Obstetrics and Gynecology

A 59-year-old postmenopausal woman with a family history of breast cancer and a recently confirmed BRCA1 pathogenic variant presents to her physician with early satiety, bloating, and increasing abdominal girth for the past month. Physical examination reveals a palpable, fixed, irregular left adnexal mass and a clinically detectable fluid wave indicating ascites. Arrange the following steps in the most appropriate chronological order for the diagnostic workup and standard management of this patient, from initial evaluation to post-remission therapy.

A 24-year-old nulliparous woman presents to the clinic reporting that she has not had a menstrual period for the past 6 months. Her menarche occurred at age 12, and her menses were previously regular, occurring every 28 days. She takes no medications, has no chronic medical conditions, and is sexually active with a male partner. Her vital signs and physical examination are unremarkable. Arrange the following diagnostic steps in the most appropriate chronological sequence for the evaluation of this patient's secondary amenorrhea, starting with the immediate first step.

A 26-year-old woman evaluates at the urgent care center due to four days of copious, malodorous vaginal discharge associated with mild dysuria. Her medical history is unremarkable, and she recently became sexually active with a new male partner. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$). Speculum examination demonstrates frothy, yellow-green fluid pooled in the posterior vaginal fornix and several punctate macular hemorrhages on the cervix. A saline microscopy preparation of the fluid reveals multiple motile, pear-shaped, flagellated organisms slightly larger than polymorphonuclear leukocytes. Which of the following is the most appropriate pharmacological intervention?

Review the following four patient profiles. Each patient is seeking a reliable method of contraception. Match each clinical scenario with the most medically appropriate contraceptive method based on the United States Medical Eligibility Criteria (US MEC) for Contraceptive Use.

A 27-year-old female presents to the outpatient clinic reporting an absence of menstruation for the past seven months. She previously experienced predictable cycles every 29 days. She denies hot flashes, nipple discharge, vision changes, or recent alterations in body weight. Physical examination shows a normal female escutcheon, no signs of hyperandrogenism, and an unremarkable bimanual pelvic examination. Arrange the following diagnostic steps in the most appropriate sequential order for evaluating this patient's condition, starting with the mandatory initial test.

Evaluate the following complex patient profiles. Match each clinical scenario with the single most appropriate, highly effective contraceptive method based on the WHO/CDC Medical Eligibility Criteria (MEC).

A 24-year-old healthy female presents to the clinic reporting an absence of menses for the past six months. She previously had regular 28-day menstrual cycles. She does not take any medications, has no chronic medical conditions, and reports no breast discharge, visual changes, or hot flashes. Physical examination reveals a normal body mass index and normal secondary sexual characteristics. Arrange the following diagnostic steps in the most appropriate chronological sequence for the initial evaluation of this patient's secondary amenorrhea, starting with the most immediate first step.

A $26$-year-old nulligravid woman presents to the gynecologist reporting the absence of menses for the past $6$ months. Prior to this, she had regular menstrual cycles occurring every $28$ days. Over the same $6$-month period, she has noted a significant increase in thick, dark hair on her face, chest, and abdomen, as well as a noticeable deepening of her voice. She has also experienced a receding hairline. She has no significant past medical history and takes no medications or supplements. Vital signs are within normal limits. Her BMI is $23 \text{ kg/m}^2$. Physical examination reveals temporal balding, severe hirsutism on the face and trunk, and clitoromegaly. Bimanual pelvic examination is limited by patient discomfort but reveals no obvious adnexal masses. A urine human chorionic gonadotropin test is negative. Serum thyroid-stimulating hormone (TSH) and prolactin levels are within normal limits. Which of the following is the most appropriate next step in the evaluation of this patient?

A 27-year-old primigravid woman at 39 weeks gestation is admitted to the labor and delivery unit in spontaneous labor. She requests and receives epidural anesthesia for pain management. Her labor progresses without complication, and her cervix becomes completely dilated. She is instructed to begin pushing. Three hours later, a vaginal examination reveals the cervix is 10 cm dilated and 100% effaced, and the fetal head is at +2 station in the direct occiput anterior position. The maternal temperature is 37.1°C (98.8°F), blood pressure is 118/76 mm Hg, and pulse is 84/min. Uterine contractions occur every 2 to 3 minutes and are strong to palpation. Continuous fetal heart rate monitoring demonstrates a baseline of 135/min, moderate variability, and symmetric, gradual decreases in the fetal heart rate that begin and end with each uterine contraction. The nadir of these decreases coincides precisely with the peak of each contraction. Which of the following is the most appropriate next step in management?

Match each clinical presentation of a breast disorder to the most appropriate initial diagnostic workup or management step.

A 34-year-old woman, gravida 2, para 1, undergoes suction dilation and curettage for an early pregnancy loss at 9 weeks gestation. The procedure is performed under general anesthesia. Cervical dilation is uncomplicated. However, during suctioning, the physician notes a sudden loss of resistance, and the cannula advances significantly further than the previously measured uterine depth. The suction is immediately turned off. Inspection of the aspirated contents in the tubing reveals fragments of yellow, fatty tissue. The patient's blood pressure is 118/76 mm Hg and heart rate is 82/min. Which of the following is the most appropriate next step in management?

A 32-year-old woman, gravida 0, comes to the physician for evaluation of infertility. She and her husband have been trying to conceive for 14 months without success. Her last menstrual period was 8 months ago; prior to this, her periods occurred regularly every 28 days. She reports a 9-kg (20-lb) weight gain over the past year, along with worsening fatigue and cold intolerance. She also notes mild facial acne and intermittent morning headaches. She says, "I've been bumping into doorframes a lot lately." Her temperature is 36.4°C (97.5°F), blood pressure is 110/70 mm Hg, and pulse is 58/min. Her body mass index is 29 kg/m². Physical examination reveals delayed relaxation of deep tendon reflexes. Visual field testing by confrontation demonstrates decreased peripheral vision bilaterally.

Laboratory studies:
Urine pregnancy test: negative
Follicle-stimulating hormone: 3 mIU/mL
Luteinizing hormone: 2 mIU/mL
Prolactin: 48 ng/mL (Normal: < 20 ng/mL)
Thyroid-stimulating hormone: 0.2 µU/mL (Normal: 0.5–5.0 µU/mL)
Free thyroxine (T4): 0.6 ng/dL (Normal: 0.9–1.7 ng/dL)

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

A 23-year-old graduate student is evaluated in the ambulatory care clinic due to bothersome facial hair and infrequent menstrual periods. Her menarche occurred at age 12, and she reports having only three to four menses per year since that time. Over the last 24 months, she has observed increasing coarse, dark hair on her upper lip, chin, and lower abdomen, prompting her to shave frequently. Her past medical history is unremarkable, and she takes no medications. Vital signs show a blood pressure of $118/76 \text{ mmHg}$, a pulse of $74/\text{min}$, and a respiratory rate of $14/\text{min}$. Her body mass index is $29 \text{ kg/m}^2$. Physical examination confirms moderate inflammatory acne over the face and back, as well as terminal hairs in a male-pattern distribution. Pelvic examination is normal, with no evidence of clitoromegaly or palpable adnexal masses. A urine human chorionic gonadotropin test is negative. Laboratory results show normal serum thyroid-stimulating hormone and prolactin levels. Which of the following is the most appropriate next step in management?

A 29-year-old nulliparous woman at 27 weeks of gestation comes to the obstetric clinic for a scheduled evaluation. She mentions that lately she feels "out of breath" when climbing stairs at home and has noticed her shoes feeling tight by the evening. She has no history of cardiopulmonary disease. Blood pressure is 114/72 mm Hg, pulse is 98/min, and respirations are 20/min. Cardiopulmonary auscultation reveals a grade 2/6 systolic murmur heard best over the left sternal border and clear breath sounds bilaterally. Trace pitting edema is noted around her ankles.

Laboratory analysis shows:
Leukocyte count: $14,200/\text{mm}^3$
Hemoglobin: $10.7 \text{ g/dL}$
Platelet count: $128,000/\text{mm}^3$
Serum creatinine: $0.5 \text{ mg/dL}$
Urine dipstick: 1+ glucose, negative for protein and blood.

Her blood type is O, Rh-positive.

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

Match each clinical scenario describing an acute obstetric complication with its most appropriate immediate next step in management.

Match each clinical presentation of a pregnant patient with the primary underlying physiological mechanism responsible for the findings.

Match each classic clinical presentation during a primary postpartum hemorrhage with its most likely underlying etiology.

A healthy 24-year-old primigravida presents for preconception counseling. She is subsequently confirmed pregnant and initiates prenatal care at 8 weeks gestation. Her initial laboratory workup reveals she is blood type A-negative. Assuming an uncomplicated pregnancy course that concludes with the term vaginal delivery of a healthy Rh(D)-positive neonate, arrange the following routine alloimmunization screening and prophylaxis steps in the correct chronological sequence from the first trimester through the postpartum period.

Match the following clinical and laboratory findings observed during an uncomplicated normal pregnancy with their primary underlying physiological mechanisms.

A $24$-year-old woman, gravida $1$, para $0$, presents to the clinic at $8$ weeks gestation for her initial prenatal visit. Her medical history is unremarkable, and she takes a daily prenatal vitamin. Her blood pressure is $112/70\text{ mmHg}$, and her body mass index is $22\text{ kg/m}^2$. The patient is eager to ensure a healthy pregnancy and asks the physician to outline the standard schedule of recommended screenings and evaluations she will undergo over the coming months.

Arrange the following routine obstetric interventions for this patient in the correct chronological order from earliest to latest gestational age.