Midwife Licensure Exam High-Risk Pregnancy & Complications (Recognize & Refer) — High-Risk Pregnancy & Bleeding DisordersCheat Sheet

Section Title

First-Trimester Bleeding: Abortion (Miscarriage) Types

Important Facts

• LEADING CAUSE: Chromosomal abnormalities account for >50% of first-trimester abortions.
• Risk factors: maternal infection, endocrine imbalance (especially thyroid), incompetent cervix, immunologic factors, maternal age >35.
• Assessment: count/weigh perineal pads (1 g = 1 mL blood loss), note amount/character of bleeding, cramping intensity, passage of tissue (SAVE all tissue for pathology).
• Monitoring: serial beta-hCG, hemoglobin/hematocrit for anemia, vital signs for shock.
• NO STRONG EVIDENCE that strict bed rest prevents loss, but activity limitation is advised for threatened abortion.
• Rh-negative, unsensitized mothers require Rho(D) immune globulin to prevent isoimmunization.
• Emotional care is CRITICAL: never minimize the loss, use respectful language (avoid 'miscarriage' if family prefers 'loss'), offer grief support and referrals.

Key Definitions

Diagrams To Know

• Cervical os status in each abortion type (threatened=closed, inevitable/incomplete=open, complete=closed)
• Timeline of beta-hCG rise/fall in normal vs. arrested pregnancy

Common Values

Section Title

Ectopic Pregnancy: The Surgical Emergency

Important Facts

• Risk factors: pelvic inflammatory disease (PID), prior tubal surgery, previous ectopic pregnancy, intrauterine device (IUD) use, endometriosis, assisted reproductive techniques.
• Classic UNRUPTURED triad: unilateral lower-quadrant abdominal pain + delayed/abnormal menses + scant DARK vaginal spotting.
• RUPTURED TRIAD (EMERGENCY): sudden sharp stabbing pain + referred SHOULDER pain (Kehr sign) + RAPID signs of hypovolemic shock (tachycardia, hypotension, pallor, diaphoresis).
• Diagnostics: serial beta-hCG (abnormally SLOW rise, fails to double every 48-72 hours); transvaginal ultrasound (empty uterus + adnexal mass); culdocentesis (+blood = hemoperitoneum).
• Beta-hCG in ectopic typically lower than intrauterine pregnancy at same gestational age.
• Management UNRUPTURED: Methotrexate (MTX) 50 mg/m² IM dissolves trophoblastic tissue; requires folic acid AVOIDANCE, NO ALCOHOL, NO SUN EXPOSURE, strict follow-up hCG (must decline).
• Management RUPTURED: EMERGENCY salpingostomy (tube-sparing) or salpingectomy; prepare for shock → large-bore IV, 0.9% NaCl or LR, blood products, oxygen, continuous monitoring.
• Rho(D) immune globulin 300 mcg IM to Rh-negative, unsensitized mothers (or 50 mcg microdose if <13 weeks).
• Post-MTX teaching: pregnancy AVOID for 3 months (teratogenic), bleeding normal for 1-2 weeks, persistent/worsening pain = seek ER.

Key Definitions

Diagrams To Know

• Ectopic implantation sites (interstitial, isthmic, ampulla, fimbrial, ovarian, cervical, abdominal) and rupture risk by location
• MTX mechanism: inhibits dihydrofolate reductase → blocks DNA synthesis in rapidly dividing trophoblastic cells

Common Values

Section Title

Gestational Trophoblastic Disease (Hydatidiform Mole/Molar Pregnancy)

Important Facts

• Manifestations: UTERUS LARGER THAN EXPECTED for dates, dark-brown ('prune juice') or bright-red vaginal bleeding with possible PASSAGE OF VESICLES (grape-like tissue), EXCESSIVELY HIGH beta-hCG (often >100,000 mIU/mL).
• Hyperemesis gravidarum is SEVERE due to very high hCG production.
• RED FLAG: Preeclampsia signs (hypertension, proteinuria, edema) BEFORE 20 WEEKS → think molar pregnancy (preeclampsia normally after 20 weeks).
• Ultrasound findings: 'SNOWSTORM' appearance (echogenic tissue with multiple small anechoic spaces) or 'CLUSTER OF GRAPES' pattern; NO FETAL HEART TONES.
• Management: SUCTION CURETTAGE (vacuum evacuation) is primary treatment; RhoGAM to Rh-negative mothers.
• CRITICAL FOLLOW-UP: Serial beta-hCG for 6–12 MONTHS (monthly until normal, then every 3 months) to detect choriocarcinoma.
• hCG should progressively FALL to ZERO; rising/plateaued hCG = malignant transformation → chemotherapy (MTX).
• STRICT CONTRACEPTION for at least 1 YEAR: pregnancy would mask rising hCG and delay cancer detection.
• Teach patient to report abnormal bleeding, persistent hCG elevation, or any symptoms.
• Emotional support: acknowledge grief over loss of pregnancy while explaining careful monitoring for health protection.

Key Definitions

Diagrams To Know

• Complete vs. partial mole comparison (karyotype, fetal tissue, hCG level, malignancy risk)
• Post-molar pregnancy hCG monitoring timeline and when choriocarcinoma is suspected

Common Values

Section Title

Third-Trimester Bleeding: Placenta Previa

Important Facts

• Risk factors: multiparity, prior cesarean delivery or previa, advanced maternal age (>35), multiple gestation (twins/multiples), smoking, cocaine use, prior uterine curettage/D&C.
• Classic presentation: PAINLESS, bright-red vaginal bleeding, usually AFTER 28 weeks; may occur with Braxton-Hicks contractions.
• Uterus is SOFT, NON-TENDER with NORMAL tone (unlike abruption).
• Malpresentation common: breech, transverse lie (placenta blocks engagement of vertex).
• Diagnosis: TRANSVAGINAL (NOT transabdominal) ultrasound is gold standard; avoids speculum/digital exam until previa ruled out.
• ABSOLUTE CONTRAINDICATION: DO NOT perform vaginal exam, speculum exam, or rectal exam until previa excluded → can perforate low-lying placenta and cause catastrophic hemorrhage.
• Management STABLE PRETERM: Expectant management aims to prolong pregnancy; admit, bed rest, IV access, blood typed/crossmatched.
• Betamethasone 12 mg IM every 24 hours × 2 doses if delivery likely before 34 weeks (accelerates fetal lung maturity).
• Delivery: CESAREAN SECTION for total/partial previa at term or with heavy bleeding; marginal may allow trial of vaginal delivery if stable.
• HIGH RISK: Postpartum hemorrhage (lower segment contracts poorly; placental site may not compress adequately) → have uterotonic agents ready (oxytocin, ergot, carboprost).
• Pelvic rest: NO sexual intercourse, douches, or strenuous activity.

Key Definitions

Diagrams To Know

• Placental implantation locations in previa (total, partial, marginal, low-lying) relative to internal os
• Transvaginal ultrasound interpretation and distance measurement from os

Common Values

Section Title

Third-Trimester Bleeding: Abruptio Placentae (Placental Abruption)

Important Facts

• STRONGEST RISK FACTOR: Maternal hypertension (chronic or gestational/preeclampsia); also cocaine use, trauma (MVA, falls, intimate partner violence), short umbilical cord, smoking, anticoagulation, uterine anomaly.
• Pathophysiology: retroplacental bleeding causes placental separation → loss of placental function → fetal hypoxia + maternal hemorrhage + release of thromboplastin into maternal circulation → DIC.
• Classic triad: (1) PAINFUL vaginal bleeding, (2) RIGID, BOARD-LIKE, TENDER uterus with INCREASED TONE, (3) Signs of SHOCK (may exceed visible bleeding if concealed).
• Bleeding is DARK RED (as opposed to bright red in previa).
• Fetal distress and uterine hyperactivity/tetany are common.
• Diagnosis: clinical (no imaging can rule out abruption definitively); ultrasound may show retroplacental clot but normal ultrasound does NOT exclude abruption.
• Severity grading: Grade 0 (asymptomatic, found at delivery), Grade 1 (minor separation, stable), Grade 2 (moderate, fetal distress), Grade 3 (severe, fetal demise, DIC risk).
• Management is OBSTETRIC EMERGENCY: position LEFT LATERAL TILT (improves perfusion), oxygen, large-bore IV × 2, aggressive fluid/blood replacement (0.9% NaCl, LR, RBC, FFP, platelets, cryoprecipitate for DIC).
• Continuous fetal heart rate monitoring; measure fundal height (expanding girth suggests CONCEALED bleeding).
• Monitor coagulation: platelets, PT/PTT, fibrinogen, D-dimer (watch for oozing from IV sites, gums, petechiae, hematuria = DIC).
• EMERGENCY CESAREAN DELIVERY for significant abruption, fetal compromise, or maternal instability.
• Expectant management only for GRADE 1 (minor) abruption with stable vitals and reassuring FHR; frequent reassessment mandatory.
• Complication: DIC develops in up to 10% of abruptions; risk increases with severity and fetal demise.

Key Definitions

Diagrams To Know

• Abruption severity grading (0-3) with clinical features and management approach
• Pathophysiology cascade: placental separation → hemorrhage → thromboplastin release → DIC activation

Common Values

Section Title

Rho(D) Immune Globulin (RhoGAM): Must-Know Pharmacology

Important Facts

• Mechanism: RhoGAM provides PASSIVE antibody (does NOT stimulate mother's own B cells to make anti-D); suppresses maternal immune response, protecting future pregnancies from hemolytic disease.
• STANDARD DOSE: 300 mcg IM at 28 weeks gestation + again WITHIN 72 HOURS after delivery of Rh-positive infant.
• MICRODOSE: 50 mcg IM used for FIRST-TRIMESTER events (spontaneous/induced abortion, ectopic pregnancy, molar pregnancy) if <12-13 weeks gestation.
• Also indicated after: amniocentesis, chorionic villus sampling (CVS), cordocentesis, abdominal trauma, placental abruption, antepartum hemorrhage, external cephalic version, fetal demise.
• Eligibility MUST CHECK: (1) Mother is Rh-NEGATIVE (RhD negative), (2) Mother's indirect Coombs is NEGATIVE (not already sensitized), (3) Baby is Rh-POSITIVE (RhD positive) OR baby's type is UNKNOWN.
• CONTRAINDICATION: Do NOT give if mother is already sensitized (positive indirect Coombs test) — RhoGAM provides no benefit and may worsen hemolytic disease.
• Dose adjustment: If excessive fetomaternal hemorrhage (>4 mL fetal RBCs or >15 mL fetal whole blood), calculate additional RhoGAM: 1 mL fetal RBCs requires 20 mcg RhoGAM; 1 mL fetal whole blood requires 4 mcg RhoGAM.
• Kleihauer-Betke test or flow cytometry quantifies fetal RBCs in maternal circulation to determine RhoGAM dose.
• Administration: Intramuscular (never IV); note lot number and document in chart.
• Timing: 28-week dose given regardless of prior sensitization (routine); post-event doses within 72 hours (efficacy decreases after 72 hours, minimal benefit after 28 days).
• Informed consent: Explain that RhoGAM is derived from human plasma (blood product); rare risk of infection but standard precautions minimize risk.
• Advise mother: avoid future pregnancies with non-Rh-negative partners if already sensitized; all non-O blood types carry transfusion risks in sensitized mothers.

Key Definitions

Diagrams To Know

• RhoGAM timing: 28-week routine dose + post-event doses within 72 hours for specific obstetric situations
• Eligibility decision tree: Rh status, Coombs result, baby's Rh status, sensitization history

Reactions Or Equations

Common Values

Section Title

Nursing Assessment & Monitoring in Pregnancy Bleeding

Important Facts

• ESTIMATION: Classify bleeding as SPOTTING (light), LIGHT (moderate amount), MODERATE (soaks 1-2 pads/hour), or HEAVY (>2 pads/hour).
• Count and WEIGH all perineal pads (save for measurement); note color (bright vs. dark red), presence of clots (>2 cm = significant), passage of tissue (SAVE for pathology).
• Monitor vital signs frequently: tachycardia is EARLY sign of shock (often >100 bpm before BP drops); hypotension is LATE sign.
• Other early shock signs: narrow pulse pressure, cool/clammy skin, restlessness/anxiety, delayed capillary refill, concentrated urine.
• Urine output target: ≥30 mL/hour (sign of adequate perfusion); oliguria (<25 mL/hr) suggests shock progression.
• ABSOLUTE CONTRAINDICATION with third-trimester bleeding: NO vaginal exam, NO digital cervical exam, NO rectal exam until previa ruled out by ultrasound → risk of catastrophic hemorrhage.
• Speculum exam is safe (visualize bleeding without digital trauma).
• IV access: Two LARGE-BORE (18-gauge or larger) peripheral lines for rapid fluid/blood infusion; central line for massive transfusion protocol.
• Fluid resuscitation: 0.9% NaCl or Lactated Ringer's for initial bolus (20-30 mL/kg), then maintain at 50-100 mL/hr depending on ongoing loss and urine output.
• Blood products: O-negative for emergent transfusion (before type/cross complete); transition to type-specific when available.
• Continuous fetal heart rate monitoring: assess baseline (110-160 bpm), variability (reassuring if 6-25 bpm fluctuation), accelerations (reassuring), decelerations (concerning if variable/late patterns).
• Monitor for DIC: watch for oozing from IV insertion sites, gums, petechiae, hematuria; assess coagulation labs (platelets, PT/PTT, fibrinogen, D-dimer).
• Position: LEFT LATERAL tilt in preterm (improves uteroplacental perfusion); semi-Fowler's in term (if not contraindicated by type of bleed).
• Nothing by mouth: NPO status in case emergency surgery needed.
• Emotional support: acknowledge loss, avoid clichés ('everything happens for a reason'), offer privacy for parents to grieve, facilitate baptism/blessing if desired, provide referrals to grief counseling and support groups (e.g., SHARE, RESOLVE in Philippines).

Key Definitions

Diagrams To Know

• Progression of hypovolemic shock: early/compensated → late/decompensated → irreversible
• Assessment checklist: vital signs, urine output, skin perfusion, mental status, bleeding characteristics, fetal response

Reactions Or Equations

Common Values

Section Title

Disseminated Intravascular Coagulation (DIC) in Bleeding Disorders

Important Facts

• Triggers in obstetrics: missed abortion (retained fetus >4-6 weeks), abruptio placentae, amniotic fluid embolism (AFE), severe sepsis/chorioamnionitis, placental abruption with fetal demise, HELLP syndrome.
• Pathophysiology: release of thromboplastin (tissue factor) into maternal circulation → triggers coagulation cascade → consumes platelets, fibrinogen, and factors II, V, VIII → microthrombi form in capillaries → organ damage + bleeding from factor depletion (coagulopathy) + hemolysis.
• Laboratory findings: DECREASED platelets (<100,000/μL), DECREASED fibrinogen (<100 mg/dL), ELEVATED PT/INR, ELEVATED aPTT, ELEVATED D-dimer (>500 ng/mL).
• Clinical signs: OOZING from IV insertion sites, surgical wounds, gums; petechiae/purpura (especially on lower extremities, buttocks); hematuria; hematemesis; vaginal bleeding beyond expected; decreased urine output; altered mental status (microthrombi in brain).
• Severity: DIC scoring combines laboratory findings (platelets, D-dimer, PT prolongation, fibrinogen) + overt bleeding; >5 points = overt DIC (requires aggressive treatment).
• Management: (1) REMOVE THE TRIGGER (deliver baby, evacuate molar pregnancy, treat infection, remove dead fetus), (2) Restore circulating volume (0.9% NaCl, LR), (3) Replace consumed factors (packed RBCs, fresh frozen plasma for factors II/V/VII/X, platelets for count <50,000, cryoprecipitate for fibrinogen <100 mg/dL), (4) Monitor coagulation labs every 4-6 hours until stable.
• Cryoprecipitate: contains fibrinogen, von Willebrand factor, factors VIII and XIII; dosed at 10 units (each unit contains 150-250 mg fibrinogen); give 10 units (40 g fibrinogen) to target fibrinogen >150 mg/dL.
• Fresh frozen plasma: contains all vitamin K–dependent and other labile factors; dosed at 10-15 mL/kg to correct PT/aPTT prolongation.
• Nursing: maintain two large-bore IVs; monitor labs closely; watch for signs of bleeding/clotting; maintain urine output ≥30 mL/hr; avoid invasive procedures (NG tube, Foley if possible) that increase bleeding; explain treatment plan to family.
• Prognosis: DIC in obstetrics has better outcomes than in other settings (removal of trigger often curative); maternal mortality is ~10-15% with modern management; monitor for long-term sequelae (organ damage, psychological trauma).

Key Definitions

Diagrams To Know

• DIC pathophysiology cascade: trigger → thrombin generation → platelet/fibrinogen consumption → coagulopathy + microthrombi + bleeding
• Coagulation lab interpretation in DIC: platelets ↓, fibrinogen ↓, PT ↑, aPTT ↑, D-dimer ↑

Common Values

Section Title

Other Critical Pharmacology in High-Risk Pregnancy Bleeding

Important Facts

• Betamethasone dose: 12 mg IM given as TWO DOSES, 24 hours apart.
• Indication: PRETERM DELIVERY EXPECTED before 34 weeks (placenta previa with bleeding, preeclampsia, abruption, etc.).
• Efficacy peak: 24 hours to 7 days after administration; benefit decreases after 7 days.
• Benefits: Reduces RDS by ~50%, intraventricular hemorrhage (IVH) by ~50%, neonatal mortality by ~30%.
• Contraindications: Active infection (chorioamnionitis, maternal sepsis) — steroid may worsen; ongoing maternal seizures (not absolute but caution); maternal hypersensitivity.
• Side effects: Maternal hyperglycemia (monitor glucose, especially in diabetics), insomnia, mood changes, transient increase in WBC.
• Use in diabetes: May require insulin adjustments; monitor glucose closely.
• Documentation: Record lot number, dates/times of both doses, route (IM), site; educate mother on expected mild hyperglycemia and sleep disturbance.
• Dexamethasone: Alternative agent (8 mg IM × 4 doses, 12 hours apart) — less commonly used; betamethasone is preferred.
• Repeat courses: Single repeat course may be considered if risk of preterm delivery persists and <7 days since first course; excessive repeat courses increase neonatal infections and growth restriction (not routine).
• Must be given BEFORE delivery — has NO benefit if given after baby is born.

Key Definitions

Diagrams To Know

• Betamethasone efficacy timeline: onset at 24 hours, peak at 7 days, minimal benefit after 7 days
• Indications for betamethasone in obstetric bleeding (previa with bleeding, abruption, preeclampsia)

Reactions Or Equations

Item

PAINLESS bright-red bleeding AFTER 28 weeks = PLACENTA PREVIA; PAINFUL dark-red bleeding with rigid uterus = ABRUPTIO PLACENTAE. This single distinction is heavily tested on NLE.

Rank

1

Why Critical

Guides immediate bedside decisions: previa = avoid vaginal exam (catastrophic bleed risk), maintain expectant mgmt if stable; abruption = emergency surgery prep, anticipate DIC, monitor coagulation labs.

Item

NEVER perform vaginal exam with third-trimester bleeding until previa is ruled out by ULTRASOUND (transabdominal or transvaginal). Even a speculum exam or digital cervical exam can perforate a low-lying placenta and cause fatal hemorrhage.

Rank

2

Why Critical

Violation of this rule is a common NLE 'trap' — you will see questions asking 'What is the first nursing action?' The answer is ULTRASOUND, NOT vaginal exam, NOT speculum exam.

Item

Rh-negative, unsensitized mother → give RhoGAM 300 mcg IM at 28 weeks + within 72 hours postpartum (if baby Rh-positive). MICRODOSE (50 mcg) for first-trimester losses (<13 weeks). Check maternal INDIRECT COOMBS is negative (eligibility). Mother's Coombs POSITIVE = do NOT give RhoGAM.

Rank

3

Why Critical

RhoGAM is one of the most frequently tested pharmacology items on NLE. Know the timing, dose, eligibility, and reason (passive antibody suppresses maternal response).

Item

Ectopic pregnancy rupture = SURGICAL EMERGENCY. Triad: unilateral abdominal pain + SHOULDER-TIP pain (Kehr sign from diaphragmatic irritation) + shock signs (tachycardia, hypotension, pallor). Do NOT wait for imaging — prepare for emergency salpingostomy/salpingectomy and massive transfusion.

Rank

4

Why Critical

NLE loves testing recognition of ectopic rupture and shock management. The shoulder pain is the KEY finding that distinguishes ruptured ectopic from other causes of abdominal pain in pregnancy.

Item

Hydatidiform mole: UTERUS LARGER THAN DATES, excessively high beta-hCG (often >100,000 mIU/mL), 'snowstorm' ultrasound, preeclampsia BEFORE 20 WEEKS. After evacuation, follow serial hCG for 6-12 months; rising hCG = choriocarcinoma (malignant transformation). Patient must AVOID PREGNANCY for 1 year.

Rank

5

Why Critical

High-yield combo: recognize clinical picture, anticipate malignancy, know that new pregnancy masks rising hCG and delays cancer detection, counsel contraception.

Item

DIC (disseminated intravascular coagulation) is triggered by missed abortion (retained >4-6 weeks), abruptio placentae with fetal demise, amniotic fluid embolism, sepsis. Watch for OOZING from IV sites, bleeding gums, petechiae, hematuria. Labs: ↓ platelets, ↓ fibrinogen, ↑ PT/aPTT, ↑ D-dimer. Management: remove trigger + blood products (FFP, platelets, cryo).

Rank

6

Why Critical

DIC complicates the most severe bleeding disorders and requires immediate recognition. Failure to spot DIC signs can be fatal — the exam will test both lab interpretation and clinical recognition.

Item

Betamethasone 12 mg IM × 2 doses (24 hours apart) accelerates fetal lung maturity when preterm delivery expected BEFORE 34 WEEKS. Must be given BEFORE delivery, not after. Peak efficacy 24 hours to 7 days; minimal benefit after 7 days.

Rank

7

Why Critical

Betamethasone is standard of care in preterm bleeding (previa, abruption, preeclampsia). NLE will ask about indication, dose, timing, and what it prevents (RDS, IVH, neonatal mortality).

Item

Methotrexate (MTX) for unruptured ectopic pregnancy: 50 mg/m² IM single dose. Mechanism: inhibits dihydrofolate reductase → blocks folate metabolism → stops trophoblastic proliferation. AVOID folic acid, alcohol, sun exposure. Follow declining hCG. Pregnancy avoid for 3 months (teratogenic).

Rank

8

Why Critical

MTX is the medical (non-surgical) option for stable, unruptured ectopic. NLE tests dose, mechanism, contraindications, and follow-up (hCG monitoring). Know difference from surgical approach.

Item

Estimate blood loss in pregnancy: Count/weigh perineal pads (1 g = 1 mL). Early shock signs: tachycardia (>100), restlessness, cool clammy skin, narrow pulse pressure. HYPOTENSION is LATE sign. Monitor urine output (goal ≥30 mL/hr); oliguria (<25 mL/hr) = shock progression. Establish large-bore IV × 2 for rapid resuscitation.

Rank

9

Why Critical

Hemorrhage assessment and shock management appear on every NLE. Know early signs (you act before BP drops) vs. late signs. Know what fluids to give and how to monitor perfusion (UOP, mental status, vital signs).

Item

Abortion types by cervical status: threatened (closed, may continue) → inevitable (open, loss certain) → incomplete (open, tissue partial) → complete (closed, all out) → missed (closed, fetus dead inside). Assessment: pad count, cramping, tissue passage, hCG, ultrasound. Emotional support is critical (never minimize loss). Rh-negative → RhoGAM.

Rank

10

Why Critical

First-trimester bleeding is heavily tested. Know how to differentiate types by cervical findings and outcome. Know that only threatened has potential to continue; all others = loss confirmed. Know emotional care is nursing priority.

Tip

When you see 'third-trimester bleeding' on the exam, IMMEDIATELY think: Is this painless (previa) or painful (abruption)? This single distinction guides ~80% of your answer. If painful + rigid uterus → emergency, DIC risk, cesarean. If painless + soft uterus → expectant, position rest, no vaginal exam.

Context

NLE loves testing the painless vs. painful distinction. Many students confuse them or forget the uterine findings. Always ask yourself: 'What color is the blood? Is the uterus soft or rigid?' You will get it right.

Tip

For any obstetric bleeding, write down IMMEDIATELY: pad count, vital signs, fetal heart rate, urine output, and blood loss estimate in mL. Do NOT guess. The exam may give you a scenario like 'patient soaked 4 pads in 2 hours' — calculate: 4 pads × 15 g/pad = 60 g = 60 mL. This is 'light' bleeding, NOT shock yet. Trending is key.

Context

Hemorrhage quantification separates good nurses from mediocre ones on NLE. Examiners want to see systematic assessment, not vague 'heavy bleeding' descriptions.

Tip

RhoGAM eligibility check: Mother Rh-negative + Mother's indirect Coombs NEGATIVE = GIVE. Mother Rh-negative + Mother's indirect Coombs POSITIVE = DO NOT GIVE (already sensitized, RhoGAM useless). This single check appears in multiple NLE questions. Memorize it.

Context

Many students forget to check the Coombs test and mistakenly say 'give RhoGAM to Rh-negative mothers.' Wrong — you must verify she is NOT already sensitized. The Coombs test is the gate-keeper.

Tip

If you see 'beta-hCG rising slowly' or 'fails to double,' think ECTOPIC until proven otherwise. If you see 'beta-hCG extremely high (>100,000)' at early gestation + uterus larger than dates + snowstorm ultrasound, think MOLAR PREGNANCY. These labs are HUGE clinical clues on NLE.

Context

NLE loves testing hCG patterns. Train yourself to know: normal rise (doubles every 48-72 hrs) vs. slow rise (ectopic, miscarriage) vs. excessively high (mole). The pattern tells the story.

Tip

For shock in obstetric bleeding, remember the sequence: (1) TACHYCARDIA appears first (100-120 bpm), (2) COOL SKIN and restlessness follow, (3) NARROW PULSE PRESSURE develops, (4) HYPOTENSION appears LAST. If you wait for hypotension to act, you're too late. Act on early signs. This is the difference between pass and fail on shock questions.

Context

Shock is the #1 killer in obstetric bleeding. NLE will test whether you recognize EARLY shock vs. waiting for LATE (decompensated) shock. Early recognition = early intervention = saving mother and baby.

Rows

Columns

• Type
• Cervical Os
• Bleeding
• Cramping
• Passage of Tissue
• Outcome
• Management

Table Title

First-Trimester Abortion Types: Cervical Status & Outcome

Rows

Columns

• Feature
• Placenta Previa (Painless)
• Abruptio Placentae (Painful)

Table Title

PAINLESS vs. PAINFUL Third-Trimester Bleeding: Placenta Previa vs. Abruptio Placentae

Rows

Columns

• Feature
• Complete Mole
• Partial Mole

Table Title

Complete Mole vs. Partial Mole: Karyotype, Fetal Tissue, & Malignancy Risk

Rows

Columns

• Feature
• Ectopic Pregnancy (Unruptured)
• Choriocarcinoma (Post-Molar)

Table Title

Methotrexate (MTX) Use in Bleeding Disorders: Ectopic vs. Molar Malignancy

Rows

Columns

• Scenario
• Dose
• Timing
• Mother's Eligibility
• Notes

Table Title

Rho(D) Immune Globulin (RhoGAM): Timing, Dose, and Eligibility