Obstetrics and Gynecology

Match each postpartum clinical presentation with its most accurate underlying pathophysiologic mechanism.

A 27-year-old primigravida at 20 weeks gestation comes to the prenatal clinic complaining of severe vulvar itching and a burning sensation when urinating for the past four days. She also reports a noticeable increase in vaginal discharge but denies any foul odor, abdominal cramping, or vaginal bleeding. Her pregnancy has been uncomplicated to date. Vital signs are within normal limits. Pelvic examination reveals prominent erythema and excoriation of the vulva. The vaginal walls are erythematous, and there is a thick, white, clumpy discharge adherent to the vaginal mucosa. The cervical os is visually closed and appears normal. Vaginal pH is 4.2. Microscopic examination of the discharge mixed with a potassium hydroxide (KOH) preparation reveals branching, thread-like structures with budding organisms. Which of the following is the most appropriate next step in management for this patient?

A 33-year-old nulligravid woman comes to the clinic for a routine wellness examination. She states that her menstrual cycles have always been irregular, occurring every $45$ to $60$ days, with menses lasting $7$ to $8$ days and accompanied by heavy flow. Her medical history includes type 2 diabetes mellitus, chronic hypertension, and obesity. Her body mass index is $38$ kg/m $^2$. Pelvic examination shows a normal-appearing cervix with no visible lesions. A Pap test is performed, and the cytology report reveals atypical glandular cells. High-risk human papillomavirus testing is negative. Which of the following is the most appropriate next step in the management of this patient?

An obese 61-year-old female patient with type 2 diabetes mellitus is evaluated in the gynecology clinic for an episode of unprovoked vaginal bleeding that occurred 10 years after her final menstrual period. Arrange the following interventions in the standard chronological order for her diagnostic workup and therapeutic management, assuming abnormal findings are confirmed at each progressive step.

Match each patient's clinical presentation with the most appropriate contraceptive method based on efficacy, symptom management, and medical eligibility criteria.

Match each genetic syndrome or environmental exposure with the gynecologic malignancy for which it carries the highest risk.

A 68-year-old woman comes to the office due to a 2-week history of vaginal spotting. She reached menopause 18 years ago and had not experienced any bleeding until now. Over the past month, she has also noticed new-onset breast fullness and tenderness. Her medical history is significant for type 2 diabetes mellitus and hypertension. Pelvic examination reveals a small amount of dark blood in the vaginal vault and a palpable, non-tender, 8-cm right adnexal mass. Transvaginal ultrasound demonstrates a solid and cystic right ovarian mass, and the endometrial echo complex measures 14 mm in thickness. Which of the following is the most appropriate next step in the management of this patient?

Evaluate the following patient profiles and match each with the most medically appropriate contraceptive method, adhering to the US Medical Eligibility Criteria (MEC) and specific patient preferences.

A $31$-year-old woman is evaluated at the clinic for her annual wellness examination. She reports feeling well and has no pelvic pain, abnormal vaginal discharge, dyspareunia, or irregular bleeding. Her medical history is unremarkable. She is in a monogamous relationship and uses a copper intrauterine device that was inserted three years ago. Vital signs include a blood pressure of $112/70$ mm Hg, heart rate of $74$/min, and temperature of $36.9^\circ$ C ($98.4^\circ$ F). Speculum examination shows a grossly normal cervix with the device strings visible at the external os. Bimanual examination reveals a mobile, anteverted uterus with no cervical motion tenderness or adnexal masses. A Papanicolaou test is obtained. One week later, the cytology report indicates negative for intraepithelial lesion or malignancy, but notes the presence of Actinomyces-like organisms. Which of the following is the most appropriate next step in the management of this patient?

A 29-year-old woman is evaluated in the hospital prior to discharge. Three days ago, she was admitted with severe lower abdominal pain, a temperature of $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), a blood pressure of $110/70\text{ mmHg}$, and a heart rate of $112\text{/min}$. Pelvic examination at that time revealed purulent cervical discharge, pronounced cervical motion tenderness, and a palpable, tender left adnexal mass. A copper intrauterine device string was visible at the cervical os. Pelvic ultrasonography confirmed a $6\text{-cm}$ left tubo-ovarian abscess. She was admitted and started on intravenous cefoxitin and oral doxycycline. Over the past 72 hours, she has become afebrile, her heart rate has decreased to $78\text{/min}$, and her pelvic pain has significantly improved. Her leukocyte count has normalized to $7,500/\text{mm}^3$. She is currently tolerating a regular diet. Endocervical nucleic acid amplification testing from admission returned positive for *Chlamydia trachomatis* and negative for *Neisseria gonorrhoeae*. Blood cultures show no growth. She will be discharged to complete a 14-day total course of therapy. Which of the following is the most appropriate next step in management?

A 34-year-old woman presents to the outpatient clinic complaining of severe vulvar pruritus and a thick vaginal discharge. Arrange the following clinical steps in the most appropriate chronological sequence for the evaluation and management of this patient's suspected recurrent vulvovaginal candidiasis (RVVC).

A 29-year-old nulligravid woman with a BMI of 34 kg/m² comes to the clinic seeking evaluation for an inability to conceive over the past 14 months. She has a history of irregular menstrual cycles occurring every 45 to 60 days. Physical examination reveals moderate facial acne and terminal hair growth on her chin. Semen analysis of her partner is within normal limits, and a hysterosalpingogram demonstrates patent fallopian tubes bilaterally. Arrange the following management steps in the correct chronological sequence for this patient's anovulatory infertility, progressing from the most appropriate initial therapy to the most advanced intervention.

A $24$-year-old woman, gravida $1$, para $0$, is admitted to the labor and delivery unit at $39$ weeks and $4$ days of gestation in spontaneous active labor. Her prenatal course was uncomplicated. Maternal vital signs are: blood pressure $118/76\text{ mm Hg}$, pulse $82/\text{min}$, and temperature $37.1\text{ C}$. The estimated fetal weight is $3200\text{ g}$ ($7\text{ lb } 1\text{ oz}$).

Cervical examination reveals the cervix is $6\text{ cm}$ dilated, $90\%$ effaced, and at $0$ station. The fetal membranes are ruptured, and clear amniotic fluid is noted.

Over the next hour, tocodynamometry demonstrates regular uterine contractions occurring every $3$ to $4$ minutes. External fetal monitoring shows a baseline heart rate of $140/\text{min}$ with moderate variability. However, there are recurrent, abrupt decreases in the fetal heart rate to $90/\text{min}$ that last for $40$ to $60$ seconds before rapidly returning to baseline. The onset of these decreases varies in relationship to the peak of the uterine contractions.

The patient is repositioned to the left lateral decubitus position, administered a $500\text{ mL}$ intravenous normal saline bolus, and provided supplemental oxygen. After $30$ minutes, the fetal heart rate tracing remains unchanged with moderate variability.

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

A nulliparous woman presents to the labor unit at 40 weeks and 2 days of gestation reporting regular uterine contractions. She is 24 years old and has had an uncomplicated pregnancy. On initial assessment, her cervix is dilated to 5 cm and completely effaced, with the fetal vertex at 0 station. Over the next hour, her contractions occur every 3 minutes. The continuous fetal monitor displays a baseline heart rate of 130/min with moderate variability. However, there are recurrent, abrupt decreases in the fetal heart rate to 80/min that reach their nadir within 15 seconds. These episodes last approximately 45 seconds and occur concurrently with the majority of the contractions before rapidly returning to baseline. The nursing staff assists the patient in changing to the left lateral decubitus position and administers an intravenous normal saline bolus, but the fetal heart rate pattern does not change. A subsequent cervical examination reveals no palpable umbilical cord.

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

A 30-year-old woman presents to the clinic for evaluation of secondary amenorrhea. Her last menstrual period was 10 months ago, shortly after she stopped breastfeeding her first child. Her pregnancy was complicated by a severe postpartum hemorrhage requiring an emergent suction curettage. She denies headaches, visual disturbances, hot flashes, or galactorrhea. Her body mass index is 23 kg/m². Physical examination reveals normal breast development and a normal-appearing vagina and cervix. Arrange the following steps in the most appropriate sequential diagnostic algorithm to evaluate this patient's amenorrhea, from the initial test to the final definitive diagnostic procedure.

A healthy 24-year-old gravida 1 para 0 at 39 weeks gestation is admitted to the maternity ward in spontaneous active labor. Her prenatal course was uncomplicated. She is currently utilizing continuous epidural analgesia and reports excellent pain control. Her temperature is 37.1°C (98.8°F), blood pressure is 120/76 mmHg, and pulse is 82/min. Uterine contractions are occurring every 3 to 4 minutes and feel firm on palpation. A sterile vaginal examination reveals the cervix is 8 cm dilated and 100% effaced, with the fetal vertex at +1 station. Continuous electronic fetal monitoring demonstrates a baseline heart rate of 145/min with moderate variability. During each uterine contraction, the fetal heart rate trace exhibits a gradual, symmetrical decrease to a nadir of 120/min. The nadir of the heart rate precisely aligns with the peak of the contraction, and the heart rate smoothly returns to baseline simultaneously with the resolution of the contraction. Which of the following is the most appropriate next step in management?

A 68-year-old multiparous woman presents to her primary care physician reporting a recent episode of vaginal bleeding. She states that she noticed bright red blood on her undergarments yesterday, which was entirely unexpected as her last menstrual period occurred more than 15 years ago. Her medical history is significant for hypertension and type 2 diabetes mellitus, which are managed with lisinopril and metformin. Her vital signs are within normal limits. A speculum examination reveals a small amount of dark blood in the vaginal vault, but no cervical or vaginal lesions are visible. The bimanual examination is unremarkable. Which of the following is the most appropriate next step in the evaluation of this patient?

A 59-year-old woman is evaluated in the gynecology clinic for a persistent, clear vaginal discharge over the past three months. She has not experienced any vaginal bleeding. Menopause occurred 8 years ago. Her past medical history is significant for type 2 diabetes mellitus and a body mass index of 37 kg/m². Current medications include metformin and lisinopril. On speculum examination, the vaginal mucosa appears pale and thin, and the cervix has no visible lesions or bleeding. Bimanual examination reveals a small, mobile uterus and no adnexal masses. A cervical cytology specimen is collected, which subsequently returns positive for atypical glandular cells. To further investigate, the physician performs a transvaginal ultrasound in the office, which demonstrates normal-sized ovaries and an endometrial stripe measuring 3 mm in thickness. Based on these findings, which of the following is the most appropriate next step in the patient's management?

A 33-year-old gravida 2, para 1, at 39 weeks gestation is admitted to the hospital in active labor. Her prenatal course was uncomplicated. Her previous pregnancy resulted in a low transverse cesarean delivery due to breech presentation. She strongly desires a vaginal birth and is undergoing a trial of labor after cesarean. Upon admission, cervical examination shows 5 cm dilation and 90% effacement, with the fetal head at -1 station. Epidural analgesia is administered with excellent effect. Three hours later, the patient suddenly complains of a sharp, tearing lower abdominal pain that radiates to her right shoulder, breaking through the epidural block. Concurrently, the fetal heart rate monitor demonstrates a sudden, prolonged deceleration to 75/min that has persisted for 4 minutes. A repeat cervical examination reveals 5 cm dilation and the fetal presenting part is now palpable at -3 station. Maternal blood pressure is 90/50 mm Hg and pulse is 118/min. Which of the following is the most appropriate next step in management?

A $38$-year-old G2P2 woman comes to the office seeking a reliable method of contraception. She also reports that over the past $8$ months, her menstrual periods have become increasingly heavy. She states that her menses last for $7$ to $8$ days and she frequently soaks through a thick pad every $2$ hours on the heaviest days. Her menstrual cycles remain regular, occurring every $28$ days. Her medical history is significant for frequent migraines with aura since age $20$. She smokes one pack of cigarettes daily. Her only medication is sumatriptan as needed. Vital signs include a blood pressure of $118/76 \text{ mmHg}$, pulse of $72\text{/min}$, and BMI of $23 \text{ kg/m}^2$. Pelvic examination reveals a normal-sized, mobile uterus without adnexal masses. A urine pregnancy test is negative. Laboratory studies show a hemoglobin of $10.8 \text{ g/dL}$ and a normal thyroid-stimulating hormone level. Which of the following is the most appropriate next step in management?