Obstetrics and Gynecology

A 21-year-old nulligravid woman presents to the emergency department with a 3-day history of progressively worsening lower abdominal pain, fever, and vomiting. She states she has been unable to tolerate any oral intake today. Her temperature is 39.1°C (102.4°F), blood pressure is 105/65 mm Hg, and pulse is 112/min. Pelvic examination is notable for copious yellow cervical discharge, severe cervical motion tenderness, and a palpable, exquisitely tender 7-cm mass in the left adnexa. Arrange the following steps in the most appropriate chronological sequence for the evaluation and management of this patient.

A clinical geneticist is discussing screening and prophylactic strategies with several women who have strong family histories of malignancy. For each described genetic mutation and associated gynecologic cancer risk profile, identify the correct corresponding hereditary syndrome.

Match each pregnant patient scenario with the most appropriate routine screening test or laboratory evaluation indicated at their current gestational age.

A 72-year-old resident of an assisted living facility is brought to the gynecology clinic by her daughter due to the recent discovery of blood-stained undergarments. The daughter noticed the spotting on three separate occasions over the past month. The patient has a medical history of mild Alzheimer dementia and hypertension, and she denies any abdominal or pelvic pain. Vital signs are within normal limits. On physical examination, the physician notes mild anterior vaginal wall prolapse and a smooth, 1.5-cm red, friable mass protruding through the external cervical os. A transvaginal ultrasound is performed during the visit, demonstrating normal-appearing ovaries and an endometrial thickness of 8 mm. Which of the following is the most appropriate next step in the management of this patient?

Presenting to a community health clinic, a 24-year-old female college student complains of a bilateral lower pelvic ache and abnormal vaginal spotting that began four days ago. She denies nausea, vomiting, or recent fever. Her medical history is unremarkable, and she uses a hormonal etonogestrel subdermal implant for contraception. She reports having a new male partner for the past month and inconsistent barrier protection use. Vital signs reveal a temperature of 37.1°C (98.8°F), blood pressure of 118/76 mm Hg, and heart rate of 78/min. Abdominal palpation elicits mild discomfort in the bilateral lower quadrants without guarding or rebound. During the pelvic examination, a mucopurulent discharge is noted at the cervical os, and the cervix bleeds easily upon swabbing. Bimanual examination demonstrates pronounced tenderness upon cervical motion as well as bilateral adnexal tenderness. No adnexal masses are palpable. A rapid point-of-care pregnancy test is negative. Which of the following is the most appropriate next step in the management of this patient?

A 16-year-old girl is evaluated in the clinic for absence of menarche. She reports no cyclic pelvic or abdominal pain. She has experienced normal growth spurts, and her 14-year-old sister began menstruating a year ago. She takes no medications and has no significant past medical history. Vital signs are within normal limits. On physical examination, height is at the 65th percentile and weight is at the 60th percentile. Breast development is Tanner stage 4, and pubic and axillary hair are Tanner stage 4. Pelvic examination reveals normal female external genitalia and a shortened, 3-cm blind-ending vaginal pouch. Transabdominal ultrasonography reveals the absence of a uterus and cervix, but symmetric, morphologically normal ovaries are visualized. Laboratory evaluation shows a serum testosterone concentration of 40 ng/dL (reference range for females: 15-70 ng/dL). Karyotype analysis reveals a 46,XX chromosomal pattern. Which of the following is the most appropriate next step in the management of this patient?

Following an uncomplicated term pregnancy, a patient is admitted to the labor unit in the active phase of the first stage of labor. After receiving epidural anesthesia for pain management, she begins to complain of dizziness and nausea. Her current vital signs show a blood pressure of $82/48$ mmHg and a heart rate of $110$/min. Continuous electronic fetal monitoring reveals a baseline heart rate of $130$/min with moderate variability. The tracing also demonstrates recurrent, gradual, and symmetric decreases in the fetal heart rate that begin after the peak of each uterine contraction and resolve only after the contraction has completely finished. Which of the following is the most appropriate initial management step?

An otherwise healthy $24$-year-old nulliparous woman comes to the obstetric clinic at $29$ weeks gestation for a scheduled prenatal visit. She reports a recent onset of generalized fatigue and states she frequently needs to catch her breath after walking up a single flight of stairs to her apartment. The patient also notes intermittent "fluttering" sensations in her chest that last for a few seconds and resolve spontaneously. She denies any chest pain, fainting episodes, nighttime coughing, or orthopnea. Routine $28$-week laboratory tests, including a complete blood count and a $1$-hour oral glucose challenge test, performed last week were within normal limits. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $102/62$ mm Hg, pulse is $96$/min, and respirations are $18$/min. On physical examination, the apical impulse is palpated in the fourth intercostal space, slightly lateral to the midclavicular line. Auscultation of the heart reveals a grade $2/6$ systolic ejection murmur at the left upper sternal border and a distinct third heart sound ($S_3$). The lungs are clear to auscultation bilaterally. Trace bilateral pitting pedal edema is noted. An in-office electrocardiogram demonstrates normal sinus rhythm with a leftward shift of the QRS axis compared to her first-trimester baseline, with no ST-segment or T-wave abnormalities. Which of the following is the most appropriate next step in the management of this patient?

An obstetric patient in her second pregnancy is admitted to the labor and delivery unit at 39 weeks and 4 days of gestation. Her previous pregnancy resulted in an uncomplicated vaginal delivery at term. She has a history of diet-controlled gestational diabetes mellitus. Currently, she reports painful uterine contractions that began four hours ago. She has not requested or received any systemic analgesia or regional anesthesia. Maternal temperature is 37.1°C (98.8°F), blood pressure is 118/76 mmHg, and pulse is 82/min. A sterile cervical examination reveals 5 cm dilation, 90% effacement, and the fetal vertex is at -1 station. Continuous electronic fetal monitoring is applied. Over the subsequent 50 minutes, the fetal heart rate tracing demonstrates a stable baseline of 145/min, continuous minimal variability (amplitude range of 3 to 4 beats/min), and a complete absence of both accelerations and decelerations. Uterine contractions are occurring every 4 minutes with a normal resting tone. Based on these clinical findings, which of the following is the most appropriate next step in management?

A 27-year-old woman, gravida 1, para 0, contacts the obstetrics clinic after a positive home pregnancy test. She is scheduled for a comprehensive prenatal care program. Her physician outlines the expected timeline of routine diagnostic tests and evaluations for an uncomplicated pregnancy. Arrange the following standard prenatal screenings and evaluations in the correct chronological order from earliest to latest gestational age.

Assess the following clinical scenarios. For each patient—all of whom have a negative serum beta-hCG today and seek reliable contraception—select the most appropriate and safest method according to the World Health Organization Medical Eligibility Criteria (WHO MEC).

Match each clinical presentation of an intrapartum or postpartum complication with its most likely underlying etiology.

Match the following classic clinical presentations and laboratory findings of lower genital tract infections to their correct diagnosis and corresponding optimal pharmacotherapy.

A 67-year-old woman, gravida 1, para 1, presents to her gynecologist with a recent episode of painless vaginal bleeding. She reached menopause at age 53. Her past medical history is significant for type 2 diabetes mellitus, chronic hypertension, and obesity (BMI $41 \text{ kg/m}^2$). Pelvic examination is unremarkable, and there is no active bleeding from the cervical os. Transvaginal ultrasonography is performed and demonstrates a $14\text{-mm}$ thickened, heterogeneous endometrial stripe. Arrange the following steps in the most appropriate chronological order for her comprehensive evaluation and definitive management.

A 32-year-old woman, gravida 2, para 1, presents to the clinic at 8 weeks of gestation for her initial prenatal visit. Her blood type is O-negative. Her previous pregnancy was complicated by severe preeclampsia requiring an indicated preterm delivery at 31 weeks of gestation. Her vital signs today are within normal limits, and a viable intrauterine pregnancy is confirmed by ultrasound. Assuming the current pregnancy progresses normally without acute complications, arrange the following recommended maternal screening and prophylactic interventions in the correct chronological order from earliest to latest in gestation.

Match each clinical vignette describing an intrapartum or postpartum complication to the most appropriate immediate intervention.

An emergency response team brings a $22$-year-old primigravida at $11$ weeks gestation to the hospital due to severe, intractable nausea and vomiting that has persisted for three weeks. She has lost $10\%$ of her pre-pregnancy body weight and has been entirely unable to tolerate oral intake for the past four days. Prior to arrival, paramedics established intravenous access and administered $2$ liters of $5\%$ dextrose in $0.9\%$ saline to treat suspected dehydration and hypoglycemia.

Upon arrival, the patient is lethargic, confused, and disoriented to time and place. Neurologic examination reveals prominent horizontal nystagmus, bilateral sixth cranial nerve palsies, and an unsteady, wide-based gait.

Laboratory studies show:
- Sodium: $134$ mEq/L
- Potassium: $3.2$ mEq/L
- Chloride: $96$ mEq/L
- Bicarbonate: $29$ mEq/L
- Glucose: $125$ mg/dL
- Aspartate aminotransferase (AST): $65$ U/L

Which of the following is the most likely pathophysiologic mechanism for this patient's acute neurologic presentation?

During a scheduled initial prenatal evaluation, a pregnant patient at $9$ weeks of gestation undergoes routine laboratory screening. The patient is $26$ years old, has never been pregnant before, and reports only mild early morning nausea. Her medical history is unremarkable, and she denies any palpitations, tremors, weight loss, or heat intolerance. On physical examination, her vital signs are blood pressure $112/68 \text{ mm Hg}$, pulse $78/\text{min}$, and respiratory rate $14/\text{min}$. The thyroid gland is normal in size without palpable nodules or tenderness. A thyroid function panel reveals a thyroid-stimulating hormone (TSH) level of $0.2 \text{ \mu U/mL}$ (non-pregnant reference range: $0.4-4.0 \text{ \mu U/mL}$) and an elevated total thyroxine (T4) level. Her free T4 level is within normal limits. Which of the following is the most appropriate next step in the management of this patient's thyroid findings?

A 23-year-old female collegiate cross-country runner comes to the university health center because she has not had a menstrual period for 8 months. Her body mass index (BMI) is 17.8 kg/m². She mentions intense training for an upcoming national competition and strict caloric restriction. Arrange the following diagnostic and management steps in the most appropriate sequential order for evaluating and managing this patient.

A 29-year-old woman, gravida 2, para 1, at 40 weeks gestation is in the second stage of labor. She chose not to receive regional anesthesia and is laboring with intermittent nitrous oxide. Following a prolonged second stage, the fetal head delivers but immediately retracts tightly against the maternal perineum. Routine gentle downward traction fails to deliver the anterior shoulder.

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