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

Amniotic fluid: oligohydramnios

Placental: molar preg

Diagnosis
Fundus smaller than dates
Obtain OB ULTRASOUND:
o

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

Amniotic fluid: 4-quad AFI <5 cm

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

preeclampsia

nutritional supply e.g. hypertension,

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

Amniotic fluid: polyhydramnios

Placental: molar preg, fetal hydrops, infection

Uterine: leiomyomas

Diagnosis
Fundus larger than dates
Obtain OB ULTRASOUND:
o

Fetal: # of fetuses; fetal biometry (BPD, HC, AC, FL) shows macrosomia

Amniotic fluid: 4-quad AFI >25 cm

Placental: texture, appearance

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

Cramping: none or minimal

Internal cervical os: closed

Ultrasound: normal findings

Management:
o

Conservative management

Diagnosis & Management

MISSED abortion
Characteristics:
o

Bleeding: none

Cramping: none

Internal cervical os: closed

Ultrasound: non-viable pregnancy

Management:
o

Scheduled D&C, RhoGAM if Rh-

Diagnosis & Management

INEVITABLE abortion
Characteristics:
o

Bleeding: YES

Cramping: YES

Internal cervical os: dilated

Tissue passed: none

Ultrasound: POC remains in uterus

Management:
o

Emergency D&C, RhoGAM if Rh-

Diagnosis & Management

INCOMPLETE abortion
Characteristics:
o

Bleeding: YES

Cramping: YES

Internal cervical os: dilated

Tissue passed: YES

Ultrasound: POC remains in uterus

Management:
o

Emergency D&C, RhoGAM if Rh-

Diagnosis & Management

COMPLETED abortion
Characteristics:
o

Bleeding: Minimal

Cramping: Minimal

Internal cervical os: dilated

Tissue passed: YES

Ultrasound: Normal uterus stripe

Management:
o

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

Diagnosis & Management

SEPTIC abortion
Characteristics:
o

History: Non-sterile uterine instrumentation

Bleeding: Minimal

Cervical os: purulent discharge

Uterus: tender

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

Incompetent cervix

Mullerian anomaly

Submucus leiomyoma

Diagnosis & Management

Incompetent Cervix
Characteristics:
o

Painless cervical dilation.

Non-viable gest age.

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.

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.

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.

Assoc with twins,accessory placental lobe

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.

Assoc: prev classical CS, XS oxytocin, trauma.

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 42 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

Dates sure
o

cervix favorable

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

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

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

Severe preeclampsia

Eclampsia

HELLP syndrome

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 (

No Symptoms (HA, epig pain, visual ).

No Signs (DIC, cyan, oliguria, pulm edema).

H&H, uric acid, BUN, creat)

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.

Onset > 20 wks gestation (if true GDM)

Onset any time during pregnancy.

Due to

No

Resolves after delivery (if true GDM).

hPL, placental insulinase, cortisol.

in fetal anomalies (if true GDM).

Diagnosis
TYPE 1 diabetes mellitus
Findings:
o

Onset prior to pregnancy.

Due to islet cell destruction.

Plasma insulin level is

Fetal anomalies may be

Unable to achieve nonPG euglycemia without insulin.

.
.

Diagnosis
TYPE 2 diabetes mellitus
Findings:
o

Onset prior to pregnancy.

Due to insulin resistance.

Plasma insulin level is

Fetal anomalies may be

Is able to achieve nonPG euglycemia without insulin.

EUGLYCEMIA management
All Preg Glucose Intolerance

.
.

Diet: ADA diet (

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

complex CHO).

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

22-24 wk Fetal echo

other anomalies
cardiac anomalies
( if

Anomaly PREVENTION
Type 1 & 2 Diabetes Mellitus

Preconception
EUGLYCEMIA

Preconception
FOLIC ACID 4 mg po /day

first trimester Hb A1C)

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

Eisenmengers syndrome

Marfans syndrome

Tetralogy of Fallot

Diagnosis & Management

Mitral STENOSIS
Findings:

Most common acquired heart disease.

Problem: narrow valve

Results: LA

diastolic filling.

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.

Problem: narrow valve

Results: LA

diastolic filling.

Atrial fib, SBE, emboli.

Management:
o

Watch decompensation: PND, syncope, JVD.

Avoid fluid overload:

Avoid tachycardia: anemia, exercise, sedation.

Vag delivery; invasive monitoring; SBE prophylax

Na+ diet, diuretics.

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!