Obstetrics and Gynecology

While rounding on the labor and delivery unit, an attending physician evaluates a full-term pregnant woman undergoing a trial of labor after a previous low transverse cesarean section. The pregnancy has been entirely uncomplicated to date. Over the last six hours, her labor progressed normally, and the fetal head was documented at a $+1$ station. Suddenly, the patient reports a severe, tearing pain in her lower abdomen that persists between contractions. On physical examination, the fetal presenting part is now palpated at a $-2$ station. The continuous fetal heart rate monitor, which previously showed a category I tracing, now demonstrates a sustained fetal heart rate of $80$ beats per minute lasting for over four minutes. Vaginal bleeding is scant, but the patient's heart rate has increased to $115$ beats per minute and her blood pressure is $90/55$ mmHg. Which of the following is the most appropriate next step in the management of this patient?

During a routine follow-up appointment, a 68-year-old female reports a recent onset of bothersome urinary leakage. Over the past month, she has experienced frequent episodes where a sudden, intense desire to pass urine is immediately followed by incontinence. Additionally, she reports an increase in nighttime awakenings to void. Her past medical history includes poorly controlled type 2 diabetes mellitus, essential hypertension, and painful peripheral neuropathy. Medication adjustments one month ago included the addition of amitriptyline. Current vital signs are within normal limits. On physical examination, there is mild suprapubic fullness but no identifiable anterior or posterior vaginal wall defects. The Q-tip test demonstrates a maximum straining angle of $15^\circ$ from the horizontal. Bedside bladder ultrasonography demonstrates a residual volume of 410 mL immediately after the patient voluntarily voids. Dipstick urinalysis shows no abnormalities. Which of the following is the most appropriate next step in the care of this patient?

A 28-year-old nulliparous woman is evaluated in the hospital for persistent abdominal pain. Two days ago, she was admitted with severe bilateral lower abdominal pain, a temperature of $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), and purulent cervical discharge. At that time, pelvic examination revealed extreme cervical motion tenderness and a palpable, tender fullness in the left adnexa. A transvaginal ultrasound demonstrated a $6\text{ cm}$ complex, multiloculated cystic mass in the left adnexa with thick walls and internal debris. She was diagnosed with a tubo-ovarian abscess and immediately started on intravenous cefoxitin and doxycycline.

Today ($48\text{ hours}$ after admission), she reports her left lower quadrant pain has progressively worsened. Her temperature is $39.0^\circ\text{C}$ ($102.2^\circ\text{F}$), blood pressure is $112/72\text{ mm Hg}$, and pulse is $114\text{ /min}$. Abdominal examination shows hypoactive bowel sounds and significant left lower quadrant tenderness with guarding, but no rebound tenderness. Her leukocyte count has increased from $16,500\text{ /mm}^3$ on admission to $21,000\text{ /mm}^3$ today. Which of the following is the most appropriate next step in management?

An active 71-year-old woman is evaluated in the clinic to discuss surgical intervention for severe pelvic organ prolapse. She has a history of five vaginal deliveries. Over the past year, she has experienced a bothersome vaginal bulge and a sensation of pelvic heaviness that worsens after prolonged standing. She occasionally has to apply manual pressure to her perineum to initiate voiding. Two months ago, a trial of conservative management with a vaginal ring pessary was attempted but was discontinued because the patient experienced recurrent dislodgment and discomfort. She currently denies any involuntary leakage of urine with coughing, laughing, or physical exertion. Vital signs are within normal limits. Body mass index is $28 \text{ kg/m}^2$. Pelvic examination in the supine position reveals an anterior vaginal wall prolapse that descends $4 \text{ cm}$ beyond the hymen during the Valsalva maneuver. The apical and posterior vaginal compartments are well supported. Post-void residual volume is $45 \text{ mL}$. The patient is eager to proceed with surgical repair. Which of the following is the most appropriate next step in the management of this patient?

A $32$-year-old parous woman presents for evaluation of a $9$-month history of absent menstruation. She previously experienced regular $30$-day menstrual cycles. Her obstetric history is notable for a difficult vaginal delivery three years ago that was complicated by postpartum hemorrhage and required emergent uterine curettage. She denies hot flashes, visual disturbances, or galactorrhea. Her BMI is $21 \text{ kg/m}^2$. Based on standard diagnostic algorithms for secondary amenorrhea, arrange the following management steps in the correct chronological sequence to definitively confirm her suspected diagnosis. Assume all preliminary laboratory results and withdrawal tests yield non-diagnostic or negative results (e.g., normal hormone levels or absence of withdrawal bleeding), thereby necessitating progression to the next step down the diagnostic pathway.

A 72-year-old multiparous woman presents to the urogynecology clinic with a sensation of pelvic pressure and a vaginal bulge. Examination reveals stage III anterior vaginal wall prolapse. After discussing treatment options, she elects for conservative management with a vaginal pessary. The physician prepares to fit the patient for a ring pessary with support. Arrange the following steps of the pessary fitting and management process in the correct chronological order, from the initial evaluation to the final discharge instructions.

A 62-year-old woman comes to the office reporting a three-week history of breast tenderness, abdominal bloating, and intermittent vaginal spotting. She underwent menopause at age 51 and has not experienced any vaginal bleeding until now. Her past medical history is notable for well-controlled hypertension. She takes amlodipine and has no history of hormone replacement therapy. Vital signs are within normal limits. Pelvic examination reveals a parous cervix with a small amount of dark blood in the vaginal vault. Bimanual examination is notable for a slightly enlarged, mobile uterus and a palpable, firm, 9-cm mass in the left adnexa. Transvaginal ultrasound demonstrates a 9.5-cm complex, solid and cystic left ovarian mass and an endometrial stripe thickness of 16 mm. A urine pregnancy test is negative. Which of the following is the most appropriate next step in the evaluation of this patient?

Emergency medical services bring a 58-year-old woman to the hospital after she experienced a sudden onset of severe lower abdominal pain and a sensation of a "bulge" in her vagina. The symptoms began abruptly one hour ago while she was straining to pass stool. Four weeks prior to presentation, she underwent a total laparoscopic hysterectomy for recurrent, heavy uterine bleeding. Her temperature is 37.1°C (98.8°F), blood pressure is 118/76 mm Hg, pulse is 102/min, and respirations are 18/min. On physical examination, the lower abdomen is tender to palpation. Pelvic examination demonstrates a separation at the vaginal apex. A hyperemic segment of small bowel is visible protruding through the defect into the vaginal canal. Which of the following is the most appropriate next step in the management of this patient?

A 26-year-old woman is referred to the emergency department by her university health clinic due to a 3-day history of escalating pelvic pain and high fever. Upon arrival, her temperature is 39.3°C (102.7°F), heart rate is 112/min, and blood pressure is 108/65 mmHg. Speculum examination demonstrates copious, yellow-green cervical exudate. Bimanual examination elicits exquisite pain on cervical manipulation and identifies a boggy, 8-cm mass in the right adnexal region. Arrange the following clinical steps in the most appropriate chronological sequence for managing this patient's condition.

A 55-year-old woman is evaluated on postoperative day 1 following an anterior colporrhaphy and a vaginal hysterectomy for pelvic organ prolapse. She reports lower abdominal discomfort and a strong urge to urinate, but she is unable to pass urine despite multiple attempts over the last six hours. Her vital signs are stable. Physical examination reveals a palpable, tender, suprapubic mass. Arrange the following steps in the most appropriate chronological order for managing this patient's suspected postoperative urinary retention.

An obstetrician is called to the labor unit to evaluate a fetal heart rate tracing for a 28-year-old patient. The patient is a gravida 3, para 2 at $40$ weeks gestation. She was admitted $4$ hours ago in spontaneous labor and was subsequently started on an intravenous oxytocin infusion for labor augmentation due to a secondary arrest of dilation. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $115/75\text{ mmHg}$, and pulse is $88/\text{min}$. The tocodynamometer demonstrates $7$ uterine contractions in a $10$-minute period. The fetal heart rate tracing reveals a baseline of $135/\text{min}$, minimal variability, and visually apparent, gradual decreases in the fetal heart rate that begin after the peak of each contraction and return to baseline after the contraction ends. Which of the following is the most appropriate next step in the management of this patient?

A 28-year-old woman, gravida 1, para 1, comes to the office 3 weeks after a difficult vaginal delivery. Her delivery was complicated by a prolonged second stage of labor and required forceps assistance. For the past 5 days, she has experienced a continuous leakage of clear fluid from her vagina. She has no dysuria, fever, abdominal pain, or fecal incontinence. Her voiding frequency is normal, but she feels constantly damp and must wear a sanitary pad at all times. Physical examination shows normal vital signs. The abdomen is soft and non-tender. A cotton swab test reveals a straining angle of $25^\circ$ (normal is $<30^\circ$). Speculum examination reveals a small pool of clear fluid in the posterior vaginal fornix. The fluid has a slight ammonia-like odor. Which of the following is the most appropriate next step in diagnosis?

A $48$-year-old multiparous woman presents to the clinic complaining of heavy, irregular vaginal bleeding, foul-smelling discharge, and deep pelvic pain for the past $3$ months. She has not seen a physician in over a decade. Pelvic examination reveals a $6$-cm friable, exophytic mass replacing the cervix. Rectovaginal examination demonstrates nodularity and induration extending into the medial aspect of the right parametrium, but not to the pelvic sidewall. Arrange the following steps in the most appropriate sequence for the diagnosis, staging, and definitive management of this patient's condition.

Identify the most likely diagnosis for each of the following third-trimester obstetric presentations.

A 15-year-old girl is brought to the clinic by her mother for evaluation of absent menstrual periods. She has never menstruated. Physical examination reveals a height at the 5th percentile for age, Tanner stage 1 breast development, and normal-appearing female external genitalia with a patent vagina. A urine pregnancy test is negative. Arrange the following diagnostic and management actions in the most appropriate sequential order according to the standard algorithmic approach for primary amenorrhea.

Evaluate the following clinical and laboratory profiles of patients presenting with amenorrhea. Match each profile to the most likely underlying diagnosis.

Match each clinical presentation of urinary incontinence with its most appropriate next step in management.

Following a routine well-woman examination, a 52-year-old nulligravid patient is asked to return to the clinic to discuss her cervical cytology results. She transitioned through menopause at age 50 and denies any postmenopausal bleeding, pelvic pressure, or abnormal vaginal discharge. Her current health is excellent with no chronic medical conditions, and she takes no medications. Pelvic examination demonstrates normal external genitalia, a parous-appearing cervix without gross lesions, and a small, mobile uterus without adnexal masses. The cytology report notes the presence of atypical glandular cells (AGC). A concurrent high-risk human papillomavirus (HPV) test is negative. Which of the following is the most appropriate next step in the diagnostic evaluation?

Match each patient's clinical presentation with the most accurate diagnosis and guideline-concordant management step.

Match each of the following clinical presentations of patients experiencing secondary amenorrhea or oligomenorrhea with the primary pathophysiological mechanism responsible for their reproductive endocrine dysfunction.