OB SEMINAR REVIEW

Maternal Anatomy

Bony Pelvis

1. Sacrum
2. Coccyx
3. 2 innominate bone = fusion of ilium + ischium + pubis
a. False Pelvis – above the linea terminalis
b. True Pelvis – important for child bearing

Diameters

1. Antero – posterior Diameter (AP Diameter) – distance between symphysis pubis to sacral promontory

a.
Obstetric Conjugate = Diagonal Conjugate – 1.5 cm to 2 cm
 Most important
 Cannot be measured clinically
 Shortest distance between symphysis pubis to sacral promontory
 Normal: > 10 cm
b. Diagonal Conjugate
 Measured clinically
 Lower margin of symphysis pubis to sacral promontory
 > 11.5 cm
c. True Conjugate
 Upper margin of symphysis pubis to sacral promontory
 Most cephalad
2. Transverse Diameter
 Greatest distance between sides of linea terminalis
 Normal: 13 cm
3. 2 Oblique Diameter
 Distance between sacroiliac synchondrosis to contralateral iliopubic eminence
 Normal: < 13 cm

Shape of Pelvis

1. Gynecoid
 P>A
 Ideal type for vaginal delivery
 More common in women
2. Android
 P<A
 Usually in males
 Heart shape
 Poorest prognosis
3. Platypelloid
 P=A
 Transverse oval (flat A & P sides) almost circular
 4. Anthropoid
 P<A
 Longitudinal oval

Clinical Pelvimetry

1. Inlet
 AP diameter should be > 11.5cm
 Sacral promontory is accessible or not? Normal: not accessible
2. Midpelvis
 Hollow sacral curvature
 Interspinous diameter should be > 10 cm
 Blunted ischial spines
 Sidewalls should be parallel
 Sacrosiatic notch should accommodate 2-3 fingerbreadths
3. Outlet
 Intertuberous diameter – fist should be accommodated between ischial tuberosities
 Subpubic angle > 90
 Movable coccyx

Prenatal Care

 Gravida – # of pregnancy
 Parturient – in labor
 Puerpera – after delivery

 G – # of pregnancy
 P – pregnancies > 20 weeks
 T – pregnancies > 37 weeks
 P – pregnancies < 37 weeks
 A – abortion, ectopic pregnancy, H. mole
 L – living

Mean Length of Pregnancy – 280 days or 40 weeks

Age of gestation

I. Naegele’s Rule – expected date of pregnancy

 + 7 days
 - 3 months
 + 1 year
II. Quickening
 Primi – 18-20 weeks AOG
 Multi – 16-18 weeks AOG
III. Fundic Height
 Corresponds to AOG at 18 – 32 weeks
IV. UTZ
 Crown rump length – 6 – 14 weeks (1st trimester)
 Biparietal diameter – after 14 weeks (2nd trimester)
 Femoral length - 3rd trimester

1st trimester UTZ – should have fetal heart tone (about 7 weeks AOG)

Note:

 FHT can be heard through

 UTZ at 6 – 7 wks AOG
 Doppler at 10 -12 wks AOG
 Stethoscope at 18 – 20 weeks.
  - HCG – peaks at 60 – 90 days
 Chadwick’s sign – vaginal mucosa is bluish to purplish
 Hegar’s sign – softening of the uterine isthmus
  Fetal weight
 Ultrasound
 Johnson’s Rule: Wt (grams) = Fundic ht (cm) – n x 155
o n = 12 if vertex is above the ischial spine
o n = 11 if below the ischial spine
 Palmar method: 500 grams per palm surface
 Wt (grams) = Fundic Height + station x 100
 Abdominal enlargement
 0 – 12 weeks uterus is a pelvic organ
 12 wks AOG – uterus is at the symphysis pubis
 16 wks AOG – uterus is midway between the symphysis pubis and the umbilicus
 20 wks AOG – uterus is at the level of the umbilicus

Fetal Orientation

1. Lie
 Longitudinal
 Transverse
 Oblique
2. Presentation
 Cephalic
 Chin
 Shoulder
 Breech
3. Attitude
 Flexed
 Extended
4. Position – position of the presenting part
 Cephalic – occiput (Eg. Left Occiput Anterior)
 Chin – mentum (Eg. Left Mentum Anterior)
 Shoulder – acromion (Eg. Right Acromion Dorsoposterior)
Note: if shoulder presentation, the position of the back is also stated
 Breech – sacrum

Leopold’s Maneuver

I. Fundic Grip – what fetal part occupies the fundus?

II. Umbilical Grip – which side is the fetal back?
III. Pawlick’s Grip – what is the fetal presenting part? Is it engage or not?
IV. Pelvic Grip – which side is the cephalic prominence (fetal attitude)? Is it engage or not?

Note:

 Listen FHT at the side where the fetal back is at 18 weeks AOG

Labor & Delivery

Reporting: Eg. Pregnancy uterine, 40 weeks, cephalic, in labor

TRUE LABOR:

 Contractions is regular
a. Every 5 mins
b. Early labor – every 15 mins
c. Active labor – 3 – 5 mins
 Intensity increases gradually
 Intervals shorten gradually
 Cervix dilates
Mechanism of Labor

1. Engagement
 The biparietal diameter of the fetal head in occiput presentation passes through the pelvic inlet.
 The fetal head tends to accommodate to the transverse axis of the pelvic inlet, whereas the sagittal suture, lies roughly midway
between the symphysis and the sacral promontory.
 In some cases, the sagittal suture is deflected either posteriorly toward the promontory (anterior asynclitism) or anteriorly
toward the symphysis (posterior asynclitism).
 Moderate degrees of asynclitism are the rule in normal labor
2. Descent
 Flexed fetus descends.
 It is brought about by 1 or more of 4 forces:
a. Pressure of the amniotic fluid
b. Direct pressure of the fundus upon the breech with contractions
c. Bearing down efforts of maternal abdominal muscles
d. Extension & Straightening of the fetal body
3. Flexion
 The descending head flexes as it meets resistance either from the cervix, pelvic wall or pelvic floor.
 The chin comes in contact with the fetal thorax.
 Pelvic diameter being presented: suboccipitobregmatic diameter.
4. Internal Rotation
 The fetal head turns placing the occiput towards the symphysis pubis anteriorly from its original position or posteriorly toward
the sacrum

5. Extension
 The sharply flexed head reached the vulva & presses out on the pelvic floor, two forces come into play:
a. Force exerted by the uterus, acts more posteriorly
b. Force applied by the resistant pelvic floor, and
c. Symphysis, acts more anteriorly
 The resultant vector is in the direction of the vulvar opening, causing head extension.
 This brings the base of the occiput into direct contract with the inferior margin of the symphysis pubis.
6. External Rotation
 The delivered head undergoes restitution (e.g. if the occiput was originally directed toward the left, it rotates towards the left
ischial tuberosity)
 Resitution of the head to the oblique position is followed by external rotation completion to the transverse position.
 This movement corresponds to rotation of the fetal body and serves to bring its bisacromial diameter into relation with the
anteroposterior diameter of the peliv outlet.
 It places one shoulder anteriorly behind the symphysis and the other is posteriorly.
7. Expulsion
 The anterior shoulder appears under the symphysis pubis, and the perineum soon becomes distended by the posterior shoulder.
 After delivery of the shoulders, the rest of the body quickly passes

Phases of Parturition

A. Phase 0: Uterine quiescence and Cervical Softening

 Braxton-Hicks contraction
B. Phase 1: Preparation for Labor – cervical ripening
C. Phase 2: Labor
Stages of Labor
I. Cervical effacement and dilatation: contraction until full cervical dilatation
 Start of regular contraction
 Cervical effacement – thinning of the cervix
 Cervical dilatation until 10 cm
II. Fetal expulsion: full cervical dilatation (10 cm) to delivery of the fetus
III. Placental separation and expulsion
D. Phase 3: Involution
 Freedman’s Curve

Two phases

I. Latent phase
 Preparation
 Slow dilataion
 Cervical effacement
II. Active phase
 Acceleration phase – predict labor outcome
 Minimum rate of dilatation
a. Nullipara – 1.2cm / hr
b. Multipara – 1.5cm / hr
 Phase of maximal slope – efficiency of uterine contraction
 Deceleration phase – cephalo – pelvic relationship
 Descent starts at 7-8 cm dilatation
Dystocia

I. Prolongation Disorder
a. Prolonged latent phase – Cervical dilatation of < 4 cm
 No dilatation
 No descent
 Management: bed rest
II. Protraction Disorder
 Cervical dilatation 4 -8 cm,
 Management: expectant and support
 Types:
a. Protracted active phase dilatation – there is progress or dilatation but it is slow
b. Protracted descent – there is descent but it is slow
III. Arrest Disorder
 Cervical dilatation > 8 cm
 Management: evaluate for CPD
 If with CPD – CS delivery
 If no CPD – give oxytocin
 Types:
a. Prolonged deceleration
 Not fully dilated
b. Secondary arrest of dilatation
 No engagement
 > 2 hours without progress
c. Arrest of descent
 Full cervical dilatation (10 cm)
 Initial descent
 Decent arrested for > 2hours
d. Failure of descent
 Full cervical dilatation (10cm)
 No descent for > 1 hour
Intrapartum Monitoring

I. External/ Indirect
a. Doppler
b. Cardiotocogram
 2 transducers for the HR
 Affected by the movement of the mother
II. Internal/ Direct
a. Fetal scalp
b. Needs ruptured BOW and dilated cervix

HFR Patterns

A. Fetal Heart Rate – Nomal: 110 – 160 bpm (always in increments of 5)

B. Variability of FHR
 Variation of FHR
 Normal: 5-25 bpm
C. Acceleration of FHR – increase in FHR from the baseline
D. Deceleration of FHR – decrease in FHR from the baseline
1. Early deceleration
 Symmetrical and gradual decrease in FHR
 Gradual deceleration: > 30 sec from onset of deceleration to the nadir
 Nadir simultaneous with the contraction
 Head compression
2. Late deceleration
 Gradual decrease in FHR
 Nadir is after the contraction
 Uteroplacental insufficiency
3. Variable deceleration
 Abrupt decrease in FHR
 Can be before or after contraction
 Onset of deceleration varies with successive contractions
 Last for > 15 sec to 2 mins
 > 15 bpm in amplitude
 Cord compression
4. Prolonged deceleration
 > 2mins but < 10 min
Categories of Tracing

I. Normal/reassuring patterns
 Stable baseline HR (110 – 160 bpm)
 Normal variability (5 -25 bpm)
 No deceleration
 Accelerations with contractions
II. Intermediate
III. Abnormal

Metabolic Changes in Pregnancy

a. Mild fasting hypoglycemia

b. Post prandial hyperglycemia
c. Hyperinsulinemia
DM

 Universal screening for GDM is recommended for Filipino gravidas (Filipino pregnant patients are ALL at risk for diabetes)
 For Filipino gravidas with no other risk factors aside from race and ethnicity:
o Initial tests in 1st Pre Natal Check Up (or when the only risk factor is FILIPINO, no history, no family history, unremarkable obstetric history):
FBS or HbA1c or RBS
o If initial tests are normal: 2h 75g OGTT at 24-28 weeks
**if patient has other risk factors aside from race, immediately order 75g OGTT
o If OGTT is normal: retesting at 32 weeks or earlier, if with clinical signs and symptoms of hyperglycemia both in the mother and fetus
 For high risk Filipino gravidas: 2h 75g OGTT

OVERT DM GDM
FBS ≥ 126 mg/dl ≥ 92 mg/dl
RBS ≥ 200 mg/dl
HbA1c ≥ 6.5 %
2h 75g OGTT >200 mg/dl ≥ 140 mg/dl

1 – 3. Normal metabolic changes in pregnancy.

1. Mild fasting hypoglycemia
2. Post prandial hyperglycemia
3. Hyperinsulinemia
4. One obstetric risk factor for acquiring diabetes in the present pregnancy (obstetric history).
Previous pregnancies with: LGA fetus, unexplained fetal death, baby with congenital anomalies
5. Initial test that you will request during the first prenatal check up to screen a Filipino pregnant patient at 8 weeks.
FBS
HbA1c
RBS
6. At PE, you have a Filipino pregnant patient at 24 weeks. What screening would you request?
2h 75g OGTT
7 – 8. Values for FBS and 2h 75g OGTT for patient with GESTATIONAL DM
FBS: ≥ 92 mg/dl
OGTT: 140 mg/dl
9. One MATERNAL complication of DM
Nephropathy, impaired wound healing, neuropathy, retinopathy, hypertension, cardiac problems: coronary artery disease, stroke,
immunocompromised, infections: fungal
10. One FETAL complication of DM
macrosomia, hypoglycemia(at birth), respiratory distress, preeclampsia, polyhydramnios, preterm baby, etc
11. Define HYPERthyroidism
Decreased TSG with Increased T3 or T4
12. One medical treatment for HYPERthyroidism
Thionamides (PTU, Methimazole) or Beta blockers
13. Most common form of HYPOthyroidism
Hashimoto’s thyroiditis
14. One medical treatment for HYPOthyroidism
Levothyroxine or Iodine
15. Interpret: elevated TSH, and normal FT4
Subclinical Hypothyroidism

Hypertension

I. Gestational HTN
 After 20 wks
 No proteinuria
II. Chronic HTN
 HTN before pregnancy
 HTN before 20 wks
 Persistent HTN, > 12 wks postpartum
III. Preeclampsia
 After 20 wks
 With proteinuria
 > 160/110 mmHg
 Without proteinuria but with the ff:
a. Renal insufficiency
 b. Thrombocytopenia
c. Impaired liver function
d. Pulmonary edema
e. HTN Retinopathy
IV. Preeclampsia with Severe Features
V. Eclampsia – preeclampsia with seizures
VI. Chronic HTN with Preeclampsia
 Chronic HTN with
a. New onset proteinuria
b. Increase proteinuria
c. Increase in BP

HELLP Syndrome

Management of Preeclampsia

Note: Diuretics – only given if there is pulmonary edema

Note: In HTN, normal delivery unless there is uncontrolled HTN and growth restriction

MgSO4 Toxicity

 Loss of patellar reflex

 Decrease in RR > paralysis > arrest
 Decrease in urine output

Corticosteroids

 Given 24 – 34 wks AOG

 Betamethasone: 12 mg IM every 24 hrs, 2 doses
 Dexamethasone: 6mg IM every 12 hrs, 4 doses

Antepartum Hemorrhage

I. 1st Trimester
a. Abortion
 Early – chromosomal defect
 Late – infection
b. Ectopic pregnancy = amenorrhea + abdominal pain + spotting
II. 3rd Trimester
a. Abruptio Placenta
 Uncontrolled HTN
 Anything that would distend the uterus further
 Vaginal bleeding + abdominal pain
 Sheehan’s Syndrome (with pituitary failure)
 Stabilize the mother and fetus first
b. Placenta Previa
 Previous uterine surgery
 Painless vaginal bleeding
 UTZ
 Classification depends on how near the placenta is to the cervical os
III. Placenta Accrete Syndrome

Preterm

 < 37 weeks AOG

 Investigate underlying cause
 Corticosteroids
 Tocolytics
 MgSO4
 Nifedipine
 Beta adrenergic
Post-term

 > 42 weeks AOG

 Oligohydramnios
 Macrosomia
 Induction of Labor

GYNE SEMINAR REVIEW

Infertility

 Common cause
a. Ovarian
b. Male factor
c. Tubal
d. Endometriosis

PCOS

 Insulin resistance

Androgen Excess

Unopposed estrogen stimulation from anovulation

 How does PCOS cause androgen symptoms?

Weight gain

Obesity

Excess Insulin

Increase in androgen

Symptoms

 Management
1. Weight reduction
2. OCP, progesterone only pills
3. Clomifine citrate


Usual fecundability Rate: 0.20

Day of LH surge: Advises day to have sex to conceive

Congenital Anomalies

A. Turner Syndrome
B. Mayer Rokitansky Kuster Hauser Syndrome
 Related to unilateral renal agenesis -> Renal failure
C. KlinefelterSyndrome

Imperforate Hymen

 DDX: vaginal adhesions

Grave’s Disease

a.

Endometriosis

 Theories of endometriosis
 1. Coelomic metaplasia – ability to proliferate
2. Iatrogenic metaplasia – CS scar
3. Retrograde metaplasia
 Most common theory
 Most common site: ovary
4. Lymphatic/ vascular dissemination
 Arms, lungs, thigh
 Catemenial hemothorax
 Pathognomonic Sign: uterus fixed and retroverted
 Goal of treatment of endometriosis
a. Long term: prevent recurrence
b. Short term:
 Relief of pain
 Restore or preserve fertility
 Medical treatment of endometriosis
1. GnRH Agonist – medical oophorectomy
2. OCP
3. Danazol – endometrial atrophy
4. NSAIDS
 Cause of dyspareunia in endometriosis
 Best time for internal exam in endometriosis: 1st and 2nd day of menstruation
 Gold standard for endometriosis: Laparoscopy with biopsy

PID

 Minimum criteria:
1. Pelvic organ tenderness
2. Leukorrhea or vaginal discharge
 Treatment
 Should be admitted:
a. Surgical emergencies
b. Pregnancy
c. Not responsive to oral antibiotics
d. Non-compliant
e. With Severe illness
f. Tubo-ovarian abcess
 Fitz – Hugh – Curtis – syndrome

Ovarian Reserve Test

 > 35 years old

 Chemotherapy
 Pelvic or ovarian surgery

Adenomyosis

 Diffusely enlarge or globular uterus

Athletic girls delay in menarche

 There is a delay in menarche of 0.4 years for each year of training

Mean interval between breast budding and menarche: 2.3 years + 1

Tanner Staging

Sexually Transmitted Infections

a. Trichomoniasis – strawberry cervix

Molluscum Contagiosum: elevated papule with central umbilication

Staging of Pelvic Organ Prolapse (POP)

H. Mole

 Chemoprophylaxis: methotrexate
 Ideal time for  - Hcg determination after evacuation of H. mole: 1 week