ED: 35-year-old G3P2 at 36 weeks with painful bleeding and hypertonic uterus; BP 90/55, HR 122. Most appropriate immediate intervention?
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USMLE Step 2 Quiz
Practice Pregnancy Complications in USMLE Step 2 with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.
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ED: 35-year-old G3P2 at 36 weeks with painful bleeding and hypertonic uterus; BP 90/55, HR 122. Most appropriate immediate intervention?
This quiz focuses on Pregnancy Complications, giving you a quick way to practice the rules, question types, and explanations that matter most for USMLE Step 2.
Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.
ED: 35-year-old G3P2 at 36 weeks with painful bleeding and hypertonic uterus; BP 90/55, HR 122. Most appropriate immediate intervention?
Explanation: This question tests knowledge of pregnancy complications in obstetrics and gynecology, specifically stabilizing hemorrhagic shock in abruption. Understanding pregnancy complications involves recognizing signs of hypovolemia and coagulopathy in abruption. In this scenario, specific details such as hypotension, tachycardia, painful bleeding, and hypertonic uterus require immediate resuscitation. The correct answer, 'Begin IV fluids, type and cross, and transfuse as needed', aligns with guidelines for maternal stabilization. A common distractor might suggest 'Administer terbutaline to relax the uterus', which does not address hemodynamic instability. Teaching strategies include emphasizing ABCs in obstetric emergencies. Practice applying these principles through case studies and simulations for rapid response.
L&D: 32-year-old G2P1 at 34 weeks with preeclampsia develops tonic-clonic seizure. Airway protected. Most effective immediate treatment?
Explanation: This question tests knowledge of pregnancy complications in obstetrics and gynecology, specifically treating eclampsia seizures. Understanding pregnancy complications involves rapid administration of anticonvulsants in preeclampsia progression. In this scenario, specific details such as tonic-clonic seizure at 34 weeks require immediate therapy. The correct answer, 'IV magnesium sulfate bolus and infusion', aligns with guidelines as first-line for eclampsia. A common distractor might suggest 'IV diazepam as sole therapy', which is less effective long-term. Teaching strategies include emphasizing magnesium dosing and monitoring. Practice applying these principles through case studies and simulations for emergency response.
ED: 35-year-old G3P2 at 36 weeks has sudden abdominal pain and heavy vaginal bleeding; uterus firm, fetal tracing shows late decelerations. Next management step?
Explanation: This question tests knowledge of pregnancy complications in obstetrics and gynecology, specifically the management of placental abruption with fetal distress. Understanding pregnancy complications involves recognizing clinical signs like sudden pain, heavy bleeding, firm uterus, and fetal heart rate abnormalities. In this scenario, specific details such as 36 weeks gestation, firm uterus, and late decelerations point towards abruption requiring urgent intervention. The correct answer, 'Initiate maternal stabilization and urgent delivery', aligns with guidelines for managing abruption with hemodynamic instability or fetal compromise. A common distractor might suggest 'Perform digital cervical exam to assess dilation', which is contraindicated due to risk of exacerbating bleeding. Teaching strategies include emphasizing rapid assessment and stabilization in obstetric emergencies. Practice applying these principles through case studies and simulations to improve recognition of abruption signs.
A 26-year-old primigravid woman at 9 weeks gestation presents with moderate vaginal bleeding and severe lower abdominal cramping. On physical examination, her cervix is 2 cm dilated, and products of conception are visible at the cervical os. A bedside ultrasound shows a gestational sac in the lower uterine segment with no fetal cardiac activity.
Which of the following is the most likely diagnosis?
Explanation: This patient's presentation is consistent with an inevitable abortion, which is characterized by vaginal bleeding, a dilated cervical os, but no passage of products of conception from the uterus yet. The presence of products of conception at the os indicates that passage is imminent. A threatened abortion would have a closed cervical os. An incomplete abortion involves the passage of some, but not all, products of conception. A missed abortion involves fetal demise without cervical change or passage of tissue.
A 32-year-old primigravid woman at 36 weeks gestation is brought to the emergency department due to a new-onset severe headache and visual disturbances. Her blood pressure is 165/112 mmHg. A urine dipstick shows 3+ proteinuria. Laboratory studies are significant for a platelet count of 85,000/mm³, an AST of 150 U/L, and a serum creatinine of 1.4 mg/dL. The fetal heart tracing is reassuring.
Which of the following is the most appropriate immediate management for this patient?
Explanation: This patient presents with preeclampsia with severe features, as evidenced by severe-range blood pressure (≥160/110 mmHg), headache, and laboratory findings consistent with HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets). The most critical initial step is to prevent eclamptic seizures by administering magnesium sulfate. Definitive management is delivery, which should be initiated promptly. While antihypertensives like labetalol are also necessary to control blood pressure, seizure prophylaxis with magnesium sulfate is the priority in the setting of severe features. An emergency cesarean delivery is not required if the fetal status is reassuring and there are no contraindications to a trial of labor. Further diagnostic testing like a 24-hour urine collection would delay necessary treatment.
A 29-year-old G2P1 woman at 28 weeks gestation undergoes a 3-hour, 100-gram oral glucose tolerance test due to a family history of diabetes. Her results are as follows: fasting 102 mg/dL (normal <95), 1-hour 205 mg/dL (normal <180), 2-hour 160 mg/dL (normal <155), and 3-hour 148 mg/dL (normal <140).
Which of the following is the most appropriate initial management for this patient?
Explanation: The patient's oral glucose tolerance test is diagnostic for gestational diabetes mellitus (GDM), with all four values exceeding the upper limit of normal (diagnosis requires at least two abnormal values). The initial and cornerstone of management for GDM is lifestyle modification, which includes dietary counseling (e.g., diabetic diet) and regular exercise. Pharmacologic therapy, such as insulin or metformin, is reserved for patients who fail to achieve glycemic control with diet and exercise alone. Repeating the test is unnecessary as the diagnosis is already established.
A 34-year-old G3P2 woman at 37 weeks gestation presents to labor and delivery with an episode of painless, bright red vaginal bleeding that started one hour ago. She denies any trauma or contractions. Her vital signs are stable, and the uterus is soft and non-tender. The fetal heart tracing is reactive with a baseline of 140/min. Her 20-week anatomy scan report mentioned a 'low-lying placenta'.
What is the most likely diagnosis?
Explanation: The classic presentation of placenta previa is painless, bright red vaginal bleeding in the third trimester. The uterus is typically soft and non-tender, and the fetal heart tracing is often reassuring initially. A history of a low-lying placenta on a prior ultrasound further supports this diagnosis. Placental abruption typically presents with painful vaginal bleeding and a tender, firm uterus. Uterine rupture is characterized by intense abdominal pain and fetal distress. Vasa previa classically presents with bleeding immediately following rupture of membranes, accompanied by acute fetal distress.
A 25-year-old G1P0 woman at 38 weeks gestation is diagnosed with gestational hypertension. Her blood pressure has been consistently 145/95 mmHg during her clinic visit. She has no proteinuria on urine dipstick and denies headaches or visual changes. Laboratory studies are within normal limits. Her cervical exam is 1 cm dilated and 50% effaced.
Which of the following is the most appropriate management?
Explanation: According to current guidelines, delivery is recommended for patients with gestational hypertension or preeclampsia without severe features at or beyond 37 0/7 weeks of gestation. This patient is at 38 weeks. Induction of labor is the appropriate management to prevent the potential progression to preeclampsia with severe features and other adverse maternal and fetal outcomes. Expectant management is not recommended at term. While antihypertensives may be used, delivery is the definitive management. Cesarean delivery is not indicated without a maternal or fetal indication.
A 29-year-old G2P1 woman at 32 weeks gestation is brought to the emergency department after being an unrestrained driver in a motor vehicle collision. She complains of severe, constant abdominal pain and has a small amount of dark red vaginal bleeding. Her uterus is rigid and tender to palpation. Her blood pressure is 90/60 mmHg and heart rate is 120/min. The fetal heart rate is 100/min with minimal variability.
What is the most appropriate next step in management?
Explanation: This patient's presentation of trauma, painful vaginal bleeding, a rigid and tender uterus, maternal tachycardia, and fetal bradycardia is classic for a severe placental abruption. This is a life-threatening emergency for both the mother and fetus. The most appropriate next step is immediate delivery via emergency cesarean section. Diagnostic studies like ultrasound should not delay definitive management in an unstable patient. Tocolytics are contraindicated in placental abruption. Corticosteroids are appropriate for anticipated preterm birth but are not the priority over immediate delivery in the setting of maternal and fetal compromise.
A 33-year-old G1P0 woman with diet-controlled gestational diabetes (A1GDM) presents at 39 weeks for a routine prenatal visit. Her home blood glucose logs have all been within the target range. An ultrasound for fetal biometry estimates a fetal weight of 3800 g. A nonstress test is reactive.
Which of the following is the most appropriate recommendation for delivery?
Explanation: For women with well-controlled gestational diabetes (A1GDM), delivery is recommended between 39 0/7 and 39 6/7 weeks of gestation. This timing balances the risk of stillbirth associated with post-term pregnancy in diabetic mothers against the risks of prematurity. Expectant management beyond 40 weeks is generally not recommended. A primary cesarean delivery for suspected macrosomia is typically considered only when the estimated fetal weight is >4500 g. Continuous monitoring is not necessary in a well-controlled patient with reassuring fetal testing.
A 28-year-old G1P0 woman at 30 weeks gestation presents with a blood pressure of 170/115 mmHg, a severe headache, and blurred vision. She is diagnosed with preeclampsia with severe features. She is given intravenous magnesium sulfate and labetalol, and her blood pressure stabilizes to 150/100 mmHg.
What is the most definitive management for this patient's condition?
Explanation: The definitive treatment for preeclampsia is delivery of the placenta. For patients with preeclampsia with severe features, delivery is recommended at or after 34 0/7 weeks of gestation. Delivery is also indicated before 34 weeks if there is evidence of maternal or fetal instability, such as uncontrolled severe hypertension, eclampsia, pulmonary edema, or non-reassuring fetal status. Given her severe features at 30 weeks, delivery is the definitive management after initial maternal stabilization. Corticosteroids are given in anticipation of preterm delivery but do not treat the underlying disease. Antihypertensives stabilize the mother but are not definitive. Expectant management is not appropriate for unstable patients or those with severe features that do not resolve.
A 31-year-old G4P3 woman at 34 weeks gestation has a routine ultrasound that confirms a complete placenta previa. Her medical history is significant for three prior cesarean deliveries. The sonographer notes loss of the clear space between the placenta and the myometrium and multiple placental lacunae.
This patient is at highest risk for which of the following complications at the time of delivery?
Explanation: The combination of placenta previa and multiple prior cesarean deliveries is the strongest risk factor for placenta accreta spectrum (PAS). The ultrasound findings described (loss of clear space, lacunae) are also highly suggestive of PAS, a condition where the placenta invades abnormally into the uterine wall. Attempts to separate the placenta at delivery can lead to massive, life-threatening postpartum hemorrhage, which frequently necessitates a planned cesarean hysterectomy. While uterine rupture is a risk with prior C-sections, the risk of hemorrhage from PAS is higher in this specific clinical scenario.
A 35-year-old G2P1 woman at 11 weeks gestation presents for her first prenatal visit. She reports that her symptoms of nausea and breast tenderness, which were prominent weeks ago, have resolved. On transvaginal ultrasound, a fetus measuring 9 weeks gestation with no cardiac activity is visualized. The cervix is long and closed on physical examination.
Which of the following is the most appropriate next step in management?
Explanation: The ultrasound finding of a non-viable fetus without passage of tissue or cervical change is diagnostic of a missed abortion. The most appropriate next step is to counsel the patient on the three acceptable management options: 1) expectant management (awaiting spontaneous passage), 2) medical management (e.g., with misoprostol to induce passage), and 3) surgical management (dilation and curettage). The choice depends on patient preference, clinical stability, and gestational age. While Rho(D) immune globulin will be needed if she is Rh-negative, counseling on the primary management is the first step. Serial labs or ultrasounds are not necessary as the diagnosis is definitive.
A 28-year-old G1P0 woman at 36 weeks gestation is in active labor. Her membranes spontaneously rupture, which is immediately followed by a large gush of painless vaginal bleeding. The fetal heart rate, which was previously stable at a baseline of 140/min, abruptly drops to 70/min and remains there despite maternal repositioning.
Which of the following is the most likely diagnosis?
Explanation: This is the classic presentation of vasa previa, where fetal vessels traverse the membranes over the cervical os. The triad of rupture of membranes followed by painless vaginal bleeding and acute fetal distress (severe bradycardia or decelerations) is pathognomonic. The bleeding is fetal in origin, leading to rapid exsanguination and compromise. Placental abruption is typically painful. Placenta previa bleeding is not precipitated by rupture of membranes. Uterine rupture presents with intense pain, loss of fetal station, and variable bleeding.
A 29-year-old G2P1 woman with a history of a spontaneous preterm birth at 32 weeks gestation is currently 18 weeks pregnant with a singleton gestation. She is asymptomatic. A routine transvaginal ultrasound is performed to assess her cervical length, which measures 20 mm.
Which of the following interventions is the most appropriate for this patient?
Explanation: This patient has both a history of spontaneous preterm birth and a short cervix (<25 mm) detected on ultrasound before 24 weeks. In this situation, a history-indicated cerclage is the most effective intervention to reduce the risk of recurrent preterm birth. Vaginal progesterone is indicated for patients with a short cervix but no history of preterm birth. 17-OHPC is an option for patients with a history of preterm birth but a normal cervical length. Bed rest has not been shown to be effective.
A 34-year-old woman is on postpartum day 2 following a vaginal delivery at 38 weeks, which was complicated by preeclampsia with severe features. She completed a 24-hour course of magnesium sulfate. Her blood pressure is now 155/105 mmHg. She reports a mild headache but is otherwise well. She plans to breastfeed.
Which of the following is the most appropriate oral medication to manage her hypertension?
Explanation: This patient has persistent postpartum hypertension requiring treatment. First-line oral agents for postpartum hypertension, which are safe in breastfeeding, include nifedipine and labetalol. Lisinopril (an ACE inhibitor) is generally avoided in the immediate postpartum period, especially in breastfeeding mothers. Furosemide is a diuretic and not a first-line antihypertensive unless there is evidence of fluid overload, such as pulmonary edema. Clonidine can cause sedation and is not a first-line agent.
A 33-year-old primigravid woman at 33 weeks gestation was admitted for preterm labor and managed with a full course of betamethasone and 48 hours of tocolysis with nifedipine. Her contractions have now completely subsided. Her cervix is 3 cm dilated and 80% effaced, which is unchanged from admission. The fetal heart tracing is reassuring.
Which of the following is the most appropriate next step in management?
Explanation: The primary purpose of tocolytic therapy in preterm labor is to delay delivery for up to 48 hours to allow for the administration and full effect of antenatal corticosteroids. There is no evidence that maintenance tocolysis beyond this initial 48-hour period improves neonatal outcomes, and it may increase maternal side effects. Therefore, once the 48-hour window is complete and contractions have ceased, the tocolytic agent should be discontinued. Strict bed rest has not been shown to be effective and is no longer recommended. Amniocentesis is not indicated as management would not change.
A 30-year-old G3P2 woman at 35 weeks gestation presents with regular uterine contractions every 4 minutes. Her cervix is 4 cm dilated and 90% effaced. A rectovaginal culture collected two weeks ago was positive for Group B Streptococcus (GBS). The fetal heart tracing is reassuring.
Which of the following is the most appropriate management?
Explanation: This patient is in late preterm labor (34 0/7 to 36 6/7 weeks). Tocolysis is generally not recommended in this period as the risks often outweigh the benefits. Similarly, magnesium sulfate for neuroprotection is indicated for gestations less than 32 weeks. A single course of late-preterm betamethasone may be considered, but the most critical and definite intervention is intrapartum antibiotic prophylaxis for GBS to prevent neonatal sepsis. Therefore, the best course of action is to administer penicillin and allow labor to progress.
A 22-year-old G1P0 woman at 8 weeks gestation presents to her obstetrician with two days of light vaginal spotting. She denies any abdominal pain or cramping. On physical examination, her vital signs are stable, the abdomen is soft, and the cervical os is closed. A transvaginal ultrasound confirms a viable intrauterine pregnancy with fetal cardiac activity, consistent with an 8-week gestation.
What is the most likely diagnosis?
Explanation: Threatened abortion is defined as any vaginal bleeding before 20 weeks of gestation in the presence of a closed cervix and a confirmed viable intrauterine pregnancy on ultrasound. Her symptoms and findings fit this diagnosis perfectly. An inevitable abortion would present with an open cervical os. While a subchorionic hemorrhage is a common cause of threatened abortion, 'threatened abortion' is the overall clinical diagnosis. A complete abortion involves the passage of all products of conception and would show an empty uterus on ultrasound.
A 30-year-old G2P1 woman at 12 weeks gestation presents for her first prenatal visit. Her previous pregnancy was complicated by preeclampsia with severe features that required delivery at 33 weeks. Her blood pressure today is 125/75 mmHg. She has no other medical problems.
Which of the following interventions is most likely to reduce her risk of developing preeclampsia in this pregnancy?
Explanation: Prophylaxis with low-dose aspirin (81 mg/day) is recommended for women at high risk of developing preeclampsia. A history of preeclampsia in a prior pregnancy, especially with an early-onset delivery (<34 weeks), is a major risk factor. Aspirin should be initiated between 12 and 16 weeks of gestation and continued until delivery. Sodium restriction and prophylactic antihypertensives in a normotensive patient have not been shown to prevent preeclampsia. Calcium supplementation is recommended only for women with low dietary calcium intake to reduce preeclampsia risk.