Obstetrics and Gynecology

A clinic nurse is preparing an educational timeline chart for patients beginning their prenatal care. Match each routine obstetrical screening test or intervention to the precise gestational age window during which it is standardly recommended for an uncomplicated pregnancy.

A 26-year-old primigravida presents to the obstetrics clinic for her initial prenatal visit at 8 weeks gestation. She has no significant past medical history and takes a daily prenatal vitamin. Vital signs are normal. A transvaginal ultrasound confirms a viable singleton intrauterine pregnancy. The patient is eager to ensure she receives all standard prenatal care and asks about the schedule of upcoming tests. Assuming a continuous, uncomplicated pregnancy course, arrange the following routine prenatal screening and diagnostic evaluations in the correct chronological order from the earliest to the latest gestational age at which they are optimally performed.

A $38$-year-old woman comes to the clinic to discuss contraceptive options. She is sexually active with a new male partner and does not desire future fertility, but she explicitly declines any form of surgical sterilization. Her medical history is significant for poorly controlled hypertension and heavy menstrual bleeding. She smokes one pack of cigarettes daily. Her current medications include amlodipine. Her last menstrual period was $14$ days ago. Blood pressure is $164/102$ mmHg, heart rate is $78$/min, and body mass index is $24$ kg/m $^2$. Pelvic examination reveals a normal-sized, mobile uterus with no adnexal masses. Urine pregnancy test is negative. Laboratory studies show a hemoglobin level of $10.2$ g/dL. Which of the following is the most appropriate contraceptive method for this patient?

A 26-year-old woman presents to the clinic for a routine well-woman examination. She feels healthy and has no complaints. She specifically denies any pelvic pain, abnormal vaginal bleeding, malodorous vaginal discharge, or dyspareunia. Her medical history is unremarkable. She is in a monogamous relationship and has used a copper intrauterine device (IUD) for contraception for the past four years. Vital signs are within normal limits. Pelvic examination reveals normal external genitalia, a visually normal cervix with visible IUD strings, and no cervical motion tenderness or adnexal masses. A cervical cytology (Pap) smear is performed. Two weeks later, the pathology report indicates "negative for intraepithelial lesion or malignancy" but notes the incidental presence of Actinomyces-like organisms. The patient is contacted and confirms she remains completely asymptomatic. Which of the following is the most appropriate next step in management?

Match each of the following intrapartum or postpartum clinical presentations to the most likely underlying obstetric etiology.

A 28-year-old primigravida at 40 weeks gestation is admitted to the labor and delivery unit in spontaneous labor. Her prenatal course has been uncomplicated. Her vital signs are within normal limits. Cervical examination reveals dilation to 5 cm, 90% effacement, and 0 station. Epidural analgesia is providing adequate pain relief.

Continuous fetal heart rate monitoring demonstrates a baseline of 140/min, minimal variability, and no spontaneous accelerations. Over the past 45 minutes, there are intermittent decelerations occurring with approximately 30% of contractions. These decelerations begin after the peak of the contraction, take more than 30 seconds to reach their nadir, and slowly return to baseline.

In response, the patient is repositioned to the left lateral decubitus position, administered a 500-mL intravenous fluid bolus, and given supplemental oxygen. Thirty minutes later, her contractions are occurring every 3 to 4 minutes. The fetal heart rate tracing remains unchanged, with persistent minimal variability and intermittent late decelerations.

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

An established patient presents for evaluation at $32$ weeks gestation due to concerns about her heart and breathing. The $26$-year-old gravida $1$ para $0$ reports that over the past month, she has felt easily winded when climbing stairs and noticed her shoes feel tight by the end of the day. She occasionally feels her heart racing when resting. Vital signs are temperature $37.0^\circ$ C ($98.6^\circ$ F), blood pressure $112/68$ mmHg, pulse $98$/min, and respirations $18$/min. Cardiovascular examination reveals a prominent point of maximal impulse displaced slightly to the left, along with a grade II/VI systolic ejection murmur at the left upper sternal border. There is $1+$ bilateral lower extremity pitting edema up to the ankles. Pulmonary auscultation is clear. Urine dipstick yields negative results for protein. Which of the following is the most appropriate action at this time?

A $28$-year-old primigravida at $39$ weeks gestation is admitted to the labor and delivery unit in active labor. Her pregnancy has been uncomplicated. Her vital signs on admission are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $118/76$ mm Hg, and pulse $82$/min. Cervical examination shows $5$ cm dilation, $90\%$ effacement, and $0$ station. Fetal heart rate monitoring demonstrates a baseline of $145$/min with moderate variability, spontaneous accelerations, and no decelerations. Uterine contractions occur every $3$ to $4$ minutes. The patient requests pain management, and a continuous epidural infusion of bupivacaine and fentanyl is initiated. Twenty minutes later, the patient reports feeling lightheaded and nauseated. Her blood pressure is now $84/48$ mm Hg and pulse is $112$/min. Simultaneously, the fetal heart rate baseline drops to $90$/min with minimal variability and has remained at this rate for the past $4$ minutes. Which of the following is the most appropriate next step in the management of this patient?

A $29$-year-old woman, gravida $2$, para $1$, at $32$ weeks gestation comes to the clinic for a scheduled prenatal visit. She reports increased urinary frequency over the last few weeks but denies dysuria, hematuria, or urgency. She feels well, reports active fetal movements, and has no itching or abdominal pain. At $26$ weeks gestation, her $50$-g, $1$-hour oral glucose challenge test result was $110$ mg/dL. Vital signs are within normal limits. Fundal height is $32$ cm, and the fetal heart rate is $145$/min.

Which of the following is the most appropriate next action?

A 66-year-old postmenopausal woman presents to the clinic with a 2-month history of progressive abdominal bloating, early satiety, and vague pelvic pressure. She has no history of abnormal vaginal bleeding. Physical examination reveals a distended abdomen with shifting dullness, and a palpable, firm, irregular right adnexal mass. Arrange the following steps in the most appropriate sequential order for the evaluation and management of this patient, from the initial step to definitive post-surgical treatment.

A 29-year-old woman presents to the clinic reporting the absence of menses for the past eight months, accompanied by a bilateral milky nipple discharge. She previously had regular 28-day menstrual cycles. She takes no medications and reports no headaches, visual disturbances, or cold intolerance. Vital signs and physical examination are within normal limits, aside from expressible galactorrhea. Arrange the following clinical steps in the most appropriate chronological sequence for the evaluation and management of this patient.

A $33$-year-old G2P1 at $40$ weeks and $5$ days gestation is pushing in the second stage of labor. The fetal head delivers but immediately retracts tightly against the maternal perineum. The attending physician applies gentle downward traction, but the anterior shoulder fails to deliver. The estimated fetal weight by third-trimester ultrasound was $4500$ g.

Arrange the following steps for the management of this obstetric emergency in the most appropriate sequential order, from the initial response to the maneuver of last resort.

Following a prolonged second stage of labor, a multiparous patient at 40 weeks gestation delivers a 4,350-g neonate vaginally. Twelve minutes after the intact placenta is delivered, nursing staff observe a sudden, massive surge of continuous vaginal bleeding. Vital signs demonstrate a maternal heart rate of 128/min and a blood pressure of 82/48 mm Hg. Abdominal examination reveals a soft, poorly contracted uterus extending to the level of the umbilicus. After securing two large-bore intravenous lines, administering tranexamic acid, and initiating aggressive fluid resuscitation, the obstetric team begins sequential interventions for refractory uterine atony. Assuming continuous failure to achieve hemostasis at each consecutive stage, arrange the following management steps in the correct, standardized escalating sequence.

An otherwise healthy nulligravid patient in her late twenties is evaluated in the ambulatory clinic for severe vulvar pain that has worsened over the past three days, making it difficult for her to sit or walk. Vital signs are within normal limits. Pelvic examination reveals a 4-cm, exquisitely tender, erythematous, and fluctuant mass located at the left posterior vestibule near the 5 o'clock position. There is no surrounding cellulitis. The physician decides to perform an office-based procedure to definitively treat the condition and minimize the risk of recurrence.

Arrange the following procedural and management steps in the most appropriate sequential order.

A 24-year-old healthy nulligravida presents for preconception counseling. She has a regular 28-day menstrual cycle and no significant past medical history. She and her partner are actively trying to conceive and she is curious about the normal progression of pregnancy. The physician discusses the expected physiological changes and clinical milestones she will experience. Arrange the following normal clinical and physiological milestones in the chronological order in which they typically first occur during an uncomplicated primigravid pregnancy, from earliest in gestation to latest.

An obstetrician-gynecologist is evaluating a 54-year-old female who reports a single episode of bright red blood on her toilet tissue the previous morning. She attained menopause four years ago and has not experienced any vaginal bleeding since that time. Her medical history includes polycystic ovary syndrome (PCOS), essential hypertension, and type 2 diabetes mellitus. Her body mass index is 36 kg/m². Vital signs are within normal limits. Pelvic examination demonstrates normal external genitalia and a parous cervix without visible lesions. Bimanual examination reveals a mobile, non-tender uterus of normal size. Office-based transvaginal ultrasonography demonstrates a heterogeneous endometrial stripe measuring 8 mm in thickness. Which of the following is the most appropriate next step in management?

An obstetrician is evaluating a $24$-year-old woman during her first prenatal visit. She is gravida $1$, para $0$. She reports having irregular menstrual cycles and states that her last menstrual period began exactly $16$ weeks ago. She has no significant past medical history and takes no medications other than a daily prenatal vitamin. Vital signs are within normal limits. A pelvic ultrasound is performed in the office and demonstrates a single viable fetus with biometric measurements consistent with a gestational age of $14$ weeks and $3$ days. The patient expresses a strong desire for non-invasive screening for fetal aneuploidy and asks what testing options can be performed at today's visit.

Which of the following is the most appropriate screening test to offer this patient today?

Match each clinical and histopathological vignette with the most likely gynecologic neoplasm.

A 32-year-old woman, gravida 2 para 1, at 36 weeks gestation is admitted to the labor and delivery unit for management of severe preeclampsia. Upon admission, her blood pressure is $165/110$ mmHg. She is started on a continuous intravenous magnesium sulfate infusion. Initial laboratory studies reveal a platelet count of $75,000/\text{mm}^3$, an aspartate aminotransferase (AST) level of $620$ U/L, and an alanine aminotransferase (ALT) level of $650$ U/L. Four hours after admission, the patient suddenly reports acute, excruciating right upper quadrant abdominal pain that radiates to her right shoulder. She also complains of severe lightheadedness and nausea. Her blood pressure is now $82/45$ mmHg, and her heart rate is $135$/min. Physical examination demonstrates a rigid, distended abdomen with diffuse tenderness. Continuous fetal heart rate monitoring shows a baseline of $160$/min, absent variability, and recurrent late decelerations. Which of the following is the most appropriate next step in management?

A 29-year-old G1P0 at 38 weeks gestation presents to the labor and delivery ward with painful uterine contractions. Her prenatal course was uncomplicated. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $118/76\text{ mmHg}$, and pulse is $82/\text{min}$. She is currently positioned in the left lateral decubitus position and receiving a continuous intravenous infusion of lactated Ringer solution. Cervical examination reveals dilation to $6\text{ cm}$, $100\%$ effacement, and $+1$ station. The amniotic membranes ruptured spontaneously 3 hours ago, and the fluid was clear. Tocodynamometry shows uterine contractions occurring every 3 minutes and lasting 50 seconds. Fetal heart rate monitoring demonstrates a baseline of $145/\text{min}$ with moderate variability. Over the past 30 minutes, there have been recurrent, abrupt decreases in the fetal heart rate to $80/\text{min}$ that last for 40 seconds before rapidly returning to the baseline. These decelerations occur with most contractions but have a varied onset relative to the contraction peak. Which of the following is the most appropriate next step in the management of this patient?