Bedside Obstetrics and Gynecology for Postgraduates
Bedside Obstetrics and Gynecology for Postgraduates
THIRD EDITION
Richa Saxena
MBBS MD (Obstetrics and Gynecology) RCOG Associate PG Diploma in Clinical Research
Obstetrician Gynecologist—Let's Talk Woman's Health Mentor—Cracking MRCOG
New Delhi, India

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Bedside Obstetrics and Gynecology for Postgraduates
First Edition: 2010
Second Edition: 2014
Third Edition: 2023
9789354659843
Printed at:
My Mother, Mrs Bharati Saxena
and all the Mothers
Who have undergone much pain and sufferings for their children.
A mother is the most trusted friend we have, when trials, heavy and sudden, fall upon us;
When adversity takes the place of prosperity;
When friends who rejoice with us in our sunshine, desert us;
When troubles thicken around us, still she will cling to us and counsel to dissipate the clouds of darkness, causing peace to return to our hearts;
and has proven time and time again that no matter whatever circumstances may come between mother and her children, their lives are interwoven forever
—Washington Irving
Medicine is learned by the bedside and not in the classroom. Let not your conceptions of disease come from words heard in the lecture room or read from the book. See and then reason and compare and control. But see first
–William Osler
The third edition of the book, Bedside Obstetrics and Gynecology for Postgraduates, is motivated by the enormous popularity of the past editions and a commitment for maintaining the fundamentals of clinical examination that cannot be overlooked. In the changing world of artificial intelligence and virtual reality, dependency on technology in the diagnostic processes has increased drastically and bedside time with patients has reduced. However, it is pertinent that diagnostic imaging must be complementary and not a replacement for clinical examination. Through this book, I have endeavored to draw attention towards the importance of eliciting the clinical signs and symptoms more than pathology or radiology, especially for the postgraduate students.
Though the text in the third edition has been greatly revamped and updated with recent guidelines in the field of Obstetrics and Gynecology, the concept and focus, however, remains the same. The book, like its earlier editions, highlights the age-old traditional concept of history-taking and clinical examination. Keeping these in mind, all important Long Cases in Obstetrics and Gynecology have been described under the following headings: Case study, introduction, history and clinical presentation, general physical examination, specific systemic examination, differential diagnosis, management, investigations, treatment (obstetric/gynecological management), complications, and evidence-based clinical trials. Questions from past 10-year papers have been incorporated in each chapter at topic level for the postgraduate students to prepare and pass the practical examination as well as the university examination with utmost ease. To further emphasise the fact that the book is focused towards the postgraduates, the term “postgraduate” has been inserted in the previous title, “Bedside Obstetrics and Gynecology”.
While firmly holding on to traditional case-based approach, the third edition equally emphasizes on the evidence-based medicine, providing a wholesome learning to the postgraduates and residents. In line with this, evidence-based clinical trials have been added at the end of each chapter, which can be accessed by scanning a QR code given at the end of each chapter as well as at the end of table of contents on page XII. Each reference is linked to the source article, thereby allowing interested students to access the complete article or its abstract from there in just one click and remain updated with the recent advancements and developments in the field of obstetrics and gynecology. In the third edition, two new chapters “cephalopelvic disproportion”, and “adenomyosis”, have been added based on the reviews and feedback provided by the students who read this book and teachers/professors who reviewed the script. Keeping up with the updates, as the term, Dysfunctional Uterine Bleeding has become obsolete now, the redundant chapter has been removed in this edition. The textual matter of the book has been updated extensively with all new NICE/GTG guidelines including the new WHO portogram (WHO Care Guide, 2020), revised treatment and staging of malignancies including molecular staging of endometrial cancer, new management protocols for Rh negative pregnancy, preeclampsia, gestational diabetes, etc.
This book would serve as a valuable resource for the postgraduate students and residents, containing all the common and important case studies in the field of both Obstetrics and Gynecology, which they might encounter during the practical examinations, university examinations and clinical practice. Though mainly catering to postgraduate students, residents and practitioners, some intellectual undergraduate students who ultimately want to pursue their career in Obstetrics and Gynecology are also likely to find this book very useful.
Writing a book is a herculean task. It can never be completed without divine intervention and approval. Therefore, I have decided to end this preface with a small prayer of thanks to the Almighty, which I was taught in my childhood.
“Father, lead me day by day, ever in thy own sweet way. Teach me to be pure and good and tell me what I ought to do.”
–Amen
Simultaneously, I would like to extend my thanks and appreciation to all the related authors and publishers whose references have been used in this book. Book creation is teamwork and I acknowledge the way the entire staff of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, worked hard on this manuscript to give it a final shape. I would especially like to thank Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director), Mr MS Mani (Group president), Ms Chetna Malhotra (Senior Director—Professional Publishing, Marketing and Business Development), Ms Pooja Bhandari (Production Head), Ms Suchita Gera (Development Editor), Mr Ashwani Singh (Manager), Mr Rakesh Kumar (Typesetter), Ms Nirmal (Editorial Coordinator) and Ms Seema Dogra (Cover Designer) for publishing the book.
I would also like to especially thank the content strategists (Dr Mansy Gupta, Ms Isha Sindhwani, Ms Soumya Yadav) for helping me in refining the manuscript.
I strongly believe that writing a book involves a continuous learning process. Though extreme care has been taken to maintain accuracy while writing this book, constructive criticism would be greatly appreciated. Please e-mail me your comments at richa@drrichasaxena.com. Also, please feel free to visit my website, www.drrichasaxena.com for obtaining information related to various books written by me, projects that I am involved in for promotion of woman's health, and for making use of the free online resources available.
Richa Saxena
Preface to the First Edition (Extract)
The concept of a bedside book is not new, but is a novel one and unique in itself. It may sound funny, but when I told a nonmedical editor from a reputed publishing house that I was writing a book titled, “Bedside Obstetrics and Gynecology”, he laughed asking whether the book is meant to remain at the bedside of the patient or the doctor? Jokes apart, who else other than the medical personnel would know the importance of the education which takes place at the patient's bedside. In today's world of scientific advancement and technology, the clinical art of medicine is sadly dying off …
The doctors today do not believe in auscultating the patient's chest or merely palpating the patient's abdomen. A stethoscope can diagnose a consolidated lung suggestive of Kochs at a much earlier stage than a chest X-ray or even a bronchoscopic-guided biopsy. Hence, it is important for the medical personnel to become acquainted with the skills of taking history and performing a clinical examination. The purpose of the book is to promote the art of good history taking and clinical examination, and reaching the final diagnosis by obtaining only a few selective investigations or special evaluations. The book highlights the classical and systematic approach towards diagnosis of the disease. Each case study has been carefully designed to simulate the clinical practice scenarios as far as possible in order to evoke the right patient approach and clinical decision making. Unlike the small clinical vignettes described in most other books, detailed explanation of the pathology relevant to the case study in question has been described in all the chapters. One of the key features of this book is its versatility. Not only will the book be useful to the undergraduates who are required to get acquainted with the clinical examination skills but also for the busy postgraduates who are in the rush to go through the clinical scenarios.
Richa Saxena
Introduction
As previously described, this book emphasizes the patient's clinical conditions rather than the disease. For example, a patient may be presenting with jaundice, fever, and malaise, but the actual diagnosis may turn out to be hepatitis. So simply knowing about hepatitis is not enough, one needs to have the ability to diagnose the condition based on the findings of history and clinical examination.
Promoting clinical acumen is the basic purpose of this book. Each chapter has been written keeping in mind the clinical presentation of the patient. Various clinical scenarios have been divided into seven sections in all, out of which the first three deal with obstetrics and last four with gynecology. All the chapters have been divided into various subparts with the help of the symbols as described below:
Abbreviations
ACOG:
American College of Obstetricians and Gynecologists
AFI:
Amniotic Fluid Index
AFV:
Amniotic Fluid Volume
AIDS:
Acquired Immune Deficiency Syndrome
ANC:
Antenatal Care
AP:
Anteroposterior
APH:
Antepartum Hemorrhage
APLS/APS:
Antiphospholipid Antibody Syndrome/Antiphospholipid Syndrome
ARDS:
Acute Respiratory Distress Syndrome
ARM:
Artificial Rupture of Membranes
AST:
Aspartate Aminotransferase
BCSH:
British Committee for Standards in Hematology
BMI:
Body Mass Index
BP:
Blood Pressure
BPM:
Beats Per Minute
BPP:
Biophysical Profile
CBC:
Complete Blood Count
CDC:
Center of Disease Control and Prevention
CI:
Confidence Interval
CNS:
Central Nervous System
CO:
Carbon Monoxide
CPR:
Cardiopulmonary Resuscitation
CRP:
C-reactive protein
CS:
Cesarean Section
CST:
Contraction Stress Test
CT:
Computed Tomography
CTG:
Cardiotocography
CVS:
Chorionic Villus Sampling
D&C:
Dilatation and Curettage
DFMC:
Daily Fetal Movement Count
DIC:
Disseminated Intravascular Coagulation
DLC:
Differential Leukocyte Count
DVT:
Deep Vein Thrombosis
ECG:
Electrocardiogram
ECV:
External Cephalic Version
ELISA:
Enzyme-linked Immunosorbent Assay
ERCS:
Elective Repeat Cesarean Section
ESR:
Erythrocyte Sedimentation Rate
FHR:
Fetal Heart Rate
FHS:
Fetal Heart Sound
FIGO:
International Federation of Gynecology and Obstetrics
FISH:
Fluorescent in situ Hybridization
FMH:
Fetomaternal Hemorrhage
FNAC:
Fine-needle Aspiration Cytology
FSH:
Follicle-stimulating Hormone
GDG:
Guideline Development Group
GFR:
Glomerular Filtration Rate
GI:
Gastrointestinal
GnRH:
Gonadotrophin-releasing Hormone
GP:
General Practitioner
GPE:
General Physical Examinaion
GTG:
Green-top Guideline
GUM:
Genitourinary Medicine
Hb:
Hemoglobin
HIV:
Human Immunodeficiency Virus
HR:
Heart Rate
HRT:
Hormone Replacement Therapy
ICU:
Intensive Care Unit
Ig:
Immunoglobulin
IM:
Intramuscular
IUCD:
Intrauterine Contraceptive Device
IUGR:
Intrauterine Growth Restriction/Retardation
IV:
Intravenous
IVF:
In Vitro Fertilization
KFT:
Kidney Function Test
L:S ratio:
Lecithin:Sphingomyelin ratio
LFT:
Liver Function Test
LH:
Luteinizing Hormone
LMP:
Last Menstrual Period
MAS:
Meconium Aspiration Syndrome
MCH:
Mean Corpuscular Hemoglobin
MCHC:
Mean Corpuscular Hemoglobin Concentration
MCV:
Mean Corpuscular Volume
MRI:
Magnetic Resonance Imaging
MS:
Multiple Sclerosis
MTC:
Mother-to-child
NICE:
National Institute for Health and Care Excellence
NICU:
Neonatal Intensive Care Unit
NSAIDs:
Nonsteroidal Anti-inflammatory Drugs
NST:
Nonstress Test
NT:
Nuchal Thickness
OCPs:
Oral Contraceptive Pills
OPD:
Outpatient Department
OR:
Odds Ratio
OT:
Operation Theater
PC:
Platelet Count
PCOS/PCOD:
Polycystic Ovarian Syndrome/Polycystic Ovarian Disease
PCR:
Polymerase Chain Reaction
PE:
Pulmonary Embolism
PID:
Pelvic Inflammatory Disease
PIH:
Pregnancy-induced Hypertension
PO:
Per Orally or Per os
POG:
Period of Gestation
PPH:
Postpartum Hemorrhage
PROM:
Premature Rupture of Membranes
PV:
Per Vaginally
RBC:
Red Blood Cell
RCOG:
Royal College of Obstetricians and Gynecologists
RCT:
Randomized Controlled Trial
RDS:
Respiratory Distress Syndrome
RIA:
Radioimmunoassay
ROM:
Rupture of Membranes
ROS:
Reactive Oxygen Species
RPF:
Renal Plasma Flow
SC:
Subcutaneous
SL:
Sublingual
SOGC:
Society of Obstetricians and Gynecologists of Canada
STD:
Sexually Transmitted Disease
T3:
Triiodothyronine
T4:
Thyroxine
TAS:
Transabdominal Scan
TLC:
Total Leukocyte Count
TORCH:
Toxoplasmosis, Other Infections, Rubella, Cytomegalovirus, Herpes Simplex Virus
TSH:
Thyroid-stimulating Hormone
TT:
Thrombin Time
TVS:
Transvaginal Scan or Sonography
TVT:
Tension-free Vaginal Tape
UFH:
Unfractionated Heparin
US:
Ultrasonography
UTI:
Urinary Tract Infection
UV:
Ultraviolet
VBAC:
Vaginal Birth after Cesarean
VDRL:
Venereal Disease Research Laboratory
VTE:
Venous Thromboembolism
WBC:
White Blood Cell
WHO:
World Health Organization