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USMLE Step 2 — Lesson 1

OBSTETRIC
Highlights
USMLE Step 2

Elmar P. Sakala, MD, MPH

Discrepant
Fundal
Size

Case #1

• A 20 y/o woman comes to the out-pt prenatal clinic for a new OB visit.
• She is 30 wks gest by LMP.
• Fundal measurement is 24 cm.

Fundus smaller than dates

Differential Diagnosis

Fundus smaller than dates

Think of 3 uterine compartments:

o Fetal: fetal demise, IUGR


o Amniotic fluid: oligohydramnios
o Placental: molar preg

Diagnosis

Fundus smaller than dates

Obtain OB ULTRASOUND:

o Fetal: cardiac motion, fetal biometry (BPD, HC, AC, FL)


o Amniotic fluid: 4-quad AFI <5 cm
o Placental: texture, appearance

Etiology

Intrauterine Growth Restriction

SYMMETRIC IUGR:

o BPD, HC, AC, FL are less than expected due to growth potential: e.g.
aneuploidy, 1st trimester infection

ASYMMETRIC IUGR:

o AC is less than expected due to nutritional supply e.g. hypertension,


preeclampsia
Etiology

Oligohydramnios

• Premature membrane rupture


• Urinary tract anomaly
• Placental insufficiency
• Meds: indomethacin, ACE inhibitors

Management

Fundus smaller than dates


• Details are specific to the problem identified.

Case #2

• A 20 y/o woman comes to the out-pt prenatal clinic for a new OB visit.
• She is 30 wks gest by LMP.
• Fundal measurement is 35 cm.

Fundus larger than dates

Differential Diagnosis

Fundus larger than dates

Think of 4 compartments:

o Fetal: multiple fetuses, macrosomia


o Amniotic fluid: polyhydramnios
o Placental: molar preg, fetal hydrops, infection
o Uterine: leiomyomas

Diagnosis

Fundus larger than dates

Obtain OB ULTRASOUND:

o Fetal: # of fetuses; fetal biometry (BPD, HC, AC, FL) shows macrosomia
o Amniotic fluid: 4-quad AFI >25 cm
o Placental: texture, appearance
o Uterus: leiomyomas

Etiology
Polyhydramnios

• Fetal GI tract: TE fistula, duod atresia


• Fetal NTD: spina bifida, anencephaly
• Fetal hydrops: immune, nonimmune
• Diabetes mellitus: poor glucose control

Management

Fundus larger than dates

• Details are specific to the problem identified.

USMLE Step 2 — Lesson 2


FIRST
Trimester
Bleeding

Case #3

• A 25 y/o woman comes to the out-pt prenatal clinic for a return OB visit.
• She has had vaginal bleeding with no cramping.
• She is 12 wks gest by LMP.

Differential Diagnosis

First trimester bleeding

• Threatened abortion
• Missed abortion
• Inevitable abortion
• Incomplete abortion
• Completed abortion
• Molar pregnancy
• Ectopic pregnancy

Diagnosis

First trimester bleeding

SYMPTOMS

o Bleeding? Passed tissue? Contractions?

Diagnosis

First trimester bleeding

SYMPTOMS:

o Bleeding? Passed tissue? Contractions?

PELVIC EXAMINATION

o Cervical lesion? Internal cervical os dilated?

Diagnosis

First trimester bleeding

SYMPTOMS:

o Bleeding? Passed tissue? Contractions?

PELVIC EXAMINATION

o Cervical lesion? Internal cervical os dilated?

ULTRASOUND:
o Gest sac? Embryo? Cardiac motion?

Diagnosis & Management

THREATENED abortion

Characteristics:

o Bleeding: minimal
o Cramping: none or minimal
o Internal cervical os: closed
o Ultrasound: normal findings

Management:

o Conservative management

Diagnosis & Management

MISSED abortion

Characteristics:

o Bleeding: none
o Cramping: none
o Internal cervical os: closed
o Ultrasound: non-viable pregnancy

Management:

o Scheduled D&C, RhoGAM if Rh-

Diagnosis & Management

INEVITABLE abortion
Characteristics:

o Bleeding: YES
o Cramping: YES
o Internal cervical os: dilated
o Tissue passed: none
o Ultrasound: POC remains in uterus

Management:

o Emergency D&C, RhoGAM if Rh-

Diagnosis & Management

INCOMPLETE abortion

Characteristics:

o Bleeding: YES
o Cramping: YES
o Internal cervical os: dilated
o Tissue passed: YES
o Ultrasound: POC remains in uterus

Management:

o Emergency D&C, RhoGAM if Rh-

Diagnosis & Management

COMPLETED abortion

Characteristics:

o Bleeding: Minimal
o Cramping: Minimal
o Internal cervical os: dilated
o Tissue passed: YES
o Ultrasound: Normal uterus stripe

Management:

o Observation; serial quantitative β -hCG (to r/o ectopic)

Diagnosis & Management

SEPTIC abortion

Characteristics:

o History: Non-sterile uterine instrumentation


o Bleeding: Minimal
o Cervical os: purulent discharge
o Uterus: tender
o Vital Signs: Fever, tachycardia

Management:

o Admit; cultures; IV gent & clindamycin; gentle D&C

SECOND
Trimester
Loss

Case #4

• A 25 y/o woman (G2 P1Ab1) at 18 wks gest presents to the hospital maternity unit
with pelvic pressure but NO contractions.
• On exam membranes are bulging to the introitus.

Second trimester loss


Differential Diagnosis

Second trimester loss

o Incompetent cervix
o Mullerian anomaly
o Submucus leiomyoma

Diagnosis & Management

Incompetent Cervix

Characteristics:

o Painless cervical dilation.


o Non-viable gest age.
o Delivery of immature normal fetus that dies.

Management:

o Cervical cerclage (emerg now if possible; scheduled at 14 wks next


pregnancy)

Cervical CERCLAGE

Diagnosis & Management

Mullerian anomaly

History:
• Regular contractions with cervical dilation.
• Non-viable gestational age.
• Delivery of immature normal fetus that dies.

Diagnosis: Hysteroscopy or HSG

Management: Hysteroscope resection if thin uterine septum;


laparotomy if thick septum

Diagnosis & Management

Submucus leiomyoma

History:

• 2nd trim demise occurs without explanation.


• Non-viable gestational age.
• Delivery of stillborn normal fetus.

Diagnosis: Hysteroscopy or HSG

• Management: Hysteroscope resection.

THIRD Trimester Bleeding

Case #5

• A 25 y/o G2 P1Ab1 woman presents to the hospital maternity unit with painful vaginal
bleeding.
• She is 30 wks gest by LMP.
• Fetal heart tones are present.

THIRD trimester bleeding


Differential Diagnosis

THIRD trimester bleeding

• Abruptio placenta
• Placenta previa
• Vasa previa
• Uterine rupture

Diagnosis & Management

Abruptio Placenta

Findings:

o PAINFUL vag bleeding with uterus not relaxing between UCs.


o Assoc with PIH, cocaine, trauma, DIC

Sono: Normally implanted placenta


Management:

o Depends on gest age, status of Mom & fetus.

Normal
Placental
Implantation
- Fundal
- Anterior
- Posterior

Overt
ABRUPTIO
Placenta
Concealed
ABRUPTIO
Placenta

Diagnosis & Management

Placenta previa

Findings:

o PAINLESS vaginal bleeding.


o Assoc with prev PP, twins,multiparity, AMA

Sono: placenta in lower uterine segment


Types: Low-lying, partial, complete
Management:

o Depends on gest age, status of Mom & fetus.

Low
Lying
Placenta
Previa
Partial
Placenta
Previa

Total
Central
Placenta
Previa

Diagnosis & Management

Vasa previa

Findings:

o PAINLESS vaginal bleeding.


o Assoc with twins,accessory placental lobe
o Bleeding is fetal blood!

Triad: AROM, vag bleeding, fetal bradycardia


Management:

o Immediate cesarean on diagnosis!


VASA
Previa

TEST TAKING WORKSHOP

Barbara J. Irwin, BSN, RN

Diagnosis & Management

Uterine rupture

Findings:

o PAINFUL vaginal bleeding with UCs.


o Assoc: prev classical CS, XS oxytocin, trauma.
o Non-reassuring fetal monitor pattern.

Types: Complete, incomplete


Management:

o Immediate cesarean delivery on diagnosis!

USMLE Step 2 — Lesson 3


Postdates
Pregnancy

Case #6
• A 24 y/o multigravida comes to the out-pt office for a return OB visit.
• She is now 42½ wks gest by LMP. Her first prenatal visit was 6 weeks ago.
• Her fundal height measures 41 cm.
• FHT are 145 beats/min. BP is 125/75.

POSTDATES pregnancy

Level of Question Difficulty

• Recall Recognition
• Comprehension
• Application
• Analysis

Diagnosis

POSTDATES pregnancy

• >42 weeks amenorrhea


(assuming ovulation occurred on day 14)
• >294 days amenorrhea
(assuming ovulation occurred on day 14)
• >280 days postconception
(time of conception is known)

Diagnosis

POSTDATES pregnancy

• Based on Amenorrhea 6-12% (false)


• Based on Conception 3-5% (true)

Hazards
POSTDATES pregnancy

PERINATAL
MORTALITY
3-fold

Fetus in Postdates Preg?

Key question: Placental Function?

75% Maintained 25% Deteriorates


MACROSOMIA DYSMATURITY
Syndrome Syndrome
Difficult Labor Placental
& Delivery Insufficiency
Forceps, Vacuum Acidosis
Shoulder Dystocia Meconium aspiration
Birth trauma Oxygen deprivation
Cesarean Section Cesarean Section

POSTDATES pregnancy

First Question to ask:


How much confidence do you have in the GESTATIONAL AGE?

Confirming gest age

POSTDATES pregnancy
• Menstrual history
sure; planned preg; normal cycle; no Ocs
• Clinical landmarks
uterine size & FHT<12 wk; quickening
• Sonogram dating
CRL <12 wk (+ or - 5d); BPD 12-18 wk (+ or - 7d)

Differential Diagnoses

POSTDATES pregnancy

• Dates sure
o cervix favorable

• Dates sure
o cervix Unfavorable

• Dates unsure

POSTDATES Management

Dates FIRM - Cx FAVORABLE

• 1 Induce labor: AROM, oxytocin


• Intrapartum EFM looking for:
o VARIABLE decels
umbilical cord compression
o LATE decels
placental insufficiency

POSTDATES Management

What about MECONIUM?

• Incidence:
4 times more common
• Mechanism:
bowel function or acidosis

POSTDATES Management

What about MECONIUM?

Management:

• Amnioinfusion
• Suction pharynx
• Tracheal aspiration

POSTDATES Management

Dates FIRM - Cx Unfavorable

• 1 Induce labor: prostaglandin E2


• Await spont labor looking for:
o NSTs reactive 2/week
o AFIs > 5-8 cm 2/week

POSTDATES Management

Dates UNSURE

• Await spont labor looking for:

NSTs reactive 2/week

AFIs > 5-8 cm 2/week

Hypertension
in
Pregnancy

HYPERTENSION in Preg

Effect of normal
physiologic
changes of
pregnancy

Case #7

• A 21 y/o primigravida at 32 wks gest comes for a routine OB visit.


• Her BP sitting is 155/95; repeat reading was 145/90.
• Urine dipstick protein is 3+.
• No previous history of HTN.

Hypertension in Pregnancy

Differential Diagnosis

Hypertension in Pregnancy
o Mild preeclampsia
o Severe preeclampsia
o Eclampsia
o HELLP syndrome
o Chronic HTN

MILD preeclampsia

SEVERE preeclampsia

ECLAMPSIA

Can be RAPID progression!

Preeclampsia should be renamed:

Diffuse

VASOSPASTIC

Disease of Pregnancy
AGGRESSIVE Management GUIDELINES:

• MAINTAIN BP diastolic 90-100 mm Hg


• Prevent CONVULSIONS with MgSO4
• Initiate DELIVERY rapidly

Diagnosis & Management

MILD Preeclampsia
Findings:

• HTN > 140/90; proteinuria 1-2+; edema.


• Hemoconcent ( H&H, uric acid, BUN, creat)
• No Symptoms (HA, epig pain, visual ∆ ).
• No Signs (DIC, cyan, oliguria, pulm edema).

Management:

• Conservative – in hospital if < 36 wks gest


• Aggressive – if > 36 wks gest, IV MgS04
Diagnosis & Management

SEVERE Preeclampsia
Findings:

• HTN > 160/110; proteinuria 3-4+; edema


• Any Symptoms (HA, epig pain, visual ∆ ).
• Any Signs (DIC, cyanosis, oliguria, pulmon edema).

Management:

• Conservative – in ICU if 26-33 wks gest if only HTN & proteinuria present;
hydralazine; MgS04; steroids.
• Aggressive – if <26 or >33 wks, or symptoms/signs; MgS04; steroid.

Diagnosis & Management

ECLAMPSIA

Findings:

• HTN > 140/90; proteinuria; edema


• New onset of generalized convulsions.
• May occur ante/intra/postpartum.

Management:

• Conservative – NEVER.
• Aggressive – as soon as diagnosis is made; hydralazine; IV MgS04; steroids.

Diagnosis & Management

HELLP syndrome

Findings:
• Hemolysis, Elev Liver enyz, Low Platelets.
• Other findings of preeclampsia.
• May occur ante/intra/postpartum.

Management:

• Conservative – NEVER.
• Aggressive – as soon as diagnosis is made; hydralazine; IV MgS04; steroids.

Diagnosis & Management

CHRONIC hypertension

Findings:

• Pre-existent HTN or HTN prior to 20 wks that persists past 6 wks PP.
• Proteinuria is variable.

Management:

• Conservative – Aldomet is drug of choice


• Aggressive – if superimposed preeclampsia; hydralazine; MgS04, steroids

Aggressive in-patient:

• Mild PIH : > 37 wks


• Severe PIH < 26 wks
• Severe PIH > 34 wks
• Severe PIH maternal jeopardy
• Severe PIH fetal jeopardy
• Chr HTN with PIH.. any GA
• Eclampsia………… any GA
• HELLP…………….. any GA
Glucose
Intolerance in
Pregnancy

Case #8


A 36 y/o multigravid at 28 wks gest.


1 hr 50 g glucose is 165 mg/dl.


3 hr 100 g OGTT is F-90; 1hr- 190 ; 2-hr 165 ; 3-hr 145 .


Urine dipstick glucose is 3+.


• DIABETES in Pregnancy

Differential Diagnosis

DIABETES in Pregnancy

• Gestational diabetes
• Type 1 diabetes mellitus
• Type 2 diabetes mellitus

Diagnosis

GESTATIONAL diabetes
Findings:

o 2 of 4 values abnormal on 3 hr 100 g OGTT.


o Onset > 20 wks gestation (if true GDM)
o Onset any time during pregnancy.
o Due to hPL, placental insulinase, cortisol.
o No in fetal anomalies (if true GDM).
o Resolves after delivery (if true GDM).

Diagnosis

TYPE 1 diabetes mellitus


Findings:

o Onset prior to pregnancy.


o Due to islet cell destruction.
o Plasma insulin level is .
o Fetal anomalies may be .
o Unable to achieve nonPG euglycemia without insulin.

Diagnosis

TYPE 2 diabetes mellitus


Findings:

o Onset prior to pregnancy.


o Due to insulin resistance.
o Plasma insulin level is .
o Fetal anomalies may be .
o Is able to achieve nonPG euglycemia without insulin.

EUGLYCEMIA management

All Preg Glucose Intolerance

• Diet: ADA diet ( complex CHO).


• Educ: Mom re glucose control.
• Exercise: Regular, consistent
• Targets: FBS 60-90; 1 hr PP <140
• Insulin: NPH & Reg human insulin if euglycemia not achieved with diet; split dose of
2/3 AM & 1/3 PM.

Anomaly detection

Type 1 & 2 Diabetes Mellitus


Most common anomalies

• NTD defects
• CHD defects
• Sacral agenesis

Anomaly detection

Type 1 & 2 Diabetes Mellitus


13-14 wk Sono anencephaly
16-18 wk MSAFP NTD
18-22 wk Focused sono other anomalies
22-24 wk Fetal echo cardiac anomalies
( if first trimester Hb A1C)

Anomaly PREVENTION

Type 1 & 2 Diabetes Mellitus

• Preconception
EUGLYCEMIA
• Preconception
FOLIC ACID 4 mg po /day

USMLE Step 2 — Lesson 4: Medical Complications of


Pregnancy
CARDIAC
Disease in
Pregnancy

Cardiac Disease in Preg

Effect of normal physiologic changes of pregnancy

Physiology of Pregnancy Cardiac

Formula for
Cardiac OUTPUT?
(Volume of blood pumped by heart in 1 minute)

Physiology of Pregnancy Cardiac

Formula for
Cardiac OUTPUT?
(Volume of blood pumped by heart in 1 minute)

HR x SV
(Heart Rate x Stroke Volume)
Physiology of Pregnancy Cardiac

IF HR & SV

THEN

Cardiac Output
Case #9

• A 40 y/o multigravida at 18 wks gest comes to the out-pt clinic.


• History of rheumatic fever.
• SOB with mild activity.
• Pulse: 110/min; parasternal heave;
Gr 4/6 pandiastolic murmur.

Cardiac Disease in Preg

Significant Diagnoses

Cardiac Disease in Preg

• Mitral stenosis
• Eisenmenger’s syndrome
• Marfan’s syndrome
• Tetralogy of Fallot
Diagnosis & Management

Mitral STENOSIS
Findings:

• Most common acquired heart disease.


• Problem: narrow valve diastolic filling.
• Results: LA Atrial fib, SBE, emboli.

CARDIAC Cycle: Diastole/Systole

CARDIAC Cycle: Diastole/Systole

CARDIAC Cycle: Diastole/Systole


Factors worsening
MITRAL STENOSIS?

• heart rate
• blood volume

• heart rate
• blood volume

Normal changes of
PREGNANCY?

Factors worsening
MITRAL STENOSIS:
heart rate

blood volume

Normal changes of
PREGNANCY:

MITRAL
STENOSIS:
Do not go well
together

Normal changes of
PREGNANCY:

Diagnosis & Management

Mitral STENOSIS

Findings:

o Most common acquired heart disease.


o Problem: narrow valve diastolic filling.
o Results: LA Atrial fib, SBE, emboli.

Management:

o Watch decompensation: PND, syncope, JVD.


o Avoid fluid overload: Na+ diet, diuretics.
o Avoid tachycardia: anemia, exercise, sedation.
o Vag delivery; invasive monitoring; SBE prophylax

Cardiac Disease in Preg

STENOTIC
lesions are tolerated
POORLY.

USMLE Step 2 — Lesson 5: Management of Labor


Abnormal
Labor

ABNORMAL LABOR
STAGES of NORMAL LABOR

Case 12

• A 32 y/o multigravida at 39 wks gest in the maternity unit has UCs every 3-4
minutes.
• Her cervix is 1-2 cm dilated and has been the same for the past 16 hours.
• Fetal monitor strip is reassuring.
ABNORMAL labor

Significant Diagnoses

ABNORMAL labor

• Prolonged latent phase


• Prolonged active phase
• Active phase arrest
• Arrest of descent

Diagnosis & Management

Prolonged LATENT phase


Findings:

• Cervical dilation < 3 cm with UCs present.


• No labor progress >14 hrs in multipara.
• No labor progress >20 hrs in primipara

Cause:

• Injudicious analgesia, hypo/hypertonic UCs.

Management:

• Therapeutic rest or sedation; avoid cesarean.


Causes of ACTIVE phase problems:

• PELVIS
• Passenger
• Powers

PROBLEMS with
MATERNAL
BONY PELVIS

How much can you change


PROBLEMS with
MATERNAL
BONY PELVIS?

How much can you change


PROBLEMS with
MATERNAL
BONY PELVIS?
NONE!
Causes of ACTIVE phase problems:

• Pelvis
• PASSENGER
• Powers

PROBLEMS with
IN-UTERO FETAL
ORIENTATION

Nomenclature for
IN-UTERO FETAL ORIENTATION

• Fetal LIE
• Fetal PRESENTATION
• Fetal POSITION
• Fetal ATTITUDE
• STATION

Terms to remember:

Orientation of Fetus In-utero


Fetal LIE
Relationship between long axis of the
fetus & long axis of mother
Most common:
LONGITUDINAL

Terms to remember:

Orientation of Fetus In-utero


PRESENTATION
Portion of fetus overlying the pelvic inlet
Most common:
CEPHALIC

Terms to remember:

Orientation of Fetus In-utero


POSITION
Relationship between a reference point on the presenting fetal part & maternal bony
pelvis
Most common:
OCCIPUT ANTERIOR

Terms to remember:

Orientation of Fetus In-utero


ATTITUDE
Degree of flexion or extension
of fetal head
Most common:
VERTEX

Terms to remember:

Orientation of Fetus In-utero


STATION
Degree of descent of the presenting part through birth canal
(Expressed in cm above or below maternal ischial spine)
How much can you change
PROBLEMS with
IN-UTERO FETAL
ORIENTATION?

How much can you change


PROBLEMS with
IN-UTERO FETAL
ORIENTATION?
Very little!

Causes of ACTIVE phase problems:

• Pelvis
• Passenger
• POWERS

PROBLEMS with
INADEQUATE UTERINE CONTRACTIONS

Assessment of POWERS

Criteria for ADEQUACY of UTERINE CONTRACTIONS


• DURATION - 45-60 seconds
• FREQUENCY - every 2-3 minutes
• INTENSITY - > 50 mm Hg

How much can you change


PROBLEMS with
INADEQUATE CONTRACTIONS?

How much can you change


PROBLEMS with
INADEQUATE CONTRACTIONS?
Considerable!

Causes of ACTIVE phase problems:

• Pelvis
• Passenger
• POWERS

Causes of ACTIVE phase problems:

• Pelvis
• Passenger
• POWERS <- The only parameter that can be modified

Only CORRECTABLE Cause of ACTIVE phase problems:

Inadequate
POWERS

IV OXYTOCIN
Diagnosis & Management

ACTIVE phase ARREST


Findings:

• Cervical dilation > 3 cm with UCs present.


• NO Labor progress in multipara.
• NO Labor progress in primipara

Cause:

• Pelvic, Passenger, Powers.

Management:

• IV oxytocin (if inadequate UCs) or cesarean.

Diagnosis & Management

Prolonged ACTIVE phase


Findings:

• Cervical dilation > 3 cm with UCs present.


• Labor progress <1.5 cm/hr in multipara.
• Labor progress <1.2 cm/hr in primipara

Cause:

• Pelvic, Passenger, Powers.

Management:

• IV oxytocin (if inadequate UCs) or cesarean.

Diagnosis & Management

ARREST of DESCENT
Findings:

• Cervical dilation is 10 cm or “complete”.


• Delivery not take place in spite of adequate maternal pushing efforts.
• Duration > 30 min in multip or >60 min in primip.

Cause:

• Pelvic, Passenger, Powers.


Management:

• IV oxytocin, vacuum extractor, forceps or CS.

Intrapartum Fetal Monitoring

Case 13

• A 27 y/o primigravida at 41 wks gest is in labor in the maternity unit.


• She is 5 cm dilated, 100% effaced with UCs every 2-3 minutes.
• The EFM shows a baseline FHR of 140/min with decels: sudden drops of 40
beats/min lasting 15 seconds with rapid return.

ABNORMAL fetal monitor


Differential Diagnoses

ABNORMAL fetal monitor

• Early decelerations
• Variable decelerations
• Late decelerations

Diagnosis & Management

EARLY deceleration
Findings:

• Onset of the deceleration is simultaneous with the onset of the contraction.


• End of the decelerations is simultaneous with the end of the contraction.
• Deceleration is a mirror image of the contraction.

Cause:

• Vagal stimulation; fetal head compression.

Management:

• Observation – no clinical significance.


Diagnosis & Management

VARIABLE deceleration
Findings:

• Onset of the deceleration is variable with the onset of the contraction.


• End of the decelerations is variable with the end of the contraction.
• Sudden drops with rapid return to baseline.

Cause:

• Vagal stimulation; Umbil cord compression.

Management:

• Observation if mild-mod; worrisome if severe.


Diagnosis & Management

LATE deceleration
Findings:

• Onset of the deceleration is late in relation to the onset of the contraction.


• End of the decelerations is late in relation to the end of the contraction.
• Gradual drops with gradual return to baseline.

Cause:

• Uteroplacental insufficiency.

Management:

• All are worrisome!


Generic Interventions

ABNORMAL fetal monitor

• Decrease uterine activity


• Correct hypotension
• Change maternal position
• Administer high flow O2
• Vag exam r/o prolapsed cord

We have covered
The HIGHLIGHTS of
Obstetrics
USMLE Step 2

This brings us to
The END of the SESSION

BEST WISHES on the EXAM!

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