Obstetrics and Gynecology
This domain tests the emergencies that kill mothers in Nepal - postpartum haemorrhage, hypertensive disease, obstructed labour and sepsis - plus routine antenatal care, contraception and abortion law.
Core rules
- Antenatal care: at least four visits, blood pressure and urine protein at each, iron and folate, tetanus toxoid, fundal height, and haemoglobin.
- Pre-eclampsia: blood pressure ≥140/90 with proteinuria after 20 weeks. Severe features are ≥160/110, low platelets, raised liver enzymes, rising creatinine, or symptoms. Magnesium sulphate prevents fits; delivery is the definitive treatment.
- Eclampsia: Pritchard regimen - 4 g magnesium sulphate IV plus 10 g IM, then 5 g IM every 4 hours, monitoring reflexes, respiratory rate and urine output.
- Postpartum haemorrhage: uterine atony is commonest. Rub up the fundus, give oxytocin 10 IU IM, tranexamic acid 1 g within 3 hours, then misoprostol 800 micrograms sublingually; use a balloon or surgery if bleeding continues.
- Partograph: plot cervical dilatation, descent, contractions and fetal heart rate; the action line triggers intervention.
Worked example
A woman two hours after delivery bleeds heavily; the uterus is soft and boggy. This is atonic PPH. Call for help, massage the uterus, empty the bladder, give oxytocin and tranexamic acid, secure IV access with crystalloid, then misoprostol; if bleeding persists, use a condom catheter balloon and prepare for laparotomy.
Traps
- Giving ergometrine to a woman with hypertension or pre-eclampsia.
- Continuing magnesium sulphate without checking reflexes and respiratory rate.
- Using misoprostol for induction in a woman with a previous caesarean scar.
- Missing that abortion is legal in Nepal up to 12 weeks on request, and up to 28 weeks for rape, incest, fetal anomaly or risk to the mother.