Obstetrics and Gynecology

A 30-year-old woman comes to the ambulatory care clinic complaining of vulvar irritation and a profuse, unpleasant-smelling vaginal discharge that began four days ago. She recently became sexually active with a new male partner. Her temperature is 37.0°C (98.6°F), blood pressure is 118/76 mm Hg, and pulse is 78/min. Pelvic examination reveals a frothy, yellow-green discharge pooling in the vaginal vault and small, punctate hemorrhages on the ectocervix. Microscopic evaluation of the vaginal fluid suspended in normal saline demonstrates motile, flagellated organisms that are slightly larger than polymorphonuclear leukocytes. Which of the following is the most appropriate next step in management for this patient?

A 34-year-old woman, gravida 2, para 1, at 38 weeks gestation is admitted to the labor and delivery unit for induction of labor due to preeclampsia with severe features. Her medical history is notable for mild persistent asthma, for which she uses an inhaled corticosteroid. She is receiving intravenous magnesium sulfate for seizure prophylaxis and an intravenous oxytocin infusion for labor augmentation. Maintenance intravenous fluids are running at 125 mL/hr. Fourteen hours into her induction, she becomes acutely agitated and reports sudden-onset severe shortness of breath and chest tightness. She states she is unable to lie flat.

Vital signs are:
Temperature: 37.0°C (98.6°F)
Blood pressure: 172/112 mmHg
Heart rate: 118/min
Respiratory rate: 28/min
SpO2: 86% on room air

Physical examination reveals prominent jugular venous pulsations. Lung auscultation reveals scattered wheezes and bilateral fine crackles extending to the mid-lung fields. The fetal heart rate tracing demonstrates a baseline of 140/min, moderate variability, and symmetric, gradual decreases in the heart rate that nadir exactly at the peak of uterine contractions.

An arterial blood gas on room air shows:
pH: 7.44
PaCO2: 28 mmHg
PaO2: 58 mmHg
HCO3: 19 mEq/L

The patient is immediately placed on supplemental oxygen via a non-rebreather mask. Which of the following is the most appropriate next step in the management of this patient?

A 62-year-old postmenopausal woman presents to the gynecologist reporting a new onset of vaginal spotting. She has a history of estrogen receptor-positive breast cancer, for which she has been taking tamoxifen for the past four years. Her last menstrual period was 12 years ago. Pelvic examination reveals no vaginal lacerations and a normal-appearing cervix. Arrange the following steps in the most appropriate chronological order for the evaluation and definitive management of this patient's condition.

A 20-year-old woman is brought to the emergency department with acute-onset confusion, high fever, and intractable vomiting. She is currently on day 4 of her menstrual cycle. Vital signs are temperature 39.9°C (103.8°F), blood pressure 76/40 mmHg, and heart rate 142/min. Physical examination reveals generalized non-pitting edema and a diffuse, blanching, erythematous macular rash resembling a sunburn. Pelvic examination reveals a foul-smelling, retained highly absorbent tampon. Arrange the following steps in the correct chronological sequence for the comprehensive management of this patient, from immediate life-saving emergency stabilization to long-term preventive outpatient care.

A 51-year-old woman comes to the office due to a 4-day history of spotting and light vaginal bleeding. She reached menopause at age 49 and has not had any vaginal bleeding since then. Her past medical history includes obesity, type 2 diabetes mellitus, and hypertension. Current medications are metformin, lisinopril, and amlodipine. She does not use tobacco or alcohol. Vital signs show a blood pressure of 142/88 mm Hg, a pulse of 76/min, and a BMI of 34 kg/m². Pelvic examination reveals normal external genitalia and a small amount of dark red blood in the vaginal vault. The cervix appears grossly normal without any visible lesions. A urine pregnancy test is negative. A transvaginal ultrasound is performed and shows an endometrial stripe thickness of 7 mm. Which of the following is the most appropriate next step in the management of this patient?

An obstetrician is evaluating a multiparous patient at term who is in active labor with intact membranes. The fetal station is -2. To accelerate labor progress, an artificial rupture of membranes is performed. Immediately following the procedure, the fetal heart rate monitor shows a sudden, sustained bradycardia of 70/min. Pelvic examination reveals a soft, pulsating, rope-like structure protruding through the cervical os ahead of the fetal vertex. Arrange the following interventions in the most appropriate chronological order for managing this acute obstetric emergency, from the most immediate bedside action to final definitive care.

Match each patient's clinical profile with the most appropriate and safe contraceptive method according to the WHO Medical Eligibility Criteria.

A healthy 24-year-old patient is admitted in active labor at 39 weeks' gestation. She requests pain management and receives continuous lumbar epidural analgesia when her cervix is dilated to 5 cm. Fifteen minutes following the epidural bolus, the patient begins to feel lightheaded and nauseous. Her blood pressure drops from an admission baseline of 118/74 mm Hg to 82/45 mm Hg. Simultaneous continuous fetal monitoring demonstrates a baseline heart rate of 145/min that suddenly decreases to 85/min and has remained there for the past 3 minutes. The nurse immediately turns the patient onto her left side and administers a rapid intravenous bolus of isotonic crystalloid, but the maternal blood pressure remains 84/48 mm Hg and the prolonged fetal bradycardia persists. Which of the following is the most appropriate next step in management?

An obstetric unit receives a $24$-year-old primigravida at $40$ weeks gestation for an elective labor induction. Following cervical ripening, continuous administration of an intravenous uterine stimulant is initiated. Over the subsequent hour, uterine contractions intensify to a frequency of one every $2$ minutes. Between contractions, the patient mentions feeling mildly lightheaded and short of breath.

Her blood pressure is $118/76 \text{ mmHg}$, pulse is $95 \text{ /min}$, and respiratory rate is $20 \text{ /min}$. Baseline laboratory values obtained upon admission demonstrate:
Hemoglobin: $11.2 \text{ g/dL}$
Leukocyte count: $14,000 \text{ /mm}^3$
Platelet count: $200,000 \text{ /mm}^3$

An arterial blood gas analysis on room air shows:
pH: $7.44$
PaCO $_2$: $28 \text{ mmHg}$
PaO $_2$: $102 \text{ mmHg}$
HCO $_3^-$: $19 \text{ mEq/L}$

Continuous electronic fetal monitoring displays a baseline heart rate of $145 \text{ /min}$ with moderate variability. There are recurrent, symmetric decreases in the fetal heart rate that begin gradually, reach their nadir after the peak of each uterine contraction, and slowly return to the baseline after the contraction ends. The patient's cervix is $6 \text{ cm}$ dilated and $100\%$ effaced.

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

A 26-year-old woman is evaluated in the urgent care setting after seeking postcoital contraception. She reports a single episode of unprotected vaginal intercourse approximately 90 hours prior to arrival. Her medical history is notable for a high body mass index (BMI) of 33 kg/m². During the review of systems, she mentions recent onset of lower abdominal discomfort. Pelvic examination reveals a friable cervix with mucopurulent discharge, marked cervical motion tenderness, and bilateral adnexal tenderness. A point-of-care urine pregnancy test is negative.

Arrange the following emergency contraceptive options in order from MOST appropriate to LEAST appropriate for this specific patient, taking into consideration her clinical presentation, body habitus, and time elapsed.

A 34-year-old female patient (G2P2) presents for a routine gynecologic evaluation. She has no significant past medical history and takes no daily medications. Four years ago, she had a copper intrauterine device (IUD) inserted for long-term contraception. Upon questioning, she denies any lower abdominal discomfort, pain with intercourse, intermenstrual bleeding, or abnormal vaginal discharge. Vital signs are normal. On speculum examination, the vaginal vault is healthy and the cervix is grossly normal with IUD strings visualized at the external os. Bimanual examination confirms a mobile, non-tender uterus without adnexal fullness. A cervical cytology smear (Pap test) is collected. The subsequent laboratory report is negative for intraepithelial lesions and malignancy, but incidentally notes the presence of branching, filamentous organisms consistent with *Actinomyces* species. Which of the following is the most appropriate next step in the management of this patient?

A $33$-year-old pregnant patient (G $2$ P $1$) at $38$ weeks of gestation is currently on the labor and delivery unit undergoing induction for chronic hypertension. An intravenous oxytocin infusion is ongoing. Six hours after starting the induction, her cervical examination shows $5$ cm dilation, $90\%$ effacement, and the fetal vertex at a $-1$ station. Over the past $15$ minutes, she has developed sudden, severe, unremitting lower abdominal pain that does not subside between contractions. This is accompanied by a scant amount of dark red vaginal bleeding. Vital signs show a blood pressure of $155/95$ mm Hg and a heart rate of $110$/min.

The external tocodynamometer records $6$ uterine contractions in a $10$-minute window along with a persistently elevated resting uterine tone. The fetal heart rate tracing displays a baseline of $165$/min, minimal variability, and recurrent late decelerations.

The nursing staff immediately discontinues the oxytocin infusion, repositions her to the left lateral decubitus position, and administers an intravenous fluid bolus. Ten minutes later, the unremitting abdominal pain and the tetanic contraction pattern persist. The fetal heart rate tracing remains identical.

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

A 26-year-old nulligravid woman comes to the clinic because she found a lump in her left breast 1 week ago. She is premenopausal with regular 28-day menstrual cycles, and her last menstrual period was 10 days ago. She is currently not pregnant and is not lactating. She has no significant past medical history, and her family history is negative for breast or ovarian cancer. On physical examination, her vital signs are within normal limits. Breast examination reveals a 2.5-cm, firm, mobile, well-circumscribed, and non-tender mass in the upper outer quadrant of the left breast. There is no overlying skin dimpling, erythema, or nipple discharge. There is no palpable axillary or supraclavicular lymphadenopathy. Which of the following is the most appropriate next step in evaluation?

A 54-year-old postmenopausal woman comes to the clinic to discuss the results of a recent breast biopsy. A routine screening mammogram performed two weeks ago demonstrated a new 8-mm cluster of fine, pleomorphic microcalcifications in the upper outer quadrant of her right breast. Physical examination reveals no palpable breast masses, nipple discharge, or overlying skin changes. Axillary lymph nodes are not palpable. She has no personal or family history of breast, ovarian, or colon cancer. She underwent a stereotactic core needle biopsy of the calcifications. The histopathology report reveals classic lobular carcinoma in situ (LCIS) without evidence of invasive disease or atypia. Which of the following is the most appropriate next step in management?

Match each distinct clinical presentation of a breast disorder to its most likely diagnosis.

Match each clinical scenario describing a patient with a breast disorder to the most appropriate next step in management.

A 36-year-old woman comes to the clinic reporting spontaneous, intermittent bloody discharge from her left nipple for the past 6 weeks. She has noticed dark stains on her bra but denies breast pain, skin changes, or a palpable lump. She has no personal or family history of breast cancer. She takes no medications. Vital signs are within normal limits. Physical examination reveals no palpable breast masses, skin dimpling, or axillary lymphadenopathy. Gentle pressure applied to the periareolar area of the left breast elicits a few drops of serosanguineous discharge from a single duct. Diagnostic mammography and targeted ultrasound of the left breast show no abnormalities. Which of the following is the most appropriate next step in management?

A 33-year-old woman comes to the office after noticing a firm, painless lump in her left breast 2 weeks ago. Physical examination reveals a 2.5-cm, hard, nonmobile mass in the upper outer quadrant of the left breast without overlying skin changes. There is no palpable axillary lymphadenopathy. Assuming the mass is highly suspicious for early-stage invasive breast carcinoma, arrange the following steps in the most appropriate chronological sequence for her standard diagnostic workup and management.

An asymptomatic $56$-year-old female presents to the clinic to discuss her recent imaging and biopsy results. During a routine health maintenance visit last month, a bilateral mammogram was ordered which demonstrated a highly suspicious $1.8$-cm stellate density with clustered, fine linear branching calcifications in the upper outer quadrant of her left breast (BI-RADS $5$). A subsequent image-guided stereotactic core needle biopsy of the lesion was performed. The histopathology report describes classic lobular carcinoma in situ (LCIS) without evidence of invasive malignancy, atypical ductal hyperplasia, or ductal carcinoma in situ. The patient has a history of hypertension and diet-controlled type 2 diabetes mellitus. Menopause occurred at age $51$. She currently takes lisinopril. Vital signs are within normal limits. Breast examination reveals symmetrical breasts with no skin dimpling, nipple retraction, or palpable masses. There is no cervical, supraclavicular, or axillary adenopathy. Which of the following is the most appropriate next action for this patient?

A 44-year-old woman comes to the clinic after noticing a new lump in her right breast 2 weeks ago. She performs intermittent breast self-examinations and has no family history of breast or ovarian cancer. Her medical history is significant for primary hypothyroidism, for which she takes levothyroxine. Menarche was at age 12, and she has regular menstrual cycles. She had a routine screening mammogram 4 months ago, which was reported as normal with heterogeneously dense breast tissue (BI-RADS 1). Vital signs are within normal limits. On physical examination, there is a 2.5-cm, firm, non-tender, and freely mobile mass in the upper outer quadrant of the right breast. There are no overlying skin changes, nipple retraction, or nipple discharge. There is no palpable cervical, supraclavicular, or axillary lymphadenopathy. Which of the following is the most appropriate next step in management?