A 24-year-old primigravida presents at 36 weeks gestation with vaginal bleeding, mild abdominal pain, and uterine contractions that appeared after bumping into a handrail. The vital signs are as follows: blood pressure 130/80 mm Hg, heart rate 79/min, respiratory rate 12/min, and temperature 36.5℃ (97.7℉). The fetal heart rate was 145/min. Uterine fundus is at the level of the xiphoid process. Slight uterine tenderness and contractions are noted on palpation. The perineum is bloody. The gynecologic examination shows no vaginal or cervical lesions. The cervix is long and closed. Streaks of bright red blood are passing through the cervix. A transabdominal ultrasound shows the placenta to be attached to the lateral uterine wall with a marginal retroplacental hematoma (an approximate volume of 150 ml). The maternal hematocrit is 36%. What is the next best step in the management of this patient?

Admit for maternal and fetal monitoring and observation

Manage as an outpatient with modified rest

Corticosteroid administration and schedule a cesarean section after

A 30-year-old woman, gravida 2, para 1, at 42 weeks' gestation is admitted to the hospital in active labor. Pregnancy has been complicated by gestational diabetes, for which she has been receiving insulin injections. Her first child was delivered by lower segment transverse cesarean section because of a nonreassuring fetal heart rate. Her pulse is 90/min, respirations are 18/min, and blood pressure is 135/80 mm Hg. The fetal heart rate tracing shows a baseline heart rate of 145/min and moderate variation with frequent accelerations and occasional early decelerations. She undergoes an elective repeat lower segment transverse cesarean section with complete removal of the placenta. Shortly after the operation, she starts having heavy uterine bleeding with passage of clots. Examination shows a soft uterus on palpation. Her bleeding continues despite fundal massage and the use of packing, oxytocin, misoprostol, and carboprost. Her pulse rate is now 120/min, respirations are 20/min, and blood pressure is 90/70 mm Hg. Her hemoglobin is 8 g/dL, hematocrit is 24%, platelet count is 120,000 mm3, prothrombin time is 11 seconds, and partial thromboplastin time is 30 seconds. Mass transfusion protocol is activated and a B-Lynch uterine compression suture is placed to control her bleeding. Which of the following is the mostly likely cause of her postpartum complication?

Lack of uterine muscle contraction

Adherent placenta to myometrium

Infection of the endometrial lining of the uterus

Thirty minutes after vaginal delivery of a 2780-g (6-lb 2-oz) newborn at term, a 25-year-old woman, gravida 1, para 1, has heavy vaginal bleeding. Her pregnancy was complicated by pre-eclampsia. Her pulse is 111/min and blood pressure is 95/65 mm Hg. Physical examination shows a fundal height 2 inches below the xiphoid process of the sternum. A drug with which of the following mechanisms of action is most appropriate for this patient?

Depolarization of the motor end plate

Increased synthesis of cyclic AMP

Inhibition of norepinephrine reuptake

Binding to prostaglandin I2 receptors

A 57-year-old man is brought to the emergency department by his family because of several episodes of vomiting of blood in the past 24 hours. He has a history of alcoholic cirrhosis and is being treated for ascites with diuretics and for encephalopathy with lactulose. His vital signs include a temperature of 36.9°C (98.4°F), pulse of 85/min, and blood pressure of 80/52 mm Hg. On examination, he is confused and unable to give a complete history. He is noted to have jaundice, splenomegaly, and multiple spider angiomas over his chest. Which of the following is the best initial management of this patient?

Combined vasoactive and endoscopic therapy

Transjugular intrahepatic portosystemic shunt (TIPS)

A 29-year-old G1P0 presents to her obstetrician for her first prenatal care visit at 12 weeks gestation by last menstrual period. She states that her breasts are very tender and swollen, and her exercise endurance has declined. She otherwise feels well. She is concerned about preterm birth, as she heard that certain cervical procedures increase the risk. The patient has a gynecologic history of loop electrosurgical excision procedure (LEEP) for cervical dysplasia several years ago and has had negative Pap smears since then. She also has mild intermittent asthma that is well controlled with occasional use of her albuterol inhaler. At this visit, this patient’s temperature is 98.6°F (37.0°C), pulse is 69/min, blood pressure is 119/61 mmHg, and respirations are 13/min. Cardiopulmonary exam is unremarkable, and the uterine fundus is just palpable at the pelvic brim. Pelvic exam reveals normal female external genitalia, a closed and slightly soft cervix, a 12-week-size uterus, and no adnexal masses. Which of the following is the best method for evaluating for possible cervical incompetence in this patient?

Transvaginal ultrasound at 18 weeks gestation

Transabdominal ultrasound in the first trimester

Transvaginal ultrasound in the first trimester

Serial transvaginal ultrasounds starting at 16 weeks gestation

Transabdominal ultrasound at 18 weeks gestation

A 27-year-old woman, gravida 2, para 1, at 36 weeks' gestation comes to the physician for a prenatal visit. She feels well. Fetal movements are adequate. This is her 7th prenatal visit. She had an ultrasound scan performed 1 month ago that showed a live intrauterine pregnancy consistent with a 32-week gestation with no anomalies. She had a Pap smear performed 1 year ago, which was normal. Vital signs are within normal limits. Pelvic examination shows a uterus consistent in size with a 36-week gestation. Her blood group and type is A negative. Which of the following is the most appropriate next step in management?

Transabdominal doppler ultrasonography

29-year-old G2P2002 presents with foul-smelling lochia and fever. She is post-partum day three status-post cesarean section due to eclampsia. Her temperature is 101 F, and heart rate is 103. She denies chills. On physical exam, lower abdominal and uterine tenderness is present. Leukocytosis with left shift is seen in labs. Which of the following is the next best step in management?

Intravenous clindamycin and gentamicin treatment

Prophylactic intravenous cefazolin treatment

Intramuscular cefotetan treatment

Balloon tamponade techniques for USMLE Step 2 CK: High-Yield OB/GYN Lessons

Indications & Mechanism - The Pressure Play

Primary Indication: Atonic postpartum hemorrhage (PPH) refractory to uterotonic medications.
- Used when bleeding persists despite oxytocin, methylergonovine, and carboprost.
Mechanism of Action: Direct physical tamponade.
- An inflated balloon applies pressure to the uterine wall, exceeding arterial pressure.
- This collapses the open spiral arterioles at the placental site, achieving hemostasis.

Bakri balloon tamponade: placement and inflation

⭐ Balloon tamponade is a temporizing "bridge" therapy, not definitive. It buys time for patient stabilization and transfer for higher-level care (e.g., uterine artery embolization) if needed.

Device Types - The Balloon Brigade

Purpose-Built (FDA-Approved):
- Bakri Balloon: Pear-shaped silicone balloon conforming to the uterine cavity. Inflate with 300-500 mL of sterile saline.
- BT-Cath: A balloon catheter system designed for ease of use in PPH.
Off-Label Options:
- Foley Catheter: Widely available; inflate with 60-80 mL.
- Sengstaken-Blakemore Tube: Borrowed from GI hemorrhage management.
- Rusch Catheter: A straight, firm urologic catheter.

⭐ Key Feature: The Bakri balloon has a central drainage lumen to monitor ongoing blood loss from above the balloon, allowing for real-time assessment of tamponade effectiveness.

Procedure & Placement - The Inflation Drill

Bakri Balloon: Parts, Implements, and Advantages

Preparation: Position patient (dorsal lithotomy), ensure adequate anesthesia.
Placement: Manually or with forceps, guide the balloon into the uterine cavity, ensuring it's above the internal os. Confirm placement with transvaginal ultrasound.
Inflation: Instill sterile saline until the balloon is full (300-500 mL for Bakri) or bleeding stops. The uterus should feel firm abdominally.
Traction: Apply gentle downward traction and secure the catheter to the patient's thigh, creating a tamponade effect against the lower uterine segment.

⭐ The "tamponade test": After inflation, observe for 15-20 minutes. If bleeding is not significantly reduced, the balloon is likely ineffective or misplaced, and you must escalate care.

Management & Complications - The Aftermath

Post-Placement Care:
- Monitor vitals and bleeding closely; ensure continued uterotonic therapy.
- The balloon acts as a tamponade, not a definitive cure.
Removal Protocol:
- Maintain inflation for 12-24 hours.
- Deflate balloon gradually, observing for renewed bleeding for ~30 min before removal.
Potential Complications:
- Uterine rupture or perforation.
- Endometritis or chorioamnionitis.
- Device migration or spontaneous expulsion.
- Pain, cramping, or bladder tenesmus.

⭐ Prophylactic broad-spectrum antibiotics are crucial while the balloon is in situ to prevent endometritis.

High-Yield Points - ⚡ Biggest Takeaways

Indicated for postpartum hemorrhage (PPH) refractory to uterotonic agents, most commonly due to uterine atony.

Functions by exerting direct intracavitary pressure on the uterine wall to mechanically control bleeding.

Common devices include the Bakri balloon, but a Foley catheter can be an alternative.

Placement is confirmed with ultrasound to ensure it is within the uterus and not the lower uterine segment.

Inflate with sterile saline until bleeding stops, typically 300-500 mL.

Leave in place for 12-24 hours with concurrent antibiotic prophylaxis.

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