Short cases in Obstetric and Gynaecology

1. Calculate POA:
a) 40 weeks - distance from the date of examining to the EDD
b) Date of exam to LMP duration
EDD= LMP+ (7 days and 9 months)
c) Approach: Maintain good eye contact, smile at patient, introduce, ask permission
d) Introduce: I am ABC fifth year medical student.
e) Permission: May I examine you please?
f) Position : Are you okay if you lie down flat?
g) Exposure: Abdomen exposed from xiphisternum/ breast line to pubis symphysis.
Cover patient properly.
h) Put you tape at the side of the bed so that you wont forget later on.

Obstetric case

Inspection:

1. The abdomen is distended by gravid uterus as evidenced by linear nigra and striae
gravidarum. Theres also evidence of striae albicans indicating pt had pregnancy in the
past.
2. There is no previous surgical scars.
-Fenneisteil scar (suprapubic), laparoscopic (umbilicus) , laparotomy , appendectomy,
cholecystectomy scar
- If there is,measure the scar , determine whether it is old, new, healed or with keloid
3. Palpate the scar. Use two to three fingers to palpate the scar.
4. Features of scar dehiscence:
- Tenderness
- Persistent lower abdo pain
- Maternal tachycardia /hypotension
- Abnormal PV bleeding/hematuria
- Fetal bradycardia/fetal distress
- Delayed labour progress
5. Umbilicus is centrally located everted
6. Any distension of vein IVC compression
7. Obvious fetal movement (clue to where the baby limbs are!)

Palpation:

1. Soft palpation- 9 quadrants for tenderness, to gain confidence from patient

2. Deep palpation ( 1 finger breadth= 2 weeks)
 A) Fundal height-at xiphisternum not full flank- 38 weeks
- 1 finger below xiphisternum, full flank= 40 weeks

B) Symphisiofundal height
- how many cm Conclude : The cfh is x cmand sfh is xcm, therefore,
this is correspond /do not correspond to date.
C) Fetal lie and presentation
- Fundal grip upper pole hard/soft?, ballotable?
- Lateral grip smooth= back, irregular- limb
- Pelvic grip- soft/hard? Ballotable- , engagement

Hard, round, ballotable= head

Soft, broad, non-ballotable= buttock

D) Fetal heart : Pinard at anterior shoulder (110-160 bpm)

Before presenting try to estimate liquor, fetal weight

28 weeks- 1 kg
34 weeks- 2 kg
36 weeks- 2.4 kg
Term- 3.2 g

Estimated fetal weight example (2.2-2.4 kg) , use numbers with discrepancy of 2 kg.

Example of presentation

1. Normal
On inspection, the the abdomen is distended by gravid uterus as evidenced by linear
nigra and striae gravidarum. Theres also evidence of striae albicans indicating pt had
pregnancy in the past. There is no previous surgical scars, dilated veins and umbilicus
is centrally located. Fetal movement can be seen.

On superficial palpation, the abdomen is soft and non-tender.

On deep palpation, the clinical fundal height is x cm and symphisiofundal height is x
cm, corresponding to the date.

There is a singleton fetus in longitudinal lie in cephalic presentation.Fetal back is at

maternal left side. Head is 5th palpable, not engaged. The liquor is
clinicallyadequate. Estimated fetal weight is 800g (eg). Fetal heart is heard at left
iliac fossa, 120 bpm.
 *Or I w ould like to complete my examination by measuring fetal heart rate using
Pinard stetchoscope/ Doppler USS.

Checklist in presentation

1. Inspection,
2. palpation (soft, deep- CFH, SFH, corresponding),
3. no of fetus, lie, presentation , fetal back,
4. head palpapble, engagement,
5. liquor , estimated fetal weight,
6. fetal heart rate

2. Uterus smaller than date

Pt 28 weeks POA
On inspection, the the abdomen is distended by gravid uterus as evidenced by linear nigra
and striae gravidarum. Theres also evidence of striae albicans indicating pt had
pregnancy in the past. There is no previous surgical scars, dilated veins and umbilicus is
centrally located. Fetal movement can be seen.

On superficial palpation, the abdomen is soft and non-tender.

On deep palpation, the clinical fundal height is 24 cm and symphisiofundal height is 22
cm, smaller than date.

There is a singleton fetus in longitudinal lie in cephalic presentation.Fetal back is at

maternal left side. Head is 5th palpable, not engaged. The liquor is adequate. Estimated
fetal weight is 800g . Fetal heart is heard at left iliac fossa, 120 bpm.

*Or I w ould like to complete my examination by measuring fetal heart rate using Pinard
stetchoscope/ Doppler USS.

My diagnosis is uterus smaller than date evidenced by discrepancy of of SFH and CFH with
POA.

Most likely causes by can be divided into maternal and fetal

Maternal:
1.Wrong date
2. PPROM
3. Small size mother
4. Underlying heart disease
5. Underlying connective disease
6. Pregnancy induced hypertension
7. Anemia in pregnancy
8. Intrauterine infection (TORCHES)

Fetal:

1. SGA /IUGR
2. Oligohydramnios
3. Fetal anomalies ,
4. renal agenesis ,
5. chromosomal anomalies
6. Abnormal lie

How do you manage?

I would like to :
1. Take history such as mother LMP, medical conditions, nutrition, diet, social history
such as smoking and previous baby history
2. Do physical examination- maternal weight and height, cardiovascular and respiratory
examination
3. Do investigations
1. to confim my diagnosis by doing serial measurement of sfh,
2. Rule out causes by
- blood investigations eg fbc for anemia in pregnancy
- growth chart- at least 2 serial measurement to rule out SGA and IUGR
- Karyotyping- fetal anomalies by amniocentesis/cordocentesis (depends on gestation)
- Triple test(15-20 weeks)- afp, Hcg, estriol (birth defects)
3. investigate sequela of the condition by doing:
- Uterine artery Doppler for uteroplacental insufficiency

Management by causes.
3.OLigohydramnios ( inadequate liquor)

Pt 28 weeks POA
On inspection, the the abdomen is distended by gravid uterus as evidenced by linear nigra
and striae gravidarum. Theres also evidence of striae albicans indicating pt had
pregnancy in the past. There is no previous surgical scars, dilated veins and umbilicus is
centrally located. Fetal movement can be seen.

On superficial palpation, the abdomen is soft and non-tender.

On deep palpation, the clinical fundal height is 24 cm and symphisiofundal height is 22
cm, smaller than date.

There is a singleton fetus in longitudinal lie in cephalic presentation.Fetal back is at

maternal left side. Head is 5th palpable, not engaged. The fetas is easily palpable. The
liquor is inadequate. Estimated fetal weight is 800g . Fetal heart is heard at left iliac
fossa, 120 bpm.

*Or I would like to complete my examination by measuring fetal heart rate using Pinard
stetchoscope/ Doppler USS.

My diagnosis is uterus smaller than date and oligohydramnios evidenced by discrepancy of of

SFH and CFH with POA.

Most likely causes can be divided into maternal and fetal

Maternal

1. PPROM
2. Drugs (ACE-i) , NSAIDs, prostaglandin synthase inhibitor
3. Placental insufficiency : PIH, PE, heart disease
4. Intrauterine infections

Fetal:

1. Reduced fetal urine production from:

- Renal agenesis
- Chromosomal anomalies
- IUGR
2. Post date-meconium stain
3. Pulmonary hypoplasia

Investigations
 1. I would like to confirm my diagnosis by doing ultrasound, measuring the average AFI
from 4 deepest pole. If AFI < 5, then diagnosis confimed. More than 22 is
polyhydramnion.
2. Rule out causes of PPROM by doing speculum examination to do see pooling of liquor,
cough impulse, nirazine and litmus test
3. Rule out infection by full blood count, crp, high vaginal swab.
4. Rule out fetal anomalies from karyotyping, detailed scan
5. Rule out fetal causes from serial USS, iugr
6. Investigate by doing Uterine artery Doppler for uteroplacental insufficiency

Management

1. Take detailed history

2. Maternal: Treat underlying causes
3. Fetal: Check serial USS, iugr, Doppler USS, fetal kick chart
4. In labour, if IUGR, deliver by induction of labor
5. If no iugr, monitor AFI, prepare dexa

4.SGA /IUGR

Pt 28 weeks POA
On inspection, the the abdomen is distended by gravid uterus as evidenced by linear nigra
and striae gravidarum. Theres also evidence of striae albicans indicating pt had
pregnancy in the past. There is no previous surgical scars, dilated veins and umbilicus is
centrally located. Fetal movement can be seen.

On superficial palpation, the abdomen is soft and non-tender.

On deep palpation, the clinical fundal height is 24 cm and symphisiofundal height is 22
cm, smaller than date.

There is a singleton fetus in longitudinal lie in cephalic presentation.Fetal back is at

maternal left side. Head is 5th palpable, not engaged. The fetas is not easily palpable.
The liquor is adequate. Estimated fetal weight is 800g . Fetal heart is heard at left iliac
fossa, 120 bpm.

*Or I would like to complete my examination by measuring fetal heart rate using Pinard
stetchoscope/ Doppler USS.

My diagnosis is uterus smaller than date and sga/iugr evidenced by discrepancy of of SFH and
CFH with POA.

Most likely causes by can be divided into maternal and fetal

Maternal

1. Maternal anaemia
2. Pregnancy induced hypertension and pre-eclampsia
3. Small mother
4. Mother with heart disease
5. Torches infection

Fetal:

1. congenital anomalies
2. multiple pregnancy

5.Uterus larger than date

Pt 30 weeks POA
On inspection, the the abdomen is grossly distended by gravid uterus as evidenced by
linear nigra and striae gravidarum. Theres also evidence of striae albicans indicating pt
had pregnancy in the past. There is no previous surgical scars, dilated veins and
umbilicus is centrally located.

On superficial palpation, the abdomen is soft and non-tender.

On deep palpation, the clinical fundal height is 36 cm and symphisiofundal height is 35
cm, larger than date.

There is a singleton fetus in longitudinal lie in cephalic presentation.Fetal back is at

maternal left side. Head is 5th palpable, not engaged. The fetal part is very difficult to
palpate. The liquor is adequate . Estimated fetal weight is 1.2 to 1.4 kg . Fetal heart is
heard at left iliac fossa, with heart rate of 120 bpm.

*Or I would like to complete my examination by measuring fetal heart rate using Pinard
stetchoscope/ Doppler USS.

My diagnosis is uterus larger than date as evidenced by discrepancy of of SFH and CFH with
POA.

Most likely causes can be divided into maternal and fetal

Maternal

1. Wrong date
2. Pregnancy with pelvic masses such as fibroid, ovarian cyst
 3. Obesity
4. Gestational diabetes mellitus
5. Chorioangioma
6. Arteriovenous malaformation

Fetal:

1. Multiple pregnancy
2. Macrosomia
3. Polyhydramnios

Management

1. Take detailed history

2. Do physical examination on mother : BMI
3. Investigations:
Rule out causes by :
- Ultrasound: multiple pregnancy, pelvic masses, estimated fetal weight , evidence of
placenta abnormality
4. Treat underlying causes

5. Polyhydramnios
Pt 30 weeks POA
On inspection, the the abdomen is grossly distended by gravid uterus as evidenced by
linear nigra and striae gravidarum. Abdomen looks shiny with fullness of right
hypochondriac and left hypochondriac region.Theres also evidence of striae albicans
indicating pt had pregnancy in the past. There is no previous surgical scars, dilated veins
and umbilicus is centrally located.

On superficial palpation, the abdomen is soft and non-tender.

On deep palpation, the clinical fundal height is 36 cm and symphisiofundal height is 35
cm, larger than date.

There is a singleton fetus in longitudinal lie in cephalic presentation.Fetal back is at

maternal left side. Head is 5th palpable, not engaged. The fetal part is very difficult to
palpate. The liquor is clinically excessive. Fluid thrill is positive. Estimated fetal weight
is 1.2 to 1.4 kg . Fetal heart is heard at left iliac fossa, muffled with heart rate of 120
bpm.
*Or I would like to complete my examination by measuring fetal heart rate using Pinard
stetchoscope/ Doppler USS.
Maternal

1. Gestational diabetes mellitus

2. Chorioangioma
3. Arteriovenous malaformation

Fetal:

1. GIT obstruction: duodenal atresia, trachea-esophageal atresia

2. Fetal anomaly: Anenchephaly
3. Twin to twin transfusion syndrome
4. Fetal hydrops

Complications:

1. Preterm labour
2. Congenital abnormality
3. Malpresentation
4. Maternal discomfort
5. Cord prolapse
6. Postpartum hemorrhage

Investigations: I would like to confirm my diagnosis by doing ultrasound, measuring the average
AFI from 4 deepest pole. If More than 22 is polyhydramnios.

Management: Treat causes, conservatively if asymptomatic and no pressure symptoms. If

symptomatic, give indomethacin 50-200 mg till 35 weeks also for polyhydramnios.

In exam, if you have case of uterus larger than date, make sure you do fluid thrill!!!!!!!!
 6. Abnormal Lie

Tips: Mention presentation in breech ! In oblique lie, transverse, no need mentioning fetal
presentation!

BREECH

On inspection, the the abdomen is distended by gravid uterus as evidenced by linear

nigra and striae gravidarum. Theres also evidence of striae albicans indicating pt had
pregnancy in the past. There is no previous surgical scars, dilated veins and umbilicus is
centrally located.

On superficial palpation, the abdomen is soft and non-tender.

On deep palpation, the clinical fundal height is 36 cm and symphisiofundal height is 35
cm, corresponding to the date.

There is a singleton fetus in longitudinal lie in breech presentation as evidenced by :

- On fundal grip, the presenting part is hard, round and ballotable indicating the head
- On pelvic grip, the presenting part is broad, soft and non-ballotable indicating
buttock.
Fetal back is at maternal left side. The liquor is clinically adequate. Estimated fetal
weight is 1.2 to 1.4 kg . Fetal heart is heard at left hypochondriac region, with heart rate
of 120 bpm.

*Or I would like to complete my examination by measuring fetal heart rate using Pinard
stetchoscope/ Doppler USS.

OBLIQUE LIE

There is a singleton fetus in OBLIQUE lie as evidenced by :

- At right iliac fossa the presenting part is hard, round and ballotable indicating the
head
- On left hypochondriac region, the presenting part is broad, soft and non-ballotable
indicating buttock.

TRANSVERSE LIE

There is a singleton fetus in TRANSVERSE lie as evidenced by :

- At right iliac fossa the presenting part is hard, round and ballotable indicating the
head
 - On left iliac fossa, the presenting part is broad, soft and non-ballotable indicating
buttock.
- Causes of abnormal lie:

o Maternal
- Placenta praevia
- pelvic mass
- maternal obesity
- uterine abnormalities (bi-cornuate uterus)
- contracted pelvic (CPD)

o Fetal
- wrong dates (prematurity)
- polyhydromnios
- oligohydromnios
- multiple pregnancy
- fetal anomalies (hydrocephalus, anencephaly)
- IUGR / IUD
- SGA

Investigations

I would like to arrange for ultrasound to look for

- evidence of pelvic mass
- reconfirm the lie & presentation
- physical biometry head and abdominal circumference (IUGR)
- AFI
- EFW
- localization of placenta
Management

1. In uncomplicated breech presentation, there is 3 options that we can offer to the mother,
- vaginal delivery (in extended only)
- external cephalic version
- LSCS

2. Based on Canadian term breech trial study showed that the elective LSCS for
uncomplicated breech at term offer better outcome to the fetal & mother as compared to
the vaginal delivery .
3. There is a role of SVD in this uncomplicated breech after we exclude all contraindication
of VD and
- normal size baby (3.0kg)
- adequate pelvic
- flexed neck
 - multiparous
- engaged & extended breech
- pt understood about possible cx
- skill surgeon

This is because the risk of birth asphyxia is higher in vaginal delivery compared to LSCS. It is
may be due to:
- risk of cord prolapse or compression is higher
- damage to the internal organ (viscera)
- spinal cord transection
- fracture of the humerus and clavicle
- and the most dangerous cx is head entrapment

4. However, in certain cases, LSCS is strongly indicated in breech presentation. The

indications include:
Maternal:
1 CPD
2 Previous uterine scar (2 LSCS / 1 classical scar)
3 Severe medical / obstetric problem (severe PE / heart disease)
4 Precious pregnancy (hx of subfertility, medically assisted conception, hx of stillbirth)

fetus
1 Macrosomia
2 Very small fetus
3 Premature fetus (unable to cope with stress of BVD)
4 Hyperextended neck ( increase risk of head entrapment, detected by USS)

How do you manage BREECH OR ABNORMAL LIE if POA is at 34 weeks?

1. Rule out causes first
2. If no causes, see at 38 weeks for breech
3. If abnormal lie, see at 36 weeks because worried of cord prolapse. No need ECV, do C-
sec if still abnormal.

7. MULTIPLE PREGNANCY

On inspection, the the abdomen is distended by gravid uterus as evidenced by linear nigra
and striae gravidarum. Theres also evidence of striae albicans indicating pt had
 pregnancy in the past. There is no previous surgical scars, dilated veins and umbilicus is
centrally located. Fetal movement can be seen.

On superficial palpation, the abdomen is soft and non-tender.

On deep palpation, the clinical fundal height is x cm and symphisiofundal height is x cm,
corresponding to the date.

I could feel there is presence of multiple poles. One pole is at _____________ and it feels
like head /buttock as evidenced by ____________.
The second pole is at _____________
The third pole is at the ____________ and I think it is a _____________, the presentation
of the leading twin which occupies the maternal pelvis can be felt.

The liquor is clinically adequate. Fluid thrill is negative. Combined estimated fetal weight
is ________. Fetal heart can be listened at__________ and ______________

Therefore, I would like to offer my diagnosis as multiple pregnancy. My differentials will

be fibroid in pregnancy, polyhydramnios, macrosmia and wrong dates.

Gynaecology

Exposure: Above xiphisternum to thigh

Inspection: abdomen distension, describe where to where, cough impulses
Palpation: use flat of fingers.

1. Soft palpation- all quadrants

2. Deep palpation: all quadrants, then use left hand to elicit pelvic masses,
compare with gravid uterus percuss for border (side , lateral), measure the
mass.
3. Elicit from mass: site, size , shape, surface,margin, consistency, mobility,
can get below it.
4. Examine liver, spleen, ballot kidney
5. Percuss ascites, check bowel sounds

Presentation:

On inspection, the abdomen is distended/not distended from where to where. The

umbilicus is centrally located and inverted. There is no scar and no dilated veins noted. .
Cough impulses were intact.
On soft palpation, the abdomen is soft and non-tender.

On deep palpation, there is mass at_____, equal to _________ weeks gravid uterus
located at the umbilical/ iliac fossa region.

Uterus in origin:

- Centrally located, non-mobile, firm in consistency, cannot get below it

Ovarian in origin:

- Laterally located, mobile, cystic in consistency, can get below it. Positive shifting
dullness.

There is no hepatosplenomegaly, kidneys not ballotable, ascites _________. My

diagnosis is_________

I would like to complete examination by bimanual examination.

Bimanual examination

Uterus in origin: When I push the mass upwards with left hand, the cervix will moves
from my examining finger. Mass is non- mobile and located anteriorly or posteriorly.

Ovarian in origin: When I push the mass upwards, with left hand, the cervix will not
moves from my examining finger. Mass is mobile and located laterally.