars 431 residual volume 77 Messenger RNA 130
Kernicterus 94 tidal volume 77 Metabolic
Ketogenesis 145 Luteal phase 315 changes 430
Ketone bodies 145 Luteinising hormone 153, 312, 314 responses to trauma 431
Kinin system 162 Lymph nodes of pelvis Metabolism of
Kleihauer common iliac group of lymph nodes 45 fats
Betke test 219 external iliac group 45
blood test 385

mebooksfree.com

Index 473

fatty acid b-oxidation 143 Nephron, structure of 88f Outer parietal layer 88
lipogenesis 142 Nerve supply of the Ovarian
glucose 130 anterior abdominal wall 18 artery and vein 42
nucleotides 146 lower limbs 54 factor infertility 439
Metacentric chromosomes 256 Nerve to pectineus 51 follicles 234
Metaplasia and dysplasia 168t Neurofibromatosis 258, 259, 270 fossa 34
Methergine Neurohumoral response 431 hyperstimulation syndrome 440
contraindications 351 Neutral primordia 244 masses 449
dosage 351 Neutrophil polymorphs 162 dermoid cysts of the ovary 449
indications 351 New York Heart Association, functional management 450
route of administration 351 surgical treatment
side effects 351 classification of heart failure 429t Baldy-Webster’s operation 450
Methicillin-resistant, Staphylococcus aureus 430 Nicotinamide adenine dinucleotide 130, 131 modified Gillam’s ventrosuspension
Methionine 149 Nitric oxide 153
Methyldopa 306, 438 Non-steroidal anti-inflammatory drugs 428 450
Metoclopramide 306, 428 Noonan’s syndrome 263, 268 Ovaries 33
Metopic suture 55 Normal cardiovascular changes during blood supply 34
Microbiology 183-208 lymphatic supply 34
Microdeletions 261 pregnancy 101f nerve supply 34
Microvillus cells 315 Normal labour and delivery relations 34
Midazolam 428 delay in the second stage of labour 411 relations of the ovarian artery 34
Mifepristone elective episiotomy 413 Ovulation 234, 315, 316
dosage 375 high foetal head 411 Oxidation of acyl CoA 144
indications 374 partogram 412 Oxidative phosphorylation 133
mechanism of action 374 Normal menstrual cycle 315 Oxygen carrying capacity of haemoglobin 81
side effects 375 Notifiable diseases 198 Oxygen-haemoglobin dissociation curve 81
Misoprostol 385 Nuchal effect on respiration at high altitude 83
Mitochondria 125 cord 8 pulse oximetry 83
Mitochondrial DNA 255 translucency 263 shift of oxygen dissociation curve to the
Mitochondrion 126 Nucleus 125, 127 left 81
Mittelschmerz syndrome 316 Nutritional physiology in health and disease 153 the right 82
MMR vaccination 217 Oxytocin
Monoamine oxidase inhibitors 306 O adverse effects 350
Mucopolysaccharidoses 258 contraindications 350
Müllerian Oblique diameters of pelvic inlet 28 indications 349
agenesis Obstetrics 384-420 mode of administration 349
clinical features 266 cholestasis 401
treatment 266 conditions specific to pregnancy 401 P
ducts 243 early pregnancy care 384
Multiple endocrine neoplasia 259 epidemiology Packed cell volume 68
MEN 2a syndrome 333 infant mortality rate 290 Palmer’s sign 99
MEN 2b syndrome 333 neonatal deaths 289 Pancreas
MEN ii syndrome 333 perinatal mortality 289 action of insulin 310
Multiple pregnancy stillbirth rate 289 glucagon 310
aetiology 401 gestational trophoblastic diseases 385 insulin 310
complications 401 medical disorders during pregnancy 392 somatostatin 310
labour 402 post-partum complications 416 Pancreatectomy 96
maternal complications during the significance of the anterior fontanelle 56t Papanicolaou (PAP) test 177
structural changes in the newborn 418 Paracrine factors 431
antenatal period 401 transverse diameter 28 Paradidymis 244
puerperium 402 Ocular anomalies 268 Paraneoplastic syndromes and their associated
Muscles of the Oesophageal cancer 170
anterior abdominal wall Oestradiol 313 malignancies 170t
external oblique muscle 15 Oestrogens 314 Parathyroid glands
internal oblique muscle 15 Oligomenorrhoea 306 parathyroid hormone 326
pelvic floor 443f Oncofoetal antigens 171 role of calcium ion 327
Muscular dystonias 345 Oogenesis 233 serum calcium regulation 326
Musculophrenic artery 17 Opioid analgesic agent 363 Paraxial mesoderm 242
Mycobacterium 430 Opsonisation 162 Parietal eminences 57
Mycobacterium avium 272 Organisation of the immune system 208 Partial mole
Mycobacterium tuberculosis 163 Organogenesis 242 clinical presentation 388
Mycology cryptococcosis 207 Oropharynx 201 investigations histopathological examination
Mycoplasma 192 Osiander’s sign 98
Myocardial infarction 429 Osteoporosis 267, 324 388
Myometrial muscles 239 alternative treatments 325 investigations ultrasound examination 388
Myotonic dystrophy 255 risk factors for the occurrence of 325t management 388
N bisphosphonates 324 Parvovirus 205
Nasopharyngeal carcinoma 201 hormone replacement therapy 324 Patau’s syndrome 261, 263, 264
National Institute of Clinical Excellence 5 selective oestrogen receptor modulators Patent ductus arteriosus 204
Neisseria 188 Pathology of 161-182
324 miscarriage
tibolone 324 complete abortion 178

mebooksfree.com

474 Textbook for MRCOG-1

incomplete abortion 178 Pharyngeal arches 246 kinins 161
inevitable abortion 178 Phenothiazines 306 protein-derived mediators 162
missed abortion 178 Phenylalanine 149 Pleura 12
threatened abortion 178 Phenylketonuria 258 Polycystic
various skin lesions 175 Phosphatidylinositol 153 ovary syndrome 313
Pearson’s chi-squared test 290 Phrenic nerve relations of the renal disease 172
Pelvic left phrenic nerve 13 Polygenic inheritance 259
axis right phrenic nerve 13 Polymerase chain reaction 129, 201
anatomical axis 29 Physiological changes in pregnancy Polyostotic fibrous dysplasia of bones 269
obstetric axis 29 carbohydrate metabolism during pregnancy Polyposis coli 259
cavity Pompe’s disease 139
diameters of pelvic cavity 28 103 Poor haemostasis 430
plane of cavity 28 changes in Posterior
inlet 26 breast 99 abdominal wall 19
nerves 43 cardiovascular system during pregnancy colpoperineorrhaphy 444t
organs: part of the gastrointestinal tract 38 Post-operative
outlet 28 101 nutrition 431
part of autonomic nervous system 43 genital organs 98 wound infection 430
prolapse liver function tests during pregnancy 102 Post-partum
supports of the uterus 442 occurring in the gastrointestinal tract complications 416
symptoms 442 haemorrhage 417
tumours 449 during pregnancy 102 Power of suggestion 293
different types of 25f occurring in the renal system during Prader-Willi syndrome 261
Penicillins Precocious puberty 269
aminoglycosides 355 pregnancy 102 Pregnancy and the immune system
ampicillin and amoxicillin 353 respiratory system during pregnancy 102 ABO incompatibility disease 218
cephalosporins 353 thyroid glands during pregnancy 103 changes in the immune system 218
chloramphenicol 354 haematological changes during pregnancy Rh incompatibility disease 218
co-trimoxazole 353 Pregnancy dating 384
erythromycin 354 100 Naegele’s rule 384
lincosamides 354 hormonal changes during pregnancy 103 ultrasonographic dating 384
nitrofurantoin 354 iron metabolism during pregnancy 100 Pregnancy with IUD in situ 435
penicillin-g (benzyl penicillin) 352 Physiology of 67-123 Pregnancy-associated protein A 96
phenoxymethyl penicillin (penicillin v) 353 cardiovascular system Pregnancy-induced hypertension
sulphonamides 353 arterial blood pressure 87 aetiology 404
tetracycline 354 atrial fibrillation 85 clinical presentation 404
vancomycin 355 blood flow through the heart 83 complications 406
Peptides 147 cardiac cycle 83 investigations 405
Pereyra’s procedure 445, 446 conduction system of the heart 85 obstetric management 405
Perforating veins 54 electrocardiogram 85 Pregnanediol glucuronide 314
Perineal mean volume of blood flow 86 Premature ovarian failure 268
body 444 significance of ecg changes 85 Preoperative surgical asepsis 198
membrane 54 stroke volume 85 Primary amenorrhoea and delayed or absent
nerves 44 gastrointestinal system 91
Perineum 54 liver bile 94 pubertal development 267
Peritoneal consequences of removal of various Primary dysmenorrhoea 452
factors 439 Primary villi 239
malignancy 162 organs of gastrointestinal tract 95 Principles of
reflections 21 liver function tests 94 infection control and outbreak management
epiploic foramen (foramen of Winslow) portal hypertension 95
normal pregnancy 96 195
22 respiratory system 77 magnetic resonance imaging 282
greater omentum 21 urinary system microanatomy of kidney 88 parathyroids 326
greater sac 22 Pineal gland 304 Process of protein synthesis
lesser omentum 21 Pituitary gland transcription 255f
lesser sac 22 chromophobe adenoma of the pituitary 304 translation 255
of the uterus 35 hypopituitarism 304 Prochordal plate 238
Periurethral Placenta Progesterone 314
injections 446 endocrine function 96 Prolactin causes for increased level of 306
levator ani 443 beta-hCG 97 Proliferative (follicular) phase 315
Periventricular leucomalacia 201 human placental lactogen 97 Proline 149
Peroxisome 125, 126 leptin 98 Prophylaxis 204
pH of the medium 196 oestrogen 97 Propranolol 438
Phaeochromocytoma 274, 333 progesterone 97 Propylthiouracil 365
symptoms associated with 333t relaxin 98 Prostaglandins and leukotrienes 301
Phagocytic cells function of the placenta 96 Protein
mononuclear phagocytic system 211 immunological function 98 hormone receptor 302
polymorphonuclear microphages 211 immunosuppression 98 metabolism 150
Phagocytosis 162 passive immunity 98 synthesis 149
Pharmacology 344-383 placental anatomy 96 transcription of genetic code 150
transport function 96 translation of genetic code 150
Placental cotyledons 241
Plane of anatomical outlet 28
Plasma
clearance 90

mebooksfree.com

Index 475

Proteolytic enzymes 164, 196, 316 nausea 428 paracetamol 367
Protozoal infections Regulation of ranitidine 367
toxoplasmosis 208 blood glucose 141 Salmonella spp 430
trichomoniasis 208 fatty acid metabolism 144 Salpingo-oophoritis 449
Proximal convoluted tubule 88 Renal Saphenous nerve 51
Pseudomonas aeruginosa 272 anomalies 268 Sarcomatous change 452
Pseudostratification 315 corpuscle 88, 89f Sciatic nerve 54
Puberty plasma flow 90 Screening for
adolescent growth spurt 318 Renin-angiotensin-aldosterone system 330 foetal anomalies
changes in vagina 320 Reproductive echogenic bowel 409
delayed puberty 321 function 272 levels of alpha-fetoprotein 408
leptin 320 system 96 pre-implantation genetic diagnosis 407
precocious puberty 320 Reserpine 306, 438 routine ultrasound scan at 18–20+6 weeks
tanner stages Respiratory diseases
breast development 318t dead space 80 409
development of pubic hair 318t gaseous exchange 80 screening for down syndrome 408
Pubic symphysis 26, 443 haemoglobin 81 HIV infection 206
Pubococcygeus 443 Hering-Bruer reflex 79 Secretory (luteal) phase 317
Pudendal nerve 44 lung compliance and elasticity 80 Secretory vesicles 125, 126
Pulmonary embolus obstructive respiratory disease 78 Selective serotonin reuptake inhibitor 87, 438
aetiology 417 respiratory centre 79 Semen analysis 439
clinical symptoms 417 respiratory minute ventilation 79 Seminoma 438
investigations 417 restrictive respiratory disease 78 Sensorineural 200
management 417 surface tension and pulmonary surfactant 80 Septate uterus 178
Pulmonary symptoms 272 transport of carbon dioxide 81 Septum primum 250
Pure gonadal dysgenesis 274 transportation of oxygen 80 Serine 149
Purification and analysis of proteins Restriction Seven-transmembrane receptor 302
affinity chromatography 149 endonucleases 129 Sex hormone binding globulin 301
gel electrophoresis 149 fragment length polymorphism 130 Sexually transmitted
gel permeation chromatography 149 Retinoblastoma 259 disease 455
ion exchange chromatography 149 Retrograde menstruation 453 infections gonorrhoea 455
Purine metabolism 146 Retropubic Bartholin’s abscess 456
Pus cells 163 bladder neck suspension procedures 445 complications 456
Pyknosis 169 procedures 445t Fitz-Hugh-Curtis syndrome 456
Pyramid showing various levels of evidence 1f Retroverted uterus 449f investigations 456
Pyramidalis 17 Reverse chloride shift 81 medical management 456
Rheumatoid arthritis 214 symptoms 455
Q Ribonucleic acid Sheehan’s syndrome 258
messenger RNA 130 Shock
Q-banding 256 ribosomal RNA 130 cardiogenic shock 174
Q fever 195 transfer RNA 130 hypovolaemic shock 174
Quinacrine fluorescent stain 256 Rights of the unborn and newborn children 4 septic (toxaemic) shock 174
Quinolones 270, 355 Ring pessary 444 Short stature 274
Risk factors for mother-to-child transmission Sickle cell disease 258
R Sildenafil 438
206 Skene’s gland 244
Radiation 197 Role of Skin
Radioactive iodine 309 extra-hepatic tissues disinfection and antiseptics 198
Radioactivity 278 role of kidney 141 lesions 175
Radiotherapy 279 role of muscle 141 rashes 200
side effects of 280 hormones Southern blot hybridisation 129
Randomized controlled trials 1 adrenal cortex hormones 142 Specific dynamic action of food 155
Rectal nerve 44 anterior pituitary hormones 142 Specific infections hospital-acquired infections
Rectovaginal 441 epinephrine 142
Rectum glucagon 142 197
blood supply 39 insulin 142 Sperm density 439
curves of the rectum 39 thyroid hormone 142 Spermatic cord 24
folds in the rectum 39 Rough handling of tissues 430 Spermatogenesis, stages of 232
lymphatic drainage 39 Rubella 204 Spinocerebellar ataxia 259
nerve supply 39 Spirochaetes 193
peritoneal relations 39 S Spironolactone 438
relations 39 Squamosal suture 55
Rectus Sacral plexus 44 Squamous cell carcinoma 170, 177
abdominis muscle 16f Sacrotuberous ligament sacrospinous ligament Squamous epithelial cells 201
sheath Squamous metaplasia 167
above the arcuate line 19 29 Squeeze technique 438
below the arcuate line 19 Sacrum 29 Stages of chorionic villi 239
importance for the surgeon 19 Safe drugs during pregnancy Standard error of the mean 289
superior to the costal margin 19 aspirin 367 Staphyloccocus aureus 191, 187, 272
metformin 367 Clostridium botulinum 191
methyldopa 367 Clostridium difficile 191

mebooksfree.com

476 Textbook for MRCOG-1

Mycobacterium tuberculosis 187 perineal pouch 54 Thyroid
Staphylococcal infections 187 wound disruption 430 disorders during pregnancy
Stasis 162 Superior aetiology 399
Statistics 287 epigastric vessel 17 clinical presentation 400
coefficient of correlation 291 rectal artery and vein 42 complications 400
correlation 291 view of pelvic inlet 28 investigations 400
data measurement 292 Supersubparietal diameter 57 management 400
distribution 290 Surgical skills gland
error 292 dehydration 429 changes in thyroid gland during
interquartile range 291 pre-anaesthetic medications 428
linear regression 291 preparation of the skin 428 pregnancy 308
mean 290 surgery in high-risk patients 428 dyshormonogenesis 308
median 291 wound infections 430 normal functioning of thyroid glands 309
mode 291 Sweating 274 thyroid hormones 308
odds ratio 292 Syncytiotrophoblast 239, 241 Thyroid-stimulating hormone 153
parametric tests and non-parametric tests Synthesis of prostaglandins 146f Thyrotoxicosis 274
Syphilis 164 Tissue hypoxia 430
290 Systemic lupus erythematosus and pregnancy Tocolytic agents 349
placebo effect 292 Torsion 438
range 291 214 Total parenteral nutrition
relative risk 292 fatty acid deficiency 431
skewed distribution 290 T hypercarbia 431
standard hyperglycaemia: 431
deviation 291 Tardive dyskinesia 345 hypoglycaemia 431
error of mean 291 Tauri’s disease 139 hypovolaemia 431
variance 291 Tay-Sachs disease 258, 272 metabolic acidosis 431
Steam under pressure 197 Teratogenesis 366 Transcription 255
Steatorrhoea 96 Teratogenic drugs in pregnancy Transport mechanisms
Sterilisation and disinfection chlorpropramide 366 carrier-mediated transport 73
antisepsis 196 cyproterone acetate 367 diffusion 73
disinfection 196 diethylstilbestrol 366 osmosis 73
methods of sterilisation and disinfection 197 glucocorticoids 367 Transsexual patients 274
performance of a disinfectant 196 irradiation 367 Transvaginal
Stratum spongiosum 239 isotretinoin 367 tape 446
Streptococci lisinopril 367 urethropexies 446
classification of streptococci 185 lithium 366 Transverse diameters 57
group B beta-haemolytic streptococcus 185 losartan 367 Transversus abdominis muscle 16
streptococcal infection 185 phenytoin 366 Treatment for menopausal symptoms
vancomycin-resistant enterococci 186 pseudoephedrine 367 hormone replacement therapy 325
Stress urinary incontinence 445 quinine 366 selective oestrogen receptor modulators
bladder urodynamic studies 445 rifampicin 367 arzoxifene 326
management 445 statins 367 drugs in development 326
Stromal cells 239 thalidomide 366 ospemifene 326
Structural changes in the newborn thiazide diuretics 367 raloxifene 326
congenital anomalies 419 valproate 367 tibolone 326
cleft lip and palate 419 warfarin 366 Treponema pallidum 193
congenital heart defects 419 Tertiary villi 240 Triacylglycerols 143
congenital hip dislocation 419 Test for tubal patency 441 Triangles of the pelvic outlet 54
exomphalos 419 Testes 38 Tricarboxylic acid 131
jaundice in the newborn 419 Testicular Triple x syndrome 268
normal neonate 418 factors 438 Tryptophan 149
Structure of proteins failure 313 Tubal factors 439
primary structure 149 feminisation syndrome 261, 264 Tubular
quaternary structure 149 clinical features 265 epithelium 88
secondary structure 149 treatment 265 necrosis 173
tertiary structure 149 hormones 313 portion of nephron 88
Subcostal nerve 18 Testis 439 reabsorption 89
Submentum 57 Testosterone 233, 313 secretion 90
Subnuclear vacuolation 317 Tests for liver function 103t Tumour necrosis factor 163
Subsartorial plexus of nerves 52 Tetrahydrofolic acid 154 Tumourogenesis
Substances Thalassaemia epidemiology and predisposing factors for
abuse 438 clinical features 270
reabsorbed from lab findings 271 cancer 169
distal convoluted tubule 89 pathophysiology 270 neoplasia 169
loop of Henle 89 treatment 271 symptoms 169
proximal convoluted tubule 89 Think sepsis 6 tumour markers 171
Sub-urethral sling procedures 446 Thoracoabdominal nerve 18 Tumours of the genital tract
Sulphonylureas 347 Thoracolumbar region 246 cervix 176
Superficial Threonine 149 ovary 178
circumflex iliac artery 17 Thrombi 172 uterus 177
epigastric artery 17 Thromboembolism 173 vagina 176
vulva 175

mebooksfree.com

Index 477

Tunica intima 171 region 54 sintered glass filters 197
Turner’s syndrome 261, 263, 274 sinus 244 syringe filters 197
clinical features 267 Uterine vacuum 197
treatment 268 cavity 384 Vasopressin 153
Tyndallization 197 factor infertility 439 Veins accompanying the branches of femoral
Tyrosine 136, 149, 151t, 256f, 307, 308, 310 Uterine leiomyomas 177
malformations 452 artery 54
U myomas 177 Ventilation-perfusion scan 173
retroversion 449 Ventral rami 54
Ulceration and bleeding 442 soufflé 99 Vertex 56
Ultrasound Utero-placental blood flow 99 Vesical fistula vesicovaginal fistula 441
adverse effects of 281 Uterus Viruses 199
biological effects of 280 blood supply 37 Vitamins
different types of signals 280 didelphys 453 vitamin A (retinol) 154
milestones of pregnancy 281 endometrium 177 vitamin B complex 154
principles of 280 innervation of 37 vitamin C 154
properties of 281 lymphatic drainage 38 vitamin D 154
Umbilical myometrium 177 vitamin D resistant rickets 259
artery cannulation 249 parts of vitamin E 155
vein 250 cervix 36 vitamin K 155
Understanding of uterine corpus 35 Vomiting 428
adrenal structure and function 329 von Geirke’s disease 139, 270
pancreas 309 V von Willibrand’s disease 269
sex hormones 312 Vulva blood supply 31
Undescended testes 438 Vaccines 216 Vulva
Unipolar diathermy 283 conjugate vaccines 216 lymphatic drainage 31
Units of radioactivity 279 different types of 217 nerve supply 31
Urea cycle 151 DNA vaccines 216 Vulvar
Ureter live-attenuated vaccines 216 cancer 175
abdominal part of the ureter 47 recombinant vector vaccines 216 intraepithelial neoplasia 175
pelvic part of the urete 47 subunit vaccines 216 Vulvovaginal candidiasis 207
relations of toxoid vaccines 216
left ureter 47 Vagal stimulation 92 W
right ureter 47 Vagina
the abdominal part of the ureter 47 blood supply 32 Warburg-Dickens-Lipmann pathway 133
Ureteric bud 246 lymphatic drainage 32 Warfarin 173
Ureterovaginal 441 nerve supply 32 Warm liquid disinfectants 197
Urethrovaginal 441 relations 32 Wegener’s granulomatosis 164
Urge incontinence Vaginal Whartons jelly 241
management of detrusor overactivity 446 discharge WHO classification of gestational trophoblastic
medical treatment 447 bacterial vaginosis 454
anticholinergic agents 447 treatment disease 386t
behaviour modification 447 ampicillin 455 Whooping cough 199
intermittent catheterisation 447 clindamycin 455 Williams syndrome 261
musculotropic relaxants 447 lincosamides 455 Wilson’s disease 258
tricyclic antidepressants 447 metronidazole 455 Wolffian ducts 243
vaginal prosthetic devices 447 monilial infection 455 Woman’s health initiative 172
surgical treatment 447 ornidazole 455 Wound dehiscence 430
treatment of 446t tetracyclines 455 Wound healing 164
Urinary bladder tinidazole 455
blood supply 46 neoplasms 176 X
embryology 46 tissue 443t
lymphatic drainage 47 Vaginitis diagnostic features of the commonest X chromosomes 258
nerve supply 47 Xenograft 215
peritoneal relations of the bladder 46 causes of vaginitis 454t Xerophthalmia 154
venous drainage 47 Vagus nerve course and relations of vagus nerve X-linked recessive
Urinary retention 429 disorders 262
Urinary tract infection 442 in the thorax mode of inheritance 259
asymptomatic bacteruria 457 course of left vagus 13
Candida spp 457 course of right vagus 13 Y
Chlamydia 457 Valine 149
Enterobacter 457 Variables Y chromosome 243, 258
Escherichia coli 457 continuous variable 288 Yasmin 448
Klebsiella spp 457 discrete variable 288 Yellow fever 195, 199
non-gonococcal urethritis 457 Varicocoele 438 Yolk sac 236
pelvic abscess 457 Various secretory substances produced by the
Proteus spp 457 Z
Pseudomonas 457 gastric glands 91
Urochrome 89 Various types of filters Zahn 172
Urogenital air filters 197 Zidovudine 207
diaphragm 55 asbestos filters 197 Zona pellucida 235, 316
earthware filters 197 Zoonosis 195
membrane filters 197 Zoonotic disorders, different types of 195t
pressure filtration 197 Zygote 235

mebooksfree.com