Obstetrics and Gynecology

For each patient presenting with vaginal or cervical symptoms, select the most appropriate management plan regarding antimicrobial therapy and sexual partner evaluation.

Match each standard prenatal screening test or intervention with the gestational age window during which it is universally indicated for an average-risk, uncomplicated pregnancy.

During a routine prenatal visit, a 30-year-old woman at 34 weeks gestation reports experiencing episodes of lightheadedness, nausea, and a feeling of impending fainting over the past two weeks. She states that these episodes occur exclusively when she is lying flat on her back. The symptoms resolve rapidly when she turns onto her side. Her pregnancy has been uncomplicated. Her blood pressure is 112/68 mm Hg and her heart rate is 85/min while seated in the clinic. Fetal heart monitoring shows a baseline rate of 145/min with moderate variability and no decelerations. Which of the following is the most likely underlying mechanism for this patient's symptoms?

A 33-year-old woman, gravida 2, para 1, is evaluated in the birthing center at 39 weeks of gestation. She is undergoing a trial of labor after a previous low transverse cesarean delivery. Her prenatal course was uncomplicated. She is currently in the active phase of the first stage of labor, with contractions previously occurring every 3 minutes. Suddenly, the patient reports a sharp, continuous, tearing lower abdominal pain that is distinctly different from her previous contraction pain. Continuous fetal monitoring shows a sudden, prolonged deceleration with a baseline drop to 75/min for the past 4 minutes, and uterine contractions have ceased on the tocodynamometer. A sterile vaginal examination reveals the cervix is 7 cm dilated, and the fetal presenting part, which was previously at 0 station, is no longer palpable. Maternal blood pressure is 90/50 mm Hg and heart rate is 120/min. Which of the following is the most appropriate next step in management?

A $26$-year-old woman comes to the office due to the absence of menstrual periods for the past $7$ months. Previously, she had regular $28$-day cycles with normal bleeding. Over the same $7$-month period, she has noticed worsening acne, increased thick hair growth on her face and abdomen, and a deepening of her voice. She has no significant past medical history and takes no medications. A urine pregnancy test obtained in the clinic is negative. Vital signs are temperature $36.8^\circ\text{C}$, blood pressure $122/78 \text{ mmHg}$, pulse $76/\text{min}$, and respirations $14/\text{min}$. BMI is $24 \text{ kg/m}^2$. Physical examination reveals temporal hair thinning and terminal hair on the upper lip, chin, and linea alba. Pelvic examination shows clitoromegaly and a normal-sized, mobile uterus. Adnexae are difficult to palpate. Which of the following is the most appropriate next step in management?

During a routine prenatal visit at 24 weeks gestation, a primigravid patient reports new-onset, intense vulvar pruritus accompanied by a thick, white vaginal discharge over the past four days. She recently completed a course of cephalexin for an uncomplicated urinary tract infection. She denies any pelvic pain, uterine contractions, or leakage of fluid. Vital signs are within normal limits. Pelvic examination reveals marked vulvar erythema and a thick, adherent, curd-like discharge in the vaginal vault. The vaginal pH is 4.2. Microscopic evaluation of the vaginal secretions mixed with 10% potassium hydroxide demonstrates budding yeasts and branching tubular structures. Which of the following is the most appropriate management for this patient's current symptoms?

A $31$-year-old woman comes to the clinic for evaluation of amenorrhea. She has not had a menstrual period since the vaginal delivery of her first child $14$ months ago. Her pregnancy was complicated by placental abruption and severe postpartum hemorrhage that required emergency fluid resuscitation and a blood transfusion. The patient reports she was never able to produce breast milk despite multiple attempts to breastfeed. Over the past six months, she has also noted significant fatigue, a $10$-lb ($4.5$-kg) weight loss, and feeling cold all the time. On physical examination, blood pressure is $90/60$ mmHg and pulse is $58$/min. She has dry skin, sparse pubic hair, and delayed relaxation of deep tendon reflexes. A urine pregnancy test is negative.

Which of the following sets of laboratory test results is most likely in this patient?

Match each intrapartum fetal heart rate (FHR) tracing description with its primary pathophysiologic mechanism.

A 26-year-old primigravida presents to the clinic for her initial prenatal visit at 6 weeks gestation. She is currently asymptomatic and has no significant past medical history. As part of her prenatal education, the physician discusses the expected anatomical and physiological changes she will experience. Arrange the following physiological adaptations and clinical findings in the chronological order they typically occur or reach their peak or nadir during a normal, uncomplicated pregnancy.

A multiparous patient at 38 weeks gestation with a history of poorly controlled asthma and chronic hypertension is admitted for induction of labor. Her cervical exam is 4 cm dilated, 80% effaced, and at -1 station. Fetal heart rate monitoring is reassuring. Following a successful vaginal delivery of a macrosomic infant, the patient develops heavy vaginal bleeding consistent with uterine atony. The physician must select an appropriate uterotonic agent while avoiding exacerbation of her underlying conditions. Match the following medications considered for postpartum hemorrhage to their distinct pharmacological properties, adverse effects, or absolute contraindications.

A 31-year-old G2P2 patient is evaluated in the emergency department for sudden, severe left lower quadrant abdominal pain and profound chills that started 24 hours ago. Her most recent menstrual period ended three weeks ago, and she had a copper intrauterine device inserted four weeks ago. Vitals include a temperature of 38.9°C (102.0°F), a heart rate of 112/min, and a blood pressure of 110/70 mmHg. She is in visible distress. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for managing this patient's condition.

A $34$-year-old woman comes to the clinic for evaluation of severe vaginal itching and a thick, white vaginal discharge. She reports that this is her fourth such episode in the past $10$ months. For her prior episodes, she was treated with either an over-the-counter vaginal clotrimazole cream or a single dose of oral fluconazole, which completely resolved her symptoms each time. She has no history of diabetes mellitus, HIV, or immunosuppressant use. Her only medication is a combined oral contraceptive pill. Pelvic examination shows marked vulvar and vaginal erythema with adherent, cottage cheese-like discharge. Vaginal fluid analysis is performed:

Which of the following is the most appropriate pharmacotherapy for this patient's current condition?

A 16-year-old girl is brought to the outpatient clinic due to the absence of menarche. She reports no cyclical pelvic or lower abdominal pain. Her medical history is unremarkable, and she takes no medications. On physical examination, her height is at the 60th percentile and weight is at the 55th percentile. Breast development and pubic hair are both at Tanner stage 4. Pelvic examination reveals normal external female genitalia, but there is a shortened, blind-ending vaginal pouch and the cervix cannot be visualized. Arrange the following steps in the most appropriate sequential order for the diagnostic evaluation and management of this patient.

A 31-year-old woman, gravida 2, para 1, presents to the office for a scheduled prenatal evaluation at 32 weeks gestation. She reports feeling well, with appropriate fetal movement and no abdominal pain, itching, nausea, or vomiting. Her prior pregnancy was uncomplicated and resulted in a spontaneous vaginal delivery at term. Vital signs are within normal limits. Physical examination reveals a gravid uterus consistent with dates and normal fetal heart tones. She recently participated in an employer-sponsored health screening program and brings the laboratory report for review. The results show:

Which of the following is the most appropriate management regarding these laboratory findings?

An expectant mother at 22 weeks gestation is evaluated in the obstetric clinic. The 28-year-old nulliparous patient mentions newly noticed ankle swelling that worsens by the evening and feeling slightly winded when walking up the stairs to her apartment. She denies paroxysmal nocturnal dyspnea, chest pain, syncope, or palpitations. Her past medical history is unremarkable, and she takes only a daily prenatal vitamin. Vital signs show a temperature of 37.0°C (98.6°F), blood pressure of 108/68 mm Hg, pulse of 86/min, and respirations of 16/min. Cardiac auscultation reveals a grade 2/6 early systolic ejection murmur heard best at the left upper sternal border and a distinct S3 gallop. Pulmonary auscultation is clear bilaterally. There is trace pitting edema of both ankles. Which of the following is the most appropriate next step in management?

A clinical pathway coordinator is updating the standard operating procedures for a community obstetrics practice. They are mapping out the anticipated schedule of evaluations for healthy patients presenting with an uncomplicated singleton pregnancy in the first trimester. Arrange the following routine prenatal screening evaluations in the correct chronological order from earliest gestational age to latest gestational age.

A 59-year-old nulliparous female presents to her gynecologist with new-onset vaginal bleeding. She has a history of type 2 diabetes mellitus and a body mass index of 42. Arrange the following steps in the standard chronological sequence for the evaluation and definitive management of her most likely condition, from initial diagnostic testing to post-surgical care.

During a busy night shift on the labor and delivery unit, a $32$-year-old multiparous woman (G3P2) at $40$ weeks of gestation successfully delivers a $4100$ g neonate vaginally. Shortly after the third stage of labor concludes with the delivery of an intact placenta, the patient experiences a sudden, massive gush of vaginal blood. Abdominal palpation reveals a soft, poorly contracted uterus extending above the umbilicus. Assuming each intervention fails to arrest the hemorrhage, arrange the following clinical management steps in their standard procedural sequence from least invasive to most definitive.

Match each patient's clinical presentation with the most likely etiologic pathogen and its corresponding expected microscopic findings.

Match each characteristic histological or clinical presentation of a gynecologic neoplasm with its most closely associated serum tumor marker.