Obstetrics and Gynecology

Match each patient's clinical presentation and tumor molecular profile with the most appropriate targeted therapy or management strategy based on current gynecologic oncology guidelines.

A 26-year-old woman, G1P0, at 38 weeks gestation presents to the labor and delivery triage unit with painful uterine contractions. Her prenatal course has been uncomplicated. Vital signs on admission are temperature $37.0^{\circ}\text{C}$ ($98.6^{\circ}\text{F}$), blood pressure 125/80 mmHg, heart rate 92/min, and respiratory rate 18/min. Cervical examination shows 5 cm dilation, 90% effacement, and -1 station. She is admitted and receives epidural analgesia. Thirty minutes later, she complains of sudden dizziness, nausea, and dyspnea, stating "I feel like I cannot breathe." Her blood pressure is now 82/45 mmHg and heart rate is 118/min. The continuous fetal heart rate tracing reveals a baseline of 120/min with minimal variability and recurrent, visually apparent, gradual decreases in the fetal heart rate (onset to nadir $\geq$ 30 seconds) that consistently begin after the peak of each contraction and return to baseline after the contraction ends.

Laboratory studies obtained on admission:
Hemoglobin: 11.2 g/dL
Platelets: $180,000/\text{mm}^3$

Arterial blood gas (room air):
pH: 7.44
$\text{PaO}_2$: 104 mmHg
$\text{PaCO}_2$: 29 mmHg
$\text{HCO}_3^-$: 20 mEq/L

Despite the physician's explanation of the fetal tracing, the patient states, "I am terrified of surgery and absolutely refuse any operative deliveries." Which of the following is the most appropriate initial step in management?

A 35-year-old premenopausal woman, gravida 2, para 2, presents to her gynecologist for routine health maintenance. She has no active complaints, and her past medical history is unremarkable. Speculum examination reveals a normal-appearing cervix with no gross lesions. Arrange the following events in the standard sequential clinical pathway, from her initial screening abnormality to the definitive management of high-grade cervical dysplasia.

Match each patient's clinical presentation with the most likely underlying diagnosis.

Match each clinical presentation of a postpartum patient experiencing fever to its most likely underlying diagnosis.

Match each clinical presentation of an obstetric emergency to the most likely diagnosis.

A female patient in her early sixties presents to her primary care provider reporting vaginal spotting that began two weeks ago. She achieved menopause ten years ago and had been entirely asymptomatic since that time. Recently, she has also noted bilateral breast tenderness and a sensation of pelvic fullness. Her past medical history is notable only for well-controlled essential hypertension. Vital signs are within normal limits. On physical examination, her breasts are mildly tender to palpation but lack any discrete nodules, skin changes, or nipple discharge. Bimanual pelvic examination reveals a solid, mobile, palpable left adnexal mass measuring approximately 7 cm in diameter. Pelvic sonography is subsequently performed, confirming a 7.5-cm solid-cystic left ovarian mass and revealing an endometrial stripe thickness of 12 mm. Which of the following is the most appropriate next step in the management of this patient's condition?

A 30-year-old woman, gravida 2, para 2, is evaluated on postoperative day 1 following an uncomplicated scheduled cesarean delivery for a persistent breech presentation. The patient reports mild incisional pain and moderate lower abdominal cramping that worsens significantly when she breastfeeds her newborn. Her temperature is 37.7°C (99.9°F), blood pressure is 112/70 mm Hg, pulse is 82/min, and respirations are 14/min. Physical examination shows a soft abdomen with a clean, dry, and intact surgical incision. The uterine fundus is firm, palpable at the umbilicus, and mildly tender to deep palpation. Vaginal examination reveals moderate dark red bleeding without large clots. Laboratory studies show a leukocyte count of 16,500/mm³. Which of the following is the most appropriate next step in management?

A 15-year-old girl is brought to the gynecology clinic by her mother for evaluation of absent menses. On physical examination, she is at the 5th percentile for height. She has Tanner stage 1 breast development and normal external female genitalia. Arrange the following steps in the correct chronological order for the standard algorithmic diagnostic evaluation and subsequent workup of this patient.

A 46-year-old woman comes to the office to discuss the results of a recent routine Pap test, which was reported as atypical glandular cells (AGC). The patient has no current symptoms. Her menstrual cycles occur regularly every 28 days and last for 4 to 5 days. Her past medical history is significant for hypertension and class I obesity (BMI 32 $kg/m^2$). She has had no prior abnormal Pap tests. Pelvic examination demonstrates a normal-appearing parous cervix with no visible lesions or gross blood. Bimanual examination reveals a mobile, normal-sized uterus with no adnexal masses. Which of the following is the most appropriate next step in the management of this patient?

During a wellness examination, a 28-year-old female reports intense vaginal itching and a change in her vaginal discharge that began five days ago. She recently completed a 10-day course of amoxicillin-clavulanate for acute bacterial sinusitis. Her vital signs are within normal limits. Speculum examination reveals a normal-appearing cervix, marked vulvar erythema, and a thick, curd-like white vaginal discharge that adheres to the vaginal walls. The vaginal pH is 4.2. Which of the following is the most appropriate pharmacotherapy for this patient's current condition?

A $27$-year-old female presents to the gynecology clinic for contraceptive counseling. She reports that she has not had a menstrual period for the past $7$ months. Previously, her menses were regular. Over the last $3$ months, she has noticed rapidly increasing coarse facial hair, worsening acne, and a deepening of her voice. She has a history of bipolar disorder, which has been well controlled on valproic acid for the past $2$ years. She and her partner do not desire pregnancy, and she requests a reliable form of contraception to start immediately.

Vital signs are:
Temperature: $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$)
Blood pressure: $118/76\text{ mmHg}$
Pulse: $78\text{/min}$
BMI: $28\text{ kg/m}^2$

Physical examination reveals coarse hair on her upper lip, chin, and chest. Temporal balding and clitoromegaly are clearly present. Pelvic examination is otherwise unremarkable.

Laboratory studies show:

Pelvic ultrasonography demonstrates normal-sized ovaries with multiple small, peripherally arranged cysts bilaterally.

Before initiating a contraceptive method, which of the following is the most appropriate next step in the management of this patient?

Presenting for a family planning consultation, a 38-year-old gravida 2 para 2 is seeking a reliable method of birth control. She is currently sexually active with a new male partner. Review of her medical chart shows no chronic medical conditions, and she takes no daily medications. Social history is significant for a 20-pack-year smoking habit; she currently smokes approximately one and a half packs of cigarettes per day. She consumes alcohol occasionally on weekends. Today, her blood pressure is 116/74 mmHg, pulse is 76/min, and BMI is 24 kg/m². Cardiopulmonary and abdominal examinations are within normal limits. A pelvic exam shows a normal-appearing cervix without discharge, and a point-of-care urine beta-hCG test is negative. Which of the following contraceptive options is absolutely contraindicated for this patient?

A woman at 40 weeks gestation, gravida 1, para 0, is undergoing labor induction for oligohydramnios. She is 29 years of age. An oxytocin infusion was started six hours ago. She now complains of relentless, overlapping abdominal cramping. Maternal vital signs show a blood pressure of 118/72 mmHg, a heart rate of 84/min, and a temperature of 37.0°C (98.6°F). A review of the tocodynamometer reveals seven uterine contractions in the past ten minutes, lasting up to 90 seconds each. The fetal heart rate tracing demonstrates a baseline of 135/min, minimal variability, and recurrent gradual decreases in heart rate that reach their nadir after the peak of the contractions. Pelvic examination shows the cervix is 5 cm dilated, 80% effaced, and at -1 station. Which of the following is the most appropriate initial intervention?

Seeking care at a community clinic, a 26-year-old female reports that her menses completely stopped 11 months ago. She additionally describes experiencing sudden episodes of intense body warmth and sweating that frequently awaken her at night, along with new-onset vaginal discomfort during sexual intercourse. Prior to this, her menstrual cycles were regular every 29 days since menarche at age 13. She has no significant past medical history and takes no medications. Her body mass index is 21 kg/m². A urine pregnancy test performed in the office is negative. Which of the following serum hormone profiles is most likely present in this patient?

Following a prolonged second stage of labor, a multipara delivers a macrosomic infant vaginally. Shortly after placental expulsion, she develops massive vaginal hemorrhage. Abdominal examination reveals a flaccid, boggy uterus extending above the umbilicus. Despite aggressive intravenous fluid resuscitation, a continuous high-dose oxytocin infusion, and vigorous fundal massage, the patient remains hypotensive at 88/50 mm Hg and tachycardic at 122/min with ongoing brisk bleeding. Arrange the following interventions in the correct escalating sequence for managing this patient's refractory postpartum hemorrhage, starting with the most appropriate immediate next step and ending with the definitive final resort.

During a wellness visit, a 67-year-old nulligravid female reports noticing blood on her undergarments over the past three weeks. She notes her last menstrual period occurred at age 51. Her medical history includes type 2 diabetes mellitus, hypertension, and obesity. Her current body mass index is $39 \text{ kg/m}^2$. A speculum examination reveals a normal-appearing cervix with no vaginal or vulvar lesions. Transvaginal ultrasonography demonstrates an endometrial stripe thickness of $14 \text{ mm}$. Which of the following is the most appropriate next step in the management of this patient?

For each clinical vignette describing a patient with a gynecologic neoplasm, identify the most appropriate definitive surgical intervention or management step.

A 22-year-old nulligravid woman is evaluated in an urgent care center due to a two-day history of worsening, bilateral lower pelvic discomfort and an abnormal, yellowish vaginal discharge. She reports no nausea, emesis, or fever. Her vital signs are stable. Arrange the following actions in the most appropriate chronological sequence for the standard diagnostic workup and outpatient management of this patient's suspected pelvic inflammatory disease.

Match each clinical presentation of a suspected gynecologic infection with its most likely diagnosis and corresponding management strategy.