42yo G2P1001, who is 12-weeks gravid, presents to your office with concerns of public pain and a single episode of vaginal bleeding this morning. Physical examination reveals a gravid uterus with fundal height measured at the level of the umbilicus. Serum beta-hCG was found to be 745,223 mIU/mL. Ultrasound is below.
What are the important features of this case?
What is the condition that is present?
What is the next step in management?
Answer
The important features of this case are advanced maternal age (>35y), fundal height commensurate with a 20-week gestation, and a profoundly elevated beta hCG
2. The ultrasound video shows the classic “snow storm appearance” or “bunches of grapes” which is pathognomonic for hydatidiform mole, a type of gestational trophoblastic disease (GTD)
3. Initial management for GTD is methotrexate due to effectiveness, patient tolerance, and cost.
Definition – forced hyperflexion of the hips with applied suprapubic pressure during vaginal delivery
Clinical Significance – this is the primary maneuver to attempt to help relieve a shoulder dystocia during vaginal deliveries. Due to the hypermobilty of sacroilliac joint during pregnancy, this allows for rotation of the pelvis and facilitates releasing the stuck shoulder. It has been shown to have a success of close to 90%.
History – Named after William McRoberts, Jr. (1914-2006), an American obstetrician who recieved his medical doctorate from the University of Pittsburgh in 1940. He would go on to have a modest career in obstetrics culminating in Professor and Chief of Obstetrics at the University of Texas Medical School and Hermann Memorial Hospital in Dallas, TX. It was here where he his reputation as a teacher flourished and where he taught his eponymous maneuver for shoulder dystocia for over 40 years. As a testament to his teaching and a gift on retirement in 1982, two of his residents published an article naming this maneuver after their teacher and mentor.
References
Firkin BG and Whitwirth JA. Dictionary of Medical Eponyms. 2nd ed. New York, NY; Parthenon Publishing Group. 1996.
Bartolucci S, Forbis P. Stedman’s Medical Eponyms. 2nd ed. Baltimore, MD; LWW. 2005.
Yee AJ, Pfiffner P. (2012). Medical Eponyms (Version 1.4.2) [Mobile Application Software]. Retrieved http://itunes.apple.com.
42yo G2P1001, who is 12-weeks gravid, presents to your office with concerns of public pain and a single episode of vaginal bleeding this morning. Physical examination reveals a gravid uterus with fundal height measured at the level of the umbilicus. Serum beta-hCG was found to be 745,223 mIU/mL. Ultrasound is below.
Other Known Aliases – cephalic replacement, Gunn-Zavenelli-O’Leary Manuever
Definition – replacement of the fetal head back into the uterus followed by immediate cesarean delivery
Clinical Significance – this is a controversial, last resort maneuver to a shoulder dystocia and involves rotating the head back to an occiput anterior position, flexing the head , and pushing it as far cephalad as possible. The other hand can be used depress the perineum to relieve pressure on the umbilical cord. Although rarely used, single case reports do show a high rate of success.
History – Named after William Zavanelli (1926- ), an American obstetrician from California who received his medical doctorate from College of Osteopathic Physicians and Surgeons in Los Angeles in 1957. He would go on to have a modest career until 1978 when he performed his eponymous maneuver followed by a successful cesarean delivery. His partner wanted to publish the results immediately, but Zavanelli wanted to wait to see if there were any developmental issues with the child. After seven years, the case report was published. Of note, this manuever was performed 2 years prior by Gunn and his case report was published later in 1985 refuting the eponymous naming.
References
Firkin BG and Whitwirth JA. Dictionary of Medical Eponyms. 2nd ed. New York, NY; Parthenon Publishing Group. 1996.
Bartolucci S, Forbis P. Stedman’s Medical Eponyms. 2nd ed. Baltimore, MD; LWW. 2005.
Yee AJ, Pfiffner P. (2012). Medical Eponyms (Version 1.4.2) [Mobile Application Software]. Retrieved http://itunes.apple.com.
Sandberg EC. The Zavanelli maneuver: a potentially revolutionary method for the resolution of shoulder dystocia. Am J Obstet Gynecol. 1985;152(4):479-84 [link]
O’Leary J, Gunn D. Cephalic replacement for shoulder dystocia. Am J Obstet Gynecol. 1985; 153(5):592-3. [pubmed]
Definition – specialized conducting fibers composed of electrically excitable cells located just beneath the subendocardium in the inner ventricular walls of the heart
Clinical Significance – these cells actually conduct cardiac action potentials faster and more effeciently than any other cells in the heart and are responsible for the synchronized contractions of the ventricles during depolarization. They also have intrinsic pacemaking ability at 20-40 bpm to act as a back-up pacing system.
History – Named after Jan Evangelista Purkinje (1787-1869), a Czech anatomist and experimental physiologist who received his medical doctorate from Charles University in Prague in 1818. He would be appointed Professor of Physiology in Breslau in 1823 and did revolutionary work on vision. He would later create the world’s first Department of Physiology at the University of Breslau in Prussia in 1839 and the world’s second official physiology lab in 1842. During his career of physiologic discovery and research, he discovered large neurons with branching dendrites in the cerebellum (Purkinje cells), describe the change in brightness of red and blue colors as light intensity decreases (Purkinje shift), and the eye’s reduced sensitivity to dim red light compared to dim blue light (Purkinje effect). He also was the first scientist to present work on the cellular theory of biology, the first to use the term “protoplasm” to describe the fluid in cells, and the first to report on the individuality of fingerprints. But it was in 1839 when he described his eponymous fibers of the heart. He was one of the best known scientists of his era and was so famous, people would address letters to him and simply put “Purkinje, Europe”.
References
Firkin BG and Whitwirth JA. Dictionary of Medical Eponyms. 2nd ed. New York, NY; Parthenon Publishing Group. 1996.
Bartolucci S, Forbis P. Stedman’s Medical Eponyms. 2nd ed. Baltimore, MD; LWW. 2005.
Yee AJ, Pfiffner P. (2012). Medical Eponyms (Version 1.4.2) [Mobile Application Software]. Retrieved http://itunes.apple.com.
Cavero I, Guillon JM, Holzgrefe HH. Reminiscing about Jan Evangelista Purkinje: a pioneer of modern experimental physiology. Adv Physiol Educ. 2017; 41(4):528-538. [pubmed]
74yo woman, with a history of CAD and hyperlipidemia, presents to your office with a 6-month history of leg pain and swelling. She states that it seems to be worse when she is on her feet and improves when she can put her legs up. She denies worsening pain with activity or walking, but has recently developed a “rash” on her legs that is worrying her (see below). Physical examination reveals warmth to the feet and legs with scattered, thin hair. You appreciate 1+ DP and PT pulses bilaterally.
What are some bedside maneuvers or tests you can perform to differentiate between arterial and venous insufficiency?
Definition – collection of electrical conduction cells of the heart that transmit impulses from the AV node to the ventricles
Clinical Significance – this bundle of cells is responsible for communication contraction impulses from the atria to the ventricles. Any damage to this area can result in varying degrees of heart block and conduction abnormalities
History – Named after Wilhelm His Jr. (1863-1934), a Swiss-born cardiologist and anatomist who received his medical doctorate from the University of Leipzig in 1889. The son of the equally famous Basel anatomist Wilhelm His Sr., he would become professor extraordinaire at his alma mater 6 year after graduating. He also went on to be physician-in-chief at the Friedrichstadt Hospital in Dresden, chair of internal medicine in Berlin, and advisory internist for several armies during World War I. He would describe his eponymous bundle as an assistant professor in 1893.
References
Firkin BG and Whitwirth JA. Dictionary of Medical Eponyms. 2nd ed. New York, NY; Parthenon Publishing Group. 1996.
Bartolucci S, Forbis P. Stedman’s Medical Eponyms. 2nd ed. Baltimore, MD; LWW. 2005.
Yee AJ, Pfiffner P. (2012). Medical Eponyms (Version 1.4.2) [Mobile Application Software]. Retrieved http://itunes.apple.com.
His Jr, W. Die Tätigkeit des embryonalen Herzens und deren Bedeutung für die Lehre von der Hezbewegung beim Menschen. Arbeiten aus der medidizinischen Klinik zu Leipzig, 1893: 23.
Review of the Electrical Conduction System of the Heart
Cardiac cells specialized to initiate and distribute electrical impulses in an orderly and sequential manner
Sinoatrial Node
Located in superior region of the crista terminalis
SVC feeds into the right atrium
Pacemaker of the heart and initiates the heartbeat
Starts in the node, spreads down the walls of the atria, until it reaches the AV node, stimulating contraction of the myocardium
Arterial Supply – SA nodal artery via the RCA
Atrioventricular Node
Located in interatrial septum above the coronary sinus near the attachment of the septal cusp of the tricuspid valve (Triangle of Koch)
Passes SA node impulse to the AV bundle (Bundle of His)
Arterial Supply – AV nodal artery via the RCA (80-90%) or LCx (10-20%)
AV Bundle (Bundle of His)
Arises from the AV node and descends along the membranous portion of the interventricular septum, where it divides at the upper border of the muscular portion of the interventricular septum into the left and right bundles suppling their respective ventricles
Transmits AV nodal impulses through the interventricular septum to the left and right bundle branches, which gives rise to the Purkinje fibers that ultimately distribute the ventricular myocardium
Bundle Branch Blocks Pearls
R-wave = depolarization going TOWARDS the lead
S-wave = depolarization going AWAY from the lead
RBBB = delay in conduction is oriented to the RIGHT and ANTERIOR
QRS = Positive V1 and negative V6
LBBB = delay in conduction is oriented to the LEFT and either ANTERIOR or POSTERIOR
QRS = Negative V1 and positive V6
Wide QRS complex > 120 ms
Delay in conduction due to the block
Secondary Repolarization (ST-T) Abnormalities
T-wave discordance with last deflection of QRS
Causes
RBBB
More common in patients without structural heart disease
Congenital
ASD
Cardiac
Valvulopathies, ischemic heart disease
Pulmonary
Pulmonary HTN, PTE
LBBB
4 main underlying conditions
Coronary disease
Hypertensive heart disease
Aortic valve disease
Cardiomyopathies
RBBB EKG Diagnostic Criteria
QRS > 120 ms
If all other criteria met but QRS < 120 ms, it is termed incomplete RBBB
rSR’ pattern in V1 and V2
Slurred S-wave in lateral leads (I, aVL, V5, V6)
ST depression and T-wave inversion in V1-V3
LBBB EKG Diagnostic Criteria
QRS > 120 ms
Dominant S-wave in V1-V3
Moving away from the leads
Broad, monophasic (M-shaped or notched) R-wave in lateral leads (I, aVL, V5, V6)
Moving towards the leads
Appropriate discordance
ST-segment and T-wave are in OPPOSITE direction to the main vector of the QRS complex
Left axis deviation
Poor R-wave progression
SPECIAL CONSIDERATIONS
Fascicular Blocks
Anterior
Pathology
When blocked, the conduction to the high lateral portion of the ventricle is delayed
Spreads to the intact posterior fascicle and RBB
Causes left axis deviation
Criteria for left anterior fascicular block
QRS normal to slightly prolonged
Left axis deviation WITHOUT other reasons
Small R-wave and large S-wave in inferior leads (II, III, aVF)
Small Q-wave with large R-wave in lateral leads (I, aVL)
Posterior
Pathology
When blocked, the conduction to the inferior portion of the ventricle is delayed
Spreads to the intact anterior fascicle and RBB
Causes right axis deviation
Criteria for left posterior fascicular block
QRS normal to slightly prolonged
Right axis deviation WITHOUT other reasons
Small R-wave and large S-wave in lateral leads (I, aVL)
Small Q-wave and large R-wave in inferior leads (II, III, aVF)
Sgarbossa’s Criteria
Used in the presence of LBBB or paced rhythm to uncover potential ischemia
Original (1996)
Concordant ST elevation > 1mm in leads with a positive QRS complex (5 points)
Concordant ST depression > 1mm in V1-V3 (3 points)
Excessively discordant ST elevation > 5mm in leads with a negative QRS complex (2 points)
Score ≥ 3 has a specificity of 90% for detecting concomitant ischemia
Smith-Modified Sgarbossa Criteria (2012)
≥ 1 lead with ≥ 1mm of concordant ST elevation
≥ 1 lead of V1-V3 with ≥ 1mm of concordant ST depression
≥ 1 lead ANYWHERE with ≥ 1mm ST elevation AND proportionally excessive discordant ST elevation
Defined as ≥ 25% of the depth of the preceding S-wave
1893 Cottage Physician
References
Heart. In: Morton DA, Foreman K, Albertine KH. eds. The Big Picture: Gross Anatomy, 2e. McGraw-Hill; Accessed January 17, 2021.
Jaffar A. Anatomical Structure of the Heart. In: Elmoselhi A. eds. Cardiology: An Integrated Approach. McGraw-Hill; Accessed January 17, 2021.
Goldberger AL. Electrocardiography. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison’s Principles of Internal Medicine, 20e. McGraw-Hill; Accessed January 17, 2021.
Sgarbossa EB, Pinski SL, Barbagelata A, et al. Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) Investigators. N Engl J Med. 1996; 334(8):481-7. [pubmed]
Smith SW, Dodd KW, Henry TD, Dvorak DM, Pearce LA. Diagnosis of ST-elevation myocardial infarction in the presence of left bundle branch block with the ST-elevation to S-wave ratio in a modified Sgarbossa rule. Ann Emerg Med. 2012; 60(6):766-76. [pubmed]
Meyers HP, Limkakeng AT Jr, Jaffa EJ, et al. Validation of the modified Sgarbossa criteria for acute coronary occlusion in the setting of left bundle branch block: A retrospective case-control study. Am Heart J. 2015; 170(6):1255-64. [pubmed]
62yo man, with a history of COPD and 52-pack-year history of smoking, presents to your office to establish care. His shortness of breath has been manageable using tiotropium daily with albuterol 2-3x per month for exacerbation. He denies angina, chest pain, or unreasonable dyspnea with exertion. An EKG was performed and is below.
What does it show?
What are the diagnostic criteria present?
Answer
The EKG reveals a right bundle branch block most likely due to his underlying COPD and pulmonary hypertension.
Diagnostic criteria for RBBB are:
Wide QRS > 120 ms
RSR’ pattern in V1-2 (“rabbit ears”) with R’ > R
Wide, slurred S wave in I, aVL, or V5-6
Other common findings, though not always associated, is ST depression and T wave inversion in the right precordial leads (V1-3)
Clinical Significance – although not seen in every patient with cardiac tamponade, it is a common question on boards and certification examinations. These include: 1) hypotension, 2) JVD, and 3) muffled/distant heart sounds.
History – Named after Claude Schaeffer Beck (1894-1971), an American cardiac surgeon who recieved his medical doctorate from Harvard University in 1921. He would attend surgical residency at Case Western University, where he would spend his entire career. He developed a novel re-circulation technique for cardiac ischemia called the Beck Procedure, where pectoral muscle was implanted in the pericardium, and later placing a vein graft between the aorta to the coronary sinus. He also pioneered the first successful use of a defibrillator in 1947 to restore ROSC in a 14yo patient he was operating on for a congenital heart defect. His eponymous triad was first described in 1935 in an article entitled “Two cardiac compression triads” in the Journal of the American Medical Association.
References
Firkin BG and Whitwirth JA. Dictionary of Medical Eponyms. 2nd ed. New York, NY; Parthenon Publishing Group. 1996.
Bartolucci S, Forbis P. Stedman’s Medical Eponyms. 2nd ed. Baltimore, MD; LWW. 2005.
Yee AJ, Pfiffner P. (2012). Medical Eponyms (Version 1.4.2) [Mobile Application Software]. Retrieved http://itunes.apple.com.
Beck CS. Two Cardiac Compression Triads. JAMA. 1935;104(9):714-716. [link]
Theruvath P, Ikonomidis JS. Historical perspectives of The American Association for Thoracic Surgery: Claude S. Beck (1894-1971). JTCVS. 2015;149(3):655-660. [link]
