A 26-year-old primigravid woman at 39 weeks' gestation is admitted to the hospital in active labor. Pregnancy was complicated by mild oligohydramnios detected a week ago, which was managed with hydration. Her pulse is 92/min, respirations are 18/min, and blood pressure is 134/76 mm Hg. Pelvic examination shows 100% cervical effacement and 10 cm cervical dilation; the vertex is at 0 station. Cardiotocography is shown. Which of the following is the most appropriate next step in management?

Maternal repositioning and oxygen administration

A clinical diagnosis of abruptio placentae is suspected. Which of the following is the most appropriate next step in the management of this patient?

Administration of intravenous fluids

Administration of intravenous oxytocin

Administration of intramuscular betamethasone

Administration of intravenous tranexamic acid

A 36-year-old woman, gravida 3, para 2, at 37 weeks' gestation comes to the emergency department because of sparse vaginal bleeding for 3 hours. She also noticed the bleeding 3 days ago. She has had no prenatal care. Both of her previous children were delivered by lower segment transverse cesarean section. Her temperature is 37.1°C (98.8°F), pulse is 90/min, respirations are 16/min, and blood pressure is 110/80 mm Hg. The abdomen is nontender, and no contractions are felt. Examination shows that the fetus is in a vertex presentation. The fetal heart rate is 160/min and shows no abnormalities. Which of the following is the most appropriate next step in management?

Perform transvaginal sonography

Conduct contraction stress test

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 29-year-old G1P0 female at 32 weeks gestation presents to the emergency department with vaginal bleeding. She has had minimal prenatal care to-date with only an initial visit with an obstetrician after a positive home pregnancy test. She describes minimal spotting that she noticed earlier today that has progressed to larger amounts of blood; she estimates 30 mL of blood loss. She denies any cramping, pain, or contractions, and she reports feeling continued movements of the baby. Ultrasound and fetal heart rate monitoring confirm the presence of a healthy fetus without any evidence of current or impending complications. The consulted obstetrician orders blood testing for Rh-status of both the mother as well as the father, who brought the patient to the hospital. Which of the following represents the best management strategy for this situation?

If mother is Rh-negative and father is Rh-positive then administer RhoGAM

After 28 weeks gestation, administration of RhoGAM will have no benefit

If mother is Rh-positive and father is Rh-negative then administer RhoGAM

If mother is Rh-negative and father is Rh-negative then administer RhoGAM

If mother is Rh-negative and father is Rh-positive, RhoGAM administration is not needed

A student health coordinator plans on leading a campus-wide HIV screening program that will be free for the entire undergraduate student body. The goal is to capture as many correct HIV diagnoses as possible with the fewest false positives. The coordinator consults with the hospital to see which tests are available to use for this program. Test A has a sensitivity of 0.92 and a specificity of 0.99. Test B has a sensitivity of 0.95 and a specificity of 0.96. Test C has a sensitivity of 0.98 and a specificity of 0.93. Which of the following testing schemes should the coordinator pursue?

Test C on the entire student body followed by Test A on those who are positive

Test A on the entire student body followed by Test B on those who are positive

Test A on the entire student body followed by Test C on those who are positive

Test C on the entire student body followed by Test B on those who are positive

Test B on the entire student body followed by Test A on those who are positive

A 35-year-old male is brought into the emergency department for a trauma emergency. The emergency medical services states that the patient was wounded with a knife on his upper left thigh near the inguinal ligament. Upon examination in the trauma bay, the patient is awake and alert. His physical exam and FAST exam is normal other than the knife wound. Large bore intravenous lines are inserted into the patient for access and fluids are being administered. Pressure on the knife wound is being held by one of the physicians with adequate control of the bleeding, but the physician notices the blood was previously extravasating in a pulsatile manner. His vitals are BP 100/50, HR 110, T 97.8, RR 22. What is the next best step for this patient?

Coagulation studies and blood typing/crossmatch

Tourniquet of proximal lower extremity

Trauma in pregnancy for USMLE Step 2 CK: High-Yield Surgery Lessons

Initial Assessment - Pregnant & Puzzled

Prioritize maternal stabilization: a stable mother is the best fetal resuscitative measure. 📌 MFA: Mother First, Always.
Standard ATLS protocol (ABCDEs) with key modifications:
- A/B: Assume difficult airway; ↓ functional residual capacity means rapid desaturation.
- C: Aggressive fluid resuscitation. Manually displace uterus to the left to relieve aortocaval compression after 20 weeks gestation.
- Establish 2 large-bore IVs.
Secondary survey includes fetal & uterine assessment:
- Cardiotocography for viable fetus (≥24 weeks).
- Check for vaginal bleeding, amniotic fluid, or uterine contractions.

⭐ A pregnant patient can lose up to 30-35% of her blood volume before showing signs of hypotension, as physiologic hypervolemia masks early shock.

Primary Survey - Mama's ABCs

A (Airway): High risk of difficult intubation due to airway edema. Low threshold for definitive airway.
B (Breathing): ↑ O₂ demand. Provide high-flow supplemental O₂. Chest tube insertion site is higher (e.g., 3rd-4th intercostal space) due to the elevated diaphragm.
C (Circulation):
- Secure 2 large-bore IVs. Aggressive fluid resuscitation.
- Crucial: Perform left uterine displacement (LUD) by tilting the patient 15-30° to the left to decompress the inferior vena cava (IVC).
- ⚠️ Hypotension is a late and ominous sign; significant blood loss (30-35%) can occur before vitals change.

⭐ Exam Favorite: Fetal distress (tachycardia, bradycardia, late decelerations) is often the first sign of maternal hypovolemia, appearing long before maternal hypotension.

Secondary Survey - Baby's Check-in

Fetal Heart Tones (FHTs): Initial check with Doppler; confirms viability.
Cardiotocography (CTG): Continuous monitoring for ≥4-6 hours for all viable pregnancies post-trauma.
- Monitors for contractions & fetal distress (e.g., decelerations).
Bedside Ultrasound:
- Check for fetal cardiac activity, placental location (r/o previa), and amniotic fluid volume.
- Not sensitive for abruption initially.
Kleihauer-Betke (KB) Test: Consider if concerned for feto-maternal hemorrhage to quantify bleed & guide RhoGAM dose.
Rho(D) Immunoglobulin: Administer to all Rh-negative mothers after trauma.

⭐ High-Yield: The most common cause of fetal death after trauma is maternal death or shock. However, placental abruption is the most frequent serious pregnancy-specific complication.

Specific Injuries - Trauma's Triple Threat

Trauma can precipitate three catastrophic obstetric emergencies. Rapid differentiation is key, as clinical overlap exists but management diverges critically.

Placental Abruption: Revealed vs. Concealed Hemorrhage

Injury	Key Presentation	Fetal Heart Rate (FHR)	Management Pearls
Placental Abruption	Painful vaginal bleeding (can be concealed), uterine hypertonus, tender/firm uterus.	Late decelerations, ↓ variability, sinusoidal pattern.	Kleihauer-Betke test for feto-maternal hemorrhage. Immediate C-section for distress.
Uterine Rupture	Sudden, severe abdominal pain; loss of fetal station; easily palpable fetal parts.	Profound bradycardia, terminal decelerations, loss of FHR.	High risk with prior classical C-section. Emergency laparotomy & delivery.
Amniotic Fluid Embolism	Sudden CV collapse, severe hypoxia, seizures, rapid disseminated intravascular coagulation (DIC).	Catastrophic FHR changes (sudden bradycardia).	Supportive care is paramount (ACLS, massive transfusion protocol).

📌 Mnemonic (AFE): Remember the triad of Hypotension, Hypoxia, and Hemorrhage (DIC).

High‑Yield Points - ⚡ Biggest Takeaways

Maternal stabilization is always the first priority; a healthy mother is necessary for a healthy fetus.

Place patient in the left lateral decubitus position to prevent aortocaval compression and improve venous return.

Placental abruption is the most common pregnancy-specific complication of trauma, often presenting with vaginal bleeding and uterine tenderness.

Administer Rho(D) immune globulin to all Rh-negative pregnant trauma patients.

Use the Kleihauer-Betke test to screen for fetomaternal hemorrhage.

Continuous fetal monitoring is crucial if the fetus is viable (typically >24 weeks).

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