HY USMLEQ#7  Obs Gyn Concepts Step 2CK

Level = Step 2CK/3  (Inspired Uworld step 3) 

​​

A 23-year-old woman g3p2 at 35 weeks gestation comes to the emergency department due to vaginal bleeding. The bleeding began after intercourse, and she has since soaked 3 perineal pads in 2 hours. The patient has normal fetal movements and intermittent cramping but no leakage of amniotic fluid. The patient has a history of intravenous drug use and smokes a pack of cigarettes a day. Fetal heart rate tracing is 140/min with moderate variability and no decelerations. The tachometer shows contraction every 5 to 7 minutes. There is frank blood on the patient's perineal pad.

​

What is the most appropriate next step in the management of this patient? 

​

A. Digital cervical exam

B. Fetal Fibronectin testing 

C. Indometacin tocolysis 

D. Transvaginal Ultrasound 

E. Urine toxicology screen 

​​

​

​

First Step: Must Rule out Placenta Previa or Other causes of bleeding

​

✅ Transvaginal Ultrasound --> Allows visualization of the cervix and placenta location to rule out placenta previa, which can present with painless bleeding after intercourse 

​​

In third trimester vaginal bleeding, the first step is to localize the placenta.

❌ A. Digital Cervical exam --> This is quite dangerous and it is contraindicated in third-trimester bleeding until placenta previa is ruled out as this could lead to catastrophic hemorrhage. 

❌ B. Fetal fibronectin testing --> Used to assess the risk of preterm labor in symptomatic patients, but only when there is no vaginal bleeding or ruptured membranes. 

❌ C. Indomethacin is contraindicated after 32 weeks due to risk of premature ductus arteriosis closure 

❌ E. May be used later given her IV drug use history but it is not the initial management of active vaginal bleeding.