Contents. Preface... acknowledgments... vii-x xi. 1 anatomy of Female reproductive Organs 1. 2 Fundamentals of reproduction 19

Contents Preface........................................................................................................................................
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Contents

Preface.................................................................................................................................................................................... vii-x acknowledgments ........................................................................................................................................................... xi 1

anatomy of Female reproductive Organs

1

 External

Genitalia 1  Internal Genital Organs 4  Muscles and Fascia in relation to the Pelvic Organs 11  Pelvic Floor 11  Perineum 12  Pelvic Fascia 14  Pelvic Cellular Tissue 14  Female Urethra 15  The Urinary Bladder 15  Pelvic Ureter 16  The Breast 16

2

Fundamentals of reproduction  Gametogenesis  Ovulation

19

 Oogenesis

19

19  Spermatogenesis

20

22 23  Morula 24  Blastocyst 25  Implantation 25  Trophoblast 26  The Decidua 27  Chorion and Chorionic Villi 28 of Inner Cell Mass 29  Events following Fertilization 30  Fertilization

3

 Development

the Placenta and Fetal membranes

32

 The

Placenta 32  Development 32  The Placenta at Term 33  Structures 34  Placental Circulation 36  Placental Aging 39  Placental Function 39  The Fetal Membranes 41  Amniotic Cavity, Amnion and Amniotic Fluid 42  The Umbilical Cord 44

4

the Fetus  Fetal

5

46

Physiology 47

 The

Fetal Circulation 49

 Changes

of the Fetal Circulation at Birth 50

Physiological Changes During Pregnancy

52

 Genital Organs 52  Breasts 56  Cutaneous Changes 56  Weight Gain 57  Body Water Metabolism 58  Hematological

Changes 62

6

Changes 58

 Cardiovascular

System 60

 Metabolic

Changes 61

 Systemic

endocrinology in relation to reproduction

65

 Maturation of Graafian Follicles and Ovulation 65  Maintenance of Corpus Luteum after Fertilization 65  P lacental

Endocrinology 66  Protein Hormones 66  Steroidal Hormones 68  Diagnostic Value of Placental Hormones 69  Changes of Endocrine Glands during Pregnancy 70  Maintenance of Lactation 72

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7 Diagnosis of Pregnancy

73

  First Trimester (First 12 Weeks) 73   Second Trimester (13–28 Weeks) 78   Last Trimester (29–40 Weeks) 80   Differential

Diagnosis of Pregnancy 81   Summary of Diagnosis of Pregnancy 82   Chronological Appearance of Specific Symptoms and Signs of Pregnancy 82   Signs of Previous Child Birth 83   Estimation of Gestational Age and Prediction of Expected Date of Delivery 83   Estimation of Fetal Weight 84

8 The Fetus-in-Utero   Methods

85

of Obstetrical Examination 87

9 Fetal Skull and Maternal Pelvis   Fetal

94

Skull 94  Pelvis 98   Physiological Enlargement of Pelvis 105

  Maternal

10 Antenatal Care, Preconceptional Counseling and Care

106

  Procedure at the First Visit 106   Procedure at the Subsequent Visits 111   Antenatal Advice 112   Minor

Ailments in Pregnancy 114   Values of Antenatal Care 116   Preconceptional Counseling and Care 116

11 Antenatal Assessment of Fetal Well-Being

119

  Clinical

Evaluation of Fetal Well-Being 119    Special Investigations 120    Early Pregnancy 121    Antepartum Fetal Surveillance (Late Pregnancy) 121   Other Investigations in Late Pregnancy 124

12 Prenatal Genetic Counseling, Screening and Diagnosis

127

  Prenatal Genetic Screening 127   Prenatal Diagnosis 129   Noninvasive Method of Prenatal Testing 131

13 Normal Labor

134

  Causes

of Onset of Labor 134   Contractile System of the Myometrium 136   Physiology of Normal Labor 138   Events in First Stage of Labor 140   Events in Second Stage of Labor 143   Events in Third Stage of Labor 143   Mechanism of Normal Labor 145   Anatomy of Labor 149    Clinical Course of First Stage of Labor 151   Second Stage of Labor 153   Third Stage of Labor 154    Place of Delivery 154    Management of Normal Labor 155   First Stage 157   Second Stage 158   Immediate Care of the Newborn 161   Third Stage 162   Active Management of Third Stage of Labor 164

14 Normal Puerperium

168

  Involution

of the Uterus 168    Involution of Other Pelvic Structures 170   Lochia 170    General Physiological Changes 171    Lactation 172   Physiology of Lactation 173    Management of Normal Puerperium 174   Management of Ailments 176   Postnatal Care 178

15 Vomiting in Pregnancy   Vomiting

180

in Pregnancy 180   Hyperemesis Gravidarum 181

16 Hemorrhage in Early Pregnancy

185

  Spontaneous Abortion (Miscarriage) 185   Threatened Miscarriage 187   Inevitable 189   Complete 189    Incomplete

190   Missed 190   Septic Abortion 191   Recurrent 195 

  Cervical Incompetence 197   Induction of Abortion 202   Medical Termination of Pregnancy (Mtp) 202   Methods

of Termination of Pregnancy 203   First Trimester 203   Mid Trimester 204  Methods 204   Surgical Methods 205   Complications of Mtp 206

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 Medical

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xv

  Ectopic

Pregnancy 207   Tubal 208   Unruptured Tubal Ectopic Pregnancy 211   Chronic or Old Ectopic 212   Interstitial Pregnancy 214   Abdominal Pregnancy 218    Ovarian Pregnancy 220    Cornual Pregnancy 220    Cervical Pregnancy 220   Gestational Trophoblastic Diseases (Gtd) 221   Hydatidiform Mole 222   Partial or Incomplete Mole 230   Placental Site Trophoblastic Tumor (Pstt) 231   Persistent Gestational Trophoblastic Disease 231

17 Multiple Pregnancy, Amniotic Fluid Disorders, Abnormalities of Placenta and Cord   Twins

233   Triplets, Quadruplets 244  Fluid Disorders 246   Polyhydramnios 246    Abnormalities of Placenta and Cord 251   Amniotic

  Oligohydramnios

233

250 

18 Hypertensive Disorders in Pregnancy

255

  Preeclampsia

256   Etiopathogenesis 257   Pathophysiology 258   Clinical Types 260   Clinical Features 261   Complications 263   Prophylactic Measures 264   Management 264   Acute Fulminant Preeclampsia 267   Eclampsia 268   Clinical Features of Eclampsia 270   Management 271   Gestational Hypertension 276   Chronic Hypertension 277   Essential Hypertension 277   Chronic Renal Diseases in Pregnancy 278

19 Antepartum Hemorrhage

282

  Placenta

Previa 282    Clinical Features 284    Placentography 286    Differential Diagnosis 287    Complications 288   Management 289   Practical Guideline for Cesarean Delivery 291   Practical Guide to Lower Segment Approach for Placenta Previa 293   Practical Guidelines to Lower Segment Approach for Placenta Previa Accreta 293    Abruptio Placentae 294   Clinical Features 297   Complications 297   Treatment 299   Indeterminate Bleeding 301

20 Medical and Surgical Illness Complicating Pregnancy

303

  Hematological

Disorders in Pregnancy 303   Anemia in Pregnancy 303   Hemoglobinopathies 316    Sickle Cell Hemoglobinopathies 316   Thalassemia Syndromes 317   Platelet Disorders 318    Heart Disease in Pregnancy 319    Diabetes Mellitus and Pregnancy 325   Gestational Diabetes Mellitus (Gdm) 326   Overt Diabetes 327    Thyroid Dysfunction and Pregnancy 334    Jaundice in Pregnancy 335   Cholestasis 336   Viral Hepatitis 336   Epilepsy in Pregnancy 338   Asthma in Pregnancy 339   Systemic Lupus Erythematosus (Sle) 340   Tuberculosis in Pregnancy 341   Syphilis in Pregnancy 342    Parasitic and Protozoal Infestations in Pregnancy 344    Malaria 344    Toxoplasmosis 345    Listeriosis 346   Intestinal Worms 346   Pyelonephritis in Pregnancy 346   Asymptomatic Bacteriuria (Asb) 347    Viral Infections in Pregnancy 348   Rubella 348   Measles 349   Influenza 349   Chickenpox (Varicella) 349   Cytomegalovirus (CMV) 349   Parvoviruses 349   Mumps (RNA) 350   Herpes Simplex (DNA) Virus (HSV) 350   Dengue 350   Human Immunodeficiency Virus Infection (Hiv) and Acquired Immunodeficiency Syndrome (AidS) 350   Surgical Illness during Pregnancy 353   Acute Pain in Abdomen during Pregnancy 355

21 Gynecological Disorders in Pregnancy

356

  Abdominal

Vaginal Discharge 356    Congenital Malformation 356    Carcinoma Cervix with Pregnancy 357   Leiomyomas with Pregnancy 359   Ovarian Tumor in Pregnancy 360   Retroverted Gravid Uterus 361    Morbid Anatomic Changes if Left Uncared for 362    Genital Prolapse in Pregnancy 363

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22 Preterm Labor, Preterm Rupture of the Membranes, Postmaturity, Intrauterine Fetal Death

365



  Preterm Labor 365   Prelabor Rupture of the Membrane (PROM) 369   Management 369  Prolonged

and Post-term Pregnancy 371 

  Intrauterine

Fetal Death (Iufd) 375

23 Complicated Pregnancy

381

  Pregnancy

with Prior Cesarean Delivery 381    Integrity of the Scar 381    Evidences of Scar Rupture (or Scar Dehiscence) during Labor 383   Management of a Pregnancy with Prior Cesarean Delivery 383   Vaginal Birth After Previous Cesarean (Vbac) 384    Pregnancy in a Rh-negative Woman 386    Red Cell Alloimmunization 387    Fetal Affection by the Rh-antibody 388    Manifestations of the Hemolytic Disease of the Fetus and Newborn (Hdfn) 388   Prevention of Rh-immunization 389   Antenatal Investigation Protocol of Rh-negative Mothers 391   Plan of Delivery 393    Exchange Transfusion in the Newborn 396   Prognosis 397   Elderly Primigravida 398   Grand Multipara 398   Bad Obstetric History (Boh) 399   Obesity in Pregnancy 400

24 Contracted Pelvis

402

  Valiation of Female Pelvis 402   Asymmetrical or Obliquely Contracted Pelvis 405   Mechanism of Labor in Contracted Pelvis with Vertex Presentation 405   Diagnosis of Contracted Pelvis 406    Disproportion 409   Diagnosis of Cephalopelvic Disproportion (Cpd) 410   Effects of Contracted Pelvis on Pregnancy and Labor 412   Management 412    Trial Labor 412   Midpelvic and Outlet Disproportion 414

25 Abnormal Uterine Action

415

  Types

415    Uterine Inertia 416    Incoordinate Uterine Action 417    Spastic Lower Segment 418  Ring 419   Cervical Dystocia 419   Generalized Tonic Contraction 419   Precipitate Labor 420   Tonic Uterine Contraction and Retraction 420   Summary 423  Constriction

26 Complicated Labor: Malposition, Malpresentation and Cord Prolapse

424

 Occiput-Posterior

Position (Op) 424   Arrested Occipitoposterior Position 430   Deep Transverse Arrest (Dta) 431   Manual Rotation for Occipitoposterior Position 431   Breech Presentation 434    Antenatal Management 439   Management of Vaginal Breech Delivery 441   Assisted Breech Delivery 442    Management of Complicated Breech 446    Face Presentation 449    Brow Presentation 453    Transverse Lie 454   Unstable Lie 459   Compound Presentation 459   Cord Prolapse 460

27 Prolonged Labor, Obstructed Labor, Dystocia Caused by Fetal Anomalies

463

  Prolonged

Labor 463   Obstructed Labor 467   Dystocia Caused by Fetal Anomalies 468    Shoulder Dystocia 469   Hydrocephalus 470   Neural Tube Defects 471   Enlargement of Fetal Abdomen 472   Monsters 472   Conjoined Twins 473

28 Complications of the Third Stage of Labor   Postpartum

474

Hemorrhage (Pph) 474 

  Primary Postpartum Hemorrhage 475   Management of Third Stage Bleeding 477   Steps of Manual

Removal of Placenta 478   Secondary Postpartum Hemorrhage 483  Placenta 484   Placenta Accreta 486   Inversion of the Uterus 487

  Retained

29 Injuries to the Birth Canal  Vulva

489   Perineum 489   Vagina 491   Cervix 491   Pelvic Hematoma 492  Uterus 493   Visceral Injuries 499

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Contents  30 Abnormalities of the Puerperium  Puerperal

Pyrexia 500   Puerperal Sepsis 500 

500  Subinvolution

505   Urinary Complications 505 

  Breast Complications 506   Puerperal Venous Thrombosis and Pulmonary Embolism 508   Pulmonary

Embolism (Pe) 510   Obstetric Palsies 511   Puerperal Emergencies 511   Psychiatric Disorders during Puerperium 512   Psychological Response to Perinatal Deaths and Management 513

31 The Term Newborn Infant

514

  Physical

Features of the Newborn 514   Immediate Care of the Newborn 517    Infant Feeding 519   Breastfeeding 519   Artificial Feeding 524    Childhood Immunization Program 526

32 Low Birth Weight Baby   Preterm

Baby 528 

  Fetal

527 Growth Restriction (Fgr) 533

33 Disease of the Fetus and the Newborn   Perinatal

Asphyxia 541   Fetal Respiration 541 

541  

  Respiratory Distress in the Newborn 547   Idiopathic Respiratory Distress Syndrome 547  Meconium

Aspiration Syndrome (Mas) 550    Jaundice of the Newborn 551   Hyperbilirubinemia of the Newborn 552   Kernicterus 553    Hemolytic Disease of the Newborn 554   Abo Group Incompatibility 555    Bleeding Disorders in the Newborn 555   Anemia in the Newborn 556   Seizures in Newborn 557    Birth Injuries of the Newborn 558   Intracranial Hemorrhage (ICH) 559    Other Injuries 561   Perinatal Infections 563   Ophthalmia Neonatorum (Conjunctivitis) 564   Skin Infections 565    Necrotizing Enterocolitis 566    Mucocutaneous Candidiasis 567    Congenital Malformations and Prenatal Diagnosis 567    Down’s Syndrome (Trisomy 21) 568    Congenital Malformations in Newborn and the Surgical Emergencies 569   Nonimmune Fetal Hydrops (Nifh) 571

34 Pharmacotherapeutics in Obstetrics

573

  Oxytocics

in Obstetrics 573   Oxytocin 573   Ergot Derivatives 577   Prostaglandins (Pgs) 578    Antihypertensive Therapy 581    Diuretics 582    Tocolytic Agents 583    Anticonvulsants 584   Anticoagulants 585   Maternal Drug Intake and Breastfeeding 586   Fetal Hazards on Maternal Medication during Pregnancy 587   Analgesia and Anesthesia in Obstetrics 590   Anatomical and Physiological Considerations 590    Analgesia during Labor and Delivery 591   Sedatives and Analgesics 592   Inhalation Methods 592    Regional (Neuraxial) Anesthesia 593   Infiltration Analgesia 595   General Anesthesia for Cesarean Section 596

35 Induction of Labor

598

  Indications

and Contraindications 598   Parameters to Assess Prior to Induction 599   Methods of Cervical Ripening 599    Methods of Induction of Labor 600   Medical 600   Surgical 601   Combined 604    Active Management of Labor 605   Partograph 607

36 Population Dynamics and Control of Conception   Population

609

Dynamics 609   Control of Conception 610 

  Contraception 610   Method 611   Barrier Methods 611   Natural Contraception 614   Intrauterine

Contraceptive Devices (Iucds) 615   Steroidal Contraceptions 621   Combined Oral Contraceptives (Pills) 622    Injectable Progestins 628    Implant 628    Emergency Contraception (Ec) 629   Sterilization 631   Vasectomy 631   Female Sterilization 632   Laparoscopic Sterilization 635    Contraceptive 637   Contraceptive Counseling and Prescription 637   Ongoing Trials and Selective Availability 638   Centchroman Prescription 638   Combined Injectable Contraceptives 639   Biodegradable Implants 639   Newer IUDs 639

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37 Operative Obstetrics

642

  Dilatation and Evacuation 642   Management Protocol of Uterine Perforation 645   Suction Evacuation 645   Menstrual

Regulation 646 

 Manual

Vacuum Aspiration 646   Hysterotomy 647   Episiotomy 647 

  Operative Vaginal Delivery 651   Forceps 651   Ventouse 660

  Version 663   External Cephalic Version 663   Internal Version 665   Bipolar Version 666

  Destructive Operations 666   Craniotomy 666   Decapitation 668   Evisceration 668   Cleidotomy 668    Postoperative

Care Following Destructive Operations 669 Section (Cs) 669    Lower Segment 671    Classical 676  Section 677   Measures to Reduce Cesarean Births 679   Symphysiotomy 679   Cesarean

  Complication

of Cesarean

38 Safe Motherhood, Epidemiology of Obstetrics

680

  Safe Motherhood 680   Obstetric Care and the Society 681   Reproductive and Child Health (Rch) Care 681   Epidemiology of Obstetrics 683   Maternal Mortality 683   Maternal Near Miss 687    Maternal Morbidity 687    Perinatal Mortality 687    Stillbirths 690    Neonatal Deaths 690    Women’s Health (MDGs) Beyond 2015; 690

39 Special Topics in Obstetrics   Intrapartum

692

Fetal Monitoring 692   Electronic Fetal Monitoring 693   Nonreassuring Fetal Status

(Nrfs) 697  in Obstetrics 699   Classification 702   Hemorrhagic Shock 704   Endotoxic Shock 705    Acute Kidney Injury (Aki) 706   Blood Coagulation Disorders in Obstetrics 711   High-risk Pregnancy 716    Immunology in Obstetrics 719   Critical Care in Obstetrics 722   Icu 723   Shock

40 Current Topics in Obstetrics

726

  Antibiotic Prophylaxis in Cesarean Section 726   Day Care Obstetrics 726   Legal and Ethical Issues in Obstetric Practice 727   Audit In Obstetrics 728   The Preconception and Prenatal Diagnostic Techniques and PNDT Act 729   Umbilical Cord Blood Banking 729   Stem Cells and Therapies in Obstetrics 730

41 Imaging in Obstetrics (USG, MRI, CT, Radiology), Amniocentesis and Guides to Clinical Tests

732

  Ultrasound

In Obstetrics 732   Three-dimensional Ultrasonography (3D Scanning) 733   First Trimester 734   Midtrimester 735   Doppler 737   Third Trimester 739    Magnetic Resonance Imaging (Mri) in Obstetrics 739   Computed Tomography (CT) 740   Radiology in Obstetrics 740   Amniocentesis 741    Guides to Clinical Tests 742   Urine 742   Tests for Blood Coagulation Disorders 743   Collection of Blood Sample 744   Cervical and Vaginal Cytology 746

42 Practical Obstetrics

747

 Clinical

Thermometer 747   Obstetric Instruments 747   Specimens 758   Imaging Studies (Usg Plates) 759   Processing of Instruments 763   Oxytocics: Oxytocin, Methergin, Misoprostol (PGE1); Carboprost (PGF2a), Prostin (PGE2) 764   Doppler (Ultrasound) Fetal Monitor 764

Index........................................................................................................................................................................................ 765

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