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USMLE Step 2 CK
Obstetrics-Gynecology
OB Supplement – part 1

Elmar P. Sakala, MD, MPH

Professor of Gynecology & Obstetrics
Loma Linda University School of Medicine
September, 2016
© Elmar P. Sakala, MD, MPH (2016) No part of this document can be reproduced or transmitted,
in any form, or be any means, without the written permission of the author.

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Early Pregnancy bleeding
Two initial tests to perform on all stable patients
Vaginal speculum exam & vaginal sonogram.

Lower genital tract lesion on speculum exam

Individualize Rx for cervical or vaginal lesion

Cervix is CLOSED on speculum exam

Sono: viable pregnancy – THREATENED abortion – observation
Sono: non-viable preg – MISSED abortion – wait, PGE1, D&C

Cervix is OPEN on speculum exam

Sono: no POC passed – INEVITABLE abortion – wait, PGE1, D&C
Sono: some POC passed – INCOMPLETE abortion – wait, PGE1, D&C
Sono: all POC passed – MISSED – observation

Always remember Ectopic pregnancy & Molar pregnancy

PRACTICE OBSTETRIC CASES
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Fetal demise
Most common clinical findings with fetal demise ….
Uterus smaller than dates (<20 wks) & fetus not moving (>20 wks)
Must get OB sonogram to make the diagnosis

Sono: no cardiac motion? YES – Fetal Demise confirm ; NO (No problem!)

Sono: deteriorating tissues? YES – Possible DIC; NO (Continue below)
YES: DIC panel: platelets, PT, PTT, fibrinogen, FSP, peripheral smear
DIC panel confirms DIC? YES – DIC confirmed; NO (Continue below)
YES: Empty uterus now! – D&E (<20 wks) or PG induction (>20 wks)
Sono shows autopsy is needed? YES; NO (Continue below)
YES: PG induction regardless of gestational age
Mom psychologically ready to empty uterus? YES; NO (Continue below)
YES: Perform D&E (<20 wks) or PG induction (>20 wks)
NO: Serial DIC labs; allow spontaneous labor; intervene only if DIC
PRACTICE OBSTETRIC CASES
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Ectopic Pregnancy
Clinical triad present? YES – Ectopic possible; NO (ectopic ruled out)
Vital signs unstable? YES – Ectopic ruptured; NO (Continue below)
YES: perform urgent laparotomy to stop hemorrhaging
Speculum exam show lower genital tract lesion? YES; NO (Continue below)
YES: remove cervical polyp

9 PRACTICE OBSTETRIC CASES

© Elmar P. Sakala, MD MA MPH
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ALLOIMUNIZATION'
ISSUE #1: Is fetus AT RISK for Hemolytic Disease of Newborn (HDN)?
* Does patient have Atypical antibodies? YES; NO (no problem)
* Antibodies assoc with RBC hemolysis? YES; NO (no problem)
* Does FOB have Antigen on his RBC? YES; NO (no problem)
* Is Mom’s atypical antibody titer > 1:16? YES; NO (repeat monthly)
ISSUE #2: Fetus is at risk of HDN but is fetus ANEMIC?
* Is fetal MCA/PSV in normal range? YES (repeat in 2 weeks)
* Is fetal MCA/PSV in moderate range? YES (repeat in 1 week)
* Is fetal MCA/PSV in high range? YES (intervention required)
ISSUE #3: Fetus is anemic but is INTERVENTION needed?
* Is gestation < 34 weeks? YES (intrauterine transfusion & betamethasone)
* Is gestation > 34 weeks? YES (delivery & NICU do transfusion)

PRACTICE OBSTETRIC CASES

© Elmar P. Sakala, MD MA MPH
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PRETERM-LABOR'
* Does patient meet 3 criteria? YES – PTL confirmed or NO – PTL ruled out
Gest >20 but <36 wks; 3 UCs in 30 min; cervix 2 cm or changing
* Contraindications for stopping labor? YES; NO (continue below)
YES: don’t use tocolytic agents
* Pregnancy need to end? YES (Risk to Mom/Fetus); NO (continue below)
YES: plan prompt delivery; consider “prematurity interventions”
NO: select tocolytic agent & select “prematurity interventions”

* Select tocolytic agent? terbutaline (high glucose, low K), nifedipine (low BP,
tachy), indomethacin (PDA closure, oligo), MgSO4 (respiratory depression)

* Select gestational age appropriate ”prematurity interventions”

If < 32 weeks: Fetal neuro-protection
If < 34 weeks: Fetal lung surfactant induction
If < 36 weeks: GBS prophylaxis?
PRACTICE OBSTETRIC CASES
© Elmar P. Sakala, MD MA MPH
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Premature-Membrane-Rupture'
* Are speculum exam criteria (3) met? YES; NO – no problem
* “Contraindications” to prolong preg? YES; NO (continue below)
* YES: regular contractions (don’t stop labor)
* YES: fetal monitor concerning (deliver promptly)
* YES: chorioamnionitis present (antibiotics & delivery)
* Possible interventions if preterm delivery (<36 weeks) will occur
* Need fetal neuro-protection? YES or NO (< 32 weeks)
* Need fetal surfactant induction? YES or NO (< 34 weeks)
* Need GBS prophylaxis? YES or NO (< 36 weeks)
* Triage categories by gestational age if no “contraindications”
* < 24 wks - PREVIABLE? YES – induce labor or home
* 34-34 wks - PREMATURE? YES – admit & watch
* > 34 wks - “MATURE”? YES - deliver
PRACTICE OBSTETRIC CASES
© Elmar P. Sakala, MD MA MPH
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Post:term-Pregnancy'
Is pregnancy dating (> 42 weeks) unsure? YES; NO (continue below)
YES: Monitor fetal status with NST/AFI and await labor
Is fetus >5000g (non-DM) or >4500g (DM)? YES; NO (continue below)
YES: Offer scheduled cesarean delivery
Is Bishop score favorable?
YES: Induce labor with oxytocin
NO: Ripen cervix with PGE2 or transcervical foley bulb
With membrane rupture is there meconium? YES; NO (continue below)
YES: In labor: amnioinfusion
YES: After fetal head delivered: no deep suctioning
YES: After neonate delivered: no laryngoscopic visualization
of vocal cords unless baby is depressed
PRACTICE OBSTETRIC CASES
© Elmar P. Sakala, MD MA MPH
May, 2016 - Used by permission

Hypertension-in-pregnancy'
#1 – Is HTN present and what is diagnosis?
* Is BP elevation sustained with >2 values > 4 hrs apart?
* Is BP in mild (>140/90) or severe (160/110) range?
* Onset of HTN < or > 20 weeks?
* Is there proteinuria? > 300 mg on 24-hr urine
* Is there “end-organ” involvement? CNS, GI, blood, kidneys
#2 – Interventions for Maternal Benefit? Danger for Mom (CNS)
* Lower severe BP to prevent stroke? IV labatelol, hydralazine
* Prevent seizures? If eclampsia or severe P – IV MgSO4
#3 – Interventions for Fetal Benefit? Danger for Neonate (prematurity)
* Need neuro-protection? if < 32 wks (IV MgSO4)
* Need surfactant induction? if < 34 wks (IM betamethasone)
* Need GBS prophylaxis? if < 36 wks (IV Pen G)
PRACTICE OBSTETRIC CASES
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GestaAonal-Diabetes'
* Is 1-hr 50g screen > 140? YES; NO – GDM ruled out
YES; perform 3-hr 100g OGTT for definitive diagnosis
* Are 2 of 4 values high on 3-hr OGTT? YES; NO – GDM ruled out
YES; educate Mom on diabetic diet and home glucose monitoring
* Home glucose above target range on diet? YES; NO – doing well
YES; start meds: po glyburide or subcutaneous insulin
* Home glucose above target range on medications? YES; NO – doing well
YES; Adjust dietary compliance, activity compliance & medications
* Risk factors fetal death? YES; (on meds, coexisting cHTN, unexplained demise)
YES: start twice weekly NST/AFI at 32 weeks
NO: No NST, q 4 wk sonograms for fetal growth, deliver 39 weeks
* Sono estimated fetal weight > 4500g? YES – offer primary CS
NO: Induce labor, insulin drip, anticipate vaginal delivery
NO: Watch for arrest of dilation, descent & shoulder dystocia
NO: Watch for uterine atony, persisting glucose intolerance
PRACTICE OBSTETRIC CASES
© Elmar P. Sakala, MD MA MPH
May, 2016 - Used by permission

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Thrombophilia-in-pregnancy-- J

When'do'a'workup?'
Does patient have a personal history of VTE? NO – continue to family
history only if patient DOES NOT have personal history of VTE
Does 1st degree relative have history of VTE?
NO: Don’t workup or anticoagulate
YES: Workup & anticoagulate only if high-risk thrombophilia
Does patient have a personal history of VTE? YES
YES: VTE assoc with transient risk factor? No workup or anticoag
YES: VTE hormonally assoc: (preg, OCPs)? Workup & anticoag
YES: VTE idiopathic: no risk factors? Workup & anticoag

5 inherited thrombophilias to test for?

COMMON: Factor V Leiden (FVL), Prothrombin Gene Mutation (PGM)
RARE: Antithrombin defic (ATD), Protein C defic (PCD), Protein S defic (PSD)
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Antenatal-fetal-tesAng'
NST non-reactive (NR)? YES; NO – no problem
YES: Perform Vibroacoustic Stimulation (VAS)
NST still NR after VAS? YES; NO – no problem
YES: Perform Complete Biophysical Profile (BPP)
BPP is 8 or 10? No problem
BPP is 0 or 2? Deliver fetus promptly
BPP is 4 or 6? Triage by gestational age
> 36 weeks - deliver
< 36 weeks – perform CST – need 3 UCs in 10 minutes
CST repetitive late decelerations? YES; NO – no problem
YES: If CST is positive perform prompt delivery regardless
of gestational age
PRACTICE OBSTETRIC CASES
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J 3-tiered categorization of FHR patterns
Category I NORMAL
 Baseline rate: 110-160 beats/min
 Baseline variability: moderate
 Late or Variable decelerations: absent
 Early decelerations: present or absent
 Accelerations: present or absent
Category III ABNORMAL
ABSENT VARIABILITY plus any of following:
 Recurrent LATE decelerations
 Recurrent VARIABLE decelerations
 Bradycardia
 Sinusoidal pattern
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INTERPRETATION:
strongly predictive of normal
acid-base status at this time
ACTION: routine monitoring
INTERPRETATION:
not predictive of abnormal acid-
base status at this time
ACTION: continued surveillance &
reevaluation
INTERPRETATION:
strongly predictive of abnormal
acid-base status at this time
ACTION: intrauterine resuscitation;
if no resolution then prompt
delivery
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J Definition: blood loss > 500 mL

with VD or > 1000 mL with CS Postpartum-Hemorrhage'
Uterus palpable? NO – uterine inversion; YES - continue below
NO; manual uterine & or IV oxytocin
Uterus firm, midline below umbilicus? NO – atony; YES - continue below
NO; uterine massage then IV oxytocin, IM ergot, Im PG-F2
Placenta complete? NO – retained placenta; YES – continue below
NO; manual uterine exploration or uterine curettage
Unrepaired laceration? YES – unrepaired tears; NO – continue below
YES; Identify and repair bleeding lacerations
Generalized oozing? YES - DIC; NO – continue below
YES; Remove all POC, give selected blood products prn, ICU care
Unexplained persistent bleeding? YES - continue below
YES; B-Lynch sutures, uterine artery ligation, hysterectomy

PRACTICE OBSTETRIC CASES

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J Definition: T > 100.4 F (38 C) on > 2

occasions, > 6 hrs apart (not 1st 24 hr). Postpartum-Fever'
PPD #0: Are there lung crackles? YES – Atelectasis; NO - continue below
YES: avoid CXR or antibiotics; ambulate, deep breathing
PPD #1-2: Is there dysuria & flank pain? YES – UTI; NO - continue below
YES: UA & culture; single agent IV antibiotic (cefotetan)
PPD #2-3: Is uterus tender? YES – ENDOMETRITIS; NO – continue below
YES; IV gentamicin & clindamycin until afebrile x 24 hrs
PPD #4-5: Exam wound pus? YES – Wound abscess; NO – continue below
YES; open wound; cultures; wet-to-dry dressings
PPD #4-5: CT pelvic mass? YES – Pelvic abscess; NO – continue below
YES; percutaneous drainage by interventional radiology
PPD #5-6: Unexplained persistent spiking fevers? YES - continue below
YES; Diagnosis of exclusion; IV heparin to double baseline PTT

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