Obstetrics and Gynecology

An expectant mother at $31$ weeks of gestation arrives at the obstetric clinic for a routine assessment. The $27$-year-old patient notes that over the past few weeks, her shoes have felt tight by the evening and she experiences mild dyspnea after walking up a single flight of stairs. She denies headaches, visual disturbances, and right upper quadrant abdominal pain. Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $116/74\text{ mm Hg}$, pulse $96/\text{min}$, and respirations $18/\text{min}$. Physical examination reveals a point of maximal impulse that is displaced upward and to the left. Cardiac auscultation demonstrates an early systolic murmur (grade $2/6$) at the left sternal border and an audible third heart sound ($S_3$). Lungs are clear to auscultation bilaterally. The lower extremities show $1+$ bilateral pitting edema. Laboratory evaluation reveals the following:

Leukocyte count: $13,500/\text{mm}^3$
Hemoglobin: $11.2\text{ g/dL}$
Platelet count: $155,000/\text{mm}^3$
Serum creatinine: $0.5\text{ mg/dL}$

Urine dipstick is negative for protein. Which of the following is the most appropriate action for this patient's current presentation?

A 34-year-old G4P3 woman experiences massive postpartum hemorrhage due to uterine atony immediately following an uncomplicated vaginal delivery of a 4100-g (9 lb) neonate. Despite the administration of continuous intravenous oxytocin and vigorous bimanual uterine massage, profuse vaginal bleeding persists. Her blood pressure decreases to 76/40 mm Hg and her heart rate increases to 132/min. Assuming each successive intervention fails to arrest the hemorrhage, arrange the following management steps in the correct escalating sequence according to standard obstetric protocols.

A 32-year-old pregnant woman, gravida 2, para 1, is admitted to the labor and delivery unit at 39 weeks gestation in active labor. Her pregnancy has been uncomplicated. Her pulse is 86/min and blood pressure is 118/76 mm Hg. Pelvic examination reveals the cervix is 7 cm dilated and 90% effaced, with the fetal vertex at 0 station. Artificial rupture of membranes is performed to facilitate internal fetal monitoring, yielding clear amniotic fluid. Thirty minutes later, the fetal heart rate tracing demonstrates a baseline of 145/min with moderate variability. However, there are recurrent, abrupt decreases in the fetal heart rate to 90/min that last for 30 to 45 seconds before rapidly returning to the baseline. The nadir of these decelerations occurs less than 30 seconds after their onset. The nurse immediately repositions the patient into the left lateral decubitus position and administers a bolus of intravenous normal saline, but the fetal heart rate pattern persists over the next three contractions. Which of the following is the most appropriate next step in management?

During a visit to the urgent care clinic, a 21-year-old college student describes experiencing deep, aching lower pelvic pain that has progressively worsened over the past three days. She also reports noticing blood on her toilet tissue between her regular menstrual cycles. She has had two new sexual partners in the last six months and uses oral contraceptives inconsistently. Her vital signs show a temperature of 38.3°C (100.9°F), a heart rate of 98/min, and a blood pressure of 112/72 mm Hg. Palpation of the lower abdomen elicits tenderness without guarding. A speculum examination reveals a friable cervix with thick, yellow exudate at the os. During the bimanual exam, the patient vocalizes significant pain when the cervix is mobilized laterally, and both adnexa are tender to palpation, though no discrete masses are felt. A point-of-care pregnancy test is negative. In addition to obtaining samples for nucleic acid amplification testing, which of the following is the most appropriate next step in the management of this patient?

Match each specific gestational age window during a normal pregnancy to the corresponding routine prenatal screening test or intervention that is optimally performed during that timeframe.

While waiting in the obstetric triage area, a primigravida at $38$ weeks of gestation abruptly loses consciousness and exhibits generalized tonic-clonic motor activity. Moments prior to this event, she had complained of a severe, unrelenting headache and seeing 'flashing lights'. Her last recorded blood pressure, taken ten minutes earlier, was $185/115\text{ mmHg}$. During the convulsion, the continuous external fetal monitor records a sudden, prolonged drop in the fetal heart rate to $65\text{/min}$.

Arrange the following critical management steps in the correct chronological sequence to appropriately address this acute emergency.

Match each etiology of primary postpartum hemorrhage with its classic physical examination finding or clinical presentation.

A 31-year-old gravida 2, para 1 at 39 weeks and 4 days gestation is evaluated on the labor and delivery unit. Her prenatal course was uncomplicated. She is currently in the second stage of labor and has been actively pushing for 45 minutes with adequate epidural analgesia. The cervix is completely dilated and 100% effaced. The fetal presenting part is the vertex in the direct occiput anterior position at +3 station. Maternal vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 118/76 mmHg, and a heart rate of 88/min. Uterine contractions are occurring every 3 minutes. Over the past 5 minutes, the continuous fetal heart rate monitor demonstrates an abrupt decrease in the baseline to 75/min with absent variability and no return to the previous baseline of 145/min. Immediate repositioning of the patient to the left lateral decubitus position and administration of an intravenous normal saline bolus do not improve the tracing. Which of the following is the most appropriate next step in management?

A 22-year-old nulliparous woman presents to the labor unit at 38 weeks and 5 days of gestation complaining of intense, frequent contractions. Her prenatal care has been routine and uncomplicated. Vital signs are within normal limits, with a blood pressure of 118/74 mmHg and a heart rate of 88/min. She declines epidural analgesia. On digital cervical examination, she is 6 cm dilated and 100% effaced, and the fetal vertex is at 0 station. There is no evidence of vaginal bleeding.

Electronic fetal monitoring demonstrates a baseline heart rate of 145/min with minimal variability. The tocodynamometer records 7 to 8 uterine contractions per 10-minute window. Each contraction lasts approximately 80 seconds, though the uterus is soft to palpation between contractions. Symmetrical, gradual decreases in the fetal heart rate that reach their nadir after the peak of the contraction are seen repeatedly. In response, the clinical team implements left lateral maternal positioning, administers a rapid intravenous fluid bolus, and provides supplemental oxygen. Fifteen minutes later, the high contraction frequency and the abnormal fetal heart rate pattern persist.

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

A 31-year-old gravida 2, para 1 woman at 35 weeks gestation is brought to the emergency department due to sudden-onset, severe, continuous abdominal pain and moderate dark vaginal bleeding. Her pregnancy is complicated by chronic hypertension, for which she takes labetalol. Her blood pressure is 165/100 mm Hg, and her pulse is 115/min. On physical examination, the uterus is hypertonic, rigid, and exquisitely tender to palpation. Fetal monitoring reveals a baseline heart rate of 165/min with minimal variability and recurrent late decelerations. The tocodynamometer demonstrates high-frequency, low-amplitude contractions. Maternal repositioning, supplemental oxygen, and an intravenous fluid bolus have been administered, but the fetal heart rate tracing remains unchanged. Which of the following is the most appropriate next step in management?

A 27-year-old primigravida presents for her initial prenatal visit at 8 weeks gestation. Her blood type is subsequently confirmed to be O, Rh(D)-negative. She experiences an uncomplicated pregnancy and delivers a healthy, Rh(D)-positive infant at 39 weeks gestation. A routine postpartum screening test indicates the presence of a significant fetomaternal hemorrhage. Arrange the following clinical steps regarding her Rh(D) management in the standard chronological sequence required to evaluate and prevent maternal alloimmunization, from the first trimester through her postpartum care.

A 24-year-old primigravid woman at 39 weeks gestation is evaluated on the labor and delivery unit. She is in spontaneous active labor following an uncomplicated prenatal course. Her temperature is 37.1°C (98.8°F), blood pressure is 118/76 mm Hg, and pulse is 82/min. Cervical examination reveals 7 cm dilation, 100% effacement, and +1 station. Continuous electronic fetal monitoring demonstrates a baseline heart rate of 145/min with moderate variability. There are periodic, symmetric, gradual decreases in the fetal heart rate that begin exactly as the uterine contractions start, reach their nadir at the peak of the contractions, and return to baseline as the contractions end. The lowest heart rate recorded during these episodes is 125/min. What is the most appropriate next step in the management of this patient?

Identify the most likely underlying obstetric complication for each of the following acute intrapartum or postpartum presentations.

A 45-year-old woman is evaluated in the clinic for persistent vaginal symptoms. Three weeks ago, she presented with a profuse, malodorous, yellowish-green vaginal discharge and severe vulvar pruritus. At that time, speculum examination revealed punctate macular hemorrhages on the ectocervix. A saline wet mount confirmed the presence of motile, flagellated organisms with multiple polymorphonuclear leukocytes. The vaginal pH was $6.5$. She was prescribed a $7$-day course of oral metronidazole, $500$ mg twice daily. During today's visit, she reports that her symptoms briefly improved but completely returned five days ago. The patient confirms strict adherence to the prescribed medication regimen and states she has abstained from all sexual contact since before her initial visit. Her medical history is otherwise unremarkable. Repeat saline microscopy of the discharge today demonstrates the same motile organisms seen previously. Which of the following is the most appropriate next step in management?

A 32-year-old gravida 1 para 0 woman at 39 weeks gestation is admitted to the labor and delivery unit in active labor. Her prenatal course has been uncomplicated. Cervical examination reveals 6 cm dilation, 100% effacement, and 0 fetal station. The patient requests analgesia, and a lumbar epidural is placed. Fifteen minutes later, she reports the sudden onset of nausea and lightheadedness. Her temperature is 37.1°C (98.8°F), blood pressure is 80/45 mm Hg, and heart rate is 118/min. Prior to the epidural, continuous fetal monitoring demonstrated a baseline of 140/min with moderate variability and no decelerations. Currently, the monitor shows a sudden decrease in the fetal heart rate to 85/min that has persisted for the past 4 minutes. Uterine contractions are occurring every 3 to 4 minutes. The patient is immediately repositioned to the left lateral decubitus position and an intravenous normal saline bolus is initiated, but the maternal blood pressure remains low and the fetal heart rate remains at 85/min. Which of the following is the most appropriate next step in management?

A nulligravid 24-year-old female is evaluated in the emergency department for a 3-day history of progressively worsening lower pelvic pain, severe nausea, and subjective fevers. She reports having a new sexual partner over the past 2 months and admits to inconsistent barrier protection. Her temperature is 38.9°C (102.0°F), blood pressure is 100/60 mm Hg, and pulse is 112/min. Physical examination demonstrates marked bilateral lower quadrant tenderness with involuntary guarding. Speculum examination reveals a purulent endocervical exudate. Bimanual examination elicits severe cervical motion tenderness and reveals a palpable, exquisitely tender 6-cm right adnexal fullness.

Arrange the following steps in the most appropriate chronological sequence for the evaluation and management of this patient.

A 27-year-old nulligravid woman is admitted to the gynecology service with worsening lower abdominal pain, chills, and purulent vaginal discharge over the past three days. Her temperature is 38.8°C (101.8°F), blood pressure is 115/75 mm Hg, and pulse is 98/min. Pelvic examination reveals significant cervical motion tenderness and a palpable, tender left adnexal mass. A transvaginal ultrasound demonstrates a 7-cm complex, multiloculated left adnexal fluid collection consistent with a tubo-ovarian abscess. There is no free fluid in the cul-de-sac. The patient is hemodynamically stable and has a soft abdomen with normal bowel sounds. Arrange the following steps in the most appropriate chronological order for the standard evidence-based management of this patient's condition.

Match each complex puerperal complication described in the clinical vignette to its precise pathophysiologic mechanism and cornerstone of management.

A 24-year-old woman comes to the clinic to discuss contraceptive options. She is sexually active with a new male partner and does not desire pregnancy. The patient has a history of severe, throbbing headaches that occur once a month. Before the onset of the headache, she typically sees a "flashing zigzag line" that slowly moves across her field of vision. She has no other medical conditions and takes no daily medications. Her blood pressure is 118/76 mm Hg, and body mass index is 22 kg/m². Which of the following contraceptive methods is absolutely contraindicated in this patient?

Seeking evaluation at a community health clinic, a $32$-year-old woman (G2P2) reports a $3$-day history of continuous, dull bilateral lower abdominal pain accompanied by new-onset malodorous vaginal discharge. She states she has been in a new monogamous sexual relationship for the past $2$ months. Her medical history is unremarkable, and she uses a copper intrauterine device (IUD) that was placed $3$ years ago for contraception. Vital signs show a blood pressure of $118/76\text{ mmHg}$, a pulse of $88\text{/min}$, and a temperature of $37.7^\circ\text{C}$ ($99.9^\circ\text{F}$). Speculum examination reveals a normal-appearing cervix with visible IUD strings and thick, yellowish-green mucopurulent discharge at the cervical os. Bimanual examination elicits significant cervical motion tenderness as well as bilateral adnexal tenderness without palpable masses. A urine pregnancy test is negative. Pelvic ultrasound confirms the IUD is appropriately positioned within the endometrial cavity and demonstrates normal-appearing ovaries with no complex fluid collections or tubo-ovarian abscesses. The patient tolerates oral fluids without difficulty. Which of the following is the most appropriate next step in management?