📘 Hyperemesis Gravidarum

(Important for OBG Nursing, GNM/BSc Nursing, NHM, AIIMS, NORCET, GPSC Staff Nurse Exams)

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✅ 1. Introduction / Definition:

Hyperemesis Gravidarum is a severe form of nausea and vomiting during pregnancy that leads to:

• Weight loss (≥5% of pre-pregnancy weight)
• Dehydration
• Electrolyte imbalance
• Ketonuria

It is more serious than normal morning sickness and requires medical management.

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✅ 2. Classification:

1. Mild Hyperemesis – Nausea and occasional vomiting, tolerating some fluids and food.
2. Moderate – Persistent vomiting, unable to retain food, dehydration evident.
3. Severe Hyperemesis – Profound dehydration, electrolyte disturbance, starvation ketosis, weight loss, hospitalization required.

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✅ 3. Causes / Risk Factors:

• Elevated hCG levels (e.g., multiple pregnancy, molar pregnancy)
• Increased estrogen levels
• First pregnancy (primigravida)
• History of hyperemesis in previous pregnancy
• Obesity
• Motion sickness history
• Psychological factors (stress, emotional disturbances)
• Helicobacter pylori infection (possible role)

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✅ 4. Pathophysiology:

• Increased hormonal levels (especially hCG and estrogen) stimulate the vomiting center in the brain.
• Vomiting leads to fluid and electrolyte loss, nutritional deficiency, and metabolic imbalances.
• If untreated, results in ketosis, hypokalemia, and even Wernicke’s encephalopathy due to thiamine deficiency.

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✅ 5. Clinical Manifestations / Signs & Symptoms:

• Persistent nausea and vomiting (beyond 12–16 weeks gestation)
• Weight loss
• Signs of dehydration: dry mucous membranes, poor skin turgor
• Dizziness or fainting
• Tachycardia, hypotension
• Ketonuria
• Electrolyte imbalance (hypokalemia, hyponatremia)
• Constipation or decreased urine output
• Irritability, depression

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✅ 6. Diagnostic Evaluation:

• Clinical history and physical examination
• Urinalysis – to detect ketones
• CBC – may show hemoconcentration
• Serum electrolytes – to detect imbalances
• Liver function tests
• Thyroid function tests (rule out thyrotoxicosis)
• Ultrasound – to check for multiple gestation or molar pregnancy

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✅ 7. Management:

🔹 Hospitalization Criteria:

• Unable to retain oral intake
• Severe dehydration
• Electrolyte disturbances
• Weight loss >5%
• Ketonuria

🔹 Medical Management:

• IV fluids – Normal saline or Ringer’s lactate to rehydrate
• Electrolyte replacement – Potassium, sodium, etc.
• Antiemetics – Ondansetron, promethazine, metoclopramide
• Thiamine supplementation – To prevent Wernicke’s encephalopathy
• Vitamin B6 + Doxylamine – First-line for mild cases
• Nutritional support – If severe, may require enteral or parenteral nutrition

🔹 Psychological support – Address anxiety, depression, or fear related to pregnancy

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✅ 8. Complications:

🔸 Maternal:

• Dehydration and electrolyte imbalance
• Hypokalemia, hyponatremia
• Wernicke’s encephalopathy (vitamin B1 deficiency)
• Esophageal rupture (rare)
• Renal failure (in severe cases)

🔸 Fetal:

• Intrauterine growth restriction (IUGR)
• Low birth weight
• Preterm labor (if poorly managed)

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✅ 9. Nurse’s Role:

• Monitor vital signs, intake/output, weight
• Administer IV fluids, antiemetics, and thiamine as prescribed
• Maintain accurate fluid balance chart
• Provide small, frequent bland meals when oral intake resumes
• Offer psychological support and reassurance
• Educate the mother about signs of worsening symptoms

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✅ 10. Golden One-Liners for Quick Revision:

• Hyperemesis gravidarum = Severe NVP + Weight loss + Dehydration
• Associated with high hCG levels (e.g., twins, molar pregnancy)
• Watch for ketonuria and electrolyte imbalances
• Treat with IV fluids, antiemetics, and thiamine
• Monitor for Wernicke’s encephalopathy

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✅ 11. MCQs for Practice:

Q1. Which hormone is primarily associated with hyperemesis gravidarum?
a) Estrogen
b) Progesterone
c) hCG
d) Prolactin
Correct Answer: c) hCG
Rationale: High levels of hCG are linked to nausea and vomiting in early pregnancy.

Q2. What is the most dangerous complication of untreated hyperemesis gravidarum?
a) Hyperglycemia
b) Wernicke’s encephalopathy
c) Hypercalcemia
d) UTI
Correct Answer: b) Wernicke’s encephalopathy
Rationale: Caused by thiamine deficiency in prolonged vomiting.

Q3. Which sign indicates dehydration in hyperemesis gravidarum?
a) Bradycardia
b) Increased urine output
c) Dry mucous membranes
d) Weight gain
Correct Answer: c) Dry mucous membranes
Rationale: It is a typical sign of dehydration due to fluid loss.

Q4. What should be checked before restarting oral feeding in a hyperemesis patient?
a) Hemoglobin level
b) Presence of ketones in urine
c) Blood group
d) Hematocrit
Correct Answer: b) Presence of ketones in urine
Rationale: Ketonuria indicates starvation; feeding should resume once ketones reduce.

Q5. What is the first-line combination therapy in mild hyperemesis gravidarum?
a) Metoclopramide + Thiamine
b) Promethazine + Ondansetron
c) Vitamin B6 + Doxylamine
d) Vitamin C + Iron
Correct Answer: c) Vitamin B6 + Doxylamine
Rationale: This combination is safe and effective for early NVP.

📘 Hydatidiform Mole (Molar Pregnancy)

(Important for OBG Nursing, GNM/BSc Nursing, NHM, AIIMS, NORCET, GPSC Staff Nurse Exams)

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✅ 1. Introduction / Definition:

Hydatidiform mole is a type of gestational trophoblastic disease (GTD) where there is abnormal proliferation of trophoblastic tissue with the formation of grape-like vesicles in the uterus.

It is a non-viable pregnancy resulting from abnormal fertilization and is classified under benign GTD, though it has malignant potential.

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✅ 2. Types / Classification:

🔹 Complete Mole:

• No fetal parts
• All chorionic villi are edematous (grape-like)
• Karyotype: 46,XX (diploid, paternal origin only)
• Higher risk of malignancy (choriocarcinoma)

🔹 Partial Mole:

• Some fetal parts present
• Some normal villi, some cystic
• Karyotype: Triploid (e.g., 69,XXY)
• Lower malignant potential

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✅ 3. Causes / Risk Factors:

• Maternal age <20 or >35 years
• Previous molar pregnancy
• Nutritional deficiency (low protein, vitamin A, folic acid)
• Asian ethnicity
• History of miscarriage
• Use of ovulation-inducing drugs

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✅ 4. Pathophysiology:

• Abnormal fertilization (usually of an empty ovum by one or two sperm)
• Leads to proliferation of trophoblastic tissue without normal embryo formation
• Villi swell and form cystic masses → uterine enlargement, high hCG, and complications

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✅ 5. Clinical Manifestations / Signs & Symptoms:

• Painless vaginal bleeding in the first trimester
• Excessive uterine enlargement for gestational age
• High β-hCG levels
• Severe nausea and vomiting (hyperemesis gravidarum)
• Passage of grape-like vesicles
• No fetal heart tones
• Symptoms of thyrotoxicosis (tachycardia, heat intolerance) due to high hCG
• May develop preeclampsia before 20 weeks (which is otherwise rare)

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✅ 6. Diagnostic Evaluation:

• Ultrasound – Snowstorm or cluster-of-grapes appearance, no fetus (complete mole)
• Serum β-hCG – markedly elevated (>100,000 mIU/ml)
• CBC – for anemia
• Coagulation profile
• Thyroid function tests – to check for thyrotoxicosis
• Chest X-ray – to rule out lung metastasis (if malignancy suspected)

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✅ 7. Management:

🔹 Initial Management:

• Suction evacuation (preferred method for uterine evacuation)
• Dilation and curettage (D&C) if suction unavailable
• Blood transfusion if bleeding
• Rh immunoglobulin (if Rh-negative)

🔹 Follow-up:

• Serial β-hCG monitoring: weekly until negative ×3, then monthly up to 6–12 months
• Avoid pregnancy during follow-up period (use contraception)
• Monitor for gestational trophoblastic neoplasia (GTN) or choriocarcinoma

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✅ 8. Complications:

🔸 Immediate:

• Severe vaginal bleeding
• Anemia
• Hyperemesis
• Preeclampsia

🔸 Late:

• Persistent gestational trophoblastic disease (GTN)
• Choriocarcinoma (more common in complete mole)
• Uterine rupture (rare)

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✅ 9. Nurse’s Role:

• Educate the patient about the nature and seriousness of the disease
• Monitor vital signs, vaginal bleeding, signs of infection
• Emotional support for pregnancy loss
• Ensure β-hCG follow-up compliance
• Teach contraception and delay of pregnancy
• Report signs of GTN: rising hCG, bleeding, cough, or lung metastasis symptoms

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✅ 10. Golden One-Liners for Quick Revision:

• Hydatidiform mole = abnormal trophoblastic proliferation
• Snowstorm appearance on ultrasound is diagnostic
• hCG levels are markedly elevated
• Suction evacuation is treatment of choice
• Follow-up with serial hCG to monitor for malignancy

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✅ 11. MCQs for Practice:

Q1. What is the most common presenting symptom of hydatidiform mole?
a) Painful bleeding
b) Painless vaginal bleeding
c) Abdominal cramps
d) Fever
Correct Answer: b) Painless vaginal bleeding
Rationale: It is the hallmark sign of molar pregnancy.

Q2. What is the diagnostic ultrasound finding in molar pregnancy?
a) Ring of fire
b) Double decidual sac
c) Snowstorm pattern
d) Empty sac
Correct Answer: c) Snowstorm pattern
Rationale: It reflects multiple hydropic villi without fetal structures.

Q3. Which hormone is significantly elevated in hydatidiform mole?
a) Estrogen
b) Progesterone
c) hCG
d) FSH
Correct Answer: c) hCG
Rationale: Abnormal trophoblastic proliferation increases hCG massively.

Q4. What is the recommended follow-up after molar pregnancy evacuation?
a) Serum estrogen levels
b) Chest X-ray every month
c) Weekly β-hCG levels until negative
d) Repeat D&C every month
Correct Answer: c) Weekly β-hCG levels until negative
Rationale: hCG monitoring ensures no malignant transformation.

Q5. What is the first-line treatment for molar pregnancy?
a) Hysterectomy
b) Laparotomy
c) Suction evacuation
d) Medical abortion
Correct Answer: c) Suction evacuation
Rationale: Safest and most effective method for complete removal.

📘 Ectopic Pregnancy

(Important for OBG Nursing, GNM/BSc Nursing, NHM, AIIMS, NORCET, GPSC Staff Nurse Exams)

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✅ 1. Introduction / Definition:

Ectopic pregnancy is defined as the implantation of a fertilized ovum outside the uterine cavity.
The most common site is the fallopian tube (especially the ampullary region), but it can also occur in the ovary, cervix, abdomen, or cesarean scar.

It is a life-threatening emergency due to the risk of tubal rupture and hemorrhage.

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✅ 2. Classification / Types:

🔹 Based on site:

1. Tubal pregnancy (most common – ~95%)
   • Ampullary (most frequent)
   • Isthmic
   • Fimbrial
2. Ovarian pregnancy
3. Abdominal pregnancy
4. Cervical pregnancy
5. Cornual (interstitial) pregnancy
6. Cesarean scar pregnancy

🔹 Based on progression:

1. Unruptured
2. Ruptured – Emergency with internal bleeding
3. Chronic ectopic – Resolved but with retained products

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✅ 3. Causes / Risk Factors:

• Pelvic inflammatory disease (PID)
• Previous ectopic pregnancy
• Tubal surgery or sterilization
• Intrauterine device (IUD) usage
• Assisted reproductive techniques (ART)
• Congenital abnormalities of fallopian tubes
• Smoking
• History of infertility

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✅ 4. Pathophysiology:

• Normally, the fertilized ovum travels to the uterus for implantation.
• In ectopic pregnancy, tubal damage or altered motility causes the zygote to implant outside the uterus.
• The growing embryo causes stretching, inflammation, and may lead to tubal rupture, resulting in massive intra-abdominal bleeding.

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✅ 5. Clinical Manifestations / Signs & Symptoms:

• Amenorrhea (missed period)
• Unilateral pelvic or abdominal pain
• Vaginal spotting or bleeding
• Shoulder tip pain (due to diaphragmatic irritation from blood)
• Signs of shock in ruptured ectopic:
  • Hypotension
  • Tachycardia
  • Pallor
  • Fainting or collapse
• Adnexal mass or tenderness on pelvic examination

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✅ 6. Diagnostic Evaluation:

• Urine pregnancy test (UPT) – Positive
• Serum β-hCG – Lower than expected for gestational age; plateauing or declining
• Transvaginal ultrasound (TVS) – No intrauterine gestational sac; adnexal mass may be seen
• Culdocentesis – May reveal free blood in pouch of Douglas
• Laparoscopy – Gold standard for diagnosis

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✅ 7. Management:

🔹 Medical Management (for unruptured cases):

• Methotrexate (single or multiple dose regimen)
  • Inhibits rapidly dividing trophoblastic cells
• Criteria:
  • Hemodynamically stable
  • No fetal heartbeat
  • β-hCG < 5000 mIU/ml
  • Mass < 3.5 cm
  • No rupture or bleeding

🔹 Surgical Management (for ruptured or unstable cases):

• Laparoscopy or laparotomy
  • Salpingostomy – Tube preserved
  • Salpingectomy – Tube removed

🔹 Post-treatment follow-up:

• Monitor β-hCG until undetectable
• Rh immunoglobulin if mother is Rh-negative

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✅ 8. Complications:

🔸 Maternal:

• Tubal rupture and internal hemorrhage
• Hypovolemic shock
• Infertility (due to tubal damage)
• Recurrence of ectopic pregnancy
• Death (if untreated)

🔸 Psychological:

• Emotional distress due to loss of pregnancy
• Anxiety or depression

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✅ 9. Nurse’s Role:

• Monitor vital signs and symptoms of shock
• Prepare for emergency surgery if ruptured
• Educate patient on signs of ectopic pregnancy for future
• Provide emotional and psychological support
• Monitor β-hCG levels post-treatment
• Administer methotrexate carefully (if applicable)
• Ensure Rh typing and give Rhogam if Rh-negative

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✅ 10. Golden One-Liners for Quick Revision:

• Ectopic pregnancy = implantation outside uterus
• Most common site = fallopian tube
• Methotrexate is used for unruptured ectopic pregnancy
• Shoulder tip pain = sign of internal bleeding
• TVS + β-hCG used for diagnosis

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✅ 11. MCQs for Practice:

Q1. What is the most common site for ectopic pregnancy?
a) Ovary
b) Cervix
c) Fallopian tube
d) Abdomen
Correct Answer: c) Fallopian tube
Rationale: Over 95% of ectopic pregnancies occur in the fallopian tube.

Q2. Which of the following is a classic triad of ectopic pregnancy?
a) Amenorrhea, nausea, vomiting
b) Amenorrhea, pain, vaginal bleeding
c) Hypertension, proteinuria, edema
d) Fever, chills, abdominal pain
Correct Answer: b) Amenorrhea, pain, vaginal bleeding
Rationale: These are the hallmark features of ectopic pregnancy.

Q3. What is the first-line investigation for suspected ectopic pregnancy?
a) MRI
b) Laparotomy
c) Transvaginal ultrasound
d) X-ray abdomen
Correct Answer: c) Transvaginal ultrasound
Rationale: TVS helps detect absence of intrauterine pregnancy and visualize adnexal mass.

Q4. Which drug is used in the medical management of unruptured ectopic pregnancy?
a) Misoprostol
b) Oxytocin
c) Methotrexate
d) Carboprost
Correct Answer: c) Methotrexate
Rationale: Methotrexate is a folic acid antagonist that stops trophoblastic growth.

Q5. A woman presents with ectopic pregnancy and is Rh-negative. What should be administered?
a) Vitamin K
b) Doxycycline
c) Rh immunoglobulin
d) Calcium gluconate
Correct Answer: c) Rh immunoglobulin
Rationale: To prevent Rh isoimmunization in future pregnancies.

📘 Placenta Previa

(Important for OBG Nursing, GNM/BSc Nursing, AIIMS, NORCET, NHM, GPSC Staff Nurse Exams)

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✅ 1. Introduction / Definition:

Placenta previa is a condition in which the placenta is implanted partially or completely over the internal cervical os, obstructing the opening of the cervix.

• It is a common cause of painless, bright red vaginal bleeding in the second half of pregnancy (typically after 20 weeks gestation).

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✅ 2. Types / Classification:

There are four main types of placenta previa:

1. Total (Complete) – Placenta completely covers the internal cervical os.
2. Partial – Placenta partially covers the internal os.
3. Marginal – Placenta reaches the margin of the os but does not cover it.
4. Low-lying – Placenta implanted in the lower uterine segment near the os, but not touching it.

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✅ 3. Causes / Risk Factors:

• Previous cesarean section
• Previous placenta previa
• Multiple pregnancies
• Uterine surgeries or curettage
• Smoking and drug abuse
• Advanced maternal age
• In vitro fertilization (IVF)

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✅ 4. Pathophysiology:

• In normal pregnancy, the placenta is implanted in the upper uterine segment.
• In placenta previa, due to defective endometrium or prior uterine injury, implantation occurs in the lower uterine segment.
• As pregnancy advances and the lower segment stretches, the placental attachment may disrupt, leading to bleeding.

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✅ 5. Clinical Manifestations / Signs & Symptoms:

• Painless vaginal bleeding in the second or third trimester
• Bright red blood
• Soft, non-tender uterus
• Fetal heart rate usually normal
• Abnormal fetal presentation (e.g., breech, transverse)

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✅ 6. Diagnostic Evaluation:

• Ultrasound (Transabdominal or Transvaginal) – confirms placental location
• Fetal monitoring (non-stress test, biophysical profile)
• Complete blood count (CBC)
• Coagulation profile
• Avoid digital vaginal examination unless placenta previa is ruled out

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✅ 7. Management:

🔹 Medical Management:

• Hospitalization if bleeding occurs
• Monitor fetal and maternal vital signs
• Administer corticosteroids if <34 weeks (for fetal lung maturity)
• Blood transfusion if required

🔹 Surgical Management:

• Cesarean section is the delivery method of choice in most cases
• Emergency C-section in case of uncontrolled bleeding

🔹 Nursing Management:

• Monitor bleeding, vital signs, fetal heart rate
• Maintain IV access and prepare for emergency delivery
• Emotional support and counseling
• Educate about avoiding sexual intercourse and physical exertion

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✅ 8. Complications:

• Maternal hemorrhage and hypovolemic shock
• Preterm labor
• Placenta accreta
• Fetal hypoxia or death
• Need for hysterectomy in severe cases

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✅ 9. Nurse’s Role:

• Early identification through antenatal care
• Monitoring and reporting any vaginal bleeding
• Educating mother on warning signs
• Providing psychological support
• Preparing for cesarean delivery if needed

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✅ 10. Golden One-Liners for Quick Revision:

• Placenta previa causes painless bright red bleeding in late pregnancy.
• Ultrasound is the diagnostic tool of choice.
• Cesarean section is the preferred mode of delivery.
• No vaginal examination should be done if previa is suspected.
• Risk increases with previous C-section and multiple pregnancies.

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✅ 11. MCQs for Practice:

Q1. What is the most common symptom of placenta previa?
a) Abdominal pain
b) Painless vaginal bleeding
c) Hypertension
d) Nausea
Correct Answer: b) Painless vaginal bleeding
Rationale: Placenta previa typically presents with painless, bright red bleeding in the second half of pregnancy.

Q2. Which diagnostic test confirms placenta previa?
a) MRI
b) Amniocentesis
c) Ultrasound
d) Pelvic X-ray
Correct Answer: c) Ultrasound
Rationale: Ultrasound, especially transvaginal, is the safest and most accurate method to diagnose placenta previa.

Q3. Which of the following is contraindicated in a patient with placenta previa?
a) Ultrasound
b) Pelvic examination
c) Blood transfusion
d) Corticosteroids
Correct Answer: b) Pelvic examination
Rationale: Vaginal/pelvic exams are avoided to prevent provoking bleeding.

Q4. In placenta previa, the recommended mode of delivery is usually:
a) Vaginal delivery
b) Instrumental delivery
c) Cesarean section
d) Induced labor
Correct Answer: c) Cesarean section
Rationale: Due to the risk of hemorrhage, C-section is the safest method for delivery.

Q5. Which is a risk factor for placenta previa?
a) Teenage pregnancy
b) Primigravida
c) Previous cesarean section
d) Hyperemesis gravidarum
Correct Answer: c) Previous cesarean section
Rationale: Previous uterine surgery increases the risk due to possible scar tissue altering implantation site.

📘 Abruptio Placentae

(Important for OBG Nursing, GNM/BSc Nursing, AIIMS, NORCET, NHM, GPSC Staff Nurse Exams)

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✅ 1. Introduction / Definition:

Abruptio placentae is a condition in which the normally implanted placenta separates prematurely from the uterine wall after the 20th week of gestation and before the birth of the fetus.

• It is a serious obstetric emergency and a leading cause of maternal and fetal morbidity and mortality.

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✅ 2. Types / Classification:

1. Revealed (External) – Blood escapes through the cervix and is visible externally.
2. Concealed (Internal) – Blood is trapped behind the placenta, with no visible vaginal bleeding.
3. Mixed (Combined) – Features of both revealed and concealed types.

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✅ 3. Causes / Risk Factors:

• Hypertensive disorders (e.g., preeclampsia)
• Abdominal trauma (e.g., accident, fall, domestic violence)
• Sudden uterine decompression (e.g., rapid loss of amniotic fluid)
• Smoking, alcohol, and cocaine use
• Multiparity
• Previous history of abruptio placentae
• Advanced maternal age

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✅ 4. Pathophysiology:

• Premature separation of placenta causes rupture of maternal blood vessels.
• Hemorrhage occurs between uterine wall and placenta.
• Leads to uteroplacental insufficiency, reduced oxygen to fetus, and risk of disseminated intravascular coagulation (DIC) in the mother.

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✅ 5. Clinical Manifestations / Signs & Symptoms:

• Sudden, severe abdominal pain
• Dark red vaginal bleeding (may be absent in concealed type)
• Uterine tenderness and rigidity (board-like abdomen)
• Signs of hypovolemic shock (e.g., low BP, rapid pulse)
• Fetal distress or absent fetal heart sounds
• Premature labor

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✅ 6. Diagnostic Evaluation:

• Ultrasound – may help confirm diagnosis but not always reliable
• Clinical examination – history, palpation, fetal heart rate
• CBC, coagulation profile
• Non-stress test (NST) and fetal biophysical profile
• Monitor maternal and fetal vital signs

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✅ 7. Management:

🔹 Medical Management:

• Hospitalization
• Stabilize mother: IV fluids, oxygen, blood transfusions if needed
• Monitor vital signs, fetal well-being
• Corticosteroids if preterm (<34 weeks)

🔹 Surgical Management:

• Emergency Cesarean section in severe cases or fetal distress
• Vaginal delivery may be considered if fetal demise has occurred and mother is stable

🔹 Nursing Management:

• Continuous monitoring of maternal and fetal status
• IV access and blood crossmatching
• Monitor for signs of shock, DIC
• Provide emotional support and reassurance

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✅ 8. Complications:

🔸 Maternal:

• Hypovolemic shock
• DIC (disseminated intravascular coagulation)
• Postpartum hemorrhage
• Renal failure
• Death

🔸 Fetal:

• Premature birth
• Hypoxia
• Stillbirth
• Intrauterine growth restriction (IUGR)

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✅ 9. Nurse’s Role:

• Early identification and reporting of warning signs
• Do not perform vaginal exam in undiagnosed bleeding
• Monitor uterine tone and fundal height
• Educate the mother about rest and warning signs in future pregnancies
• Ensure availability of emergency supplies and consent for surgery

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✅ 10. Golden One-Liners for Quick Revision:

• Abruptio placentae presents with painful, dark red bleeding.
• Uterine tenderness and rigidity are hallmark features.
• A major cause of DIC and maternal shock.
• Ultrasound is not always reliable; clinical signs are key.
• Immediate C-section may be required for fetal or maternal distress.

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✅ 11. MCQs for Practice:

Q1. What is the hallmark symptom of abruptio placentae?
a) Painless bright red bleeding
b) Painful dark red bleeding
c) Foul-smelling discharge
d) Sudden rupture of membranes
Correct Answer: b) Painful dark red bleeding
Rationale: Abruptio placenta is characterized by painful vaginal bleeding due to placental detachment.

Q2. Which of the following is a known risk factor for abruptio placentae?
a) Hypothyroidism
b) Multiparity
c) Iron deficiency
d) Anemia
Correct Answer: b) Multiparity
Rationale: Multiparity is a significant risk factor due to repeated uterine stretching and possible vascular changes.

Q3. Which of the following types of abruptio placenta has no visible bleeding?
a) Revealed
b) Concealed
c) Mixed
d) Marginal
Correct Answer: b) Concealed
Rationale: In concealed type, blood accumulates behind the placenta and does not exit vaginally.

Q4. Which of the following is an immediate complication of abruptio placentae?
a) Pre-eclampsia
b) Eclampsia
c) DIC
d) Chorioamnionitis
Correct Answer: c) DIC
Rationale: Due to release of thromboplastin from damaged placental tissue, DIC is a serious complication.

Q5. What is the preferred mode of delivery in case of severe abruptio placentae with fetal distress?
a) Normal vaginal delivery
b) Forceps delivery
c) Cesarean section
d) Vacuum extraction
Correct Answer: c) Cesarean section
Rationale: Emergency cesarean is indicated when maternal or fetal life is at risk.

📘 Abortion

(Important for OBG Nursing, GNM/BSc Nursing, AIIMS, NORCET, NHM, GPSC Staff Nurse Exams)

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✅ 1. Introduction / Definition:

Abortion is defined as the termination of pregnancy before the fetus reaches viability, which is usually considered before 20 weeks of gestation or when the fetal weight is less than 500 grams.

• It may occur spontaneously (miscarriage) or be induced (planned or therapeutic).

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✅ 2. Types / Classification:

🔹 A. Spontaneous Abortion (Miscarriage):

1. Threatened Abortion – Vaginal bleeding with closed cervical os and viable fetus.
2. Inevitable Abortion – Bleeding with open cervix, abortion cannot be prevented.
3. Incomplete Abortion – Part of the products of conception are expelled, rest retained.
4. Complete Abortion – All products of conception are expelled.
5. Missed Abortion – Fetus dies but is retained in uterus without symptoms.
6. Septic Abortion – Infection is present in the uterus after abortion.
7. Recurrent Abortion – Three or more consecutive spontaneous abortions.

🔹 B. Induced Abortion:

1. Medical Abortion – Use of drugs like mifepristone + misoprostol.
2. Surgical Abortion – Manual vacuum aspiration, dilation and curettage (D&C).
3. Therapeutic Abortion – Done for maternal/fetal medical indications.
4. Elective Abortion – Done voluntarily, allowed legally under conditions.

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✅ 3. Causes / Risk Factors:

• Chromosomal abnormalities (most common in first trimester)
• Infections (TORCH)
• Hormonal imbalances (e.g., low progesterone)
• Uterine abnormalities (e.g., fibroids, septate uterus)
• Maternal diseases (e.g., diabetes, hypertension)
• Trauma or physical injury
• Exposure to teratogens (drugs, radiation)
• Lifestyle factors (smoking, alcohol, stress)

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✅ 4. Pathophysiology:

• Interruption in hormonal support (mainly progesterone) or uteroplacental insufficiency may trigger uterine contractions.
• The endometrial lining separates from the uterine wall.
• Fetus and/or placenta may be expelled partially or completely.
• This may result in bleeding, infection, or retained products.

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✅ 5. Clinical Manifestations / Signs & Symptoms:

• Vaginal bleeding (spotting to heavy bleeding)
• Abdominal cramping or pain
• Passage of tissue or clots
• Cervical dilation (on examination)
• Absence of fetal heartbeat (in missed abortion)
• Fever or foul-smelling discharge (in septic abortion)

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✅ 6. Diagnostic Evaluation:

• Ultrasound (USG) – To confirm fetal viability and completeness
• Speculum and bimanual examination – To assess cervical status
• Serum hCG levels – Falling levels indicate nonviable pregnancy
• CBC – To assess for anemia and infection
• Blood group typing – To check Rh factor and prevent isoimmunization

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✅ 7. Management:

🔹 For Threatened Abortion:

• Bed rest, avoidance of physical/sexual activity
• Progesterone supplementation (if indicated)

🔹 For Inevitable/Incomplete Abortion:

• Hospitalization
• Evacuation of uterus (D&C, suction curettage)
• Antibiotics if infection suspected

🔹 For Complete Abortion:

• Observation and follow-up
• No intervention usually needed

🔹 For Missed Abortion:

• Medical induction or surgical evacuation

🔹 For Induced Abortion:

• As per Medical Termination of Pregnancy (MTP) Act and guidelines

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✅ 8. Complications:

• Hemorrhage
• Infection (sepsis)
• Uterine perforation
• Retained products of conception
• Infertility (rare)
• Psychological impact (grief, depression)

---

✅ 9. Nurse’s Role:

• Provide emotional support and counseling
• Monitor vital signs and bleeding
• Prepare for surgical/medical management
• Educate regarding contraception and future pregnancy planning
• Ensure aseptic technique and post-procedure care
• Administer Rho(D) immunoglobulin if Rh-negative mother

---

✅ 10. Golden One-Liners for Quick Revision:

• Abortion is termination of pregnancy before 20 weeks or 500 g.
• Mifepristone + Misoprostol is the preferred drug combo for medical abortion.
• Threatened abortion has closed cervix with viable fetus.
• Missed abortion is silent fetal death with retained products.
• Septic abortion requires aggressive antibiotics and possible surgical intervention.

---

✅ 11. MCQs for Practice:

Q1. What is the most common cause of spontaneous abortion in the first trimester?
a) Infection
b) Hormonal imbalance
c) Chromosomal abnormalities
d) Trauma
Correct Answer: c) Chromosomal abnormalities
Rationale: Genetic defects account for most early miscarriages.

Q2. Which of the following indicates a missed abortion?
a) Open cervix and active bleeding
b) Painful uterine contractions
c) Retained dead fetus with no symptoms
d) Passage of all products of conception
Correct Answer: c) Retained dead fetus with no symptoms
Rationale: Missed abortion involves fetal death with no immediate expulsion or symptoms.

Q3. What is the legal limit for MTP in India as per latest amendment (2021)?
a) 12 weeks
b) 20 weeks
c) 24 weeks
d) 28 weeks
Correct Answer: c) 24 weeks
Rationale: As per the Medical Termination of Pregnancy (Amendment) Act, 2021, the upper gestational limit is 24 weeks for special categories.

Q4. Which type of abortion presents with foul-smelling discharge and fever?
a) Missed abortion
b) Threatened abortion
c) Septic abortion
d) Complete abortion
Correct Answer: c) Septic abortion
Rationale: Septic abortion involves uterine infection.

Q5. Which hormone is essential for pregnancy maintenance and its deficiency leads to abortion?
a) Estrogen
b) Oxytocin
c) Progesterone
d) Prolactin
Correct Answer: c) Progesterone
Rationale: Progesterone stabilizes the endometrium and supports pregnancy.

📘 Pre-eclampsia

(Important for OBG Nursing, GNM/BSc Nursing, AIIMS, NORCET, NHM, GPSC Staff Nurse Exams)

---

✅ 1. Introduction / Definition:

Pre-eclampsia is a pregnancy-specific multisystem disorder characterized by:

• New-onset hypertension after 20 weeks of gestation
  AND
• Proteinuria or signs of organ dysfunction (even without proteinuria)

It is a major cause of maternal and fetal morbidity and mortality.

---

✅ 2. Classification / Types:

1. Mild Pre-eclampsia:
   • BP ≥140/90 mmHg but <160/110 mmHg
   • Proteinuria: ≥1+ on dipstick or ≥300 mg/24 hrs
2. Severe Pre-eclampsia:
   • BP ≥160/110 mmHg on two occasions
   • Proteinuria ≥3+ or ≥5 g/24 hrs
   • Signs of organ involvement: headache, visual changes, elevated liver enzymes, low platelets (HELLP syndrome), pulmonary edema, fetal growth restriction
3. Superimposed Pre-eclampsia:
   • Pre-eclampsia in a woman with chronic hypertension

---

✅ 3. Causes / Risk Factors:

• First pregnancy (primigravida)
• Teenage or advanced maternal age (>35 years)
• Multiple pregnancy (twins/triplets)
• Obesity
• Chronic hypertension
• Diabetes mellitus
• Renal disease
• Family history of pre-eclampsia
• Autoimmune disorders (e.g., SLE, antiphospholipid syndrome)

---

✅ 4. Pathophysiology:

• Abnormal placental development → poor placental perfusion
• Endothelial cell dysfunction → vasospasm, increased vascular permeability
• Results in:
  • Hypertension
  • Proteinuria
  • Edema
  • Organ damage (liver, kidneys, brain)

---

✅ 5. Clinical Manifestations / Signs & Symptoms:

• Elevated blood pressure (≥140/90 mmHg)
• Proteinuria
• Edema (face, hands, feet)
• Headache
• Visual disturbances (blurred vision, photophobia)
• Epigastric or right upper quadrant pain
• Decreased urine output (oliguria)
• Hyperreflexia or clonus
• Fetal growth restriction (IUGR)

---

✅ 6. Diagnostic Evaluation:

• Blood pressure monitoring
• Urine analysis for protein (dipstick, 24-hour)
• CBC (low platelets)
• Liver function tests (LFTs) – ↑ AST, ALT
• Renal function tests – ↑ creatinine, ↓ GFR
• Ultrasound – for fetal growth
• NST (Non-Stress Test) – to monitor fetal wellbeing

---

✅ 7. Management:

🔹 Mild Pre-eclampsia:

• Rest and observation
• Monitor BP and proteinuria
• Regular fetal monitoring
• Antihypertensives if BP >150/100 mmHg

🔹 Severe Pre-eclampsia:

• Hospitalization
• Magnesium sulfate – to prevent seizures
• Antihypertensives (labetalol, hydralazine, nifedipine)
• Monitor for eclampsia, HELLP syndrome
• Delivery is the definitive cure (usually after 37 weeks or earlier if maternal/fetal compromise)

---

✅ 8. Complications:

🔸 Maternal:

• Eclampsia (seizures)
• HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets)
• Placental abruption
• Renal failure
• Pulmonary edema
• DIC
• Maternal death

🔸 Fetal:

• Intrauterine growth restriction (IUGR)
• Prematurity
• Hypoxia
• Stillbirth

---

✅ 9. Nurse’s Role:

• Monitor vital signs, urine output, reflexes
• Monitor fetal heart rate (FHR)
• Administer and monitor magnesium sulfate (check for toxicity)
• Maintain seizure precautions
• Educate the patient on warning signs
• Prepare for delivery if indicated
• Emotional support and health teaching

---

✅ 10. Golden One-Liners for Quick Revision:

• Pre-eclampsia is diagnosed after 20 weeks gestation.
• Classic triad: hypertension, proteinuria, and edema.
• Magnesium sulfate is used for seizure prevention.
• Delivery of the fetus and placenta is the only definitive treatment.
• HELLP syndrome is a severe variant of pre-eclampsia.

---

✅ 11. MCQs for Practice:

Q1. Which of the following is NOT a feature of pre-eclampsia?
a) Hypertension
b) Proteinuria
c) Seizures
d) Edema
Correct Answer: c) Seizures
Rationale: Seizures are seen in eclampsia, not pre-eclampsia.

Q2. What is the drug of choice for seizure prophylaxis in pre-eclampsia?
a) Diazepam
b) Phenytoin
c) Magnesium sulfate
d) Lorazepam
Correct Answer: c) Magnesium sulfate
Rationale: Magnesium sulfate is the standard drug to prevent eclampsia.

Q3. HELLP syndrome includes all EXCEPT:
a) Hemolysis
b) Elevated liver enzymes
c) Low platelet count
d) High WBC count
Correct Answer: d) High WBC count
Rationale: WBC count is not a component of HELLP syndrome.

Q4. Which of the following antihypertensives is commonly used in severe pre-eclampsia?
a) Atenolol
b) Methyldopa
c) Labetalol
d) Propranolol
Correct Answer: c) Labetalol
Rationale: Labetalol is preferred in pregnancy for rapid BP control.

Q5. The definitive treatment for pre-eclampsia is:
a) Rest
b) Diuretics
c) Antihypertensives
d) Delivery
Correct Answer: d) Delivery
Rationale: Removal of the placenta cures the condition.

📘 Eclampsia

(Important for OBG Nursing, GNM/BSc Nursing, AIIMS, NORCET, NHM, GPSC Staff Nurse Exams)

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✅ 1. Introduction / Definition:

Eclampsia is a severe complication of pregnancy characterized by the onset of tonic-clonic seizures (convulsions) in a woman with pre-eclampsia, and without any other identifiable cause of seizures.

• It is a life-threatening obstetric emergency and a major cause of maternal and fetal mortality.

---

✅ 2. Classification / Types:

1. Antepartum eclampsia – Seizures occur before the onset of labor.
2. Intrapartum eclampsia – Seizures occur during labor.
3. Postpartum eclampsia – Seizures occur within 48 hours after delivery.

---

✅ 3. Causes / Risk Factors:

• Pre-eclampsia (underlying)
• Primigravida
• Multiple pregnancy (twins, triplets)
• Teenage or elderly pregnancy
• Chronic hypertension
• Renal disease
• Obesity
• Poor antenatal care
• History of eclampsia in previous pregnancy

---

✅ 4. Pathophysiology:

• Severe endothelial dysfunction and vasospasm due to pre-eclampsia
• Leads to cerebral edema, ischemia, and increased intracranial pressure
• Sudden changes in cerebral perfusion trigger generalized seizures

---

✅ 5. Clinical Manifestations / Signs & Symptoms:

• Generalized tonic-clonic seizures
• Loss of consciousness
• Foaming at mouth, tongue biting
• Cyanosis, muscle rigidity, jerky movements
• Hypertension (≥160/110 mmHg)
• Proteinuria
• Severe headache
• Blurred vision or photophobia
• Epigastric pain (sign of impending seizure)
• Decreased urine output

---

✅ 6. Diagnostic Evaluation:

• Clinical diagnosis based on seizures in a pre-eclamptic woman
• Urinalysis – proteinuria
• BP measurement
• Serum creatinine, LFTs, CBC – to assess organ function
• CT/MRI Brain – only if seizures persist despite treatment (to rule out other causes)
• Fetal assessment – Non-stress test (NST), ultrasound

---

✅ 7. Management:

🔹 Emergency Management of Seizure:

• Place patient in left lateral position
• Ensure airway patency, suction if needed
• Administer oxygen
• Prevent injury: padded side rails, remove sharp objects

🔹 Drug Therapy:

• Magnesium sulfate (MgSO₄) – drug of choice for preventing and controlling seizures
  • Loading dose: 4–6 g IV over 15–20 min
  • Maintenance dose: 1–2 g/hr IV infusion
• Antihypertensives (e.g., labetalol, hydralazine, nifedipine)

🔹 Monitoring for Magnesium Toxicity:

• Respiratory rate <12/min
• Urine output <30 ml/hr
• Loss of deep tendon reflexes
• Antidote: Calcium gluconate IV (10 ml of 10%)

🔹 Delivery:

• Definitive treatment is delivery of the baby and placenta
• Vaginal delivery preferred if stable and cervix favorable
• Cesarean section if maternal or fetal compromise exists

---

✅ 8. Complications:

🔸 Maternal:

• Cerebral hemorrhage
• Pulmonary edema
• Acute renal failure
• Disseminated intravascular coagulation (DIC)
• HELLP syndrome
• Maternal death

🔸 Fetal:

• Intrauterine growth restriction (IUGR)
• Fetal hypoxia
• Preterm birth
• Intrauterine fetal death (IUFD)

---

✅ 9. Nurse’s Role:

• Monitor vital signs, especially BP and respiratory rate
• Administer and monitor MgSO₄ therapy
• Monitor urine output and signs of Mg toxicity
• Keep calcium gluconate at bedside
• Maintain seizure precautions
• Emotional support to mother and family
• Assist in safe delivery planning
• Health education for future pregnancy care

---

✅ 10. Golden One-Liners for Quick Revision:

• Eclampsia = Pre-eclampsia + Seizures
• Magnesium sulfate is the drug of choice for seizure control
• Calcium gluconate is the antidote for MgSO₄ toxicity
• Occurs after 20 weeks, usually in primigravida
• Delivery is the definitive treatment

---

✅ 11. MCQs for Practice:

Q1. Which drug is used for preventing seizures in eclampsia?
a) Diazepam
b) Phenytoin
c) Magnesium sulfate
d) Carbamazepine
Correct Answer: c) Magnesium sulfate
Rationale: MgSO₄ is the standard drug for seizure prevention and control in eclampsia.

Q2. Which of the following is an early warning sign of impending eclampsia?
a) Polyuria
b) Photophobia and headache
c) Vaginal bleeding
d) Constipation
Correct Answer: b) Photophobia and headache
Rationale: Severe headache and visual disturbances are signs of cerebral involvement.

Q3. What is the antidote for magnesium sulfate toxicity?
a) Atropine
b) Naloxone
c) Calcium gluconate
d) Flumazenil
Correct Answer: c) Calcium gluconate
Rationale: It is given IV to reverse magnesium toxicity symptoms.

Q4. What is the position of choice for an eclamptic woman during seizure?
a) Supine
b) Prone
c) Left lateral
d) Right lateral
Correct Answer: c) Left lateral
Rationale: This position improves uteroplacental blood flow and prevents aspiration.

Q5. Which of the following is NOT a complication of eclampsia?
a) Cerebral hemorrhage
b) Retinal detachment
c) HELLP syndrome
d) Pulmonary edema
Correct Answer: b) Retinal detachment
Rationale: Retinal detachment is not commonly associated with eclampsia; other three are well-known complications.

📚🍬 Gestational Diabetes Mellitus (GDM)

📘 Highly Important for GNM/BSc Nursing, NHM, AIIMS, NORCET, GPSC & Midwifery/Obstetric Nursing Exams

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✅ 1. Introduction / Definition:

Gestational Diabetes Mellitus (GDM) is a condition characterized by glucose intolerance with onset or first recognition during pregnancy (usually in the 2nd or 3rd trimester).

“GDM is defined as carbohydrate intolerance of variable severity with onset or first recognition during pregnancy.”

---

✅ 2. Classification:

• A1 GDM: Controlled by diet and exercise
• A2 GDM: Requires insulin or oral hypoglycemic agents

---

✅ 3. Causes / Risk Factors:

• Hormonal changes (placental hormones cause insulin resistance)
• Obesity or excessive weight gain
• Age > 25 years
• Family history of diabetes
• History of GDM in previous pregnancy
• PCOS (Polycystic Ovarian Syndrome)
• Previous macrosomic baby (>4 kg)
• Ethnic groups with high diabetes prevalence (e.g., South Asians)

---

✅ 4. Pathophysiology:

1. Pregnancy hormones (hPL, estrogen, progesterone) →
2. Increased insulin resistance →
3. Pancreas fails to compensate →
4. Elevated blood glucose levels during pregnancy

---

✅ 5. Signs & Symptoms:

• Often asymptomatic
• Excessive thirst (polydipsia)
• Frequent urination (polyuria)
• Fatigue
• Recurrent urinary or vaginal infections
• Large-for-date uterus (macrosomia)

---

✅ 6. Diagnostic Evaluation:

Test	Timing	Criteria
Glucose Challenge Test (GCT)	24–28 weeks	50g glucose → if >140 mg/dL after 1 hr → do OGTT
Oral Glucose Tolerance Test (OGTT)	After GCT	100g or 75g glucose with serial blood samples
Fasting Blood Glucose	Anytime	>92 mg/dL = GDM
HbA1c	Not routine in GDM but may be used for baseline	>6.5% suggests diabetes

✅ India follows DIPSI criteria – 75g glucose, 2-hour >140 mg/dL = GDM

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✅ 7. Maternal Complications:

• Polyhydramnios
• Preeclampsia
• Preterm labor
• Increased risk of cesarean delivery
• Risk of developing type 2 diabetes mellitus (T2DM) later in life

---

✅ 8. Fetal Complications:

• Macrosomia (birth weight >4 kg)
• Shoulder dystocia
• Neonatal hypoglycemia
• Respiratory distress syndrome (RDS)
• Stillbirth if unmanaged
• Increased risk of childhood obesity and diabetes

---

✅ 9. Management:

🟢 A. Lifestyle Modifications:

• Medical Nutrition Therapy (MNT): Low glycemic diet
• Moderate exercise: Walking, yoga
• Monitor blood glucose levels regularly

🟢 B. Pharmacologic:

• Insulin therapy (safest during pregnancy)
• Metformin or Glibenclamide (oral agents, used selectively)

🟢 C. Monitoring:

• Fetal growth by USG
• NST / BPP for fetal well-being
• Weekly glucose charting
• Plan delivery at 38–40 weeks

---

✅ 10. Nursing Responsibilities:

• Educate on diet, exercise, and self-monitoring of blood glucose
• Assist in insulin administration
• Monitor for hypoglycemia or hyperglycemia
• Prepare for early delivery if complications arise
• Postpartum follow-up for diabetes testing at 6–12 weeks

---

✅ 11. Golden One-Liners for Quick Revision:

• GDM is first detected in pregnancy, not before
• Placental hormones cause insulin resistance
• Macrosomia and hypoglycemia are key fetal complications
• DIPSI 75g test is used in India
• GDM increases risk of type 2 DM later in life

---

✅ 12. MCQs for Practice:

Q1. GDM usually develops during which trimester?
a) First
b) Early second
✅ c) Late second or third
d) Postpartum

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Q2. Most common fetal complication of GDM is:
a) Anencephaly
✅ b) Macrosomia
c) Oligohydramnios
d) Neural tube defect

---

Q3. The test used to screen GDM in India is:
a) HbA1c
✅ b) DIPSI 75g OGTT
c) Glucagon stimulation test
d) GCT with 100g

---

Q4. A blood glucose reading of 2-hour post 75g glucose >140 mg/dL indicates:
✅ a) GDM
b) Normal
c) Anemia
d) Hypertension

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Q5. Best treatment option for uncontrolled GDM is:
a) Multivitamins
b) Oral contraceptives
✅ c) Insulin therapy
d) Corticosteroids

📘 PRETERM LABOR

(Highly Important for GNM, BSc Nursing, Midwifery, NHM, AIIMS, NORCET, GPSC & Staff Nurse Exams)

✅ 1. Introduction / Definition:

Preterm labor is defined as the onset of regular uterine contractions resulting in cervical changes (dilation and/or effacement) before 37 completed weeks of gestation.

It is a major cause of neonatal morbidity and mortality, especially when it occurs before 34 weeks.

---

✅ 2. Classification (by gestational age):

1. Extremely preterm: <28 weeks
2. Very preterm: 28–32 weeks
3. Moderate to late preterm: 32–37 weeks

---

✅ 3. Causes / Risk Factors:

• Multiple gestation (twins, triplets)
• Infections (urinary tract infection, bacterial vaginosis, chorioamnionitis)
• Preterm premature rupture of membranes (PPROM)
• Uterine anomalies or overdistention
• Previous history of preterm birth
• Cervical incompetence
• Smoking, alcohol, or drug abuse
• Poor nutrition or low maternal weight
• Short interval between pregnancies
• Placenta previa or abruptio placentae
• Stress or trauma

---

✅ 4. Pathophysiology:

• Inflammation or infection triggers release of prostaglandins.
• Leads to uterine contractions and cervical changes.
• May also be caused by mechanical factors like uterine stretch or hormonal changes that stimulate early labor.

---

✅ 5. Clinical Manifestations / Signs & Symptoms:

• Regular uterine contractions (every 10 minutes or less)
• Low backache or pelvic pressure
• Menstrual-like cramping
• Vaginal spotting or watery discharge
• Cervical dilation and/or effacement
• Shortened cervix on transvaginal ultrasound

---

✅ 6. Diagnostic Evaluation:

• Speculum and digital pelvic exam – assess cervical status
• Cardiotocography (CTG) – monitor uterine contractions and fetal heart rate
• Transvaginal ultrasound – cervical length <2.5 cm is a risk
• Fetal fibronectin (fFN) test – positive result predicts risk of preterm birth
• Urinalysis and culture – rule out infection
• CBC, CRP – to check for infection/inflammation

---

✅ 7. Management:

🔹 A. General Management:

• Hospitalization and monitoring
• Bed rest (controversial but often advised)
• Hydration – may reduce contractions

🔹 B. Tocolytic Therapy (to delay labor temporarily):

Used to delay delivery for 48 hours to allow corticosteroids to act:

• Nifedipine (calcium channel blocker)
• Indomethacin (NSAID, before 32 weeks)
• Magnesium sulfate (also for neuroprotection)
• Terbutaline / Ritodrine (β-mimetics, less common now)

🔹 C. Corticosteroids (for fetal lung maturity):

• Betamethasone 12 mg IM × 2 doses 24 hours apart
  OR
• Dexamethasone 6 mg IM × 4 doses 12 hours apart
  Given if gestation is between 24–34 weeks.

🔹 D. Antibiotics (if infection present):

• For UTI or chorioamnionitis
• Prophylaxis for Group B Streptococcus if indicated

🔹 E. Magnesium Sulfate:

• For neuroprotection of fetus if delivery is imminent before 32 weeks

---

✅ 8. Complications:

🔸 Maternal:

• Side effects of tocolytics (e.g., hypotension, tachycardia)
• Infection (chorioamnionitis)
• Anxiety, stress

🔸 Fetal / Neonatal:

• Respiratory distress syndrome (RDS)
• Intraventricular hemorrhage (IVH)
• Necrotizing enterocolitis (NEC)
• Sepsis
• Cerebral palsy
• Low birth weight and prematurity-related complications

---

✅ 9. Nurse’s Role:

• Monitor uterine contractions and fetal heart rate
• Administer medications: tocolytics, steroids, antibiotics
• Educate the mother about signs of labor
• Provide emotional support
• Maintain bed rest and hydration protocols
• Prepare for neonatal resuscitation if preterm delivery occurs
• Teach danger signs to report (leaking, bleeding, contractions)

---

✅ 10. Golden One-Liners for Quick Revision:

• Preterm labor = Onset of labor before 37 weeks
• Nifedipine is the most commonly used tocolytic
• Betamethasone accelerates fetal lung maturity
• fFN test is useful for predicting preterm birth risk
• Magnesium sulfate protects against cerebral palsy

---

✅ 11. MCQs for Practice:

Q1. What is the most common cause of preterm labor?
a) Diabetes
b) UTI
c) Infections (e.g., chorioamnionitis)
d) Hypertension
Correct Answer: c) Infections (e.g., chorioamnionitis)
Rationale: Intrauterine infections are a leading cause of preterm labor.

Q2. Which drug is used for fetal lung maturity in preterm labor?
a) Nifedipine
b) Betamethasone
c) Magnesium sulfate
d) Oxytocin
Correct Answer: b) Betamethasone
Rationale: Corticosteroids promote surfactant production in fetal lungs.

Q3. Which tocolytic is most commonly used for preterm labor?
a) Terbutaline
b) Indomethacin
c) Nifedipine
d) Ritodrine
Correct Answer: c) Nifedipine
Rationale: Nifedipine is a calcium channel blocker widely used for tocolysis.

Q4. Which test predicts risk of preterm labor?
a) Amniocentesis
b) fFN test
c) Pap smear
d) Karyotyping
Correct Answer: b) fFN test
Rationale: Fetal fibronectin is a biomarker for risk of preterm birth.

Q5. What is the primary goal of tocolytic therapy?
a) Induce labor
b) Cure preterm labor
c) Delay delivery for corticosteroids
d) Improve cervical dilation
Correct Answer: c) Delay delivery for corticosteroids
Rationale: Tocolytics help buy time for steroid benefit in fetal lung maturity.

📘 Post Maturity (Post-term Pregnancy)

(Important for OBG Nursing, GNM/BSc Nursing, NHM, AIIMS, NORCET, GPSC Staff Nurse Exams)

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✅ 1. Introduction / Definition:

Post maturity or post-term pregnancy is defined as a pregnancy that extends beyond 42 completed weeks (≥294 days) from the first day of the last menstrual period (LMP).

It increases the risk of maternal and fetal complications due to aging of the placenta and decreased amniotic fluid.

---

✅ 2. Classification:

1. True Post-term Pregnancy – Confirmed dates, pregnancy exceeds 42 weeks.
2. Prolonged Pregnancy – Uncertain dates, fetus appears post-mature but less than 42 weeks.

---

✅ 3. Causes / Risk Factors:

• Primigravida
• Family history of post-term pregnancies
• Fetal anencephaly
• Placental sulfatase deficiency
• Incorrect dating (most common reason)
• Obesity
• Male fetus

---

✅ 4. Pathophysiology:

• After 40 weeks, the placenta begins to age (placental insufficiency).
• Leads to reduced oxygen and nutrient transfer.
• Decreased amniotic fluid (oligohydramnios) and increased risk of meconium aspiration.
• Postmature fetus develops features of chronic hypoxia and malnutrition.

---

✅ 5. Clinical Manifestations / Signs & Symptoms:

• Fundal height may not increase
• Reduced fetal movements
• Dry, peeling, parchment-like skin in newborn
• Overgrown nails and hair
• Loss of subcutaneous fat (thin appearance)
• Meconium-stained amniotic fluid
• Decreased amniotic fluid (oligohydramnios)

---

✅ 6. Diagnostic Evaluation:

• Accurate dating by early ultrasound
• Non-Stress Test (NST) – assess fetal well-being
• Biophysical Profile (BPP) – evaluates fetal movement, tone, breathing, amniotic fluid
• Ultrasound – assess fetal size, growth, amniotic fluid
• Doppler studies – uteroplacental blood flow

---

✅ 7. Management:

🔹 Expectant Management (if no complications):

• Close fetal surveillance (NST and BPP every 2–3 days)
• Maternal kick count monitoring

🔹 Active Management:

• Induction of labor (usually between 41–42 weeks)
  • Use of prostaglandins or oxytocin
  • Artificial rupture of membranes (AROM) if cervix is favorable
• Cesarean section if induction fails or fetal distress occurs

---

✅ 8. Complications:

🔸 Maternal:

• Prolonged labor
• Increased chance of operative delivery
• Postpartum hemorrhage
• Perineal trauma

🔸 Fetal / Neonatal:

• Intrauterine growth restriction (IUGR)
• Oligohydramnios
• Meconium aspiration syndrome (MAS)
• Hypoxia and stillbirth
• Macrosomia (large baby)
• Shoulder dystocia
• Neonatal convulsions or death

---

✅ 9. Nurse’s Role:

• Ensure accurate gestational age assessment
• Educate about kick count monitoring
• Assist in NST and BPP testing
• Prepare for labor induction if indicated
• Monitor for signs of fetal distress
• Provide psychological support to the mother
• Assist during delivery and neonatal resuscitation if needed

---

✅ 10. Golden One-Liners for Quick Revision:

• Post-term pregnancy = >42 weeks
• Oligohydramnios and meconium aspiration are common risks
• Biophysical profile (BPP) is used for monitoring
• Labor is usually induced between 41–42 weeks
• Macrosomia and shoulder dystocia are delivery complications

---

✅ 11. MCQs for Practice:

Q1. A pregnancy is considered post-term after how many completed weeks?
a) 38 weeks
b) 40 weeks
c) 42 weeks
d) 44 weeks
Correct Answer: c) 42 weeks
Rationale: Post-maturity is defined as gestation beyond 42 completed weeks.

---

Q2. The most common complication of post-maturity for the fetus is:
a) Polyhydramnios
b) Meconium aspiration
c) Placenta previa
d) Eclampsia
Correct Answer: b) Meconium aspiration
Rationale: Aging placenta leads to fetal distress and meconium-stained fluid.

---

Q3. Which of the following is used to monitor fetal well-being in post-term pregnancy?
a) CT scan
b) Pap smear
c) Biophysical profile
d) Amniocentesis
Correct Answer: c) Biophysical profile
Rationale: BPP is a composite test that assesses fetal status.

---

Q4. Which of the following is a typical physical feature of a post-mature newborn?
a) Lanugo present
b) Vernix caseosa
c) Peeling, dry skin
d) Excessive subcutaneous fat
Correct Answer: c) Peeling, dry skin
Rationale: Post-mature infants show signs of aging like dry skin and overgrown nails.

---

Q5. The preferred time to induce labor in a post-dated pregnancy is:
a) After 38 weeks
b) At 40 weeks
c) Between 41–42 weeks
d) After 43 weeks
Correct Answer: c) Between 41–42 weeks
Rationale: To prevent post-maturity complications, induction is considered around 41–42 weeks.

📘 MULTIPLE PREGNANCY

(Highly Important for GNM, BSc Nursing, Midwifery, AIIMS, NHM, NORCET, GPSC & Staff Nurse Exams)

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✅ 1. Introduction / Definition

Multiple pregnancy is a condition in which two or more fetuses develop simultaneously in the uterus.
It can be twins, triplets, quadruplets, etc., and may result from natural conception or assisted reproductive techniques (ART).

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✅ 2. Types of Multiple Pregnancy

Type	Definition
Dizygotic (Fraternal) Twins	Two ova fertilized by two sperms (different placenta & membranes)
Monozygotic (Identical) Twins	One ovum fertilized by one sperm, which splits into two embryos
Higher-order multiples	Triplets or more (can be mono- or dizygotic)

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✅ 3. Chorionicity and Amnionicity

Chorionicity-Amnionicity	Description
Dichorionic-Diamniotic (Di-Di)	Two placentas, two amniotic sacs
Monochorionic-Diamniotic (Mo-Di)	One placenta, two sacs
Monochorionic-Monoamniotic (Mo-Mo)	One placenta, one sac

🟨 Di-Di – safest
🟥 Mo-Mo – highest risk (cord entanglement)

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✅ 4. Causes / Risk Factors

• Family history of twins (especially maternal side)
• Advanced maternal age (>35 years)
• Assisted Reproductive Technology (IVF, IUI)
• High parity (multiple previous pregnancies)
• Use of ovulation induction drugs (Clomiphene, Letrozole)

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✅ 5. Signs & Symptoms

• Rapid increase in uterine size
• Fundal height larger than gestational age
• Excessive weight gain
• Severe morning sickness
• Increased fetal parts felt on palpation
• Two or more fetal heart tones detected

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✅ 6. Diagnostic Evaluation

Investigation	Finding
Ultrasound	Confirms number of fetuses, chorionicity
Fundal Height	Higher than expected for gestational age
Serum hCG & AFP	Higher than normal (due to multiple placentas)
NST / BPP / Doppler	For fetal monitoring in late pregnancy

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✅ 7. Complications of Multiple Pregnancy

🔹 Maternal Complications

• Anemia
• Pregnancy-induced hypertension (PIH)
• Gestational diabetes
• Polyhydramnios
• Preterm labor
• Postpartum hemorrhage (PPH)

🔹 Fetal Complications

• Prematurity
• Intrauterine growth restriction (IUGR)
• Twin-to-twin transfusion syndrome (TTTS) in monochorionic twins
• Congenital anomalies
• Cord entanglement (in Mo-Mo twins)
• Intrauterine death of one fetus

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✅ 8. Management of Multiple Pregnancy

🔸 Antenatal Care

• Early confirmation and chorionicity determination via USG
• Frequent antenatal check-ups (every 2 weeks after 24 weeks)
• Monitor for PIH, anemia, preterm signs
• Iron, folic acid, calcium supplementation
• Weight gain: 15–20 kg (for twins)

🔸 Intrapartum Care

• Delivery in well-equipped hospital with NICU
• Vaginal delivery may be possible if:
  • First twin is cephalic
  • No complications
• Cesarean if:
  • Malpresentation
  • Mo-Mo twins
  • Fetal distress or discordant growth

🔸 Postpartum Care

• Monitor for PPH and anemia
• Breastfeeding support
• Neonatal care for preterm or low birth weight babies

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✅ 9. Nursing Responsibilities

• Educate the mother on warning signs (preterm pain, bleeding)
• Monitor fundal height, fetal heart rates, and vital signs
• Provide psychological support for high-risk status
• Prepare for emergency delivery or cesarean
• Assist in NICU transfer and neonatal care
• Support breastfeeding and nutritional guidance

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✅ 10. Golden One-Liners for Revision

• Dizygotic twins = Two ova, two sperms, always Di-Di
• Monozygotic twins = One ovum splits into two
• Mo-Mo twins have highest risk (cord entanglement)
• Twin pregnancy = higher risk of preterm labor & PPH
• Ultrasound is the investigation of choice for confirmation
• Twin-to-Twin Transfusion Syndrome occurs only in monochorionic twins

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✅ 11. Top 5 MCQs for Practice

1. Which of the following is a risk factor for multiple pregnancy?
a) Low maternal age
b) Smoking
c) Use of Clomiphene citrate
d) Male infertility
Correct Answer: c) Use of Clomiphene citrate
Rationale: Ovulation-inducing agents increase the chances of multiple ovulations.

2. Monozygotic twins result from:
a) Fertilization of two separate ova
b) Fertilization of one ovum that splits
c) Two sperms fertilizing two ova
d) Two sperms fertilizing one ovum
Correct Answer: b) Fertilization of one ovum that splits
Rationale: Monozygotic twins are genetically identical.

3. Twin-to-Twin Transfusion Syndrome occurs in:
a) Dichorionic twins
b) Monoamniotic twins only
c) Monochorionic twins
d) Any twin pregnancy
Correct Answer: c) Monochorionic twins
Rationale: TTTS involves abnormal vascular connections within a shared placenta.

4. Which of the following complications is common in multiple pregnancy?
a) Hyperthyroidism
b) Polyhydramnios
c) Hypoglycemia
d) Oligohydramnios
Correct Answer: b) Polyhydramnios
Rationale: Multiple fetuses increase amniotic fluid volume.

5. Which is the best investigation to confirm multiple pregnancy and chorionicity?
a) X-ray
b) Pelvic exam
c) Doppler study
d) Ultrasonography
Correct Answer: d) Ultrasonography
Rationale: USG is safe and accurate to confirm number of fetuses and placentas.

📘 TWIN-TO-TWIN TRANSFUSION SYNDROME (TTTS)

(Highly Important for GNM, BSc Nursing, Midwifery, AIIMS, NHM, NORCET, GPSC & Staff Nurse Exams)

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✅ 1. Introduction / Definition

Twin-to-Twin Transfusion Syndrome (TTTS) is a serious complication that occurs only in monochorionic (single placenta) twin pregnancies, where abnormal vascular connections between the twins cause unequal blood flow.

🧠 One twin becomes the donor, and the other becomes the recipient, leading to volume imbalance and serious fetal complications.

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✅ 2. Cause / Pathophysiology

• In monochorionic twins, the shared placenta has anastomoses (vascular connections).
• When these become unbalanced, blood flows from one twin (donor) to the other (recipient) through arteriovenous shunts.
• The donor twin becomes anemic and growth-restricted, while the recipient twin develops volume overload, polyhydramnios, and cardiac strain.

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✅ 3. Chorionicity Requirement

• Only occurs in:
  🔹 Monochorionic-Diamniotic (Mo-Di) twins
  🔹 Rarely in Monochorionic-Monoamniotic (Mo-Mo) twins
• Never occurs in Dichorionic twins

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✅ 4. Clinical Features

Donor Twin	Recipient Twin
Small for gestational age (SGA)	Large for gestational age (LGA)
Oligohydramnios	Polyhydramnios
Anemia	Polycythemia
Hypovolemia	Hypervolemia
Bladder not visible on USG	Enlarged bladder
Poor Doppler flow	Cardiac failure, hydrops fetalis

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✅ 5. Diagnostic Evaluation

Test/Procedure	Purpose/Findings
Ultrasound	Confirms monochorionic twins, discordant amniotic fluid
Amniotic Fluid Index (AFI)	Oligohydramnios in donor; polyhydramnios in recipient
Bladder visibility	Bladder absent in donor; enlarged in recipient
Doppler Studies	Assess fetal circulation, cardiac function
Fetal Echocardiography	Assess for cardiomegaly, heart failure in recipient

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✅ 6. Quintero Staging System (Grading of TTTS Severity)

Stage	Description
I	Polyhydramnios in recipient, oligohydramnios in donor, bladder visible
II	Bladder of donor twin not visible
III	Abnormal Doppler studies
IV	Hydrops fetalis in one or both twins
V	Intrauterine fetal death (IUFD) of one or both twins

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✅ 7. Management of TTTS

Severity/Stage	Management Options
Mild (Stage I)	Close monitoring (USG every 1–2 weeks)
Moderate to Severe
→ Laser Photocoagulation of placental anastomoses (first-line treatment)
→ Amnioreduction to reduce excess fluid
→ Selective feticide (in severe, untreatable cases)
→ Early delivery if viable and condition deteriorates

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✅ 8. Complications

🔹 For Donor Twin

• Growth restriction
• Hypovolemia
• Death

🔹 For Recipient Twin

• Heart failure
• Hydrops fetalis
• Polycythemia
• Death

🔹 For Both Twins

• Preterm labor
• Cerebral palsy (if survived with hypoxia)
• IUFD

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✅ 9. Nursing Responsibilities

• Monitor maternal complaints (abdominal distension, preterm pain)
• Assist in frequent ultrasounds and fetal Doppler studies
• Educate and emotionally support the mother regarding condition and risks
• Prepare the mother for possible fetal interventions or early delivery
• Ensure availability of neonatal resuscitation team during birth
• Document all findings, USG results, fetal assessments carefully

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✅ 10. Golden One-Liners for Revision

• TTTS occurs only in monochorionic twin pregnancies
• It results from unbalanced blood flow through placental anastomoses
• Laser therapy is the treatment of choice for severe TTTS
• Donor twin has oligohydramnios and anemia
• Recipient twin has polyhydramnios and cardiac overload
• Quintero staging is used to grade TTTS severity

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✅ 11. Top 5 MCQs for Practice

1. TTTS occurs in which type of twin pregnancy?
a) Dichorionic diamniotic
b) Monochorionic diamniotic
c) Dizygotic
d) All twin types
Correct Answer: b) Monochorionic diamniotic
Rationale: Only monochorionic twins share a placenta, allowing abnormal vascular connections.

2. What is the most effective treatment for severe TTTS?
a) Amniocentesis
b) Betamethasone
c) Laser photocoagulation
d) Blood transfusion
Correct Answer: c) Laser photocoagulation
Rationale: This seals abnormal placental vessels and corrects blood flow imbalance.

3. In TTTS, which of the following is seen in the donor twin?
a) Polyhydramnios
b) Cardiomegaly
c) Oligohydramnios
d) Hypertension
Correct Answer: c) Oligohydramnios
Rationale: The donor twin loses fluid and blood, leading to reduced urine output and less amniotic fluid.

4. Which TTTS stage is characterized by absent bladder in donor twin?
a) Stage I
b) Stage II
c) Stage III
d) Stage IV
Correct Answer: b) Stage II
Rationale: Stage II involves absent bladder in the donor twin.

5. What is a common complication for the recipient twin in TTTS?
a) IUGR
b) Hypovolemia
c) Heart failure
d) Anemia
Correct Answer: c) Heart failure
Rationale: The recipient twin receives excess blood volume, overloading the heart.

📘 Intrauterine Fetal Death (IUFD)

(Important for OBG Nursing, GNM/BSc Nursing, NHM, AIIMS, NORCET, GPSC Staff Nurse Exams)

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✅ 1. Introduction / Definition:

Intrauterine fetal death (IUFD) refers to the death of the fetus in the uterus after 20 weeks of gestation but before the onset of labor.

• It is also called stillbirth if the fetus is born with no signs of life.
• IUFD is a tragic event with physical and emotional consequences for the mother and family.

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✅ 2. Classification:

1. Early IUFD: 20–27 weeks of gestation
2. Late IUFD: 28 weeks to delivery
3. Term IUFD: ≥37 weeks

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✅ 3. Causes / Risk Factors:

🔹 Maternal Factors:

• Hypertension (e.g., preeclampsia, eclampsia)
• Diabetes mellitus
• Severe anemia
• Infections (e.g., TORCH, syphilis)
• Trauma
• Obesity
• Smoking, alcohol, drug abuse

🔹 Fetal Factors:

• Chromosomal abnormalities
• Congenital malformations
• Fetal growth restriction (IUGR)
• Multiple gestation

🔹 Placental Factors:

• Placental abruption
• Placenta previa
• Cord accidents (knots, prolapse)
• Placental insufficiency

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✅ 4. Pathophysiology:

• Insufficient oxygen/nutrient supply to fetus leads to hypoxia and death.
• Dead fetus remains in the uterus, which may lead to:
  • Coagulation abnormalities (DIC) if retained >4 weeks
  • Emotional and psychological distress to mother

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✅ 5. Clinical Manifestations / Signs & Symptoms:

• Absence of fetal movements
• No fetal heart tones on Doppler or stethoscope
• Decrease in uterine size (if fetus retained)
• Brownish vaginal discharge
• Regression of pregnancy symptoms (nausea, breast fullness)
• Fetal parts not palpable clearly on abdominal exam

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✅ 6. Diagnostic Evaluation:

• Ultrasound (USG) – Confirms absence of fetal cardiac activity
• Non-Stress Test (NST) – No fetal heart tracing
• Serum β-hCG – Declining levels
• X-ray (after 20 weeks) – Overlapping skull bones (Spalding’s sign)
• CBC, clotting profile – Check for anemia and DIC
• TORCH screen, VDRL, blood sugar – Search for cause

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✅ 7. Management:

🔹 Initial Steps:

• Confirm fetal death via ultrasound
• Provide psychological support and counseling
• Check for coagulation profile (fibrinogen, PT/INR)

🔹 Delivery Options:

• Induction of labor is preferred (with misoprostol or oxytocin)
• Cesarean section is avoided unless obstetrically indicated
• Dilation and evacuation (D&E) may be used in early IUFD

🔹 Post-delivery Care:

• Monitor for postpartum hemorrhage (PPH)
• Check for coagulopathy or DIC
• Collect fetal/placental tissue for autopsy and histopathology (with consent)
• Offer bereavement support and follow-up counseling

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✅ 8. Complications:

🔸 Maternal:

• Disseminated intravascular coagulation (DIC)
• Postpartum hemorrhage
• Infection (sepsis)
• Retained placenta
• Psychological issues: depression, guilt, anxiety, PTSD

🔸 Future Pregnancy Risk:

• Recurrence (especially if cause is unexplained or maternal disease is uncontrolled)

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✅ 9. Nurse’s Role:

• Support emotionally with empathy and nonjudgmental care
• Monitor vital signs, bleeding, uterine contractions
• Assist with induction and delivery
• Prepare the mother and family for seeing or holding the baby
• Encourage grieving and memory making (photos, footprints)
• Assist in investigations to determine cause
• Educate about follow-up care, contraception, and future pregnancy planning

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✅ 10. Golden One-Liners for Quick Revision:

• IUFD = fetal death after 20 weeks but before labor
• Ultrasound is the gold standard for confirmation
• Most common symptom: absent fetal movements
• Risk of DIC increases if fetus is retained >4 weeks
• Preferred mode of delivery: induction of labor

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✅ 11. MCQs for Practice:

Q1. Intrauterine fetal death is defined as fetal death after:
a) 12 weeks
b) 16 weeks
c) 20 weeks
d) 37 weeks
Correct Answer: c) 20 weeks
Rationale: IUFD is defined as fetal death occurring after 20 weeks of gestation.

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Q2. The most reliable method to confirm IUFD is:
a) Absence of fetal movement
b) X-ray
c) Ultrasound
d) CT scan
Correct Answer: c) Ultrasound
Rationale: Ultrasound showing absent fetal cardiac activity is diagnostic.

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Q3. What is the most dangerous maternal complication of IUFD?
a) Preeclampsia
b) Diabetes
c) DIC
d) UTI
Correct Answer: c) DIC
Rationale: Retained dead fetus may release thromboplastin, triggering DIC.

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Q4. What emotional support is essential for a mother after IUFD?
a) Distraction therapy
b) Denial of loss
c) Bereavement counseling
d) Immediate discharge
Correct Answer: c) Bereavement counseling
Rationale: Psychological support and counseling are vital for coping.

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Q5. What is the typical delivery method for IUFD at term?
a) Elective C-section
b) Emergency hysterectomy
c) Induction of labor
d) Vacuum extraction
Correct Answer: c) Induction of labor
Rationale: Induction is preferred unless C-section is obstetrically necessary.