OB REVALIDA SAMPLEX

PRENATAL CARE + IMPAIRED GLUCOSE + ASYMPTOMATIC BACTERIURIA + OBESITY + SEVERE

PREECLAMPSIA
CASE: 32 y/o, G2P0 (0010) came in for 1st prenatal checkup
BP: 120/80
HR: 76 bpm
RR: 14 cpm
BMI = obese
CBC: Hemoglobin 10g/dl
Urinalysis: (+) pus cells 8-10/pf, no urinary complaints
FBS:101 mg/dl
HgbA1c: 6.2%

1. Labs to request on 1st prenatal visit:

o CBC with platelet count – to check for anemia
o Blood typing and RH factor
o Urinalysis – to check for UTI
o Ultrasound if not yet taken – to check for AOG (when is CRL most accurate? 12 weeks)
o Papsmear screening
o Urine protein assessment – to know if there is proteinuria
o Urine culture
o Serologic tests for rubella, syphilis (non-treponemal RPR/VDRL), hepatitis B
o Chamydial screening, gonococcal screening for high-risk women (done on 1st and 3rd
trimester)
2. Complete diagnosis and bases
o G2P0 (0010) ___AOG, not in labor, gestational diabetes, asymptomatic bacteriuria, mild
anemia, obesity
o Bases:
▪ Gestational DM due to impaired glucose tolerance (FBS of 101)
▪ Asymptomatic bacteriuria due to pus cells seen in urinalysis with no urinary symptoms
▪ Mild anemia: hgb is 10 g/dl
▪ Obesity – BMI of __kg/m2
3. Management for all diagnosis
o Gestational DM – insulin, metformin, diabetic diet (daily caloric intake of 30-35 kcal/day)
o Aymptomatic bacteriuria – oral antibiotic therapy for 3-7 days (amoxicillin 250 mg)
o Anemia – 60-100mg elemental iron
o Obesity – Moderate exercise for atleast 150mins weekly (e.g. yoga, walking)
4. Target ranges for glucose
Capillary blood glucose targets (Antepartum)
o Preprandial - <95mg/dl
o 1 hr postmeal - < 140mg/dl
o 2 hr postmeal - <120mg/dl
5. Other parameters to know for glucose control
o Urinalysis – to assess for ketonuria
o HBA1C: <6.4%

ZAP 1
Patient came back at 33 weeks with complaints of dizziness and blurring of vision with BP of 160/100 mmHg
and urine protein of +2
1. Diagnosis and basis
o GP(TPAL, 33 weeks AOG, Severe preeclampsia
o Bases: BP of 160/100, proteinuria, dizziness and blurry vision
2. Management (4)
o Observe for 24-48, give MGSO4 for 24hrs and antihypertensives, monitor FHT and symptoms
and order labs. During the observation period, assess for the appearance of ENDPAINS
(Absolute contraindications to Expectant Mngt):
• Eclampsia
• Non reassuring fetal status
• DIC
• Pulmonary edema
• Abruptio placenta
• Intrauterine growth restriction
• Uncontrolled Severe hypertension

If any of those are present = give MGSO4 and DELIVER

• Induction of labor (assisted/forceps delivery)

• CS (if with obstetrical indications – malpresentation, CPD
If those are NOT present, assess for Relative Contraindations to Expectant Mngt:

• HELLP syndrome or Partial HELLP (hemolysis, elevated liver enzymes and low platelet counts)
• IUGR
• Severe oligohydramnios
• PPROM
• Renal insufficiency
• Persistent symptoms
If any of those are present = Give STEROIDS and DELIVER AFTER 48 HRS

• Betamethasone 12mg IM every 24 hrs for 2 doses

• Dexamethasone 6mg IM every 12 hrs for 4 doses
If NOT present = DELIVER AT 34 WEEKS while still monitoring the maternal-fetal condition

3. When to terminate/deliver the baby?

o Absolute contraindications to Expectant Mngt:
▪ Eclampsia
▪ Non reassuring fetal status
▪ DIC
▪ Pulmonary edema
▪ Abruptio placenta
▪ Intrauterine growth restriction
▪ Uncontrolled Severe hypertension

ZAP 2
PRENATAL CARE + ANTEPARTUM SURVEILLANCE

• Maternal Physical examination on 1st visit

o Complete PE
▪ Blood pressure
▪ BMI
▪ Pelvic exam and abdominal exam
• Speculum – look for signs of pregnancy - chadwick’s, signs of infection →
papsmear, growths
• Bimanual exam
• Quickening
o Primigravid: 18-20 weeks
o Multigravida: 16-18 weeks
▪ Fundal height
• Accurate at 20-34 weeks
• Measure from superior pubic symphysis to superior uterine fundus
• FH> AOG
o Check if correct ang AOG
o Multifetal pregnancy
o Polyhydramnios
o Macrosomia
o LGA
• FH<AOG
o Check if correct AOG
o Fetal demise
o Oligohydramnios
o SGA
• 12 weeks uterus becomes an abdominal organ
• 16 weeks midway between symphysis and umbilicus
• 20 weeks at the level of the umbilicus
▪ Fetal HR
• Auscultation: as early as 16 weeks but more heard at 22 weeks
• Fetal doppler: 10 weeks
• TVUS: 6 weeks
o Leopold’s maneuver
▪ L1: fundal grip check what occupies the fetal pole
• Head: hard round ballotable mass
• Breech: Large nodular mass
• Transverse: empty
▪ L2: umbilical grip, locate the fetal back and small parts
• Fetal back: hard, resistant smooth surface
• Fetal extremities: small irregular nodulations
▪ L3: pawliks grip, check if the presenting part is engaged
• Head: not engaged, hard round ballotable mass
• Shoulder: hard nodular, engaged
▪ L4: Pelvic grip, check the cephalic prominence, different position from the 3
• Cephalic prominence is at the same side of the back → face or mentum
presentation
• Opposite side of the back → occiput presentation
ZAP 3
• Fetal Physical examination
o Fetal sonography
▪ Fetal anatomy, growth and well being
o Fetal heart tones (Doppler)
▪ Normal 110-160 bpm
▪ Brady: <90 → fetal demise
o Estimated fetal weight: Johnson’s formula: (fundal ht in cm – n) x 155
▪ If head is above ischial spines – n is 13
▪ At the ischial spines – n is 12
▪ Below the ischial spines – n is 11
• Laboratory tests on 1st prenatal visit
o CBC with platelet count – to check for anemia
o Blood typing and RH factor
o Urinalysis – to check for UTI
o Ultrasound if not yet taken – to check for AOG (when is CRL most accurate? 12 weeks)
o Papsmear screening
o Urine protein assessment – to know if there is proteinuria
o Urine culture
o Serologic tests for rubella, syphilis (non-treponemal RPR/VDRL), hepatitis B
o Chamydial screening, gonococcal screening for high-risk women (done on 1st and 3rd
trimester)

ZAP 4
• Diet, drugs and disposition

o DIET
▪ Calories: increased by 100-300 kcal/day
▪ Protein: 5-6 g/day
▪ Pinggang Pinoy (Go, Grow and Glow foods)
o DRUGS
▪ Iron → 27mg elemental iron daily
• 60-100 mg if mother is large, twin pregnancy, late intake of iron, irregular intake,
and decreased hemoglobin
• Start at 4th month of pregnancy (2nd trimester) to lessen avoid additional nausea
and vomiting
• Ingest at bedtime or on empty stomach facilitates absorption and minimize
adverse GI reaction
▪ Folic acid - 400 mcg/ 4mg if there is history of NTDs from preconception until early part
of first trimester
▪ Zinc: 12mg/day
▪ Vitamin D: 15ug/day; sunlight exposure
o DISPOSITION (Explain to the px regarding: intake of coffee, diet, edema, hemorrhoids, travel
and sex)
▪ Intake of coffee is limited to 3 cups of 5oz coffee (up to 300ml only) – risk of abortion
▪ Coitus is allowed, unless there is placenta previa, preterm labor or abortion
▪ Travel is safe up to 36 weeks AOG
▪ Exercise: regular, moderate intensity physical activity for at least 150 minutes per week
(walking, stationary biking, yoga, low impact aerobics)
▪ Edema – avoid standing for long periods, wear comfortable shoes and rest with feet up
▪ Hemorrhoids
• Due to increased pressure in rectal veins
• Topical anesthetics, stool softening agents and warm soak
▪ Nausea and heartburn
• Eat small meals at frequent intervals
• If severe and persistent → hyperemesis gravidarum
▪ Headache → give acetaminophen
o Immunization
▪ Contraindicated (these live attenuated vaccines are theoretically said to cross the
placenta resulting in viral infection of the fetus)
• MMR
• Varicella
• BCG

ZAP 5
 ▪ Recommended
• Flu
• Hepatitis B
• Tetanus and Td
• Follow up
o <28 weeks: monthly (during 1st trimester)
o 28-36 weeks: every 2 weeks
o >36 weeks: weekly
• 10 Danger Signs in Pregnancy:
o Signs of Preeclampsia
▪ Headache
▪ Blurry vision
▪ Prolonged vomiting
▪ Abdominal pain
▪ Nondependent edema
o Signs of Infection (UTI, chorioamnionitis)
▪ Fever
▪ Dysuria
▪ Watery vaginal discharge
o Signs of endangered pregnancy
▪ Vaginal bleeding
▪ Decreased fetal movement

ANTEPARTUM SURVEILLANCE + CTG REVIEW

I. Fetal movement
• Maternal perception = after 28weeks gestation, daily perception of atleast 10 distinct
movements in 2hrs
• Ultrasound = 3 movements in 30mins
• Tocodynamometer
• SLEEP CYCLE – varies 20-70mins
o May be a cause of non reactive NST showing absence of accelerations (or just 1
within 20mins of beginning the test)
II. Fetal breathing
• Part of the BPS – uses ultrasound
• Paradoxical chest movements in fetus due to coughing out of AF
• 1-4 gasps/sighs per minute
III. Electronic Fetal Monitoring – NST and CST
Non-Stress Test (NST)

• Mother in semi-fowler position with left lateral tilt, perform Leopold’s, place ultrasound and
tocodynamometer transducers
CTG tracing parts:

• A – FHR tracing (normal: 110-160bpm, assess variability, check for accelerations) (round to
nearest 5 bpm)
• B – Fetal movement recorded by mother
• C – Fetal movement recorded by tocodynamometer

ZAP 6
 • D – Uterine contractions (look for decelerations)
Baseline FHR: normal is 110-160 bpm
Baseline FHR Variability (variability due to tag and pull effect of sympa and parasym:
• Absent – undetectable (fetal compromise – acidemia)
• Minimal variation: <5 bpm (usually accompany fetal bradycardia, may be due to MgSO4,
asleep fetus, narcotics, general anes, or analgesics kahit na reactive pa ung NST)
• Moderate: 6-25 bpm (NORMAL)
• Marked - >25 bpm
FHR Acceleration: (corresponds to fetal movement)
• Acceleration means ABRUPT (<30secs from onset to peak) in FHR from baseline
• Check for the AOG!! Remember 32 weeks
o >32weeks = 15 beats from baseline lasting 15 seconds
o <32weeks = 10 beats from baseline lasting 10seconds
• Interpretation:
o REACTIVE NST = 2 or more accelerations peaking at 15beats from baseline, each
lasting 15secs or more but less than 2mins (>32 weeks AOG) in a 20minute window.
o NON-REACTIVE NST = just 1 or absent accelerations (may be due to MgSO4, fetal
sleep, smoking)
• Management options:
REACTIVE <20mins NONREACTIVE NONREACTIVE +
SPONTANEOUS
DECELERATIONS
Repeat after 2-3 days or Extend for 20mins Pag may decelerations, DO
weekly • Reactive = repeat test NOT EXTEND = EXPEDITE
after 2-3 days or DELIVERY (there is fetal
weekly distress already)
• Non-reactive padin =
EXTEND for another
20mins
• If nonreactive padin
after 60 minutes = DO
ULTRASOUND with
CST or BPP or
DELIVER na

Contraction Stress Test (CST)

• To test for uteroplacental function
• Contraindications: PPROM, previous classical CS (uterus may rupture), multifetal
pregnancy, placenta previa
• There should be atleast 3 contractions in 10minutes
• If there are no contractions, nipple stimulation can be done for 2mins..if none repeat
after 5mins
• The important thing to note here is the presence of decelerations (late or variable)
• Interpretation and management:
o Negative CST = NO late decels or significant variable decels = proceed with
LABOR INDUCTION
o Positive CST = presence of late decels following 50% or more of contractions or
even if there are less than 3 contractions in a 10min period = CS DELIVERY
o Others: Equivocal-suspicious (intermittent late decels), equivocal-
hyperstimulatory (decels are frequent q2mins or lasts >90s) and unsatisfactory
Decelerations: check muna if gradual or abrupt ung deceleration!!
(decelerations are signs of interruption in the O2 transfer between the mother and fetus)
ZAP 7
 • Early decelerations – GRADUAL (onset to nadir >30secs) decrease and return of FHR in
MIRROR IMAGE to the uterine contractions.
o Most common cause: HEAD COMPRESSION (due to vagal stimulation;
considered physiologic; occurs in the pelvic division where cervix is already 8cm
and head is at or below the ischial spines – 0, +1, +2)
• Late decelerations – GRADUAL decrease and return of FHR AFTER uterine
contractions.
o Most common cause: UTEROPLACENTAL INSUFFICIENCY
o Other causes: maternal hypotension from epidural anesthesia and uterine
hyperactivity
• Variable decelerations – ABRUPT (onset to nadir <30secs) decrease and return of FHR
atleast 15 beats from baseline lasting 15 secs but less than 2mins , regardless of uterine
contractions
o Most common cause: CORD COMPRESSION
• Prolonged Deceleration – apparent decrease and return of FHR atleast 15 beats but
duration is 2minutes or more but less than 10mins
o Cord prolapse, uterine hyperactivity, maternal supine hypotension, abruptio
placenta, impending birth

CATEGORY OF FHR TRACING:

CRITERIA MANAGEMENT
CATEGORY 1 Baseline rate: normal (110-160) - No specific action required
Baseline variability: moderate (6-25bpm) - Observe and await vaginal delivery
Accelerations: + or – or do assisted delivery if head is
Late or variable decelerations: absent already low (e.g. station +4)
Early decelerations: + or -
CATEGORY 2 Indeterminate/unrecognizable Continue surveillance and reevaluation
Usually prolonged decelerations Do resuscitative measures and ancillary
tests to ensure fetal well being:
- Improve fetal oxygenation and
uteroplacental blood flow (lateral
decubitus position, reduction of
uterine contractions)
- Diminish uterine activity
(discontinue oxytocin, administer
tocolytics)
- Relieve cord compression
(reposition mother, amnioinfusion)
CATEGORY 3 ABSENT VARIABILITY with any of the • Discontinue labor stimulation
following: • Treatment of maternal hypotension
• Recurrent late decels • Change in maternal position so that
• Recurrent variable decels uterus is not compressing the IVC
• Bradycardia (sinusoidal pattern) and improve venous return
Associated with fetal acidosis • Treatment of tachysystole
• If despite resuscitation, tracing did
not improve = DELIVER BY CS

IV. Sonographic Assessment – fetal biometry, biophysical profile including AF volume, and
doppler velocimetry
a. Fetal biometry – monitor growth of the fetus thru measurements of biparietal diameter, abdominal
circumference, femur length
b. Biophysical Profile: 5 components
1. NST
2. Fetal breathing = 1-4 gasps/sighs per minute

ZAP 8
 3. Fetal movement = 3 or more body/limb movements in 30mins
4. Fetal tone = 1 or more episodes of extension and flexion of extremity OR opening and clsing of
hand in 30 mins
5. Amniotic fluid volume = single vertical pocket 2-8cm
• Scoring: 2 if normal, 0 if abnormal
• Interpretation:
o BPS of 8-10 is normal (normal pH) = healthy baby
o BPS of below 4 (fetal asphyxia) = DELIVER
o In between (possible fetal asphyxia) = DELIVER but if BPS is >6, observe first and repeat
testing
c. Doppler velocimetry – to assess fetal and maternal blood flow
Fetal vessels:
• Umbilical artery – to confirm the fetal growth restriction
• Middle Cerebral artery – to evaluate fetal anemia
• Ductus venosus
Maternal vessels: uterine artery (increased resistance to flow in hypertensive pregnancies)

BREECH + CS
CASE: ___y/o G1P0, pregnancy uterine, 36 weeks and 2 days AOG, Frank breech in labor, prior low segment
CS (indicate if advanced maternal age)

• Presentation and basis

o IE
o FHT location (leopolds)
• Risk factors of breech
o Premature gestational age
o Abnormal amniotic fluid volume
o High parity with relaxed uterus
o Multifetal gestaion
o Prior breech delivery/prior CS delivery
• Types of breech
o Frank breech – thighs are flexed at the hips and extended on the knees so that the feet are
close to head; Anus pubic symphysis are palpated → forms a straight line; most favorable for
vaginal delivery
o Complete breech – thighs are flexed at the hips and flexed on the knees (parang indian sit);
pwedeng vaginal
o Incomplete breech – one or both feet or knees lie below the breech or at the lowermost portion
of the birth canal or outside
▪ Point of reference would still be the sacrum
▪ Least favorable for vaginal delivery -> CS na dapat
• Leopolds maneuver
o L1 (Fundal grip) – fundus is occupied by a hard, round, ballotable mass (cephalic)
o L2 (Umbilical grip) – fetal back is at the right/left and fetal small parts on the left/right; FHT is
located at the right/left upper quadrant
o L3 (Pawlik’s grip) – lower uterine segment is occupied by large nodular mass (movable above
the pelvic inlet – unengaged) (breech)
o L4 (Pelvic grip) – after engagement, 4th maneuver shows firm breech beneath the symphysis
pubis

ZAP 9
• Types of vaginal breech delivery
o Spontaneous – fetus is expelled spontaneously w/o traction or manipulation, only support is
done; least traumatic
o Partial breech extraction – the mother is asked to push and the fetus is delivered
spontaneously until the umbilicus. The rest of the body is delivered with traction and assisted
maneuvers:
▪ Pinard’s maneuver → to deliver the feet, press on the popliteal fossa then laterally
sweep the each leg away from the midline
▪ Loveset maneuver → to deliver the arms that are placed upwards, press on the
antecubital fossa then sweep the arm from face to chest..then rotate the baby 180
degrees to deliver the posterior arm
▪ Nuchal arm delivery → rotate the fetus in a half circle to remove nuchal arms
▪ Mauriceau maneuver →in here the baby is in prone position. We put our index and
middle finger over the malar prominences to flex the head, while the other hand is
placed on the subocciput to assist flexion of the head. An assistant is required to apply
subpubic pressure until the head is delivered.
▪ Modified prague maneuver → done if the fetus is in supine. 2 fingers should grasp the
shoulders at the back then the other hand should grasp the baby’s feet upwards over the
mother’s abdomen
▪ ENTRAPMENT OF THE HEAD
• Piper’s forceps – long shank
• Duhrssen incision → 2,10, and 6 o’clock position → to widen the canal (minimize
bleeding since it will avoid the laterally located cervical branches of the uterine
artery)
• Symphysiotomy → cutting of the ligaments in the pelvis
• Zavanelli maneuver → last resort where we replace the fetus into the uterus then
proceed with CS
o Total breech extraction
▪ Total assistance of delivery by the obstetrician from the feet upwards.
• Route of Delivery (CS vs Vaginal)
▪ Vaginal if
• >2500 grams
• Adequate pelvis; check if primi ba si patient kasi if oo, di pa tested ung pelvis
• Cervix must be fully dilated
▪ CS if
• <2500 (head is larger than the buttock) or >4000g (large baby)
• (+) Growth restriction
• Inadequate pelvis
• Hyperextended head
• Incomplete or footling breech
• CS Incisions (classical, kerr, kronig)
o Classical
▪ Vertical incision above the LUS up to the uterine fundus
▪ Done if LUS cannot be safely be exposed
• Myoma at the LUS
• Invasive CA
• Placenta previa
o Low transverse incision (Kerr)
▪ Incision at the LUS
ZAP 10
 ▪ Preferred over classical
• Easy repair
• Least likely to rupture
• No adherence to the bowels
o Low segment vertical incision (Kronig)
▪ Vertical incision at the LUS
▪ Disadvantages
• Dissects the bladder
• Can extend downward into the cervix
• More likely to rupture
• Absolute indications for CS:
o Non reassuring fetal heart status
o Abnormal placentation (e.g. placenta previa – blocks the cervical os)
o Inadequate pelvis/small maternal pelvis/CPD
o Fetal asphyxia
o Maternal request
o Severe preeclampsia which can develop to eclampsia
o Incomplete breech (footling breech)
• External Cephalic Version
o Done at 37 weeks; if before - might revert to breech
o Indications - fetus with greater than 36 weeks of gestation with malpresentation, reassuring fetal
status, and no contraindications to vaginal delivery
o Contraindications – any contraindication to vaginal delivery, rupture of membranes, uterine
malformations, recent vaginal bleeding
o Procedure: Give tocolytic agent to relax the uterus (250g terbutaline SC) and conduct analgesia
(Epidural). Coat the abdomen with UTZ gel then we do a forward roll. Each hands grasps one of
the fetal poles. The buttocks are elevated or pushed upwards from the maternal pelvis and
rotated in clockwise fashion towards the fundus, while the head is directed towards the pelvis. If
forward roll is unsuccessful, we can do a backward flip done on the opposite direction.
• Delivery complications:
Maternal Fetal
• CS – incision tear extensions • Risk for preterm delivery
• Vaginal – vaginal wall and cervical wall • Trauma to fetal head d/t head entrapment
lacerations; perineal tears, uterine atony – skull fractures
due to analgesia; infections • Brachial nerve palsy
• Umbilical cord prolapse
• Hip dysplasia

GESTATIONAL DIABETES MELLITUS

CASE: 35 years old G2P1(1000), 26 weeks AOG, consulted for prenatal check-up. 1st pregnancy was
delivered via NSD – term but died. With strong family hx of DM. BP 120/80mmHg, FH 30cm, IE: cephalic,
floating

• Diagnosis and basis

o G1P1 (1000), pregnancy uterine, 26 weeks AOG, t/c Gestational Diabetes Mellitus
o Bases: AOG not compatible with fundal height, strong family history of DM
• DDx (attributed to seemingly fundic height of 30cm – large for gestational age of 26 weeks)
o Polyhydramnios

ZAP 11
 o Multifetal pregnancy
o Tumors (e.g. myoma)
• Confirmatory test
One step approach Two step approach
(eto ung hinahanap na sagot ni doc) (memorize mo na din to just in case iask din)
Administer fasting 75g OGTT (fasting for 8-14hrs) Administer non-fasting 50g oral glucose challenge test
Diagnose GDM if 1 or more thresholds are met: Determine plasma sugar after an hour. If 130-140mg/dL
• FBS: >/= 92 mg/dL but less than 126 mg/dL → Do 100g OGTT after 8-14hrs fasting
• 1st hr: >180 mg/dL Diagnose GDM if 2 or more values on 100g OGTT
• 2nd hr: >/= 153 mg/dL but less than 200 mg/dL meet or exceed the thresholds:
• FBS >/= 95 mg/dL
• 1st hr: >180 mg/dL
• 2nd hr: >/= 155 mg/dL
• 3rd hr: >/= 140 mg/dL
• Maternal and Fetal effects
Maternal Fetal
Increased risk of prematurity Macrosomia
Hypertension Malpresentation
CS delivery Prematurity
Diabetic nephropathy, diabetic retinopathy, Shoulder dystocia
diabetic neuropathy, diabetic ketoacidosis Stillbirth or IUFD (IUFD is assoc. with FBS of more
Infections than 105 mg/dL)
Congenital heart disease
Miscarriage
• Antenatal Management (review niyo din ung intrapartum and postpartum management)
o Diet – diabetic diet (daily caloric intake of 30-35 kcal/kg)
o Diagnostics
▪ CBG monitoring
• Preprandial: < 95 mg/dL
• 1st hr postmeal: <140 mg/dL
• 2nd hr postmeal: <120 mg/dL
▪ Fetal surveillance tests
• Ultrasound – BPS, NST, CAS, fetal growth monitoring
• Fetal movement counting
o Mother should feel atleast 10movements within 2hrs daily/every night
o Drugs
▪ Insulin (starting dose 0.7-1.0 units/kg in divided doses)
▪ Metformin
o Disposition
▪ Weight management
▪ Lifestyle changes – avoid smoking and alcohol intake; moderate exercise
▪ Monitor comorbidities
• Postpartum evaluation
▪ Blood glucose monitoring using 75g OGTT at 6-12 weeks postpartum
• Recommended route of delivery
o Vaginal delivery if there are no maternal and fetal complications
o Elective CS at 39weeks if with CPD, macrosomia, malpresentation and fetal distress

ZAP 12
RUPTURED ECTOPIC PREGNANCY, HYPOVOLEMIC SHOCK
CASE: G3P1 (1021), RLQ pain, on and off vaginal discharge, history of ectopic and abortion, use of IUD, 3
sexual partners. PE: hypotensive, tachycardic, tachypneic, with direct and rebound tenderness, vaginal
discharge, pale-looking.

• Initial test to request = pregnancy test to rule out pregnancy

• Other diagnostic tests:
o CBC with platelet = check for anemia and leukocytosis which can be seen esp. if ruptured
o Liver panel = to check for liver function before starting methotrexate
o Serum progesterone of <5ng/ml (not reliable since values in some ectopic pregnancies may
vary from 10-25 ng/ml)
o TVS
▪ Gestational sac usually seen at 5 weeks, yolk sac with cardiac activity at 6weeks (signs
of IUP)
▪ Signs of ectopic pregnancy:
• Absence of gestational sac or pseudogestational sac
• Trilaminar endometrium <8mm thick
• Decidual cyst – anechoic area lying within the endometrial cavity
• Ring of fire – increased vascularity surrounding the anechoic sac
• Hypoechoic fluid in the rectouterine cul-de-sac due to hemoperitoneum from a
rupture (>50ml)
• Diagnosis and Bases
o G3P1 (1021), ___AOG(?), tubal pregnancy probably ruptured, hypovolemic shock
o Bases (8):
▪ Enumerate bases from the case
▪ Classical triad of ectopic pregnancy:
• Lower abdominal pain - wriggling tenderness
• Irregular menses
• Vaginal bleeding or spotting
• Risk factors (5):
o Hx of ectopic pregnancy
o Use of IUD
o Multiple sexual partners which increases risk for STIs and PID

Risk factors:
• Abnormal fallopian tube anatomy
• Prior STI
• Surgeries done for prior tubal pregnancy, sterilization, or fertility restoration
• Peritubal adhesions
• Contraceptive method failures – IUD, tubal sterilization
• Smoking

• Differential Diagnosis (2)

o Threatened abortion
o Pelvic inflammatory disease
o Appendicitis
o Tubo-ovarian abscess
o Ovarian torsion
• Pathophysiology

ZAP 13
 o Due to an anatomic problem of the fallopian tube, the blastocyst abnormally implants into
another location, mostly in the ampulla.
o It can also be due to impaired fallopian tube motility or problem in contraction and ciliary beating
that should have transported the embryo inside the uterus
• Other ancillary procedures
o Blood typing and cross matching – since there is hypovolemic shock we will be needing blood
transfusion
o Culdocentesis – to check for hemoperitoneum; fluid aspirated may contain old clots and bloody
fluid that does not clot (if it clots – may be blood from a blood vessel)
o TVS
o CBC, liver panel
• Management
o Since px is symptomatic and hemodynamically unstable:
▪ Exploratory lapatoromy
▪ Fluid resuscitation (D5LR)
▪ Blood transfusion
o After surgery, beta hcg should fall within 12 days → monitor weekly.
o Persistent or rising levels may be managed with single dose of Methotrexate 50 mg/m2 (BSA)
• Most common site of ectopic pregnancy = 70% in ampulla of fallopian tube (followed by the ishmus
then ovary)
• Differentiate the 2 conservative management (Salpingostomy vs Salpingotomy)
o Salpingostomy
▪ Gold standard in small (<2cm) unruptured ectopic pregnancy located
▪ A 10-15mm incision is done on the antimesenteric border immediately over the ectopic
pregnancy where products may be removed or flushed out via high pressure irrigation
▪ Incision is left unsutured to heal via 2ndary intention
▪ BHCG returns to normal after 20 days
o Salpingotomy
▪ Same with salpingostomy with same prognosis, but is closed with delayed absorbable
suture
o Salpingectomy – complete tubal excision until the uterotubal junction; for both ruptured or
unruptured most esp if there is extensive damage to the fallopian tube

ASSISTED VAGINAL DELIVERY **study both forceps and vaccum delivery

REVIEW:

• Most important function of AVD is TRACTION; other function is fetal heat rotation
• Types of forceps:

Simpson forceps Most common

Used to deliver fetus with molded head since it is fenestrated
English lock or sliding lock
Tucker-Mclane forceps Blade is solid and shank is narrow
Used to deliver rounded head in a multiparous mother
Kielland forceps Minimal pelvic curvature
Used for rotation of Occiput Posterior to OA
Barton forceps Rotation of the head in transverse arrest
Parang nakabend ung blades??
Piper forceps Similar to simpsons but the shank is longer to facilitate application to the aftercoming of the
head in BREECH presentation

ZAP 14
 • Maternal and fetal indications of AVD:

Fetal Indications Maternal Indications

Non reassuring FHR Prolonged second stage – most common
Premature placental separation Exhaustion – most common
Heart disease
Hypertensive condition
Pulmonary injury
Neurological (stress)
Low or outlet station

• Types of Forceps Delivery and their Criteria:

Outlet Forceps Delivery Low Forceps Delivery Midpelvic Forceps Delivery

Scalp is visible at introitus Leading point of fetal skull is at station Station is between 0 and + 2
Fetal skull has reached the pelvic floor +2 or more and not on the pelvic floor Station is above + 2 but head is
Sagittal is in the AP diameter engaged
Fetal head is at or on the perineum AND
Rotation does not exceed 45 degrees
Rotation is 45 degrees or less (left or
**pudendal block may be adequate right OA to OP, or left or righ OP to
OP) OR
Rotation is greater than 45 degrees

**regional anesthesia – epidural is

preferable

• Prerequisites for application (7)

- Experienced operator
- Engaged head
- Completely dilated cervix (2nd stage of labor)
- Fetal head position is known
- Ruptured membranes
- No cephalopelvic disproportion
- Vertex or cephalic presentation
- Fetus at least 34 weeks
- Emptied maternal bladder
- Informed consent is done
• Complications:
Maternal Fetal
Lacerations of vagina and cervix Cephalhematoma
Pelvic floor disorders – urinary incontinence, anal Subgaleal hematoma
incontinence (d/t higher degree of episiotomy) Facial nerve paralysis
Clavicular fractures
**marami pa to, check trans nalang. Aralin both complications ng forceps vs vacuum delivery
• Anesthesia used → Epidural
o Advantages:
▪ Provides superior pain relief during first and second stages of labor
▪ Facilitates patient cooperation during labor and delivery
▪ Provides anesthesia for episiotomy or forceps delivery
▪ Allows extension of anesthesia for cesarean delivery

ZAP 15
POSTPARTUM HEMORRHAGE (UTERINE ATONY, RETAINED PLACENTAL TISSUE?)
Review of PPH:
• Blood loss of more than 500 ml for NSD and
more than 1000 ml for CS
• Estimate of blood loss based on signs and
symptoms (see table and familiarize)

• More accurate way of estimating blood loss:

• Causes of PPH (for differential diagnosis) (4 T’s – tone, tissue, trauma, thrombin)
PPH CAUSES
EARLY/PRIMARY PPH Uterine atony**
(blood loss within 24hrs of delivery) Genital tract lacerations
Uterine rupture
Dissecting hematomas
Uterine inversion
Coagulation defects
LATE/SECONDARY PPH Retained placental fragments**
(blood loss after 24 hrs until 6-12 weeks postpartum) Placental polyp
Infection
Uterine subinvolution

CASE: Primipara >15 hours labor. Bleeding. BP: 100/60 mmHg. HR is slightly elevated. Uterus palpable 1 cm
above the navel. Soft tissue masses at the cervical os.

• Diagnosis and basis

o G1P0, postpartum hemorrhage secondary to Uterine atony
o Basis:
▪ Prolonged labor
▪ Vaginal bleeding in the 1st 24hrs of delivery
▪ Uterus palpated above the navel
▪ Soft boggy uterus
o Risk factors:
▪ High parity
▪ General anesthesia
▪ Overdistended uterus (Baby is large)
▪ Previous PPH
▪ Oxytocin induction/augmentation
▪ AF embolism
▪ Use of MgSO4 which relaxes the uterus
▪ Chorioamniotis which can fail uterine contractions
• Pathophysiology of bleeding in uterine atony – there are no effective uterine contractions hence, the
blood vessels are not impinged that would supposedly provide hemostasis.

ZAP 16
 • Differential diagnoses:
o Placenta accrete, increta, percreta (retained placental tissue)– due to underdeveloped
Nitabuchs layer allowing trophoblasts to invade the myometrium; most commonly caused by
prior CS section or placenta previa; basis: soft tissue masses at cervical os? (di ko sure to)
o Coagulation defect
o Uterine inversion – profuse bleeding, seen at introitus, no uterine fundus palpated
o Genital tract lacerations – bleeding, uterus is firm, may be due to big baby, assisted delivery,
primipara
o Puerperal hematoma – severe pain, bluish vulvar mass
• Give 2 laboratory tests to be requested
o CBC with hemoglobin and hematocrit – to check for anemia (hgb and hct needed for estimation
of blood loss)
o Blood typing and cross matching– for blood transfusion
o Coagulation studies – to check for coagulation defects (prolong aPTT or PT)
o Urinalysis – to check for infection
o BUN and creatinine – to check for renal function
o Electrolytes – to obtain baseline for comparison during and after fluid and blood resuscitation
• How to manage initially at the ER
o Give IV fluids (crystalloids; 2lines for uterotonics and IV administration)
o Insert foley catheter
o Request for labs
o Do uterine massage
o Give uterotonics
▪ Oxytocin 20 units/L IV infusion or 10 units IM
• Others: Methergine 0.2 mg IM (CI in HTN, heart dse and PVD)
o Carboprost 250 ug IM (CI in asthma)
o Carbetocin (oxytocin analogue) 100ug IV/IM
o Give tranexamic acid for hemostasis – should be given within 3 hrs of delivery
o Give O2 supplementation
o If patient do not respond to initial treatment → DO CONSERVATIVE MEASURES (Non-
surgical)
▪ Bimanual uterine compression – closed fist inserted to vagina and other hand is at the
abdomen to compress the fundus and prevent hemorrhage
▪ Balloon tamponade – insert foley catheter and inflate balloon (80ml fluid) to compress
uterine cavity
▪ Uterine packing – intrauterine gauze packing
o If bleeding still persists → SURGICAL
▪ Compression sutures (e.g b-lynch)
▪ Vaso-occlusive procedures – uterine artery ligation, hypogastric artery ligation
▪ Angiographic arterial embolization
o If bleeding still persists → HYSTERECTOMY
▪ If px is multiparous and does not want to preserve uterus anymore
Active management of Third Stage of Labor (to prevent PPH)
After delivery of the baby..

• Give 10units of oxytocin within 1 minute of childbirth.

• Deliver placenta by doing controlled cord traction to avoid uterine inversion
• Do fundal massage thru the abdomen after placental delivery to make it well-contracted and firm

ZAP 17
 • During recovery, palpate uterus in the abdomen every 15mins to make sure it is firm. Monitor vaginal
bleeding and check for perineum, BP and HR/PR
PRETERM PREMATURE RUPTURE OF THE MEMBRANES

• Complete diagnosis G2P0 (1001) Pregnancy Uterine, 35 weeks and 1 day, not in labor? Preterm
premature rupture of membranes for 1 hour, clear amniotic fluid; cephalic. Advanced maternal age
• Risk factors:
o Prior preterm birth or PPROM
o Advanced maternal age
o Lifestyle factors – smoking, inadequate weight gain during pregnancy
o Infection – e.g. bacterial vaginosis – which may weaken the fetal membranes due to increased
inflammatory markers such as the cytokines
o Cervical insufficiency
o Shortened cervix (<2.5cm)
• Diagnostics
o Hx of vaginal leakage of fluid
▪ Speculum: gross pooling of clear amniotic fluid from the cervical canal
o pH testing: alkaline (7.1-7.2)
o False positive result in semen, blood of infections, bacterial vaginosis
o Ultrasound – to assess amniotic fluid volume and cervical length
• Management before 34 weeks
o Close observation of maternal contractions, FHR monitor and cervical changes
o Amniocentesis if BOW not rupture
o Corticosteroids
▪ Betamethasone 12mg every 24 hrs for 2 days
▪ Dexamethasone 6mg every 12 hrs for 2 days
o Thyrotropin releasing hormone
▪ Fetal lung maturation
o Beta adrenergic agonist (terbutaline)
▪ Prevent preterm birth for 2 days to facilitate corticosteroids
o Antimicrobials, GBS prophylaxis (penicillin G 5 million units or ampicillin 2g IV every 4-6hrs
▪ Prevent chorioamnionitis and sepsis
• Management if intact bags of water
o Amniocentesis
▪ Aids in dilatation of the cervix
o Cerclage
▪ Short cervix <25 mm (NV: 25mm)
▪ Stitches at the os to prevent premature dilation
▪ For history of midtrimester pregnancy loss
▪ Cervical insufficiency; short cervix
o Progesterone
▪ Maintenance of uterine quiescence to prevent preterm birth → withdrawal → delivery
triggering event
• If Ruptured BOW
o >34 weeks – deliver with induction of labor using IV oxytocin to induce uterine contractions,
insertion of laminaria or balloon catheter to dilate cervix, GBS prophylaxis, single course
corticosteroids considered up to 36 weeks and 6 days;
o 32-33 expectant
o 24-31 → expectant

ZAP 18
 o <24 expectant or induction
• Follow up check up →patient still wants another baby
o Measure the cervical length
o Early prenatal assessment
o Avoid risk factors
ABORTION WITH RECURRENT PREGNANCY LOSS
CASE: 39 years old, G4P0 (0030) PU 12 weeks, complaint of vaginal spotting with hypogastric pain. History of
3 abortions. IE: cervix is closed.

• Diagnosis: G4P0 (0030) PU 12 weeks, Abortion, Recurrent Pregnancy loss, advanced maternal age
o Threatened → imminent → incomplete (progressive case)
• Memorize the table of different abortions
o Threatened
▪ Closed cervix
▪ Pain and light vaginal bleeding
o Inevitable
▪ Open cervix
▪ Gush of water and blood
o Incomplete
▪ Open cervix
▪ Some parts of the fetus is expulsed
▪ meaty material
o Complete
▪ Closed cervix
▪ Passage of a balloon like sac (gestational sac), whole fetus was expulsed
▪ Biglang empty upon US
o Septic
▪ Foul smelling vaginal discharge
▪ Fever
▪ infection
• Management of each type of abortions
o Threatened
▪ Close observation
▪ Acetaminophen analgesia
▪ Bed rest
▪ Evacuation if there is significant blood loss
o Inevitable
▪ Expectant management
▪ Antibiotics
▪ Corticosteroids
▪ MgSO4
o Incomplete
▪ Complete curettage
▪ Expectant
o Complete
o Missed abortion(blighted)
▪ Retained product
▪ Observation
▪ Misoprostol to hasten expulsion
ZAP 19
 o Septic abortion
▪ Penicillin G
▪ Pen G + Clindamycin
▪ Pen G + Clindamycin + Gentamicin
• Early pregnancy loss diagnosis
o CRL >/= 7mm with no heartbeat
o MSD >/= 25mm with no embryo
o After >/=11 days after US (GS with yolksac) there is no embryo with heartbeat
o After 2 weeks with GS but no yolksac there is no embryo with heartbeat
• Recurrent pregnancy loss
o 3 or more clinically failed pregnancy
o 2 ore more pregnancy loss via US
o Primary RPL → has never given birth to a live fetus
o Secondary RPL: has gave birth to a live fetus
• Diagnostic tests for recurrent pregnancy loss
o Rubella serology
o APAS, SLE
o Urinalysis
o Check for anatomic factors
▪ Uterine synchiae
▪ Leiomyoma
▪ Congenital genital tract anomalies : unicornuate and bicornuate

NSD + ANTEPARTUM SURVEILLANCE

• Diagnosis
G2P0 (1001), Pregnancy Uterine 38 weeks and 1 day by Ultrasound/LMP, Cephalic in Labor.
• Basis
• Category of the CTG tracing (Category 1 ung answer sa case)
o Category 1
o Category 2
o Category 3
• Differentiate early, late and variable
o Early deceleration
▪ Nadir at the same time with peak of contraction; mirror image; lasts for at least 30 secs
▪ Head compression
o Late deceleration
▪ Nadir after peak of contraction, lasts for at least 30 seconds
▪ Recovers to baseline
▪ Uterine insufficiency, maternal hypotension, excessive uterine activity
o Variable deceleration
▪ Abrupt deceleration
▪ Cord compression
o Prolonged deceleration
▪ >/=2 mins or less than 10 min interval per deceleration
• Variability
o Minimal (</= 5 beats per minute)
▪ Analgesics
▪ CNS depressant

ZAP 20
 ▪ MgSO4
o Moderate (6-25 beats per min)
o Marked (>/=25 minutes)
▪ Fetal breathing or movements
▪ Fetal breathing
o Sinusoidal
▪ Smooth pattern
▪ Fetal anemia (narcotics, barbiturates)
• Amniotomy
o Aids to cervical dilation by acting as a wedge
• Meconium
o Physiologic and pathologic cause
▪ Pathologic cause; fetal distress or hypoxia can cause the release of meconium, fetal
hypoxia, umbilical cord entrapment
▪ Physiologic; maturation of the fetal GIT
o Importance of meconium
• Purpose of episiotomy
o Facilitate the delivery of the head; done once there is crowing of the head
• Differentiate Median vs. Mediolateral Episiotomy (papafill-up sayo ung table na to. Memorize!)

• Degrees of laceration

ZAP 21
NORMAL LABOR AND DELIVERY
CASE: 5 cm dilated cervix, FHT heard at the right, triangular fontanelle directed at mother’s right anterior,
presenting part 1 cm above ischial spines
• What is the fetal lie, presentation, position, and station?
o Lie: Longitudinal
o Presentation: Cephalic
o Position: ROA
o Station: -1
• Side Q: What is the definition of fetal lie?
o Relationship between the long axis of the fetus to the maternal spine
• What are the expected findings in each Leopold’s maneuver?
o L1 – Large nodular mass (breech)
o L2 - fetal back on the right, fetal small parts on the left
o L3 - round ballotable mass, movable (not engaged)
o L4 - Cephalic prominence same side as the back, head is flexed
• How do you confirm rupture of membranes?
o (+) Fern test
o Pooling of amniotic fluid
o Palpation of fetal hair not fetal head
o Alkaline vaginal pH
• What is the purpose for doing episiotomy? When will you do it?
o Avoid spontaneous laceration reaching the rectal mucosa
o To widen the diameter of the introitus, to ease delivery of the fetal head
o Do it when there is crowning and the perineum is bulging
• Differentiate Midline vs Mediolateral episiotomy (papafill-up sayo ung table na to. Memorize!)

After 5 hours, Direct Occiput Anterior, station +4, fully dilated cervix
o What is your management for the case?
o Await spontaneous vaginal delivery
o What stage of labor is the patient in?
o 2nd stage, since the cervix is fully dilated
o Side Q: What are the stages of labor?
o Stage 1 of labor → start of cervical dilation and effacement
o Stage 2 of labor – 10 cm dilation (fully dilated and effaced cervix) to delivery of the fetus
o Stage 3 of labor – delivery of the placenta
o Stage 4 of labor → 1 hour following NSD

ZAP 22
SEVERE PRE-ECLAMPSIA + CTG AND NST INTERPRETATION
CASE: 37 y/o G3P1 1101, PU 33 weeks AOG came in for first prenatal checkup, with throbbing headache,
Vital Signs: BP = 160/100 HR=91, RR-normal, BMI=26, FH=29 cm, FHT=145. She was given MgSO4.
1. Complete diagnosis = G3P1 (1102), pregnancy uterine, 33 weeks AOG, not in labor, to consider severe
pre-eclampsia, advanced maternal age, overweight.
** to consider kasi wala pa result ng urine protein
**may papakitang CTG tracing to interpret
2. Interpret NST = Reactive
3. Interpret CTG, identify variation (check fetal heart rate variability) = Minimal variability
• Minimal: <5 bpm variation
• Absent – undetectable
• Moderate: 6-25 bpm (normal)
• Marked - >25 bpm
4. Maternal and Fetal Cause of CTG interpretation
• MgSO4
• Sleeping fetus
5. Interpret CTG - Prolonged deceleration
• Isolated deceleration lasting at least 2 minutes but less than 10 minutes
6. Causes of prolonged deceleration
• Uterine hyperactivity
• Umbilical cord compression
• Abruption placenta
• Uterine rupture
• Maternal supine hypotension
• Epidural or spinal anesthesia
7. Idedeliver mo na ba? Why or why not? When mo idedeliver if hindi muna?
• Not sure pero Category 2 ata ung CTG niya since may prolonged decels?
• 33 weeks palang siya → see management of severe preeclampsia remote from term below
• Correlate niyo nalang diyan answer niyo
CATEGORIES OF CTG AND THEIR MANAGEMENT
CRITERIA MANAGEMENT
CATEGORY 1 Baseline rate: normal (110-160) - No specific action required
Baseline variability: moderate (6-25bpm) - Observe and await vaginal delivery or
Accelerations: + or – do assisted delivery if head is already
Late or variable decelerations: absent low (e.g. station +4)
Early decelerations: + or -
CATEGORY 2 Indeterminate/unrecognizable Continue surveillance and reevaluation
Prolonged decelerations Do resuscitative measures and ancillary tests
to ensure fetal wellbeing:
- Improve fetal oxygenation and
uteroplacental blood flow (lateral
decubitus position, reduction of uterine
contractions)
- Diminish uterine activity (discontinue
oxytocin, administer tocolytics)
- Relieve cord compression (reposition
mother, amnioinfusion)
CATEGORY 3 ABSENT VARIABILITY with any of the • Discontinue labor stimulation
following: • Treatment of maternal hypotension
• Recurrent late decels • Change in maternal position so that
• Recurrent variable decels uterus is not compressing the IVC and

ZAP 23
 • Bradycardia (sinusoidal pattern) improve venous return
Associated with fetal acidosis • Treatment of tachysystole
• If despite resuscitation, tracing did not
improve = DELIVER BY CS

SEVERE PREECLAMPSIA MANAGEMENT

>34 weeks Remote from Term <34 weeks
(Management in the case)
Give magnesium sulfate for seizure prophylaxis Observe for 24-48, give MGSO4 for 24hrs and antihypertensives,
• LD 4-6 g TSIV or 5 g IM in buttocks monitor FHT and symptoms and order labs. During the observation
• MD 1-2 g/hr every 4 hours for 24 hours period, assess for the appearance of ENDPAINS (Absolute
• MOA: calcium antagonist (inhibits entry of Ca in contraindications to Expectant Mngt):
NMJ decreasing impulse transmission and • Eclampsia
seizure occurrence) • Non reassuring fetal status
• Avoid intoxication by ensuring adequate UO, • DIC
presence of patellar or biceps reflex and RR of • Pulmonary edema
>12cpm (no resp. depression) • Abruptio placenta
• Antidote: Calcium gluconate • Intrauterine growth restriction
Give antihypertensives (if BP is >160/110 mmHg) to • Uncontrolled Severe hypertension
prevent intracerebral hemorrhage
• For acute control – DOC (1st line): Hydralazine 5 If any of those are present = give MGSO4 and DELIVER
mg IV initially then 5mg every 30mins; 2nd line: • Induction of labor (assisted/forceps delivery)
Nicardipine • CS (if with obstetrical indications – malpresentation, CPD
• Maintenance (once BP is controlled) – DOC:
Methyldopa 3g/day If those are NOT present, assess for Relative Contraindations to
• GOAL BP: systolic 140-155/ diastolic 90-100 Expectant Mngt:
mmHg • HELLP syndrome or Partial HELLP (hemolysis, elevated
DELIVERY AFTER MATERNAL STABILIZATION: liver enzymes and low platelet counts)
• Induction of labor (assisted/forceps delivery) • IUGR
• CS (if with obstetrical indications) • Severe oligohydramnios
• PPROM
• Renal insufficiency
• Persistent symptoms

If any of those are present = Give STEROIDS and DELIVER AFTER

48 HRS
• Betamethasone 12mg IM every 24 hrs for 2 doses
• Dexamethasone 6mg IM every 12 hrs for 4 doses

If NOT present = DELIVER AT 34 WEEKS while still monitoring the

maternal-fetal condition

Use at your own risk. These are compiled from samplexes

of 2021 to February 2022. Feedback from March 2022
revalida: SAMPLEX!! <3 Typewritten cases here are
incomplete and based on what the previous rotators
remembered. Some are also my own answers so please
do not rely solely on this. Countercheck, add your own
answers and rationalize.

Goodluck!!

ZAP 24