Obstetrics and Gynecology

An expectant 34-year-old mother (G3P2) is admitted to the maternity ward at 39 weeks of gestation. She is attempting a vaginal delivery following a previous lower transverse cesarean section. While her labor is progressing, her vital signs show a pulse of 115/min and a blood pressure of 100/60 mm Hg. Suddenly, she cries out, reporting a severe, tearing pain in her lower abdomen. The continuous tocodynamometer, which previously showed regular activity, now indicates a complete cessation of uterine contractions. A rapid bedside pelvic examination reveals that the presenting fetal part, previously palpable at +1 station, has retracted and is no longer easily reached. Simultaneously, the fetal monitor displays a sudden and sustained heart rate deceleration to 80/min. Which of the following is the most likely diagnosis?

A 19-year-old female university student visits the clinic seeking a reliable method of birth control. She reports that her menstrual periods have been unpredictable since menarche at age 13, often occurring every 3 to 4 months. She also notes worsening facial acne and excess dark hair on her upper lip. Her body mass index is $32 \text{ kg/m}^2$. Blood pressure is $118/76 \text{ mmHg}$ and heart rate is $78/\text{min}$. A urine pregnancy test obtained in the clinic today is negative. During the interview, the patient mentions suffering from severe headaches that are consistently preceded by flashing lights and blind spots. The physician strongly suspects an underlying endocrinopathy but must first address her request for contraception and endometrial protection. Which of the following is the most appropriate next step in the management of this patient?

Match the following clinical presentations of gynecologic infections to their most appropriate, guideline-concordant initial management strategies.

Evaluate the following acute obstetric presentations and match each clinical scenario with its most specific underlying pathophysiologic mechanism.

An 18-year-old nulliparous woman is admitted to the labor ward at 41 weeks of gestation for a scheduled labor induction. She is currently receiving a continuous intravenous infusion of oxytocin. A cervical examination reveals 6 cm of dilation and 80% effacement. The continuous external fetal monitor displays a baseline heart rate of 140/min with moderate variability. Over the last 20 minutes, the monitor reveals symmetric, gradual decreases in the fetal heart rate that begin after the peak of the uterine contractions and slowly return to baseline only after the contractions have completely ended. Maternal vital signs are temperature 37.1°C (98.8°F), blood pressure 118/76 mm Hg, pulse 88/min, and respirations 16/min. Which of the following is the most appropriate next step in management?

A 26-year-old primigravida at 39 weeks gestation is admitted to the hospital in spontaneous labor. Her pregnancy has been uncomplicated. Her cervix is 6 cm dilated and 90% effaced. The patient is receiving continuous external fetal monitoring. Over the last 30 minutes, the fetal heart rate baseline is 135/min with moderate variability. However, there are recurrent, symmetric decreases in the fetal heart rate that begin after the peak of each uterine contraction and return to baseline only after the contraction has completely finished. The patient's blood pressure is 120/80 mm Hg and her pulse is 85/min. Which of the following is the most appropriate initial step in the management of this patient?

An obstetric patient at $16$ weeks gestation presents to her physician's office for evaluation of increased vaginal discharge that she first noticed a week ago. The $26$-year-old gravida $2$, para $1$, states that the discharge has an unpleasant, "fishy" odor, which becomes more pronounced following intercourse. She has not experienced any vulvar itching, burning with urination, or pelvic pain. Her medical history is unremarkable, and her current pregnancy has been progressing normally. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $110/70 \text{ mm Hg}$, and pulse is $78/\text{min}$. On speculum examination, a thin, homogenous, gray-white fluid is seen coating the vaginal walls. The cervix appears normal, and there is no surrounding erythema. Vaginal pH testing yields a value of $5.5$. The addition of $10\%$ potassium hydroxide to a sample of the vaginal discharge produces a strong amine odor. A wet mount preparation of the discharge shows squamous epithelial cells that are stippled and have indistinct borders due to numerous adherent bacteria. Which of the following is the most appropriate next step in management for this patient?

An outpatient evaluation is requested for a 41-year-old woman experiencing abnormal uterine bleeding. Over the last 10 months, her menstrual cycles have become highly irregular, occurring at intervals ranging from 20 to 60 days. The periods are characterized by a heavy flow that frequently requires changing a superabsorbent pad every hour during the first two days of menstruation. Her past medical history includes essential hypertension and type 2 diabetes mellitus. Her body mass index is 39 kg/m2. She has never been pregnant. Vital signs are normal. Speculum examination shows a normal-appearing cervix with a moderate amount of dark blood in the vaginal vault. Bimanual examination reveals a mobile, normal-sized uterus and no adnexal masses. Urine human chorionic gonadotropin testing is negative. Transvaginal ultrasonography shows a homogeneously thickened endometrium measuring 14 mm without focal lesions. Which of the following is the most appropriate next step in the management of this patient?

Carefully review the following laboratory and clinical profiles of pregnant patients presenting with hepatic or hematologic abnormalities. Match each clinical vignette with its most accurate diagnosis.

Match each patient's clinical presentation and diagnostic findings with the correct underlying pathophysiology and appropriate first-line management.

A 28-year-old gravida 1 para 0 at 39 weeks gestation is admitted to the labor and delivery unit in active labor. Her pregnancy has been uncomplicated. She is currently receiving a continuous intravenous oxytocin infusion for labor augmentation. Her cervix is 7 cm dilated, 100% effaced, and the fetal station is 0. Maternal blood pressure is 115/75 mm Hg and heart rate is 82/min. The fetal heart rate tracing reveals a baseline of 140/min with moderate variability. There are recurrent, gradual, symmetric decreases in the fetal heart rate that begin after the peak of the uterine contractions and return to baseline only after the contractions have completely ended. Which of the following is the most appropriate initial step in the management of this patient?

Match each clinical presentation of third-trimester or intrapartum vaginal bleeding with its most likely diagnosis.

During the active phase of labor, a term multiparous patient experiences spontaneous rupture of membranes. Shortly after, the external fetal monitor shows a baseline fetal heart rate of 145/min with moderate variability. However, there are abrupt, sharp declines in the fetal heart rate to 85/min that last for 40 seconds before rapidly returning to the baseline. These sudden drops are occurring with nearly every uterine contraction over the past 25 minutes. The patient's cervix is currently 5 cm dilated. Which of the following is the most appropriate initial step in management?

A 28-year-old G2P1 at 40 weeks gestation is in the second stage of labor. After delivery of the fetal head, it retracts tightly against the maternal perineum (turtle sign). Gentle downward traction fails to deliver the anterior shoulder. Arrange the following management steps for this complication in the correct sequential order from first to last.

A 33-year-old gravida 3, para 2 at 38 weeks gestation presents to the labor unit with painful, regular uterine contractions. Her obstetric history is notable for a primary low transverse cesarean delivery three years ago. She is currently undergoing a trial of labor. Several hours into her admission, the patient suddenly screams in agony, describing a severe, tearing pain in her lower abdomen that persists between contractions. Concurrently, the electronic fetal monitor displays a sudden and sustained fetal bradycardia of 75/min. Vaginal examination shows that the fetal presenting part, previously at +1 station, can no longer be palpated. Her blood pressure drops to 85/50 mm Hg. Which of the following is the most appropriate next step in management?

Match each clinical description of a pregnant patient after 20 weeks gestation to the most accurate hypertensive disorder of pregnancy.

A $24$-year-old woman is evaluated in the recovery room thirty minutes after giving birth to a $4.2$ kg ($9$ lb $4$ oz) male newborn. The vaginal delivery was assisted by vacuum extraction due to maternal exhaustion after a prolonged second stage of labor. The placenta delivered spontaneously and appeared grossly intact. The nurse alerts the physician because the patient's perineal pad is completely saturated with bright red blood, and blood is actively pooling on the bedsheets. The patient reports feeling lightheaded. Her temperature is $37.1^\circ$ C ($98.8^\circ$ F), blood pressure is $85/50$ mm Hg, and pulse is $122$/min. On abdominal examination, the uterus is palpated above the umbilicus and has a soft, doughy consistency. Speculum examination reveals active bleeding from the cervical os with no apparent vaginal or cervical lacerations. Which of the following is the most appropriate initial step in the management of this patient?

A 29-year-old gravida 2, para 2 delivers a 4.1 kg (9 lb) newborn vaginally. Shortly after the delivery of an intact placenta, the patient develops heavy vaginal bleeding. Her blood pressure is 90/55 mmHg and her pulse is 118/min. The uterine fundus is palpated above the umbilicus and feels soft and boggy. Assuming the hemorrhage remains refractory to each preceding intervention, arrange the following management steps for this patient's condition in the correct sequential order, from initial treatment to definitive surgical management.

A 24-year-old primigravida presents for her initial prenatal visit at 8 weeks gestation. She is healthy and has no significant past medical history. She asks about the schedule of routine screening tests she will undergo during her pregnancy. Arrange the following routine prenatal screening evaluations in the correct chronological order from earliest to latest during an uncomplicated pregnancy.

An otherwise healthy 31-year-old woman, G3P2, presents to the obstetrics clinic for a scheduled evaluation at 18 weeks gestation. She mentions occasionally feeling "out of breath" even when resting. She has no history of asthma or cardiac disease. Her vital signs are within normal limits, with a respiratory rate of 15/min and oxygen saturation of 99% on room air. Physical examination of the chest and heart is unremarkable. An arterial blood gas would most likely reveal a mild, compensated respiratory alkalosis. Which of the following normal physiologic changes of pregnancy is primarily responsible for this patient's expected acid-base status?