Obstetrics and Gynecology

A 27-year-old nulliparous woman at 24 weeks gestation comes to the clinic for a routine prenatal visit. She feels well and has no significant complaints. Her medical history is unremarkable, and she takes a daily prenatal vitamin. Vital signs are temperature 37.0°C (98.6°F), blood pressure 110/70 mmHg, pulse 82/min, and respirations 16/min. Laboratory results are as follows:

Her pre-pregnancy hemoglobin was 13.5 g/dL. Which of the following mechanisms best explains this patient's current laboratory findings?

A $29$-year-old woman, gravida $1$, para $0$, comes to the clinic for a scheduled obstetric evaluation at $34$ weeks gestation. Over the past few weeks, she has noticed increased shortness of breath when climbing stairs and mild swelling around her ankles by the evening. She has no headache, visual disturbances, or right upper quadrant abdominal pain. Her blood pressure is $116/76\text{ mm Hg}$, pulse is $88/\text{min}$, and respirations are $16/\text{min}$. On physical examination, a soft mid-systolic murmur is audible at the left upper sternal border. The lungs are clear to auscultation bilaterally. The uterus is palpated at $34\text{ cm}$ above the pubic symphysis, and $1+$ pitting edema is present at the bilateral ankles. The physician reviews the patient's recent laboratory results. Which of the following findings in this patient represents a pathological process requiring further diagnostic workup?

Match each gestational age timeframe with the most appropriate routine prenatal screening test or intervention indicated at that time for an uncomplicated pregnancy.

An expectant mother, age 30, is brought to the emergency department at 28 weeks gestation following a minor traffic accident. She reports no abdominal pain, vaginal bleeding, or shortness of breath. She has no significant medical history and takes only a daily prenatal vitamin. Vital signs show a blood pressure of $110/70$ mm Hg, pulse of $88$/min, and respiratory rate of $16$/min. Continuous fetal heart rate monitoring is reassuring. As part of a standard trauma protocol, an arterial blood gas is obtained on room air. Compared to a healthy nonpregnant state, which of the following acid-base profiles is an expected physiological finding in this patient?

A 24-year-old primigravida presents to the clinic for her first prenatal visit at 8 weeks gestation. She has an uncomplicated medical history and wishes to understand the schedule for her upcoming evaluations. As part of routine prenatal care, various screening tests and imaging studies are recommended at specific gestational ages. Arrange the following routine prenatal evaluations in the correct chronological sequence from earliest to latest in a normal, uncomplicated pregnancy.

During prenatal care, recognizing normal physiologic adaptations of pregnancy is critical to avoid unnecessary interventions for findings that would otherwise be considered pathologic in non-pregnant patients. Match the following underlying physiologic mechanisms of normal pregnancy to their corresponding clinical or laboratory manifestations.

A 32-year-old G2P1 woman at 39 weeks gestation is in the second stage of active labor. Suddenly, she gasps for air, becomes profoundly cyanotic, and loses consciousness. The fetal monitor shows an acute, prolonged deceleration to 60/min. The patient is apneic and has no palpable carotid pulse. Arrange the following management steps in the most appropriate sequential order for this catastrophic obstetric emergency.

An expectant mother at 38 weeks gestation presents to the obstetric triage unit in active labor. She has a history of a low transverse cesarean delivery three years ago and has opted for a trial of labor for her current pregnancy. Upon admission, her vital signs are stable, and contractions are occurring regularly every 3 minutes. Three hours later, she experiences a sudden, agonizing, tearing pain in her lower abdomen that does not resolve between contractions. Simultaneously, the fetal heart rate tracing demonstrates a prolonged deceleration to 70 beats per minute. A prompt cervical examination demonstrates that dilation is unchanged at 6 cm, but the fetal head has receded from 0 station to -3 station. What is the most appropriate next intervention for this patient?

A 35-year-old woman, gravida 2, para 1, at 38 weeks gestation is evaluated in the obstetric triage unit for the onset of active labor. Her surgical history is significant for an open myomectomy two years ago for a 10-cm intramural fibroid, during which the surgeon noted that the uterine cavity was entered. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is 112/70 mm Hg, pulse is 108/min, and respirations are 22/min. Arterial blood gas analysis on room air shows a pH of 7.44, $\text{PaCO}_2$ of 28 mm Hg, and $\text{HCO}_3^-$ of 20 mEq/L. The fetal heart rate tracing initially shows a baseline of 145/min with moderate variability and no decelerations. Tocodynamometry shows contractions every 3 to 4 minutes. A cervical examination reveals the cervix is 5 cm dilated and 90% effaced, with the fetal presenting part at -1 station.

Thirty minutes later, the patient suddenly reports a sharp, tearing, and continuous lower abdominal pain that does not remit between contractions. The fetal heart rate tracing abruptly demonstrates a baseline drop to 80/min that persists for 4 minutes without recovery. A repeat cervical examination reveals that the fetal head is no longer palpable.

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

A 28-year-old G1P0 woman at 38 weeks gestation is brought to the emergency department after experiencing a generalized tonic-clonic seizure at home. Her blood pressure is 168/112 mm Hg. She is currently postictal and breathing spontaneously. Continuous fetal monitoring shows a baseline heart rate of 135/min with moderate variability and no decelerations. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 31-year-old woman, gravida 2, para 1, at 28 weeks gestation, presents to the clinic for a routine prenatal visit. She reports feeling well and notes active fetal movement. Her only symptom is mild swelling of her ankles by the end of the day. Blood pressure is 112/68 mm Hg, and pulse is 84/min. Fundal height is 28 cm. Fetal heart rate is 145/min. Laboratory studies are obtained and the results are shown below:

Urinalysis shows trace protein, 1+ glucose, and is negative for leukocyte esterase and nitrites.

Which of the following findings in this patient is pathologic and requires further evaluation?

A 29-year-old G4P3 woman at 39 weeks gestation delivers a 4,200-g (9-lb 4-oz) neonate vaginally following a prolonged labor augmented with oxytocin. Shortly after the spontaneous delivery of an intact placenta, she develops profuse vaginal bleeding. Her blood pressure is 88/50 mm Hg and pulse is 122/min. On examination, the uterus is soft, boggy, and palpated above the umbilicus. A continuous oxytocin infusion is already running through two large-bore intravenous lines.

Assuming each consecutive intervention fails to control the hemorrhage, arrange the following management steps in the correct sequential order from the immediate next step to the definitive final treatment.

Match each clinical presentation of a pregnant patient with the most appropriate hypertensive disorder of pregnancy diagnosis.

A nulliparous woman at 40 weeks gestation presents to the maternity triage area with painful uterine contractions occurring every 3 minutes. Her pregnancy has been uncomplicated. Vital signs are within normal limits. On pelvic examination, the cervix is dilated to 8 cm and is fully effaced. The fetal presenting part is at +1 station. External fetal monitoring displays a baseline heart rate of 145/min with moderate variability. Symmetrical, gradual decreases in the fetal heart rate are noted, which precisely mirror the uterine contractions; the onset, nadir, and recovery of each deceleration coincide directly with the beginning, peak, and end of the corresponding contraction. The minimum fetal heart rate during these episodes is 125/min. Which of the following is the most appropriate next step in the care of this patient?

A primigravid client is admitted to the maternity ward in spontaneous active labor at term. A continuous electronic fetal monitor is applied to evaluate fetal well-being. Throughout the observation period, the tracing displays multiple episodes where the fetal heart rate abruptly decreases by 20 to 30 beats per minute from a stable baseline of 145 beats per minute. These abrupt drops reach their nadir within 15 seconds, last for approximately 30 to 40 seconds, and then rapidly return to the baseline. The decreases occur inconsistently, showing no uniform relationship to the onset or peak of the concurrent uterine contractions. Which of the following is the most likely underlying physiological cause of this fetal heart rate pattern?

Match the following postpartum complications to their classic clinical presentations and defining characteristics.

A 26-year-old woman, gravida 1, para 0, presents to the clinic at 6 weeks gestation for her initial prenatal visit. She has a completely uncomplicated medical history. Her blood type is O negative, and her partner is known to be A positive. The patient is a systems engineer and requests a highly detailed, chronological roadmap of her anticipated maternal physiological changes, physical examination milestones, and routine prenatal care interventions. Based on current obstetric guidelines for an uncomplicated normal pregnancy, arrange the following events in the correct chronological order from earliest in gestation to latest.

A gravida $1$, para $0$ patient at $38$ weeks of gestation presents to the obstetric triage unit with a chief complaint of a sudden gush of clear vaginal fluid that occurred $20$ hours ago. She is currently experiencing painful uterine contractions every $3$ to $4$ minutes. Her temperature is $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), blood pressure is $112/74\text{ mm Hg}$, pulse is $115/\text{min}$, and respiratory rate is $18/\text{min}$. Physical examination reveals a tender uterine fundus. The cervix is visually assessed at $5\text{ cm}$ dilation and $90\%$ effacement. The fetal heart rate monitor displays a baseline of $168/\text{min}$ with moderate variability and no decelerations. Which of the following is the most appropriate next step in the management of this patient?

Following a spontaneous vaginal delivery, the obstetrician examines the perineum to assess the extent of tissue injury and determine the appropriate surgical repair. Match the following degrees of obstetric perineal lacerations with the correct anatomical structures involved.

A patient at 37 weeks gestation is hospitalized on the antepartum unit for management of preeclampsia with severe features. Her admission laboratory evaluation revealed a platelet count of 70,000/mm³, an aspartate aminotransferase level of 380 U/L, and an alanine aminotransferase level of 410 U/L. She is currently receiving an intravenous magnesium sulfate infusion. Three hours after admission, she suddenly reports acute, excruciating right upper quadrant pain that radiates to her right scapula. Her vital signs now show a blood pressure of 85/45 mm Hg and a heart rate of 132/min. Electronic fetal monitoring demonstrates a baseline heart rate of 155/min with absent variability and recurrent late decelerations. Which of the following is the most appropriate next step in management?