Obstetrics and Gynecology

A 35-year-old woman, gravida 4, para 3, at 39 weeks gestation is admitted to the labor and delivery unit for labor induction due to diet-controlled gestational diabetes mellitus. Oxytocin augmentation is ongoing. Epidural anesthesia was administered two hours ago. Her current cervical dilation is $8\text{ cm}$. She suddenly becomes extremely anxious and reports severe shortness of breath. Moments later, she becomes obtunded. Her blood pressure is $60/40\text{ mmHg}$, pulse is $135\text{ /min}$, and respiratory rate is $28\text{ /min}$. Pulse oximetry shows an oxygen saturation of $78\%$ on room air. The nursing staff notes continuous oozing of dark blood from the patient's peripheral intravenous catheter site. The continuous fetal heart rate monitor, which previously showed a Category I tracing, now demonstrates a sudden, prolonged deceleration to $60\text{ /min}$ with absent variability.

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

A patient, gravida 3, para 2, is brought to the obstetrical triage unit at 37 weeks and 5 days of gestation due to the sudden onset of constant, agonizing lower abdominal pain and vaginal bleeding. Her medical history is significant for poorly controlled chronic hypertension and daily tobacco use. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 168/110 mm Hg, and a heart rate of 115/min. On physical examination, the uterine fundus is rigid and exquisitely tender to light palpation; it does not relax between perceived contractions. Dark red blood is noted at the vaginal introitus. A prior third-trimester ultrasound documented an anterior, high-lying placenta. Sterile vaginal examination demonstrates the cervix is 2 cm dilated and 50% effaced, with the fetal vertex at a -2 station. Continuous fetal monitoring displays a baseline heart rate of 165/min, undetectable variability, and repetitive late decelerations following every contraction. The tocodynamometer indicates low-amplitude, high-frequency contractions occurring every 1 to 2 minutes. Which of the following represents the most appropriate next step in the management of this patient?

A $31$-year-old woman, gravida $3$, para $2$, presents to the obstetrics clinic at $23$ weeks gestation for a scheduled evaluation. She reports new-onset, brief, sharp, pulling pains in the bilateral lower quadrants of her abdomen. The pain occurs primarily when she stands up quickly from a seated position and resolves within a few seconds. She denies vaginal bleeding, dysuria, or regular uterine contractions. Her blood pressure is $110/66$ mm Hg, pulse is $86$/min, and respirations are $16$/min. Abdominal examination reveals a soft uterus with fundal height corresponding to $23$ cm. There is mild tenderness to palpation over the lateral borders of the uterus, but no guarding or rebound tenderness. Laboratory results obtained two days ago for an employer-sponsored health screening reveal the following:

Serum sodium: $131$ mEq/L
Serum creatinine: $0.5$ mg/dL
Alkaline phosphatase (ALP): $245$ U/L
Aspartate aminotransferase (AST): $22$ U/L

Urinalysis:
Specific gravity: $1.014$
Glucose: $2+$
Protein: Trace
Leukocyte esterase: Negative
Nitrites: Negative
Microscopy: $1-2$ WBCs/hpf

Based on these clinical and laboratory findings, which of the following is the most appropriate next step in management?

An expectant mother in her first pregnancy presents to the clinic at 24 weeks of gestation for a scheduled prenatal evaluation. She reports feeling generally well but notes mild fatigue and bilateral ankle swelling after long shifts at her retail job. She takes a standard daily prenatal vitamin. Vital signs show a blood pressure of $112/68 \text{ mm Hg}$, pulse of $82/\text{min}$, and respiratory rate of $16/\text{min}$. Physical examination reveals trace bilateral pedal edema but is otherwise unremarkable. Laboratory studies return the following results:

Which of the following is the most appropriate action regarding these laboratory findings?

A series of pregnant patients present to the labor and delivery unit, and their continuous fetal heart rate (FHR) tracings are evaluated. Based on the clinical presentation and tracing characteristics, match each intrapartum scenario with its most likely underlying pathophysiology.

A 32-year-old woman, gravida 4, para 4, has an uncomplicated vaginal delivery of a 4200 g (9 lb 4 oz) neonate. Ten minutes later, the placenta is delivered intact. Shortly after, she develops heavy, continuous vaginal bleeding. Her blood pressure drops to 90/50 mm Hg, and her heart rate increases to 115/min. Abdominal examination reveals a soft, boggy uterus palpated 2 cm above the umbilicus. Two large-bore intravenous lines are placed, and aggressive fluid resuscitation is initiated. Arrange the following interventions for the management of this patient's hemorrhage in the most appropriate chronological sequence, assuming the bleeding persists despite each preceding step.

Match each patient's clinical profile with the most appropriate contraceptive method based on the World Health Organization Medical Eligibility Criteria (WHO MEC).

Match each clinical presentation of a breast disorder to its most likely corresponding histopathological finding on core needle biopsy.

An evaluation is requested for a 47-year-old female patient who desires reliable contraception. She reports a 9-month history of erratic, heavy menstrual cycles. Menses occur unpredictably every 3 to 6 weeks, lasting up to 12 days, and are accompanied by the passage of large clots. The patient's medical history includes chronic hypertension and tobacco use disorder, smoking approximately 20 cigarettes per day. Current medications include lisinopril. Vital signs show a blood pressure of 144/92 mmHg, pulse of 82/min, and a body mass index of $35\text{ kg/m}^2$. Pelvic examination demonstrates a parous, normal-appearing cervix and a globally enlarged, non-tender uterus. A urine pregnancy test is negative. Laboratory studies indicate a hemoglobin level of 9.8 g/dL. Pelvic ultrasonography reveals a heterogeneous endometrial echo complex measuring $16\text{ mm}$ in thickness with cystic changes. The patient is interested in starting a contraceptive method that will also alleviate her heavy bleeding. Which of the following is the most appropriate next step in the care of this patient?

An otherwise healthy $30$-year-old woman presents to the clinic complaining of a $3$-day history of worsening dull, bilateral lower abdominal pain and a new onset of malodorous, yellowish vaginal discharge. She reports no fever, chills, nausea, or vomiting. Her medical history is unremarkable. She has a copper intrauterine device (IUD) that was inserted $3$ years ago for contraception. She recently became sexually active with a new male partner. Vital signs include a temperature of $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), blood pressure of $120/78\text{ mm Hg}$, and pulse of $82/\text{min}$. Pelvic examination reveals a visually normal cervix with visible IUD strings and moderate purulent discharge at the cervical os. Bimanual examination elicits pronounced cervical motion tenderness and bilateral adnexal tenderness without palpable masses or fullness. A urine pregnancy test is negative. Which of the following is the most appropriate next step in the management of this patient?

An oncologist refers a 58-year-old patient to the gynecology clinic after she reports a recent episode of dark red vaginal spotting. She underwent breast-conserving surgery and radiation for early-stage hormone receptor-positive breast cancer three years ago. Since her surgery, she has been maintained on adjuvant tamoxifen therapy. The patient's last menstrual period occurred naturally at age 52. She denies pelvic pain, dysuria, or systemic symptoms. Her body mass index is $26 \text{ kg/m}^2$. Speculum examination demonstrates pale, thinned vaginal walls with a small amount of blood in the vaginal vault. The cervix appears grossly normal without lesions. Which of the following is the most appropriate next step in management?

A 28-year-old G2P1 woman at 36 weeks gestation presents to the labor triage unit complaining of mild, irregular abdominal cramping. Two hours ago, she was given intravenous fentanyl at an outside clinic for severe back pain. Her prenatal course was notable for a second-trimester anatomy ultrasound revealing a bilobed placenta. Shortly after admission, she experiences a sudden rush of clear fluid from her vagina, followed immediately by a gush of bright red blood. She denies any sharp or severe abdominal pain. Maternal vital signs are: blood pressure 118/76 mmHg, heart rate 86/min, and temperature 37.1°C (98.8°F). The abdomen is soft, non-tender, and without guarding. Fetal heart rate monitoring demonstrates a baseline of 150/min. The tracing exhibits a smooth, undulating, sine-wave-like pattern with a frequency of 3 to 4 cycles per minute, completely absent beat-to-beat variability, and no accelerations. This pattern has persisted for 25 minutes. A sterile speculum examination shows active bleeding pooling in the posterior fornix. Which of the following is the most appropriate next step in management?

A primigravid patient at $40$ weeks and $3$ days of gestation is admitted to the labor and delivery unit for an elective induction of labor. An induction is currently underway using a continuous intravenous oxytocin infusion. Her epidural analgesia is functioning well and providing adequate pain relief. Her vital signs are within normal limits, with a blood pressure of $118/74$ mm Hg, a heart rate of $82$/min, and a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$). Routine admission laboratory studies reveal a hemoglobin of $10.5$ g/dL and a platelet count of $165,000/\text{mm}^3$. A recent pelvic examination demonstrates cervical dilation of $6$ cm and effacement of $100\%$, with the fetal vertex at $0$ station. External tocodynamometry records uterine contractions occurring every $2$ to $3$ minutes. Cardiotocography displays a baseline fetal heart rate of $128$/min accompanied by minimal variability. The tracing also shows gradual, symmetric drops in the fetal heart rate to a nadir of $115$/min. The onset of each drop consistently begins after the peak of the associated contraction, and the heart rate returns to baseline only after the uterine tone has normalized. These episodes occur with nearly every contraction. Which of the following is the most appropriate next step in management?

A $26$-year-old primigravida at $40$ weeks gestation is evaluated in the labor and delivery unit. She is undergoing an induction of labor for gestational diabetes mellitus. She is currently receiving a continuous intravenous oxytocin infusion, and epidural anesthesia is in place. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $122/78\text{ mmHg}$, and pulse is $88/\text{min}$. A recent cervical examination revealed a dilation of $6\text{ cm}$, $90\%$ effacement, and $0$ station. Over the past $20$ minutes, the tocodynamometer records $7$ uterine contractions per $10$-minute window, with each contraction lasting $60$ to $80$ seconds. The fetal heart rate tracing demonstrates a baseline of $145/\text{min}$, minimal variability, and recurrent decelerations that begin after the peak of the contractions and take $\geq 30$ seconds to reach their nadir.

The nurse immediately discontinues the oxytocin infusion, repositions the patient to the left lateral decubitus position, and administers a $500\text{-mL}$ intravenous bolus of lactated Ringer solution. Fifteen minutes later, the contraction frequency remains $6$ to $7$ per $10$ minutes, and the fetal heart rate tracing continues to show recurrent late decelerations with minimal variability.

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

During a routine health maintenance visit, a 23-year-old female college student reports a bothersome change in her vaginal discharge over the past week. She describes the discharge as thin and grayish, accompanied by a noticeable malodor that is particularly prominent after sexual intercourse. She has no abdominal pain, pruritus, or dysuria. The patient has been in a monogamous relationship with a new male partner for the past month. Her temperature is 37.0°C (98.6°F) and blood pressure is 118/76 mm Hg. Abdominal examination is unremarkable. On pelvic examination, the vulva and vagina appear normal with no erythema, but a homogeneous, gray-white fluid smoothly coats the vaginal walls. The cervix appears normal, and there is no cervical motion tenderness. Vaginal pH is measured at 5.5. The addition of potassium hydroxide to the fluid produces a strong amine odor. Microscopic evaluation of a wet mount reveals multiple squamous epithelial cells with stippled appearances and indistinct borders. Which of the following is the most appropriate next step in management for this patient?

A 28-year-old woman, gravida 2, para 2, is evaluated in the outpatient clinic 3 days after an uncomplicated term vaginal delivery. She has chosen to exclusively formula-feed her newborn. The patient reports severe, bilateral breast pain and swelling that began 24 hours ago. Her temperature is 37.4°C (99.3°F), blood pressure is 118/76 mm Hg, pulse is 78/min, and respirations are 14/min. Physical examination reveals bilaterally enlarged, firm, and diffusely tender breasts. There is no focal erythema, fluctuance, or purulent nipple discharge. Which of the following is the most appropriate next step in management?

An obstetrician evaluates a $31$-year-old primiparous female in the outpatient clinic $3$ weeks after childbirth. The patient reports a constant, involuntary trickling of fluid from her vagina. Her labor course was complicated by an arrest of descent in the second stage, ultimately requiring a forceps-assisted vaginal delivery of a macrosomic infant weighing $4.2\text{ kg}$ ($9.2\text{ lbs}$). The patient states her undergarments are persistently wet regardless of her physical activity, position, or whether she is coughing. She explicitly denies pain with urination, a sudden urge to void, or any sensation of incomplete bladder emptying. Vital signs are within normal limits. A speculum examination reveals clear fluid pooling in the posterior vaginal vault, but no discrete lacerations or mucosal defects are immediately visible. Urinalysis shows no leukocyte esterase, nitrites, or abnormal cellular elements. Which of the following is the most appropriate next step in the evaluation of this patient's symptoms?

An expectant mother at $25$ weeks of gestation visits the obstetrician's office for a follow-up assessment. She is $27$ years old, gravida $1$, para $0$. Her pregnancy has been uncomplicated thus far. She reports experiencing occasional mild swelling in her ankles by the end of the day but denies headaches, visual changes, abdominal pain, contractions, or vaginal bleeding. Fetal movements are felt daily. Maternal vital signs show a blood pressure of $112/68$ mm Hg, heart rate of $82$/min, and respiratory rate of $16$/min. Fundal height is $25$ cm, and the fetal heart rate is $145$/min. Laboratory studies obtained earlier this morning yield the following results:

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

Six days following a complex total laparoscopic hysterectomy for deeply infiltrating endometriosis, a patient presents to her physician's office reporting progressive right-sided back pain. She notes that the pain occasionally radiates to her right groin and is associated with nausea and feeling feverish. The operative report indicates that extensive adhesiolysis was required due to significant anatomical distortion in the posterior cul-de-sac and broad ligament. She is currently voiding normally without dysuria. Vital signs show a temperature of $38.2^{\circ}\text{C}$ ($100.8^{\circ}\text{F}$), blood pressure of $118/76\text{ mm Hg}$, and a pulse of $88\text{/min}$. Abdominal examination is notable for a soft, non-distended abdomen with normal bowel sounds. Severe tenderness is present upon percussion of the right costovertebral angle. Laboratory testing demonstrates a leukocyte count of $11,500/\mu\text{L}$ and a serum creatinine level of $0.8\text{ mg/dL}$, which is unchanged from her preoperative baseline. Urinalysis reveals $15$-$20$ red blood cells per high-power field and is negative for leukocyte esterase and nitrites. Which of the following is the most appropriate next step in management?

A primigravid patient at 10 weeks of gestation comes to the office for an initial obstetric evaluation. The patient feels well and has no current medical concerns. She specifically notes an absence of pelvic pain, vaginal pruritus, or malodorous discharge. Her medical history is unremarkable, and she has never had a sexually transmitted infection. Pelvic examination demonstrates a normal-appearing cervix with a minimal amount of thin, grayish fluid in the posterior fornix. A sample of the fluid is evaluated under microscopy, revealing several vaginal epithelial cells with obscured borders and a stippled appearance. The addition of potassium hydroxide to the slide produces a noticeable amine odor. The vaginal pH is measured at 5.5. What is the most appropriate next step in the management of this patient?