Obstetrics and Gynecology

Seeking evaluation for severely heavy and unpredictable vaginal bleeding, a $48$-year-old G2P2 patient visits the women's health center. Her symptoms began $6$ months ago, characterized by menses occurring at random $14$- to $45$-day intervals and lasting up to $12$ days, requiring her to change super-absorbent pads every $3$ hours. She also reports feeling persistently cold, profound lethargy, and a documented $6$-kg ($13.2$-lb) weight gain during this timeframe. She notes mild acne and increased facial hair growth since her twenties, for which she was previously told she might have "ovary cysts." Five years ago, she developed an unprovoked deep venous thrombosis in her left lower extremity, which was treated with anticoagulation for $6$ months. She takes no medications currently.

Vital signs reveal a temperature of $36.6^\circ$ C ($97.9^\circ$ F), blood pressure of $132/84$ mmHg, pulse of $56$/min, and respirations of $14$/min. Her BMI is $34$ kg/m $^2$.

Pelvic examination demonstrates an active moderate flow of blood through the cervical os, but no visible vaginal or cervical lesions. The uterus is mobile, non-tender, and of normal size.

Laboratory analysis:
- Urine beta-hCG: negative
- Hemoglobin: $10.4$ g/dL
- Thyroid-stimulating hormone (TSH): $0.1$ $\mu$ U/mL (Normal: $0.4$-$4.0$ $\mu$ U/mL)
- Free thyroxine (T4): $0.5$ ng/dL (Normal: $0.9$-$1.7$ ng/dL)

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

A $26$-year-old healthy primigravida with a blood type of O-negative presents for her first prenatal visit at $7$ weeks gestation. She has an uncomplicated medical history and wishes to follow all standard prenatal care guidelines. Arrange the following routine prenatal screening and prophylactic interventions in the correct chronological order from the earliest gestational age they are indicated to the latest.

A family planning clinic provides counseling for various patients with unique medical backgrounds. Match each clinical profile below with the most appropriate contraceptive method based on the standard Medical Eligibility Criteria (MEC) guidelines.

A 31-year-old woman, gravida 1 para 0, at 40 weeks gestation is admitted to the labor and delivery unit for induction of labor due to oligohydramnios. An intravenous oxytocin infusion is initiated. Four hours later, her temperature is 37.0°C (98.6°F), blood pressure is 122/78 mm Hg, and pulse is 88/min. Cervical examination reveals the cervix is 6 cm dilated, 90% effaced, and at 0 station. The external fetal monitor demonstrates a fetal heart rate baseline of 145/min with moderate variability. Over the past 15 minutes, there are recurrent, symmetric, gradual decreases in the fetal heart rate that consistently begin after the peak of the contraction and return to baseline after the contraction ends. Uterine contractions are occurring every 1 to 1.5 minutes and lasting 60 to 70 seconds. The patient is repositioned to the left lateral decubitus position and administered an intravenous fluid bolus, but the fetal heart rate pattern persists. Which of the following is the most appropriate next step in management?

A healthy nulliparous patient at term ($39$ weeks gestation) presents in active labor and subsequently delivers a vigorous male infant vaginally. During the third stage of labor, significant umbilical cord traction is applied. Immediately following the delivery of the placenta, the patient develops catastrophic vaginal hemorrhage. Her vital signs rapidly deteriorate, showing a blood pressure of $75/40$ mm Hg and a pulse of $138$/min. Palpation of the maternal abdomen reveals that the uterine fundus is entirely unpalpable at the umbilicus. A speculum examination identifies a large, smooth, beefy-red mass extending through the dilated cervix. Intravenous fluid resuscitation and massive transfusion protocols are rapidly initiated for acute complete uterine inversion. Arrange the following definitive management steps in the correct chronological sequence.

Presenting with a dull, continuous ache in her right flank, a primigravid patient at $26$ weeks gestation is evaluated in the obstetric triage unit. She first noticed the discomfort yesterday. There is no radiation of the pain to the groin, and she has not experienced any fever, chills, urinary frequency, or dysuria. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $110/68$ mm Hg, and pulse is $82$/min. Physical examination shows a gravid uterus consistent with gestational age and trace tenderness over the right costovertebral angle. Laboratory results are as follows:

Hemoglobin: $11.2$ g/dL
Leukocyte count: $10,500/\text{mm}^3$
Blood urea nitrogen: $7$ mg/dL
Serum creatinine: $0.5$ mg/dL

Urinalysis is negative for blood, nitrites, and leukocyte esterase, showing $1$-$2$ WBCs/hpf. A right upper quadrant and renal ultrasound reveals mild dilation of the right renal pelvis and proximal ureter, without visible echogenic foci or acoustic shadowing. The left kidney appears normal. Which of the following is the most appropriate next step in management?

Correlate the following clinical assessments and microscopic laboratory findings with the correct definitive pharmacotherapy and partner management protocol.

A nulliparous patient at $38$ weeks and $5$ days gestation is monitored on the labor ward after presenting with painful uterine contractions. Her prenatal course was unremarkable. Current maternal vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $122/80$ mm Hg, and pulse $88$/min. Pelvic examination demonstrates a cervix that is $6$ cm dilated and $90\%$ effaced, with the fetal vertex at $0$ station. The amniotic membranes ruptured spontaneously one hour ago. Uterine contractions are palpable every $3$ minutes. The continuous fetal heart rate monitor displays a baseline of $140$/min with moderate variability. Throughout the last $20$ minutes, the tracing reveals recurrent, abrupt decreases in the fetal heart rate to $85$/min that last for approximately $40$ seconds before abruptly returning to the baseline. The nadirs of these decelerations have no consistent temporal relationship to the uterine contractions. Which of the following is the most appropriate initial step in the management of this patient?

A $29$-year-old nulligravid woman comes to the clinic due to the absence of menstrual periods for the past $6$ months. Prior to this, she had regular $28$-day cycles. Over the same timeframe, she has noted an unintentional $5$-kg ($11$-lb) weight gain, generalized fatigue, and the new onset of coarse dark hair on her upper lip and chin. She is sexually active and uses condoms for contraception, though she and her partner wish to conceive in the next year. Her younger sister was recently diagnosed with polycystic ovary syndrome (PCOS). Vital signs include a blood pressure of $114/72$ mm Hg, a heart rate of $54$/min, and a temperature of $36.6$°C ($97.9$°F). Her body mass index is $31$ kg/m $^2$. Physical examination reveals delayed relaxation of the deep tendon reflexes and moderate facial hirsutism. A urine pregnancy test is negative.

Laboratory results are as follows:

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

An obstetric patient in her first trimester is evaluated during a routine health maintenance visit. The $25$-year-old nullipara is currently at $9$ weeks of gestation based on a confirmed ultrasound. She mentions experiencing moderate morning sickness but emphatically denies weight loss, palpitations, heat intolerance, or tremors. Her physical examination, including palpation of the anterior neck, is entirely unremarkable with no thyromegaly or nodules detected. Due to a strong family history of endocrine disorders, a comprehensive thyroid function panel is obtained alongside standard prenatal screening. Laboratory analysis reveals a thyroid-stimulating hormone (TSH) level of $0.1 \text{ } \mu\text{U/mL}$ (Reference: $0.4 - 4.0 \text{ } \mu\text{U/mL}$), a total thyroxine ($T_4$) level of $14.5 \text{ } \mu\text{g/dL}$ (Reference: $5.0 - 12.0 \text{ } \mu\text{g/dL}$), and a free thyroxine (free $T_4$) level of $1.2 \text{ ng/dL}$ (Reference: $0.9 - 1.7 \text{ ng/dL}$). Which of the following physiological mechanisms best explains the laboratory findings observed in this patient?

A 29-year-old nulliparous woman at 40 weeks gestation is admitted to the labor and delivery unit in active labor. Her pregnancy has been uncomplicated. On admission at 09:00, her temperature is 37.2°C (99.0°F), blood pressure is 118/76 mm Hg, and pulse is 82/min. Cervical examination reveals $6$ cm dilation, $90\%$ effacement, and the fetal presenting part at $-1$ station. Spontaneous rupture of membranes occurs shortly after admission, revealing clear amniotic fluid. An intrauterine pressure catheter (IUPC) is placed to monitor contractions.

At 13:00, a repeat cervical examination shows the cervix remains $6$ cm dilated and $90\%$ effaced, with the fetal head at $-1$ station. The IUPC demonstrates 3 contractions per 10-minute period, yielding a total of $160$ Montevideo units (MVUs). The fetal heart rate tracing demonstrates a baseline of 140/min, moderate variability, positive accelerations, and no decelerations. Which of the following is the most appropriate next step in management?

Seeking evaluation for vaginal discomfort, a 23-year-old university student comes to the campus health center. She has experienced a malodorous discharge and mild vulvar itching for the past seven days. The patient reports these symptoms started shortly after she initiated a sexual relationship with a new male partner. Her medical history is unremarkable, and she takes no routine medications. Her vital signs are within normal limits. Pelvic examination displays mild vulvar erythema and a copious, frothy, yellow-green fluid pooled in the posterior vaginal fornix. The exocervix demonstrates multiple small, punctate hemorrhages. Vaginal fluid pH is measured at $6.2$. Microscopic analysis of a saline wet mount reveals an abundance of polymorphonuclear leukocytes alongside actively motile, flagellated protozoa. Which of the following is the most appropriate management plan for this patient?

A 26-year-old primigravida at 39 weeks' gestation is admitted to the labor unit and progresses to the active phase of the second stage of labor. Her pregnancy has been uncomplicated. To successfully navigate the maternal bony pelvis, the fetus must undergo a series of positional changes known as the cardinal movements of labor. Assuming a fetus in a normal occiput anterior presentation, arrange the following cardinal movements in the correct physiological and chronological sequence, beginning with the fetal head entering the pelvis.

A $25$-year-old primigravid woman at $32$ weeks gestation is evaluated in the outpatient clinic. She reports a two-week history of feeling "out of breath" and frequently needing to take deep sighs, particularly when sitting or resting. She has no chest pain, cough, orthopnea, or paroxysmal nocturnal dyspnea. Her pregnancy has been uncomplicated, and she takes a daily prenatal vitamin. Her temperature is $36.8^\circ$ C ($98.2^\circ$ F), blood pressure is $112/68$ mm Hg, pulse is $86$/min, and respirations are $18$/min. Pulse oximetry is $99\%$ on room air. Physical examination reveals clear breath sounds bilaterally. Cardiac auscultation reveals a grade $2/6$ systolic ejection murmur at the left upper sternal border. Trace bilateral lower extremity edema is present. An arterial blood gas analysis on room air reveals the following:

pH: $7.45$
PaCO $_2$: $29$ mm Hg
PaO $_2$: $102$ mm Hg
HCO $_3^-$: $18$ mEq/L

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

Arrange the following clinical events in the correct chronological sequence for the standard screening, diagnosis, and definitive management of a 34-year-old patient who is found to have high-grade cervical dysplasia.

A 28-year-old primigravid woman presents to the clinic at 8 weeks of gestation for her initial prenatal visit. She has no significant past medical history and takes only a daily prenatal vitamin. Her vital signs are within normal limits. Laboratory evaluation reveals a blood type of A, Rh-negative, with a negative antibody screen. The patient intends to pursue all standard recommended prenatal care. Arrange the following routine prenatal screening and prophylactic interventions in the correct chronological sequence in which they should be offered or administered during her uncomplicated pregnancy.

A $28$-year-old primigravid woman at $26$ weeks gestation is evaluated in the clinic for a dull ache in her right lower back and flank over the past week. She reports no fever, chills, nausea, vomiting, dysuria, or changes in urinary frequency. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $110/68\text{ mm Hg}$, and pulse is $82/\text{min}$. Physical examination reveals a gravid uterus consistent with gestational dates. There is mild right-sided flank fullness but no exquisite costovertebral angle tenderness on deep palpation.

Laboratory studies show:
Leukocyte count: $13,500/\text{mm}^3$
Hemoglobin: $11.2\text{ g/dL}$
Blood urea nitrogen: $6\text{ mg/dL}$
Serum creatinine: $0.5\text{ mg/dL}$
Urinalysis: negative for leukocyte esterase, nitrites, and blood; trace protein; $1$-$2\text{ WBCs/hpf}$.

A right upper quadrant and renal ultrasound demonstrates moderate dilation of the right renal pelvis and proximal ureter, which tapers smoothly at the pelvic brim. The left kidney and urinary tract are normal.

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

A pregnant patient, gravida $2$, para $1$, at $41$ weeks and $1$ day gestation is admitted to the labor unit for a scheduled induction of labor due to a post-term pregnancy. She is receiving a continuous intravenous infusion of a synthetic uterotonic agent to stimulate uterine activity. Her medical history is unremarkable, and her previous delivery was an uncomplicated vaginal birth.

Current maternal vital signs reveal a blood pressure of $115/75\text{ mmHg}$, heart rate of $86\text{/min}$, and temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$). Uterine contractions are occurring every $3$ to $4\text{ minutes}$ and palpate as strong. A sterile vaginal examination reveals the cervix is $5\text{ cm}$ dilated, $90\%$ effaced, and at $-1$ station.

Continuous electronic fetal monitoring displays a baseline heart rate of $140\text{/min}$ with moderate variability. Over the past $25\text{ minutes}$, the tracing demonstrates recurrent, symmetric, gradual decreases in the fetal heart rate that begin after the peak of each uterine contraction and slowly return to the baseline after the contraction ends. These decelerations are occurring with approximately $75\%$ of the contractions. The patient is repositioned to her left side and provided with supplemental oxygen, but the fetal heart monitoring pattern remains unchanged.

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

Presenting to the gynecology office for the evaluation of persistent vaginal bleeding, a 39-year-old female reports that her current bleeding episode has lasted for four consecutive weeks. Prior to the onset of this bleeding, she had not menstruated for six months. She has a known medical history of polycystic ovary syndrome (PCOS), diagnosed when she was 22, and obesity. Additionally, she reports a two-year history of episodic, severe unilateral headaches that are reliably preceded by flashing visual zig-zags; she uses over-the-counter ibuprofen for relief. She recently entered a new relationship and specifically requests a daily birth control pill to prevent pregnancy and to help regulate her cycle. Her body mass index is $37 \text{ kg/m}^2$. Vital signs are within normal limits. A urine beta-hCG test performed in the clinic today is negative. Pelvic examination demonstrates a normal-sized, non-tender uterus and no adnexal masses. Which of the following is the most appropriate next step in the management of this patient?

A 62-year-old woman comes to the clinic reporting intermittent vaginal spotting for the past month. She went through menopause at age 50. Her medical history is notable for estrogen receptor-positive breast cancer diagnosed three years ago, which was treated with lumpectomy, radiation therapy, and ongoing tamoxifen therapy. Vital signs are within normal limits. Pelvic examination demonstrates a normal-appearing vulva, thin vaginal mucosa, and a small amount of dark red blood in the vaginal vault. The cervix has no visible lesions. A transvaginal ultrasound reveals a heterogeneous endometrial stripe of 14 mm. Which of the following is the most appropriate next step in management?