Professional Documents
Culture Documents
OBSTETRIC
Highlights
USMLE Step 2
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.
Differential Diagnosis
Diagnosis
Obtain OB ULTRASOUND:
Etiology
SYMMETRIC IUGR:
o BPD, HC, AC, FL are less than expected due to growth potential: e.g.
aneuploidy, 1st trimester infection
ASYMMETRIC IUGR:
Oligohydramnios
Management
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.
Differential Diagnosis
Think of 4 compartments:
Diagnosis
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
Management
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
• Threatened abortion
• Missed abortion
• Inevitable abortion
• Incomplete abortion
• Completed abortion
• Molar pregnancy
• Ectopic pregnancy
Diagnosis
SYMPTOMS
Diagnosis
SYMPTOMS:
PELVIC EXAMINATION
Diagnosis
SYMPTOMS:
PELVIC EXAMINATION
ULTRASOUND:
o Gest sac? Embryo? Cardiac motion?
THREATENED abortion
Characteristics:
o Bleeding: minimal
o Cramping: none or minimal
o Internal cervical os: closed
o Ultrasound: normal findings
Management:
o Conservative management
MISSED abortion
Characteristics:
o Bleeding: none
o Cramping: none
o Internal cervical os: closed
o Ultrasound: non-viable pregnancy
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:
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:
COMPLETED abortion
Characteristics:
o Bleeding: Minimal
o Cramping: Minimal
o Internal cervical os: dilated
o Tissue passed: YES
o Ultrasound: Normal uterus stripe
Management:
SEPTIC abortion
Characteristics:
Management:
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.
o Incompetent cervix
o Mullerian anomaly
o Submucus leiomyoma
Incompetent Cervix
Characteristics:
Management:
Cervical CERCLAGE
Mullerian anomaly
History:
• Regular contractions with cervical dilation.
• Non-viable gestational age.
• Delivery of immature normal fetus that dies.
Submucus leiomyoma
History:
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.
• Abruptio placenta
• Placenta previa
• Vasa previa
• Uterine rupture
Abruptio Placenta
Findings:
Normal
Placental
Implantation
- Fundal
- Anterior
- Posterior
Overt
ABRUPTIO
Placenta
Concealed
ABRUPTIO
Placenta
Placenta previa
Findings:
Low
Lying
Placenta
Previa
Partial
Placenta
Previa
Total
Central
Placenta
Previa
Vasa previa
Findings:
Uterine rupture
Findings:
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
• Recall Recognition
• Comprehension
• Application
• Analysis
Diagnosis
POSTDATES pregnancy
Diagnosis
POSTDATES pregnancy
Hazards
POSTDATES pregnancy
PERINATAL
MORTALITY
3-fold
POSTDATES pregnancy
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
POSTDATES Management
• Incidence:
4 times more common
• Mechanism:
bowel function or acidosis
POSTDATES Management
Management:
• Amnioinfusion
• Suction pharynx
• Tracheal aspiration
POSTDATES Management
POSTDATES Management
Dates UNSURE
Hypertension
in
Pregnancy
HYPERTENSION in Preg
Effect of normal
physiologic
changes of
pregnancy
Case #7
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
Diffuse
VASOSPASTIC
Disease of Pregnancy
AGGRESSIVE Management GUIDELINES:
MILD Preeclampsia
Findings:
Management:
SEVERE Preeclampsia
Findings:
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.
ECLAMPSIA
Findings:
Management:
• Conservative – NEVER.
• Aggressive – as soon as diagnosis is made; hydralazine; IV MgS04; steroids.
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.
CHRONIC hypertension
Findings:
• Pre-existent HTN or HTN prior to 20 wks that persists past 6 wks PP.
• Proteinuria is variable.
Management:
Aggressive in-patient:
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:
Diagnosis
Diagnosis
EUGLYCEMIA management
Anomaly detection
• NTD defects
• CHD defects
• Sacral agenesis
Anomaly detection
Anomaly PREVENTION
• Preconception
EUGLYCEMIA
• Preconception
FOLIC ACID 4 mg po /day
Formula for
Cardiac OUTPUT?
(Volume of blood pumped by heart in 1 minute)
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
Significant Diagnoses
• Mitral stenosis
• Eisenmenger’s syndrome
• Marfan’s syndrome
• Tetralogy of Fallot
Diagnosis & Management
Mitral STENOSIS
Findings:
• 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:
Mitral STENOSIS
Findings:
Management:
STENOTIC
lesions are tolerated
POORLY.
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
Cause:
Management:
• PELVIS
• Passenger
• Powers
PROBLEMS with
MATERNAL
BONY PELVIS
• 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:
Terms to remember:
Terms to remember:
Terms to remember:
Terms to remember:
• Pelvis
• Passenger
• POWERS
PROBLEMS with
INADEQUATE UTERINE CONTRACTIONS
Assessment of POWERS
• Pelvis
• Passenger
• POWERS
• Pelvis
• Passenger
• POWERS <- The only parameter that can be modified
Inadequate
POWERS
IV OXYTOCIN
Diagnosis & Management
Cause:
Management:
Cause:
Management:
ARREST of DESCENT
Findings:
Cause:
Case 13
• Early decelerations
• Variable decelerations
• Late decelerations
EARLY deceleration
Findings:
Cause:
Management:
VARIABLE deceleration
Findings:
Cause:
Management:
LATE deceleration
Findings:
Cause:
• Uteroplacental insufficiency.
Management:
We have covered
The HIGHLIGHTS of
Obstetrics
USMLE Step 2
This brings us to
The END of the SESSION