Obstetrics and Gynecology

An otherwise healthy couple arrives at the reproductive endocrinology clinic for their first consultation regarding primary infertility. They have been actively attempting to conceive for 18 months without success. The female partner is 27 years old, reports predictable 28-day menstrual cycles, and denies any history of pelvic pain, abdominal surgeries, or sexually transmitted infections. The male partner is 29 years old and has no significant past medical history. They are eager to understand the step-by-step process of their care. Arrange the following steps of their evaluation and management in the most appropriate standard chronological sequence, starting from the initial diagnostic step and concluding with the most advanced therapeutic intervention.

Match each obstetric clinical scenario to the most appropriate targeted pharmacologic intervention, taking into account the specific indications and contraindications for each patient.

An established $37$-year-old patient visits the outpatient clinic requesting a new birth control strategy. Over the last $9$ months, she has experienced increasingly heavy menstrual bleeding, often soaking through her clothes and requiring her to take days off work. She previously relied on condoms but desires a highly effective, long-acting method. Her medical background is significant for recurrent right-sided headaches that are preceded by visual bright spots, for which she occasionally takes sumatriptan. She currently consumes one pack of cigarettes per day. Vital signs include a blood pressure of $122/78$ mm Hg, a heart rate of $76$/min, and a body mass index (BMI) of $23$ kg/m $^2$. General physical and pelvic examinations are unremarkable. A urine human chorionic gonadotropin test is negative.

Laboratory studies reveal:
Hemoglobin: $10.5$ g/dL
Thyroid-stimulating hormone: $2.1$ mIU/L
Prolactin: $14$ ng/mL

The patient firmly declines any permanent surgical interventions. Which of the following is the most appropriate next step in the management of this patient?

A 19-year-old collegiate gymnast comes to the clinic for evaluation of absent menstrual periods for the past 10 months. Menarche occurred at age 13, and her menses were previously regular, occurring every 28 to 30 days. She trains approximately 25 hours per week and follows a strict, calorie-restricted diet to maintain her competition weight. Four weeks ago, she sustained a tibial stress fracture. She does not use tobacco, alcohol, or illicit drugs. She is not sexually active. Vital signs show a blood pressure of 94/60 mm Hg and a heart rate of 52/min. Her BMI is $17.8 \text{ kg/m}^2$. Physical examination is unremarkable except for fine, downy hair over her face and arms. Pelvic examination reveals normal female external genitalia and a normal appearing cervix.

Laboratory studies show:

A dual-energy x-ray absorptiometry (DEXA) scan reveals a Z-score of $-2.2$ at the lumbar spine. The patient is anxious about her bone health and requests a prescription to "fix her hormones." She states she must maintain her current training intensity for an upcoming championship. Which of the following is the most appropriate next step in the management of this patient?

Match each classic clinical finding in a patient with primary postpartum hemorrhage to its most likely underlying etiology.

A 25-year-old woman is evaluated in the emergency department for severe bilateral lower quadrant abdominal pain, intractable nausea, and a fever of $39.1^{\circ}\text{C}$ ($102.4^{\circ}\text{F}$). She is unable to tolerate oral fluids. On pelvic examination, there is severe cervical motion tenderness and a palpable left adnexal fullness. Arrange the following steps in the correct chronological sequence for the standard diagnostic workup and management escalation of this patient's suspected complicated Pelvic Inflammatory Disease (PID).

Following a spontaneous vaginal delivery of a $4150\text{ g}$ neonate, a $28$-year-old multiparous patient develops sudden, massive vaginal hemorrhage. The delivery was complicated by a prolonged second stage. During the third stage of labor, strong umbilical cord traction was applied prior to spontaneous placental separation. The patient now reports severe, agonizing lower abdominal pain and severe lightheadedness. Vital signs show a blood pressure of $76/40\text{ mmHg}$ and a heart rate of $142/\text{min}$. Pelvic examination reveals a firm, smooth, beefy-red mass completely filling the vaginal vault, with the placenta still densely attached to its surface. Abdominal palpation fails to identify a uterine fundus in the pelvis. An initial bedside attempt by the physician to manually push the mass cephalad is thwarted by a tightly contracted lower cervical ring. Massive transfusion protocol is activated. Arrange the following subsequent critical management steps in the correct chronological order.

A 25-year-old woman presents to the ambulatory care clinic with complaints of increased, yellowish vaginal discharge for the past week. She denies any pelvic pain, fever, nausea, or burning with urination. The patient is sexually active with a new male partner and reports inconsistent use of barrier contraception. Her medical history is unremarkable, and she takes only a daily oral contraceptive pill. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 118/76 mmHg, and a heart rate of 78/min. On pelvic examination, the vagina appears normal, but the cervix is erythematous, edematous, and bleeds easily upon speculum contact. A sample of mucopurulent discharge is visible at the cervical os. Bimanual examination demonstrates a normal-sized, non-tender uterus and no adnexal masses or cervical motion tenderness. A rapid nucleic acid amplification test (NAAT) performed in the clinic on a cervical swab returns positive for *Neisseria gonorrhoeae* and negative for *Chlamydia trachomatis*.

Which of the following is the most appropriate pharmacotherapy for this patient?

A 25-year-old primigravida at 38 weeks gestation is evaluated in the labor and delivery unit for active labor. Her pregnancy has been uncomplicated. Her temperature is 37.0°C (98.6°F), blood pressure is 118/76 mm Hg, and pulse is 82/min. Cervical examination reveals 5 cm dilation, 100% effacement, and 0 station. Artificial rupture of membranes was performed 1 hour ago, yielding clear amniotic fluid. Uterine contractions are occurring every 3 to 4 minutes and palpate as strong. External fetal monitoring shows a baseline heart rate of 140/min with moderate variability. Over the last 30 minutes, there are abrupt decreases in the fetal heart rate to 85/min that last for 40 to 50 seconds before rapidly returning to baseline. These decreases occur in association with 60% of the uterine contractions, and their timing varies relative to the peak of the contractions. The patient is currently positioned in the left lateral decubitus position and is receiving a bolus of intravenous lactated Ringer solution, but the fetal heart rate pattern remains unchanged. Which of the following is the most appropriate next step in management?

A 34-year-old woman comes to the office for evaluation of secondary amenorrhea. Her last menstrual period was 14 months ago. At that time, she underwent a dilation and curettage for an incomplete abortion, which was complicated by postpartum endometritis requiring intravenous antibiotics. Prior to this pregnancy, her menstrual cycles were regular every 28 days. She reports no hot flashes, galactorrhea, weight changes, or visual disturbances. Her body mass index is 23 kg/m². Physical examination reveals normal secondary sexual characteristics and no evidence of hirsutism or acne. A urine pregnancy test is negative. Serum laboratory testing shows normal levels of follicle-stimulating hormone, luteinizing hormone, prolactin, and thyroid-stimulating hormone. A 10-day course of oral medroxyprogesterone acetate is administered, but no withdrawal bleeding occurs. Subsequently, she is given a 21-day course of oral estrogen followed by 7 days of progestin, which also fails to induce withdrawal bleeding. Which of the following is the most likely diagnosis?

A 32-year-old woman comes to the office due to the absence of menstrual periods for the past 9 months. Her menarche occurred at age 13, and her menses were previously regular, occurring every 28 days and lasting 5 days. Over the last year, she has experienced progressive fatigue, cold intolerance, and a 5-kg (11-lb) weight gain despite a decreased appetite. She has no headaches, visual disturbances, or galactorrhea. Her medical history is unremarkable, and she takes no medications. Vital signs show a blood pressure of 102/64 mmHg and a pulse of 54/min. Physical examination reveals dry, cool skin and a delayed relaxation phase of the deep tendon reflexes. Pelvic examination is normal with no clitoromegaly. A urine pregnancy test is negative.

Laboratory evaluation shows:
Thyroid-stimulating hormone (TSH): 1.3 mIU/L (Normal: 0.5–5.0 mIU/L)
Free thyroxine (T4): 0.4 ng/dL (Normal: 0.8–1.8 ng/dL)
Prolactin: 12 ng/mL (Normal: < 25 ng/mL)
Follicle-stimulating hormone (FSH): 3 mIU/mL (Normal: 5–20 mIU/mL)
Luteinizing hormone (LH): 2 mIU/mL (Normal: 5–20 mIU/mL)

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

An obstetrical care team is evaluating a patient at 39 weeks gestation who is undergoing an induction of labor for gestational diabetes mellitus. She is currently receiving a continuous intravenous oxytocin infusion. Ten minutes ago, she reported a sudden onset of mild shortness of breath. Her vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $122/78\text{ mm Hg}$, heart rate $95\text{/min}$, and respiratory rate $20\text{/min}$. Oxygen saturation is $98\%$ on room air. An arterial blood gas analysis reveals:

* $\text{pH}$: $7.44$
* $\text{PaCO}_2$: $29\text{ mm Hg}$
* $\text{PaO}_2$: $104\text{ mm Hg}$

The electronic fetal monitor demonstrates a baseline heart rate of $145\text{/min}$ with moderate variability. In the past 20 minutes, there have been five uterine contractions. Following three of these contractions, the fetal heart rate gradually decreased to a nadir of $125\text{/min}$, with the nadir occurring after the peak of the contraction, before returning to the baseline. The cervix is 5 cm dilated and 80% effaced. Which of the following is the most appropriate next step in management?

Match each clinical presentation of a gynecologic infection with the most appropriate, guideline-concordant next step in management.

Match each severe intrapartum or puerperal complication to its most classic clinical presentation and associated risk factors.

A $28$-year-old woman, gravida $2$, para $1$, at $40$ weeks of gestation is evaluated on the labor unit. She was admitted $6$ hours ago in spontaneous labor. Her prenatal course was unremarkable. Spontaneous rupture of membranes occurred $3$ hours ago, yielding clear fluid. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $118/76\text{ mm Hg}$, and pulse is $82/\text{min}$. Vaginal examination reveals the cervix is $7\text{ cm}$ dilated, $100\%$ effaced, with the fetal vertex at $0$ station. An external tocodynamometer records uterine contractions every $3$ to $4\text{ minutes}$. The fetal heart rate tracing demonstrates a baseline of $145/\text{min}$ with moderate variability. There are recurrent, visually abrupt decreases in the fetal heart rate to $85/\text{min}$. The time from the onset of the deceleration to the absolute nadir is consistently $15$ to $20\text{ seconds}$. These decelerations last approximately $50\text{ seconds}$ and occur with over $80\%$ of the contractions. Notably, the nadir of each deceleration exactly matches the peak of the corresponding uterine contraction. Position changes to the left lateral decubitus and an intravenous fluid bolus fail to alter the fetal heart rate pattern. 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. She reports that her "water broke" an hour ago at home, followed immediately by a moderate amount of bright red vaginal bleeding. She denies any uterine contractions or abdominal pain. Her two previous deliveries were by cesarean section. Her blood pressure is 110/70 mm Hg, and her pulse is 88/min. The fetal heart rate tracing demonstrates a baseline of 140/min with a smooth, undulating, sine-wave-like pattern oscillating with an amplitude of 15 beats per minute at a frequency of 4 cycles per minute. There is no beat-to-beat variability, and no accelerations or decelerations are noted. The uterus is soft and non-tender on palpation. Which of the following is the most appropriate next step in management?

During a routine evaluation at a women's health clinic, a 31-year-old G2P2 reports a 4-day history of worsening lower pelvic discomfort, deep dyspareunia, and intermittent vaginal spotting. Her last menstrual period occurred 2 weeks ago. She mentions becoming sexually active with a new partner two months ago. Her medical history is significant for the insertion of a copper intrauterine device three years ago. Her temperature is 38.2°C (100.8°F), blood pressure is 110/70 mmHg, and pulse is 88/min. Speculum examination reveals a yellow, mucopurulent discharge at the cervical os along with visible intrauterine device strings. Bimanual examination elicits significant cervical motion tenderness as well as bilateral adnexal fullness and guarding. A urine pregnancy test is negative. Which of the following is the most appropriate next step in the management of this patient?

A 32-year-old woman with poorly controlled type 2 diabetes mellitus comes to the clinic reporting severe vulvovaginal burning and irritation that has persisted for the past 3 weeks. She has been treated with two separate courses of oral fluconazole and a 7-day course of over-the-counter topical miconazole with no relief. Her last hemoglobin A1c was 8.7%. Pelvic examination reveals significant vulvovaginal erythema and edema with a few superficial excoriations. There is a moderate amount of thin, whitish vaginal discharge. The vaginal pH is 4.3. Microscopic evaluation of the discharge with saline and 10% potassium hydroxide (KOH) preparations reveals numerous inflammatory cells and small budding yeasts, but no pseudohyphae are identified. Which of the following is the most appropriate next step in management?

Match each clinical presentation of a third-trimester hepatic or hypertensive complication with its corresponding underlying pathophysiologic mechanism.

Match each intrapartum fetal heart rate pattern to its most likely underlying physiological etiology.