Obstetrics and Gynecology

A 54-year-old woman comes to the clinic for a routine wellness examination. She went through menopause $3$ years ago and reports no vaginal bleeding, discharge, or pelvic pain. Her past medical history is notable for type 2 diabetes mellitus and hypertension. Her BMI is $32 \text{ kg/m}^2$. A speculum examination reveals a normal-appearing cervix with no visible lesions. A Pap test is performed and the cytology report indicates atypical glandular cells (AGC). A subsequent human papillomavirus (HPV) test is negative. Which of the following is the most appropriate next step in management?

Match each patient's clinical presentation and associated gynecologic neoplasm with the most likely underlying genetic mutation and hereditary syndrome.

Match each intrapartum or puerperal hemorrhagic complication with its classic clinical presentation, underlying pathophysiology, or appropriate initial management step.

Match each clinical presentation of elevated blood pressure during pregnancy to the most accurate diagnostic classification according to current obstetric guidelines.

Match each ultrasound or clinical finding in a multifetal gestation to the most likely associated monochorionic twin complication.

A 31-year-old nulligravid woman presents to the emergency department with severe, worsening lower abdominal pain, chills, and purulent vaginal discharge for the past 3 days. She has a copper intrauterine device that was placed 2 years ago. Her temperature is $39.2^\circ C$, blood pressure is $105/65$ mmHg, and heart rate is $112$/min. Pelvic examination reveals extreme cervical motion tenderness, uterine tenderness, and a palpable, exquisitely tender, $7 \times 6$ cm mass in the right adnexa. Laboratory studies demonstrate a leukocyte count of $18,500/\mu L$. The patient has a documented history of severe anaphylaxis to penicillins and cephalosporins. Pregnancy test is negative. Arrange the following steps in the most appropriate chronological sequence for the evidence-based management of this patient's condition.

An ambulatory care physician is evaluating a 21-year-old female college student who reports bilateral lower pelvic cramping and is found to have pronounced cervical motion tenderness on examination. Although she initially receives a diagnosis of an uncomplicated ascending pelvic infection, her clinical status deteriorates over the next several days, ultimately leading to a minimally invasive surgical procedure. Arrange the following clinical steps in the standard chronological sequence for escalating the care of this condition.

During morning rounds on the postpartum unit, a 29-year-old woman, gravida 2, para 2, is evaluated two days after an uncomplicated spontaneous vaginal delivery at term. She mentions experiencing intermittent, crampy pain in her lower abdomen that noticeably worsens when she breastfeeds her infant. The patient also reports a dark red vaginal discharge that necessitates changing a sanitary pad every 4 to 6 hours. Her current temperature is 37.1°C (98.8°F), blood pressure is 112/72 mmHg, pulse is 70/min, and respirations are 14/min. Physical examination shows a firm uterine fundus palpable midway between the umbilicus and the pubic symphysis. Which of the following is the most appropriate next step in management?

A 57-year-old woman presents to the gynecology clinic for evaluation of blood-tinged vaginal discharge. She first noticed the discharge on her undergarments three days ago. The patient underwent natural menopause at age 51. Her past medical history is significant for type 2 diabetes mellitus, hypertension, and hyperlipidemia. Current medications include metformin, lisinopril, and atorvastatin. She does not use hormone replacement therapy. Vital signs are within normal limits, and her body mass index is 34 kg/m². Speculum examination shows pale, thinned vaginal walls with a small amount of dark red blood pooled in the posterior fornix. The cervix appears flush with the vaginal vault and has no gross lesions. A transvaginal ultrasound is performed and demonstrates a heterogeneous endometrial stripe with a thickness of 9 mm. The adnexa are unremarkable bilaterally. Which of the following is the most appropriate next step in management?

Match each classic peripartum clinical scenario presenting with acute maternal hemodynamic compromise to its corresponding primary underlying hemodynamic profile.

A 46-year-old woman is evaluated in the outpatient clinic for a 5-month history of heavy and irregular vaginal bleeding. She states that her menstrual cycles were previously regular, occurring every 28 days and lasting 5 days, but they now occur at random intervals with heavy flow and the passage of large blood clots. Her medical history includes type 2 diabetes mellitus, hypertension, and obesity. Current medications are metformin and lisinopril. Her body mass index is $36 \text{ kg/m}^2$. Vital signs are within normal limits. Pelvic examination demonstrates a normal-appearing vagina and cervix, with a normal-sized, non-tender uterus and no palpable adnexal masses. A point-of-care urine beta-hCG test is negative. Which of the following is the most appropriate next step in management?

A 24-year-old woman, G1P0, at 14 weeks gestation presents to the emergency department with a 2-day history of worsening lower abdominal pain, chills, and a malodorous vaginal discharge. She has a history of asthma and a documented severe allergy to amoxicillin, which caused anaphylaxis and required intubation during childhood. Her temperature is 38.8°C (101.8°F), blood pressure is 112/70 mm Hg, and pulse is 110/min. Physical examination reveals a friable cervix with purulent exudate. Bimanual examination demonstrates exquisite cervical motion tenderness and bilateral adnexal tenderness without palpable masses. Transabdominal ultrasound confirms a viable intrauterine gestation with a normal fetal heart rate and no adnexal fluid collections. Which of the following is the most appropriate next step in management?

An 81-year-old woman is evaluated for a sensation of pelvic pressure and a mass protruding from her introitus that has worsened over the past several months. She states that the sensation is most noticeable after standing for long periods. Her medical history includes severe chronic obstructive pulmonary disease requiring home oxygen and a myocardial infarction 2 months ago. Pelvic examination reveals a large anterior vaginal wall defect that descends beyond the hymenal ring with Valsalva maneuver. The patient finds this condition highly bothersome and requests treatment. Which of the following is the most appropriate next step in management?

An obstetrician-gynecologist is evaluating a 58-year-old woman (gravida 3, para 3) who reports two weeks of daily vaginal spotting and a new sensation of pelvic pressure. Her last menstrual period was 7 years ago. She has a documented medical history of poorly controlled type 2 diabetes mellitus and a BMI of 36 kg/m². Pelvic examination identifies a firm, irregularly contoured mass in the left adnexa. Subsequent transvaginal ultrasound confirms a 7-cm complex left adnexal mass with both solid and cystic components, alongside an abnormally thickened endometrial echo complex measuring 11 mm. The physician prepares to perform an office endometrial biopsy as the critical next step. The differential diagnosis for her concurrent endometrial thickening and adnexal mass includes several distinct neoplastic processes. Match the following suspected gynecologic neoplasms with their underlying molecular drivers, pathognomonic histology, and defining clinical associations.

An 18-year-old female presents to the gynecology clinic for evaluation of primary amenorrhea. She reports that all of her peers have already started menstruating, but she has never had a menstrual bleed. Her medical history is unremarkable, and she takes no medications. Vital signs are within normal limits. On physical examination, she is tall for her family with well-developed breasts (Tanner stage V). Axillary and pubic hair are notably sparse. Pelvic examination reveals normal external female genitalia, but the vaginal vault is shortened and ends in a blind pouch. A urine pregnancy test is negative. Arrange the following diagnostic and management steps in the most appropriate chronological sequence for this patient.

Presenting for a scheduled prenatal visit at 16 weeks gestation, a 28-year-old gravida 1, para 0 describes a newly developed, malodorous vaginal discharge. She notes the odor is particularly strong after intercourse. She denies any dysuria, pelvic pain, or vulvar pruritus. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $112/70\text{ mmHg}$, and pulse is $78/\text{min}$. Speculum examination demonstrates a thin, homogeneous, grayish-white fluid smoothly coating the vaginal walls without associated vulvovaginal erythema or friability. Vaginal pH is 5.5. A sample of the discharge is placed on a slide with normal saline; microscopic evaluation reveals numerous squamous epithelial cells whose borders are completely obscured by adherent coccobacilli. Which of the following is the most appropriate management for this patient?

Following a sudden gush of clear vaginal fluid 18 hours ago, a pregnant patient at 38 weeks gestation presents to the maternity ward. She is a nulliparous woman whose prenatal course was uncomplicated. She currently reports mild, irregular lower abdominal cramping. Her temperature is 38.7°C (101.7°F), blood pressure is 112/70 mmHg, and heart rate is 116/min. The fetal heart tracing shows a baseline of 175/min with moderate variability and an absence of decelerations. Uterine fundal palpation elicits moderate tenderness. A sterile speculum examination confirms pooling of fluid that turns nitrazine paper blue. Subsequent digital examination shows the cervix is 3 cm dilated and 80% effaced, with the fetal vertex at -1 station. Which of the following is the most appropriate next step in management?

An ambulatory 22-year-old female patient seeks medical evaluation at a primary care office for recent-onset lower abdominal aching and malodorous vaginal discharge. She reports becoming sexually active with a new partner one month ago. Her vital signs are stable and she is afebrile at this initial visit. A point-of-care pregnancy test is negative. Arrange the following clinical steps in the most appropriate chronological sequence for the management of this patient. Assume that her clinical course begins with standard care for uncomplicated pelvic inflammatory disease but later requires escalation of care due to outpatient treatment failure and the subsequent discovery of an unruptured tubo-ovarian abscess.

Shortly after admission to the labor and delivery unit, a multigravid patient at $38$ weeks gestation experiences spontaneous rupture of membranes. Her prenatal records indicate an uncomplicated pregnancy, though a second-trimester anatomy scan noted a velamentous cord insertion. Immediately following the rupture of membranes, the nurse observes approximately $150\text{ mL}$ of bright red fluid pooling on the underpads. The external fetal monitor, which previously showed a category I tracing, now demonstrates a sudden, persistent decrease in the fetal heart rate to $75/\text{min}$ that has lasted for $4$ minutes without any sign of recovery. The patient denies any sharp abdominal pain, and her uterus is soft and non-tender between mild contractions. Maternal blood pressure is $115/75\text{ mmHg}$ and heart rate is $88/\text{min}$. Which of the following is the most appropriate initial management for this patient?

An 18-year-old woman is brought to the clinic by her mother due to the absence of spontaneous menarche. The patient states she has never had menstrual bleeding or spotting. She is a high school senior and performs well academically, though she notes a lifelong inability to smell her mother's cooking or her own perfume. She denies headaches, visual changes, or galactorrhea. She takes no medications and does not use illicit substances. Vital signs include a blood pressure of 110/70 mm Hg, heart rate of 72/min, respiratory rate of 14/min, and BMI of 21 kg/m^2. Physical examination reveals Tanner stage 1 breast development and Tanner stage 2 pubic hair. External genitalia appear normal and there is no clitoromegaly. Based on the standard diagnostic and management algorithm for primary amenorrhea, arrange the following clinical steps in the most appropriate sequential order for this patient.