A 29-year-old woman, gravida 1, para 0, at 36 weeks' gestation is brought to the emergency department after an episode of dizziness and vomiting followed by loss of consciousness lasting 1 minute. She reports that her symptoms started after lying down on her back to rest, as she felt tired during yoga class. Her pregnancy has been uncomplicated. On arrival, she is diaphoretic and pale. Her pulse is 115/min and blood pressure is 90/58 mm Hg. On examination, the patient is lying in the supine position with a fundal height of 36 cm. There is a prolonged fetal heart rate deceleration to 80/min. Which of the following is the most appropriate action to reverse this patient's symptoms in the future?

Lying in the left lateral decubitus position

Gentle compression with an abdominal binder

Lying in the supine position and elevating legs

Performing the Valsava maneuver

A 25-year-old G1P0 woman at 22 weeks’ gestation presents to the emergency department with persistent vomiting over the past 8 weeks which has resulted in 5.5 kg (12.1 lb) of unintentional weight loss. She has not received any routine prenatal care to this point. She reports having tried diet modification and over-the-counter remedies with no improvement. The patient's blood pressure is 103/75 mm Hg, pulse is 93/min, respiratory rate is 15/min, and temperature is 36.7°C (98.1°F). Physical examination reveals an anxious and fatigued-appearing young woman, but whose findings are otherwise within normal limits. What is the next and most important step in her management?

Admit and begin intravenous rehydration

Begin treatment with vitamin B6

Begin treatment with metoclopramide

Obtain a basic electrolyte panel

Obtain a beta hCG and pelvic ultrasound

A 21-year-old woman comes to the physician because she had a positive pregnancy test at home. For the past 3 weeks, she has had nausea and increased urinary frequency. She also had three episodes of non-bloody vomiting. She attends college and is on the varsity soccer team. She runs 45 minutes daily and lifts weights for strength training for 1 hour three times per week. She also reports that she wants to renew her ski pass for the upcoming winter season. Her vital signs are within normal limits. Physical examination shows no abnormalities. Which of the following is the most appropriate recommendation?

Stop playing soccer, continue strength training, and do not buy a ski pass

Stop playing soccer, stop strength training, and do not buy a ski pass

Continue playing soccer, stop strength training, and do not buy a ski pass

Stop playing soccer, continue strength training, and buy a ski pass

Continue playing soccer, continue strength training, and do not buy a ski pass

A 29-year-old woman presents to a medical office complaining of fatigue, nausea, and vomiting for 1 week. Recently, the smell of certain foods makes her nauseous. Her symptoms are more pronounced in the mornings. The emesis is clear-to-yellow without blood. She has had no recent travel out of the country. The medical history is significant for peptic ulcer, for which she takes pantoprazole. The blood pressure is 100/60 mm Hg, the pulse is 70/min, and the respiratory rate is 12/min. The physical examination reveals pale mucosa and conjunctiva, and bilateral breast tenderness. The LMP was 9 weeks ago. What is the most appropriate next step in the management of this patient?

Beta-HCG levels and a transvaginal ultrasound

Beta-HCG levels and a transabdominal ultrasound

Beta-HCG levels and a pelvic CT

A 23-year-old nulligravida presents for evaluation 5 weeks after her last menstrual period. Her previous menstruation cycle was regular, and her medical history is benign. She is sexually active with one partner and does not use contraception. A urine dipstick pregnancy test is negative. The vital signs are as follows: blood pressure 120/80 mm Hg, heart rate 71/min, respiratory rate 13/min, and temperature 36.8°C (98.2°F). The physical examination is notable for breast engorgement, increased pigmentation of the nipples, and linea nigra. The gynecologic examination demonstrates cervical and vaginal cyanosis. Measurement of which of the following substances is most appropriate in this case?

Blood human chorionic gonadotropin

Urinary human chorionic gonadotropin

Management of common pregnancy complaints for USMLE Step 3: High-Yield OB/GYN Lessons

GI Uprisings - Tummy Troubles Takedown

Nausea & Vomiting (NVP) / "Morning Sickness"
- Initial: Lifestyle changes (small, frequent meals; avoid triggers like spicy/fatty foods), ginger, acupressure.
- First-line pharmacotherapy: Pyridoxine (Vitamin B6) +/- Doxylamine.
- Second-line: Antihistamines (Dimenhydrinate, Diphenhydramine).
- Refractory: Dopamine antagonists (Metoclopramide) or Serotonin antagonists (Ondansetron).
  - ⚠️ Ondansetron: Use with caution in 1st trimester; small ↑ risk of cardiac malformations & orofacial clefts.
Gastroesophageal Reflux Disease (GERD)
- Initial: Lifestyle (elevate head of bed, avoid eating 2-3 hrs before sleep).
- Pharmacotherapy: Antacids (Calcium Carbonate) → H2-receptor blockers (Famotidine) → Proton Pump Inhibitors (Omeprazole) for severe/refractory cases.

⭐ Hyperemesis Gravidarum: Suspect if patient has persistent vomiting, weight loss >5% of pre-pregnancy body weight, ketonuria, and electrolyte abnormalities. Requires IV hydration and antiemetics.

Musculoskeletal Malaise - Aches, Pains & Strains

Low Back Pain: Exaggerated lumbar lordosis & hormonal joint laxity (↑ relaxin, progesterone).
- Management: Pelvic tilt exercises, proper posture, supportive shoes, maternity support belt.
- Avoid NSAIDs, especially in the 3rd trimester. Acetaminophen is preferred.
Round Ligament Pain: Sharp, stabbing pain in the lower abdomen or groin, often with sudden movements (e.g., rolling in bed). Usually occurs in the 2nd trimester.
- Management: Reassurance, positional changes, local heat.
Symphysis Pubis Dysfunction (SPD): Severe pelvic girdle pain, waddling gait. Worsened by weight-bearing activities.
- Management: Pelvic support garments, physical therapy, activity modification.

Round Ligament Pain in Pregnancy

⭐ Exam Favorite: Round ligament pain is a diagnosis of exclusion. Always rule out more serious causes like appendicitis, placental abruption, or preterm labor if pain is severe, rhythmic, or associated with other systemic symptoms.

Systemic Stresses - Plumbing & Pressure

Edema & Varicosities
- Pathophysiology: Progesterone → venous dilation; Uterine growth → IVC & pelvic vein compression → ↑ hydrostatic pressure.
- Presentation: Swelling in legs, ankles, feet. Vulvar varicosities & hemorrhoids are common.
- Management:
  - Leg elevation, compression stockings.
  - Sleep in left lateral decubitus position to relieve IVC compression.
  - For hemorrhoids: sitz baths, topical anesthetics, stool softeners.
- ⚠️ Red Flag: Sudden, unilateral, or painful swelling may indicate DVT. Facial/hand edema can signal preeclampsia.
Gastroesophageal Reflux (GERD)
- Pathophysiology: Progesterone relaxes the lower esophageal sphincter (LES).
- Management: Lifestyle (small meals, avoid triggers) → Antacids (calcium carbonate) → H2 blockers or PPIs.
Constipation
- Pathophysiology: Progesterone ↓ gut motility; iron supplementation exacerbates.
- Management: ↑ Fiber & fluid intake, exercise. Stool softeners (docusate) are first-line.

⭐ Supine Hypotensive Syndrome: In late pregnancy, the gravid uterus compresses the IVC when supine, reducing venous return & cardiac output, causing hypotension and dizziness. Management is immediate repositioning to the left lateral decubitus position.

High‑Yield Points - ⚡ Biggest Takeaways

Nausea/vomiting: First-line is vitamin B6 ± doxylamine. For severe cases (hyperemesis gravidarum), use IV fluids and antiemetics.

GERD: Start with lifestyle modifications. If persistent, use calcium carbonate.

Constipation: Managed with increased fiber, fluids, and exercise. Docusate is a safe stool softener.

Asymptomatic bacteriuria: Always treat in pregnancy to prevent pyelonephritis. Common antibiotics include nitrofurantoin and cephalexin.

Low back pain: Treat with acetaminophen, proper posture, and pelvic tilt exercises.

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