This document provides information on various topics related to obstetrics and gynecology: - Risks and outcomes associated with different gestational ages, labor interventions, and deliveries. - Predictors and management of preterm labor, postpartum hemorrhage, breech presentation, and other high-risk pregnancies. - Details on twin pregnancies, screening tests for fetal abnormalities, and caesarean section risks. - Risks of various gynecological procedures like laparoscopy, hysteroscopy, and hysterectomy. - Causes and management of infertility, endometriosis, fibroids, and heavy menstrual bleeding. - Details on contraception

1. Numbers for MRCOG
Indunil Piyadigama
WCH

3. Past dates
• 20% will not deliver till 41 weeks
• 10% will go beyond 42 weeks
• Still birth 1/1000
• IOL
– 15% Instrument
– 20% CS
– 15% failed induction

4. Instrument delivery
• 10% in UK
– 15% for IOL
– 40% for VBAC
• Fecal incontinence
– Baseline 10%
– Ventouse 25%
– Forceps 40%

5. OASI
• UK 3%
– Primi 6%
– Multi 2%
• Risk factors
– Ventouse 2X
– Midline epsiotomy 4X
– Nulliparity 6X
– Forceps 6X (with epis reduced to 1.3X)

6. • 70% asymptomatic after 1 year
• 10% fecal incontinence
• 20% flatus incontinence or fecal urgency
• Risk of 3/4th degree tear next pregnancy 5%

7. • You are about to repair an episiotomy and
selected lignocaine with adrenalin as local
anesthetic. What is the dose you will use.
• A. 1mg/kg
• B. 2mg/kg
• C. 3mg/kg
• D. 5mg/kg
• E. 7 mg/kg

8. 3rd stage of labour
• Oxytocin reduces risk of PPH by 60%
Passive Active
NV 5% 10%
Bleeding >1l 3% 1%
Blood transfusion 4% 1%

9. 500-100ml >1000ml SE
Syncynon 5U/10U Similar
Syntometrine Superior Similar 5X
PG Less effective

10. 1. Para 2 is concerned about risk of bleeding
after delivery as she had a PPH around 1000ml
of loss in her previous delivery 3 years back.
She asks whether any thing can be given to
reduce the risk of PPH this time.

11. A Physiological management
B Active management of 3rd stage
C Syntocinon 5 U IV
D Syntocinon 10 U IV
E Syntocinon 5 U IM
F Syntocinon 10 U IM
G Syntocinon 5U + Ergometrin 0.5mg IM (Syntometrin)
H Tranexamic acid 0.5mg + Syntocinon 5U IV
I Cryoprecipitate 10U
J FFP
K No need of further products

12. 2. Primigravida is awaiting for elective CS. She
has had several episodes of bleeding in the
antenatal period which were thought due to
placenta previa. However in the last USS at 36
weeks there was no evidence of placenta
previa.

13. A Physiological management
B Active management of 3rd stage
C Syntocinon 5 U IV
D Syntocinon 10 U IV
E Syntocinon 5 U IM
F Syntocinon 10 U IM
G Syntocinon 5U + Ergometrin 0.5mg IM (Syntometrin)
H Tranexamic acid 0.5mg + Syntocinon 5U IV
I Cryoprecipitate 10U
J FFP
K No need of further products

14. 2. Primigravida developed a Primary PPH after an
instrumental delivery which was managed with
machanical, pharmocological methods and using blood
and blood products. She is still bleeding but not as much
previously. Her blood investigation results are as follows
Hb- 10.3
Plt - 90
INR - 1.3
Fibrinogen - 2.2

15. A Physiological management
B Active management of 3rd stage
C Syntocinon 5 U IV
D Syntocinon 10 U IV
E Syntocinon 5 U IM
F Syntocinon 10 U IM
G Syntocinon 5U + Ergometrin 0.5mg IM (Syntometrin)
H Tranexamic acid 0.5mg + Syntocinon 5U IV
I Cryoprecipitate 10U
J FFP
K No need of further products

16. CTG
• Most worrying pattern is associated with
acidosis in 50%
• Positive predictive value for Hypoxia is 30%
• Inter-observer variation 30%

17. Obstetric emergencies

18. Shoulder dystocia
• Incidence 0.5%
• Risk factors
– Previous dystocia 25% recurrence
– DM 2 fold risk
• Permanent brachial plexus injury 10%
• ELCS in DM >4.5kg - 500 prevent 1 permanent
BPI

19. Cord prolapse
• Incidence 0.5%
• Breech 2X
• Perinatal mortality 1%

20. Maternal collapse
• Incidence 0.5%
• CPR 30% of normal cardia output achieved
• If not tilt only 10%

21. Amniotic fluid embolism
• 1 in 10000
• Maternal mortality 25%

22. Complicated pregnancies

23. VBAC
VBAC ERCS
Maternal Rupture 0.5%
Success 75%
Instrument delivery 40%
OASI 5%
Death 4/100000 13/100000
Fetal Respiratory morbidity
38 – 6%, 39 – 1%
Still birth 1/1000 beyond 39
weeks

24. Predictors successful VBAC
Previous vaginal birth 90%
Malpresentation 85%
Fetal distress 75%
Risk factors Rupture risk
Induction with PG 1%
Augmentation with oxytociin 1-1.5%
Past 2 sections 1.3%
Previous rupture 5%
Classical 12%
Detection of rupture
CTG abnormal 80%
No symptoms 50%
Pain, vaginal bleeding, fetal
heart rate abnormality
10%

25. • Risk of placenta previa after 3 CS:
• A. 3%
• B. 11%
• C. 32%
• D. 44%
• E. 61%

26. Placenta previa
• Incidence 0.5%
Number of CS Incidence of PP Accreta if PP
1 1% 3%
2 2% 10%
3 3% 40%
4 10% 60%

27. Placental abruption
• Incidence 0.5%
• If one abruption 10%
• If two abruptions 25%

28. Vasa praevia
• 1 in 2000

29. Breech
Incidence
28 weeks 20%
36 weeks 5%
Term 3-4%
• Successful ECV in 1 in 2
• Risk of spontaneous version in successful cases
5%
• Failed ECV becoming cephalic 5%

30. Preterm labour
• Incidence 10%
– 1/3 Indicated
– 2/3 Spontaneous
Method Risk of delivery within 7 days
TVS cervical length after
30 weeks
< 15mm before 32 weeks 50% PPV for preterm labour
Long cervix risk 4%
fFN >50ng/dl between 20-36 weeks 40% PPV
If negative only 1%
Speculum rpt
measurements
10% PPV

31. Interventions for preterm labour
Tocolysis
Effectiveness
24hrs 50% reduction
48hrs 45% reduction
7 days 40% redcution
Nifedipine – atosiban similar
Atosiban – betoblocker similar
Nifedipine > betablocker
SE Nifedipine < b blocker
Atosiban < b blocker
Outcome Nifedipine reduced NEC/IVH/RDS
No benefit on still birth or neonatal death

32. Corticosteroids risk reduction
Short term RDS 45%
IVH 45%
NEC 55%
Neonatal death 30%
Infection in 48hrs 45%
Long term Development delay 50%
Cerebral palsy 40%
MgSO4 risk reduction
30% in cerebral palsy
40% gross motor dysfunction
Cystic periventricular leucomalacia

33. PROM - 8%
• Risk of neonatal infections increase to 1%
• Risk in normal labour 0.5%
• 60% will go to labour within 24hrs

34. SGA
Method Sensitivity for SGA Specificity for
SGA
Palpation alone 20% 98%
SFH 30% 88%
Customized SFH charts 50%
Customized EFW chart 70% 90%

35. Still birth
• 0.5%
• 50% unexplained
• 33% SGA
• 30% DIC in 4 weeks
• 85% spontaneously deliver within 3 weeks

36. Twins
• Incidence – 3%
Dizygotic Monozygotic
70% 30%
DCDA 30%, MCDA 70%
ART 95% dizogotic 5% monozygotic
Dichorionic Monochorionic
70% 30%
Out of these 90% dizygotic
5% can be monozygotic

37. Singleton Dichorionic Monochorionic
Perinatal mortality 0.5% 1.5% 3%
Miscarriage 1% 2% 10%
Structural anomalies 3% 6% Even higher
Chromosomal 2X Same risk as each
singleton
SGA Higher than
singleton
15%
Single IUFD Both die 15%
Neurodevelopment
disability 25%
TRAP 1%
TTTS 15%
TAPS 15% (only 2%
spontaneous)

38. Gestational age at which monitoring starts for
TTTS.
• A. 14
• B. 16
• C. 18
• D. 20
• E. 24 wks

39. USS landmarks
4+3 GS by TVS
5 Yolk sac
6 2-3mm embryo with cardiac activity
7 Amnion
8 GS 25mm with limb buds
9 Midgut herniation, choroid plexus
10 Skeletal ossification
11 Most structures
12 Midgut back to body by 11+5
14 Bladder should be seen

40. Screening for Downs
Sensitivity False positive
Combined test Free B hcg
PAPP – A
NT
90% <2%
Quad test AFP + hCG + uE3 +
Inhibin
73% 3%
Cell free DNA 99% < 0.1%

41. Changes in other chromosomal abnormalities
Trisomy Abnormality Other
Downs Increase HCG, Inhibin
13 Increased AFP
18 Reduced uE3 Microcephaly, choroid plexus
cysts, CVS abnormal
Turners All increased Cystic hygroma
Horse shoe kidney

42. Caesarean section
Immediate
Bladder damage 1/1000
Thrombosis 1/1000
Ureteric injury 3/10000
Emergency hysterectomy 8/1000
Intermediate
Endometritis 20/100
Wound infection 10/100
Readmission 5/100
Haemorrage 5/100
ICU 9/1000
ERPC 5/1000
Fetal
Laceration 1/100
Respiratory morbidity 1/100

43. • Risk of nerve entrapment after one CS using
Pfannenstiel incision
• A <1%
• B. 2%
• C. 4%
• D. 6%
• E. 8%

44. Gynaecology

45. Laparoscopy
• Overall serious risk 2/1000
• (major vessels, Bladder, Uterus, Bowel)
• 15% of bowel injuries are not diagnosed at
surgery
• 50% of major complications are related to
entry

46. Risk of adhesion formation with midline
incisions.
• A. 10
• B. 20
• C. 30
• D. 40
• E. 50%

47. • Umbilical adhesions
– No previous surgery 0.5%
– Previous laparoscopy 15%
– Suprapubic incision 25%
– Midline incision 50%

48. Hysteroscopy
• Overall serious complications 2/1000

49. Hysterectomy
• Overall serious complications 4/100
– Haemorrage and transfusion 2/100
– Urinary tract injury 7/1000
– Bowel injury 4/10000
– Return to theatre 7/1000

50. Oophorectomy before 65 years Disadvantages
Increased CVS disease 2X
Increased hip fractures 2X
Reduce overall survival by 10 years
No change in breast cancer or stroke
Advantages
Ovarian cancer reduced from 0.5% to 0

51. Miscarriage
• Incidences
– <30 – 10%
– 35 – 15%
– 40 – 50%
– 45 – 90%
– Past 3 miscarriages – 40%

52. Risk of uterine perforation during surgical
evacuation
• A. 1:1000
• B. 2:1000
• C. 3:1000
• D. 4:1000
• E. 5:1000

53. Complications ERPC Misoprostol
Failure 1% 1%
Rpt procedure 5% 5%
Specific Cervical damage 1/100 Bleeding 1/1000
Uterine perforation 4/1000 Rupture 1/1000
Uterine perforation postpartum 5%

54. Contraception failure
Vasectomy/Implant 0.5
DMPA/LNG 1
COCP/POP 3 (up to 50)
LRT 5
IUCD 6
Male condom 20
Female condom 40

55. PCOS numbers
• Free testosterone > 3nmol/l
• SHBG < 30nmol/l
• Free androgen index >5%
• Presence of 12 or more antral follicles
measuring 2-9mm
• Increased ovarian volume >10ml

56. Subfertility
Causes
Male 25% SFA issues 20
Female 45% Ovulation 20
Tubal 15
Endometrial 10
Unexplained 30%
Secondary subfertility 40% tubal factor

57. Method of OI Clinical pregnancy Live birth rate in 12
months
Risks
Clomiphene 65% 40% Multiple 10%
OHSS 5%
Letrazole 30%
Gonadotrophin 65% 60% Multiple can be
reduced to 5% with
TVS
LOD 65 60% No risk of multiple or
OHSS

58. Endometriosis
• 10%
• Infertile cohort 50%
• Pelvic pain cohort 90%
• Diagnostic laparoscopy
– Sensitivity 95%, specificity 85%

59. Fibroids
• Incidence 25%
• GnRHa
– In 3/52 amenorrhoic
– In 3 months Fibroid volume reduction 40%
• SPRMs
– Amenorrhoeic 2 weeks before
– 25% volume reduction
• UAE
– Fibroid reduction 40%
– Improvement in HMB over 1 year >80%
– 30% needs reintervention in 5 yrs
– Reduced pregnancy rates (50%)
• Myomectomy
– Improvement in HMB >80%
– Pregnancy rate 80%
– Recurrence 30%
– Adhesions 98%

60. Heavy menstrual bleeding
Management Effectiveness
Tranexamic 60% reduced blood loss
NSAIDs 30% reduced blood loss
COCP 40% reduced blood loss
LNG 90% reduced blood loss
20% amenorrhoic by 1 year
Progesterone 80% reduced blood loss
If injected 70% amenorrhoic by 1 year
GnRH 90% amenorrhoic by 1 year
Endometrial ablation 80% reduced blood loss
40% amenorrhoic by 1 year

61. • Risk of progression of simple hyperplasia to
carcinoma?
• A. 1%
• B. 2%
• C. 4%
• D. 10%
• E. 20%

62. EM hyperplasia
Endometrial Hyperplasia (EH) without atypia
• Regression > 80%
• Malignancy risk in 20yrs 5%
Atypical Hyperplasia (AH)
• Malignancy risk in 20yrs 25%
• Concomitant CA up to 40%
• risk of co-existing ovarian CA up to 4%,

63. A 22 yrs old woman is found to be BRCA 1 carrier.
What is her lifetime risk for developing ovarian
cancer?
• A 10%
• B. 20%
• C. 40%
• D. 50%
• E. 60%

64. Types Risk of OC Risk of BC Other CA
BRCA 1
(chromosome 17)
40% 80%
BRCA 2
Chromosome 13)
20% 80%
HNPCC (lynch
TII)
12% Endometrial
Peutz Jeghers 20% risk of sex
cord stromal

65. Thank you

67. Good Luck!