Obstetrics and Gynecology

A 39-year-old woman comes to the emergency department due to a 24-hour history of high fever, chills, and right-sided back pain. She also reports a constant sensation of vaginal wetness that requires her to change her sanitary pad multiple times a day. Ten days ago, the patient underwent an uncomplicated total abdominal hysterectomy for severe endometriosis. Her temperature is 39.0°C (102.2°F), blood pressure is 110/65 mmHg, and pulse is 112/min. She has no pain with urination and voids normally. Physical examination shows pronounced tenderness to percussion over the right costovertebral angle. On speculum examination, a pool of clear fluid is visualized in the vaginal vault. The vaginal cuff appears well-approximated without erythema. A transurethral catheter is placed, and a retrograde instillation of a dilute methylene blue solution into the bladder is performed. A sterile tampon placed in the vagina for 15 minutes is subsequently removed; it is saturated with clear, yellowish fluid but shows no evidence of blue discoloration. Which of the following is the most appropriate next step in management?

A 32-year-old nulliparous woman is evaluated in the clinic for the absence of menstruation over the past $8$ months. She and her partner have been having unprotected intercourse for the past year without conception. The patient additionally complains of chronic fatigue, feeling cold even in a warm room, and new-onset dull, bilateral morning headaches. Her vital signs include a blood pressure of $110/70 \text{ mm Hg}$, heart rate of $58/\text{min}$, and respiratory rate of $12/\text{min}$. Body mass index is $24 \text{ kg/m}^2$. Physical examination shows pale and dry skin, and a delayed relaxation phase of the Achilles tendon reflexes. Visual field testing by confrontation is normal. Pelvic examination is unremarkable.

Laboratory results:
Serum beta-hCG: negative
Follicle-stimulating hormone: $2.4 \text{ mIU/mL}$
Luteinizing hormone: $1.1 \text{ mIU/mL}$
Prolactin: $45 \text{ ng/mL}$ (Normal: $4-23 \text{ ng/mL}$)
Thyroid-stimulating hormone: $1.2 \text{ mIU/L}$ (Normal: $0.5-5.0 \text{ mIU/L}$)
Free thyroxine (T4): $0.4 \text{ ng/dL}$ (Normal: $0.9-1.7 \text{ ng/dL}$)

Which of the following is the most appropriate next step in the evaluation or management of this patient?

A 62-year-old G3P3 postmenopausal woman presents to the urogynecology clinic with a sensation of vaginal fullness and progressive difficulty with bowel movements over the past year. She reports needing to press her fingers against the posterior wall of her vagina to successfully defecate. She desires a comprehensive plan to address her symptoms and asks about the standard protocol. Arrange the following evaluation and management steps for this patient in the standard clinical sequence, proceeding from the initial diagnostic assessment to the most invasive definitive treatment.

A 30-year-old female presents to the outpatient clinic reporting the cessation of her menstrual cycles over the last 7 months. She previously experienced predictable 28-day intervals. Recently, she has been troubled by nighttime awakenings associated with intense sweating and flushing. She is sexually active with a single male partner and relies on barrier contraception. Medical history is noncontributory, and she takes no daily medications. Her body mass index is 22 kg/m $^2$. Vital signs are temperature 37.0°C (98.6°F), blood pressure 112/74 mm Hg, pulse 76/min, and respirations 14/min. Pelvic examination demonstrates pale, thinned vaginal epithelium with minimal secretions. The uterus is normal in size and non-tender, with no adnexal masses appreciated. A point-of-care urine pregnancy test is negative.

Arrange the following diagnostic and management steps in the most appropriate clinical sequence to evaluate and treat this patient's condition.

A primigravid patient at 39 weeks and 5 days of gestation is admitted to the labor and delivery ward in active labor. She has no significant past medical history and her prenatal course was unremarkable. Pelvic examination reveals a cervix that is 7 cm dilated and 100% effaced, with the fetal vertex at 0 station. Clear amniotic fluid is noted following spontaneous membrane rupture three hours ago. Uterine contractions are occurring every 3 minutes. The continuous fetal heart rate monitor shows a baseline of 145/min with moderate variability. During the last 40 minutes, there are recurrent, abrupt decreases in the fetal heart rate to 85/min that last for approximately 45 seconds. The onset, depth, and duration of these decelerations vary from one contraction to the next, often without a consistent relationship to the peak of the contraction. Initial resuscitative measures, including maternal repositioning to the left lateral decubitus position and administration of an intravenous fluid bolus, have been performed. Despite these interventions, the fetal heart rate pattern remains unchanged. Which of the following is the most appropriate next step in management?

Match each severe obstetric complication with its most characteristic diagnostic hallmark, imaging finding, or clinical presentation.

A 24-year-old G1P0 woman at 33 weeks gestation presents to the obstetric triage unit with painful uterine contractions and leakage of clear vaginal fluid that began 8 hours ago. Her prenatal course has been uncomplicated. On admission, her temperature is 39.1°C (102.4°F), blood pressure is 112/72 mm Hg, pulse is 118/min, and respiratory rate is 18/min. Physical examination reveals a diffusely tender uterine fundus. A sterile speculum examination confirms pooling of amniotic fluid in the posterior vaginal fornix. The cervix is visibly 4 cm dilated and 80% effaced. Continuous fetal heart rate monitoring demonstrates a baseline of 170/min, minimal variability, and no decelerations. The patient is fully oriented. When the physician discusses the clinical findings, she states, 'I understand the risks, but I strongly want to have a vaginal delivery. I refuse any surgical intervention unless my baby is in imminent, life-threatening danger.' Which of the following is the most appropriate next step in management?

A $32$-year-old G2P1 at $35$ weeks gestation is hospitalized for preeclampsia with severe features. She is receiving continuous intravenous magnesium sulfate and oxytocin for labor induction. Over the past $4$ hours, her total urine output has been $45$ mL. She now reports profound weakness and blurry vision. Her blood pressure is $155/95$ mmHg, and heart rate is $88$/min. Her respiratory rate is $10$/min, and oxygen saturation is $91\%$ on room air. Neurologic examination reveals no muscle contraction upon percussion of the patellar tendons. Fetal heart rate monitoring demonstrates a baseline of $130$/min, minimal variability, and recurrent late decelerations with $60\%$ of contractions.

Arterial blood gas (room air):
pH: $7.29$
pCO $_2$: $54$ mmHg
pO $_2$: $62$ mmHg
HCO $_3^-$: $25$ mEq/L

Serum chemistry from $1$ hour ago:
Creatinine: $1.5$ mg/dL (baseline $0.7$ mg/dL)

What is the most appropriate next step in management?

Match each clinical vignette describing a characteristic gynecologic neoplasm with the serum tumor marker most likely to be elevated in that patient.

A multiparous patient at term delivers a healthy neonate via a spontaneous vaginal delivery. Twenty minutes following the intact delivery of the placenta, she develops profuse vaginal bleeding. Her blood pressure drops to 88/50 mm Hg, and her pulse rises to 122/min. Abdominal examination reveals a soft, enlarged uterus palpated above the umbilicus. A continuous intravenous oxytocin infusion was initiated upon placental delivery.

Arrange the following interventions in the correct escalating sequence for managing refractory postpartum hemorrhage due to uterine atony, from the immediate next step to the final definitive surgical treatment.

A 26-year-old woman presents to the clinic with a 9-month history of absent menses. Over the past 6 months, she has noticed a rapid increase in thick, dark hair on her face and chest, temporal hair thinning, and a noticeable deepening of her voice. She had menarche at age 12, and her menstrual cycles were previously regular, occurring every 28 days. She takes no medications and is not sexually active. Her body mass index is $23 \text{ kg/m}^2$. Vital signs are within normal limits. Physical examination reveals severe nodulocystic acne over the face and back, temporal balding, and notable clitoromegaly. A urine pregnancy test is negative. Serum thyroid-stimulating hormone and prolactin levels are within normal limits. Which of the following is the most appropriate next step in evaluation?

A 52-year-old woman is newly diagnosed with stress urinary incontinence. She is interested in a stepwise approach to her treatment, wanting to try the least invasive options first before considering surgery. Arrange the following management strategies for stress urinary incontinence in the correct sequential order from the most conservative (first-line) to the most invasive (definitive) therapy.

A $24$-year-old nulligravid woman comes to the clinic due to worsening lower abdominal pain and a new, foul-smelling vaginal discharge over the past $4$ days. She has a copper intrauterine device (IUD) that was inserted three years ago. She recently became sexually active with a new male partner. Her temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure is $118/76\text{ mm Hg}$, and pulse is $92\text{/min}$. Speculum examination shows a yellow, mucopurulent discharge exuding from the cervical os, and the IUD strings are clearly visible in the vaginal vault. Bimanual examination reveals pronounced cervical motion tenderness and bilateral adnexal tenderness. There are no palpable adnexal masses, and a pelvic ultrasound is unremarkable aside from a properly positioned intrauterine device. A urine pregnancy test is negative. Which of the following is the most appropriate next step in management?

Correlate the following clinical presentations of acute intrapartum and third-trimester emergencies with their primary defining pathophysiologic mechanism.

A 26-year-old woman, gravida 1, para 0, presents for a scheduled prenatal visit at 27 weeks gestation. Her last prenatal visit was at 22 weeks. The patient reports urinating more frequently and experiencing a mild, dull ache in her right flank for the past week. She denies dysuria, hematuria, fever, and chills. Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $110/68 \text{ mm Hg}$, and pulse $86/\text{min}$. Physical examination shows a gravid uterus consistent with dates and trace bilateral lower extremity edema. There is mild right costovertebral angle tenderness. Fetal heart tones are $145/\text{min}$.

Laboratory results are as follows:
Hemoglobin: $10.8 \text{ g/dL}$
Leukocyte count: $14,500/\text{mm}^3$
Platelets: $175,000/\text{mm}^3$
Serum creatinine: $0.5 \text{ mg/dL}$

Urinalysis:
Protein: Trace
Glucose: $1+$
Leukocyte esterase: Negative
Nitrites: Negative
WBC: $2-3/\text{hpf}$
RBC: $0-1/\text{hpf}$

A transabdominal renal ultrasound demonstrates mild dilation of the right renal pelvis and proximal ureter. The left kidney is normal.

Which of the following is the most appropriate next step in management?

A 32-year-old gravida 3, para 2 woman at 38 weeks gestation is admitted to the labor and delivery unit in active labor. Her prenatal course was uncomplicated. Her temperature is 37.1°C (98.8°F), blood pressure is 122/78 mmHg, and pulse is 84/min. The fetal heart rate baseline is 145/min with moderate variability and no decelerations. A sterile vaginal examination reveals the cervix is 5 cm dilated and 80% effaced, with the fetal vertex at -2 station and bulging amniotic membranes. Shortly after the examination, the patient experiences spontaneous rupture of membranes with a large gush of clear fluid. The continuous fetal monitor immediately records an abrupt decrease in the fetal heart rate to 75/min that does not resolve over the next 3 minutes. A repeat vaginal examination reveals a soft, pulsatile, rope-like mass in the vaginal vault extending past the fetal presenting part. Which of the following is the most appropriate next step in the management of this patient?

A 57-year-old woman is evaluated in the clinic for three weeks of intermittent vaginal spotting. She experienced menopause seven years ago and had no vaginal bleeding until this recent episode. She denies abdominal pain, weight loss, or changes in bowel and bladder habits. Her past medical history is significant only for hypertension, which is well controlled with amlodipine. Her body mass index is 24 kg/m². Vital signs are within normal limits. On pelvic examination, the vulva and vagina appear atrophic. The cervix has no visible lesions, but blood is noted at the external os. Bimanual examination reveals a firm, mobile, non-tender, 8-cm mass in the right adnexa. A transvaginal ultrasound demonstrates an 8.5-cm right ovarian mass with both solid and cystic components. The endometrial stripe thickness is measured at 13 mm. Which of the following is the most appropriate next step in the management of this patient?

Seeking evaluation for worsening fatigue and irregular vaginal bleeding, a 46-year-old woman presents to the gynecology clinic. For the past eight months, her menstrual cycles have become highly unpredictable, varying from $21$ to $45$ days in length. When she does menstruate, the bleeding lasts up to $10$ days and is extremely heavy, often requiring her to use two maxi pads simultaneously. Her previous cycles were regular, occurring every $28$ days. Her medical history includes type 2 diabetes mellitus, obesity, and hypothyroidism. Her current medications are metformin and levothyroxine. Vital signs include a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $135/85 \text{ mmHg}$, and heart rate of $88\text{/min}$. Her BMI is $36 \text{ kg/m}^2$. Pelvic examination demonstrates a normal-appearing cervix; the uterus is normal in size, mobile, and non-tender without palpable adnexal masses. A urine beta-hCG test is negative. Laboratory studies reveal a hemoglobin concentration of $10.1 \text{ g/dL}$.

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

During a routine wellness visit, a $38$-year-old G2P2 patient expresses interest in resuming prescription birth control. She previously used an etonogestrel/ethinyl estradiol vaginal ring for several years without adverse effects, but discontinued it prior to her last pregnancy. She gave birth $8$ months ago and is no longer breastfeeding. She hopes to attempt pregnancy again in approximately $12$ to $18$ months. Her menstrual cycles have resumed but are characterized by severe lower abdominal cramping and heavy bleeding lasting $8$ days, requiring her to change pads every $2$ hours. Medical history is notable for generalized anxiety disorder and tobacco use disorder; she consumes approximately $20$ cigarettes daily. Vital signs include a blood pressure of $146/92$ mmHg and a body mass index of $28 \text{ kg/m}^2$. Pelvic examination is unremarkable, and a urine beta-hCG test is negative. She requests a new prescription for the vaginal ring. Which of the following is the most appropriate contraceptive management for this patient?

Evaluated in the emergency department for severe nausea, vomiting, and vaginal bleeding, a 22-year-old primigravida reports her last menstrual period occurred $10$ weeks ago. Her blood pressure is $155/95$ mm Hg, and her pulse is $110$/min. Physical examination reveals a uterus that is palpable midway between the pubic symphysis and the umbilicus. Fetal heart tones cannot be auscultated by Doppler. Quantitative serum $\beta$-hCG is $250,000$ mIU/mL. Pelvic ultrasonography demonstrates a heterogeneous, echogenic intrauterine mass containing multiple small cystic spaces, with no fetal pole identified. Which of the following is the most appropriate next step in the management of this patient?