Obstetrics and Gynecology

A 64-year-old woman presents to the clinic complaining of new-onset vaginal bleeding. She reached menopause 12 years ago. Her body mass index is 36 kg/m^2. A transvaginal ultrasound is performed and reveals an irregularly thickened endometrial stripe of 14 mm. Arrange the following subsequent clinical steps in the correct chronological order for the standard evaluation and management of this patient's condition.

Match each etiology of secondary amenorrhea with its characteristic endocrine laboratory profile.

Identify the optimal pharmacological management for each distinct presentation of lower genital tract infection by pairing the clinical findings with the correct therapeutic approach.

A patient at 36 weeks of gestation, who is pregnant with her first child, presents to the obstetrical triage unit complaining of sudden, intense abdominal pain accompanied by a moderate amount of dark vaginal bleeding. She recently relocated and has had limited prenatal care. Triage vital signs demonstrate a blood pressure of 168/108 mmHg, a heart rate of 112/min, and a respiratory rate of 18/min. On physical examination, the uterus is hypertonic, firm to palpation, and diffusely tender. The electronic fetal heart monitor reveals a baseline of 105/min with absent variability and recurrent late decelerations. Which of the following is the most appropriate next step in the management of this patient?

During a routine annual examination, a 63-year-old woman with a body mass index of 36 kg/m² mentions she experienced two days of mild, self-resolving vaginal spotting a month prior. She had her final menstrual period twelve years ago. Her medical history includes hypertension managed with amlodipine and type 2 diabetes mellitus managed with metformin. Vital signs are normal. A pelvic examination demonstrates atrophic external genitalia and pale vaginal walls, with no active bleeding or palpable masses. The cervix is flush with the vaginal vault. A transvaginal ultrasound is performed in the office, which shows a homogeneous endometrial stripe measuring 7 mm in thickness with no focal lesions. The adnexa are unremarkable. Based on these findings, which of the following is the most appropriate next step in the management of this patient?

Pair each distinct clinical presentation of a gynecologic neoplasm with its most defining molecular defect or characteristic histopathologic hallmark.

During a routine visit to the university health center, a 24-year-old female college student reports that she has not had a menstrual period for the past 5 months. She previously experienced predictable 28-day cycles. Additionally, she expresses significant distress over rapidly worsening, dark hair growth on her face and chest that began roughly at the same time her periods stopped. Recently, she also noticed that her voice has become noticeably deeper. She takes no medications and has no significant past medical history. Vital signs are temperature 37.0°C (98.6°F), blood pressure 118/76 mmHg, pulse 78/min, and respirations 14/min. BMI is 24 kg/m². A urine pregnancy test is negative. Physical examination reveals terminal hair on the chin and abdomen, temporal balding, and clitoromegaly. Bimanual pelvic examination is unremarkable. Which of the following is the most appropriate next step in management?

A 59-year-old nulliparous woman is evaluated in the clinic for two days of bloody vaginal discharge. She has not had a menstrual period for seven years. Her past medical history is notable for obesity, hypertension, and diet-controlled type 2 diabetes mellitus. Speculum examination reveals a small amount of dark blood in the vaginal vault with normal-appearing cervical and vaginal mucosa. Bimanual examination is unremarkable. Which of the following is the most appropriate next step in management?

A $61$-year-old woman presents to the gynecology clinic for a follow-up appointment. Ten days ago, she was evaluated for a single, unprovoked episode of vaginal bleeding. Her last menstrual period occurred $11$ years ago. At her initial visit, a transvaginal ultrasound was performed, demonstrating a heterogeneous endometrial stripe with a maximum thickness of $9$ mm. An in-office endometrial aspiration biopsy was subsequently obtained. The patient reports no further vaginal bleeding and is otherwise asymptomatic. Her medical history is significant for hypertension and type 2 diabetes mellitus. Her body mass index is $33$ kg/m $^2$. Today, the pathology report from the endometrial biopsy is reviewed and states, 'Scant cellular material consisting of superficial squamous cells, blood, and mucus; insufficient endometrial glandular tissue for diagnosis.' Which of the following is the most appropriate next step in management?

Following an uncomplicated vaginal delivery of a macrosomic neonate at 39 weeks gestation, a multiparous patient experiences significant postpartum bleeding. The placenta delivered spontaneously and intact 10 minutes prior. On examination, the patient is tachycardic at 120/min and hypotensive at 90/50 mmHg. Abdominal palpation reveals a flaccid uterus extending above the umbilicus. After establishing adequate intravenous access and initiating fluid resuscitation, the clinical team begins a stepwise algorithmic response to her condition. Arrange the following interventions in the most appropriate sequential order of escalation according to standard postpartum hemorrhage management protocols.

Match each umbilical arterial cord blood gas profile with the intrapartum clinical scenario most likely to have produced it.

A $74$-year-old nulliparous woman presents to the clinic with an $8$-month history of progressive vulvar pruritus and a recently enlarging, painful mass. She has applied over-the-counter hydrocortisone cream with no relief. Physical examination reveals a firm, irregular, $3$ cm ulcerated lesion located on the right labium majus. The lesion is $2.5$ cm away from the clitoris and the urethral meatus. No inguinal lymphadenopathy is palpated on examination.

Assuming the initial investigation confirms invasive squamous cell carcinoma, and subsequent surgical staging reveals positive ipsilateral inguinal lymph nodes, arrange the following standard management steps in the most appropriate chronological order.

A 29-year-old G1P0 woman at 38 weeks gestation is admitted to the labor and delivery unit with severe preeclampsia. While being evaluated, she suddenly loses consciousness and develops generalized tonic-clonic movements lasting for 60 seconds. Her blood pressure is 170/112 mmHg. The fetal heart rate tracing shows prolonged bradycardia. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A female college sophomore presents to the ambulatory care center complaining of progressively worsening pelvic pain and unusual vaginal discharge over the past $72$ hours. The $19$-year-old patient reports that the pain is bilateral and accompanied by a low-grade fever. Her past medical history is notable for recalcitrant nodulocystic acne, which is currently managed with oral isotretinoin. She relies on a progestin-only pill for contraception and mentions she recently started a sexual relationship with a new male partner without using barrier protection. On triage, her temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure is $112/72$ mmHg, heart rate is $94$/min, and respiratory rate is $16$/min. Physical examination reveals a mucopurulent cervical discharge. Bimanual examination demonstrates pronounced cervical motion tenderness and bilateral adnexal tenderness without palpable masses. A point-of-care urine pregnancy test is negative. She is tolerating oral hydration without difficulty. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A 24-year-old nulligravid woman presents to the clinic with a 6-month history of absent menses. Menarche occurred at age 13, and her menstrual cycles were previously regular, occurring every 28 days. She reports running 40 to 50 miles per week and has recently adopted a strict low-calorie diet to prepare for a marathon. Her body mass index (BMI) is 17.2 kg/m². Vital signs show a temperature of 36.5°C (97.7°F), a heart rate of 52/min, and a blood pressure of 90/60 mmHg. Physical examination reveals a thin female with no hirsutism, acne, or galactorrhea. A urine pregnancy test is negative. Which of the following serum laboratory profiles is most likely present in this patient?

A $26$-year-old nulligravid woman comes to the clinic reporting a lack of menstrual periods for the past $6$ months. Previously, her menstrual cycles were regular, occurring every $28$ days. Over the last $4$ months, she has noticed rapid development of severe acne, increased hair growth on her face and chest, and deepening of her voice. Her past medical history is notable for migraines with aura, for which she occasionally takes sumatriptan. She takes no other medications. Her blood pressure is $118/76$ mm Hg, pulse is $72$/min, and BMI is $24$ kg/m $^2$. Physical examination shows terminal hair on the upper lip, chin, and chest, as well as distinct clitoromegaly. A urine pregnancy test is negative. Serum thyroid-stimulating hormone (TSH) and prolactin levels are within normal limits. The patient asks if she can start a birth control pill to help regulate her periods and clear her acne. Which of the following is the most appropriate next step in management?

A 28-year-old woman, G2P2, presents to her gynecologist with a 3-day history of progressively worsening lower abdominal pain, chills, and an abnormal vaginal discharge. She relies on a copper intrauterine device (IUD) for contraception, which was placed two years ago. Her temperature is 38.1°C (100.6°F).

Arrange the following diagnostic and management steps in the most appropriate chronological sequence for this patient, assuming she initially receives standard outpatient care but fails to demonstrate clinical improvement over the subsequent 72 hours.

A 23-year-old woman is initially diagnosed with uncomplicated pelvic inflammatory disease (PID). Arrange the following diagnostic and management steps in the correct chronological sequence, representing a typical escalation of care for a patient whose condition progressively worsens into a refractory tubo-ovarian abscess.

Match each gynecologic malignancy with its most characteristic primary route of spread or classic pattern of metastasis.

Match each etiology of postpartum febrile morbidity with its most characteristic clinical presentation.