OB/GYN cases appear on CCS more often than most test-takers expect, and they are among the most anxiety-inducing because you are managing two patients simultaneously. The good news: OB CCS cases follow predictable patterns. The key is knowing the critical actions for each trimester-specific emergency and acting fast.
The Golden Rule: Every Woman of Childbearing Age Gets a Pregnancy Test
This cannot be overstated. On CCS, if your patient is female and between ages 12–55, order a urine pregnancy test (beta-hCG) as one of your first actions — regardless of the chief complaint. A positive pregnancy test changes your entire differential and management plan.
First Trimester Complications
Ectopic Pregnancy
Presentation: Lower abdominal pain + vaginal bleeding + positive pregnancy test
Red flags: Hemodynamic instability, peritoneal signs
Workup:
• Quantitative beta-hCG
• Transvaginal ultrasound (TVU) — no intrauterine pregnancy with hCG > 1,500–2,000
• CBC, type and crossmatch (prepare for surgery)
• Rh status (give RhoGAM if Rh-negative)
Management:
• Stable, unruptured, hCG < 5,000: Methotrexate (medical management) + serial hCG monitoring
• Unstable or ruptured: OB/GYN surgical consult — STAT. Laparoscopic salpingectomy. IV fluids and transfusion as needed. ICU if hemodynamically unstable.
Threatened/Inevitable/Complete Miscarriage
• Pelvic exam to assess cervical os (open vs. closed)
• TVU to assess fetal viability
• Rh status → RhoGAM if Rh-negative
• Emotional support and counseling
• Follow-up hCG levels to confirm resolution
> Practice Alert: OB emergency cases are heavily tested on Step 3 CCS. The StudyCCS question bank includes ectopic pregnancy, placental abruption, and preeclampsia scenarios with different acuity levels. These cases test split-second decision-making — the kind of reflexes you can only build through practice.
Second and Third Trimester Bleeding
Placental Abruption
Presentation: Painful vaginal bleeding, rigid/tender uterus, fetal distress
Risk factors: Hypertension, trauma, cocaine use, prior abruption
Management:
• Do NOT perform digital cervical exam until placenta previa is ruled out
• Continuous fetal monitoring
• IV access x 2, type and crossmatch, CBC, coagulation panel (DIC risk)
• Aggressive fluid resuscitation
• OB/GYN consult — STAT
• If severe with fetal distress → emergent cesarean section
• If mild and stable → admit for monitoring, betamethasone if preterm (24–34 weeks)
Placenta Previa
Presentation: Painless vaginal bleeding, especially in third trimester
Risk factors: Prior C-section, multiparity, prior previa
Management:
• Absolutely NO digital cervical exam (can cause massive hemorrhage)
• Transvaginal ultrasound (safe — does not touch cervix)
• Continuous fetal monitoring
• Type and crossmatch, CBC
• Bed rest, pelvic rest
• Betamethasone if preterm (24–34 weeks)
• Planned cesarean delivery at 36–37 weeks if stable
• Emergent cesarean if massive hemorrhage or fetal distress
Preeclampsia and Eclampsia
Preeclampsia
Diagnosis: New-onset hypertension (≥140/90) after 20 weeks gestation + proteinuria (≥300 mg/24h or protein/creatinine ratio ≥0.3) OR severe features
Severe features (any one):
• SBP ≥ 160 or DBP ≥ 110
• Thrombocytopenia (platelets < 100,000)
• Elevated liver enzymes (2x normal)
• Renal insufficiency (creatinine > 1.1)
• Pulmonary edema
• New-onset headache or visual disturbances
Workup:
• CBC with platelets, BMP, LFTs, LDH, uric acid
• 24-hour urine protein or spot protein/creatinine ratio
• Coagulation panel
• Continuous fetal monitoring
Management:
• Preeclampsia without severe features, ≥37 weeks: Delivery (induction of labor)
• Preeclampsia without severe features, <37 weeks: Expectant management with close monitoring
• Preeclampsia with severe features: IV magnesium sulfate (seizure prophylaxis) + antihypertensives (labetalol IV or hydralazine IV) + delivery planning
• If <34 weeks: Betamethasone for fetal lung maturity, then deliver after 48 hours if possible
• If ≥34 weeks with severe features: Deliver after magnesium and BP stabilization
Eclampsia (Seizures in Preeclamptic Patient)
Immediate management:
1. Magnesium sulfate IV bolus then continuous drip (first-line for eclamptic seizures)
2. Protect airway, left lateral decubitus position
3. Antihypertensive (labetalol or hydralazine IV)
4. Continuous fetal monitoring
5. Emergent delivery (cesarean if fetal distress, induction if stable)
Magnesium toxicity monitoring:
• Check reflexes (loss of deep tendon reflexes = early sign)
• Monitor respiratory rate (respiratory depression)
• Check magnesium levels
• Have calcium gluconate at bedside (antidote)
HELLP Syndrome
Diagnosis: Hemolysis + Elevated Liver enzymes + Low Platelets
• Often a variant of severe preeclampsia
• CBC, LDH (elevated with hemolysis), peripheral smear (schistocytes), LFTs, coagulation panel
• Management: Magnesium + delivery. Platelet transfusion if < 20,000 or if bleeding.
Postpartum Hemorrhage
Definition: Blood loss ≥ 1,000 mL or signs/symptoms of hypovolemia after delivery
Immediate management:
• Bimanual uterine massage (most common cause is uterine atony)
• IV oxytocin (first-line for atony)
• Methylergonovine (second-line — contraindicated in hypertension)
• Carboprost/misoprostol (third-line)
• IV fluids, type and crossmatch, transfuse as needed
• If medical management fails → surgical intervention (B-Lynch suture, uterine artery embolization, hysterectomy)
• Think "4 T's": Tone (atony), Trauma (laceration), Tissue (retained placenta), Thrombin (coagulopathy)
Other High-Yield OB Topics for CCS
Gestational diabetes: Screen at 24–28 weeks with glucose tolerance test. Manage with diet first, then insulin if needed. Monitor fetal growth.
Prenatal visit: Complete physical exam, CBC, blood type/Rh, urinalysis, STI screening, rubella immunity, hepatitis B, HIV. Folic acid supplementation. Discuss genetic screening.
Preterm labor: Tocolytics (nifedipine or indomethacin) if < 34 weeks, betamethasone for fetal lung maturity, GBS screening, magnesium for neuroprotection if < 32 weeks.
Group B Streptococcus: Screen at 35–37 weeks. If positive → IV penicillin during labor.
Don't-Miss Diagnoses
1. Ectopic pregnancy — Abdominal pain + bleeding + positive hCG. Ruptured ectopic = surgical emergency.
2. Placental abruption — Painful bleeding + rigid uterus + fetal distress. Emergent cesarean if severe.
3. Eclampsia — Seizures in pregnancy. Magnesium sulfate immediately.
4. HELLP syndrome — Can mimic other conditions. Check CBC, LFTs, LDH.
5. Amniotic fluid embolism — Sudden cardiovascular collapse during labor. Rare but catastrophic.
6. Uterine rupture — Sudden pain + loss of fetal station + fetal distress in patient with prior C-section scar.
The Complete Order Set: OB Emergency (ER)
Immediate:
• Urine pregnancy test, quantitative beta-hCG
• CBC, type and crossmatch, Rh status
• BMP, LFTs, coagulation panel
• Transvaginal ultrasound
• Continuous fetal monitoring (if viable gestational age)
• IV access x 2
Condition-Specific:
• Ectopic: methotrexate (if stable) or surgical consult (if ruptured)
• Abruption/previa: OB consult, continuous monitoring, prepare for delivery
• Preeclampsia: magnesium sulfate, antihypertensives, delivery planning
• Postpartum hemorrhage: uterine massage, oxytocin, escalate as needed
Disposition:
• ICU for eclampsia, massive hemorrhage, DIC
• L&D for active OB management
• Floor for stable preeclampsia monitoring
• Follow-up with OB/GYN
• RhoGAM if Rh-negative with any bleeding event
OB cases can make or break your CCS score. The StudyCCS question bank includes multiple pregnancy complication scenarios — from routine prenatal visits to eclamptic emergencies — with scoring that rewards rapid magnesium administration and appropriate delivery timing.
Related Articles:
• CCS Abdominal Pain: Step-by-Step Workup & Management
• CCS Approach by Chief Complaint: ER vs Clinic vs Floor
• CCS Preventive Care & Discharge Cheat Sheet
• Ultimate Guide to CCS Section of Step 3 (2026)