Obstetrics and Gynecology

A 32-year-old woman, gravida 1, para 0, abortus 1, comes to the clinic to be evaluated for a 15-month history of inability to conceive. She reports that her menstrual cycles occur at regular 28-day intervals but consist of only very light spotting for 1 to 2 days. Prior to her pregnancy, her menses lasted 5 to 6 days with normal flow. Her obstetric history is significant for an elective termination of pregnancy 3 years ago at 9 weeks gestation. The procedure was complicated by heavy bleeding requiring a repeat dilation and curettage. She subsequently developed a fever and was successfully treated with intravenous antibiotics for postabortal endometritis. She takes a daily prenatal vitamin and has no other medical conditions. Her body mass index is $22 \text{ kg/m}^2$. Pelvic examination reveals a normal-appearing cervix and a mobile, normal-sized uterus without adnexal masses.

Laboratory studies show:
Follicle-stimulating hormone: $6.2 \text{ mIU/mL}$
Luteinizing hormone: $5.8 \text{ mIU/mL}$
Estradiol: $90 \text{ pg/mL}$
Thyroid-stimulating hormone: $1.8 \text{ \mu U/mL}$
Prolactin: $14 \text{ ng/mL}$

A 10-day course of oral medroxyprogesterone acetate is administered, but the patient experiences no vaginal bleeding upon cessation of the medication. Which of the following is the most likely pathophysiologic mechanism of this patient's current condition?

A 29-year-old nulligravid woman presents to the gynecology clinic for evaluation of an inability to conceive over the past 16 months. She reports that her menstrual cycles have become progressively infrequent, with her last menstrual period occurring 4 months ago. She also recently noticed a spontaneous, milky bilateral nipple discharge. Her past medical history is unremarkable, and she takes no medications. Vital signs are within normal limits. Pelvic examination is normal, and breast examination confirms bilateral galactorrhea. Arrange the following diagnostic and therapeutic steps in the most appropriate sequential order for the evaluation and management of this patient.

A 27-year-old woman, G1P0, is evaluated in the obstetric triage area at 31 weeks gestation. She reports a sudden gush of clear vaginal fluid that occurred 48 hours ago. Since this morning, she has developed chills and diffuse abdominal discomfort. Her temperature is 39.2°C (102.6°F), blood pressure is 110/70 mmHg, and heart rate is 115/min. Physical examination reveals a tender uterine fundus. Speculum examination shows a pool of purulent fluid in the posterior vaginal fornix. Fetal monitoring demonstrates a baseline heart rate of 175/min with moderate variability and no decelerations. Tocodynamometry shows irregular uterine contractions occurring every 8 to 10 minutes. Which of the following is the most appropriate next step in management?

A married couple visits a fertility specialist to discuss their lack of success in having a second child. They have not used contraception for $18$ months. The $32$-year-old female partner states she has not menstruated since the birth of their son two years ago. She describes chronic lethargy, decreased appetite leading to a $4$-kg ($8.8$-lb) weight loss, and frequently wearing sweaters even in warm weather. A review of her medical records reveals that her previous pregnancy ended in a vaginal delivery complicated by severe uterine atony and life-threatening blood loss, necessitating endotracheal intubation, massive transfusion, and emergency pelvic arterial embolization. She notes that she was never able to produce breast milk for her infant in the postpartum period. Physical examination reveals delayed relaxation of deep tendon reflexes and a blood pressure of $90/60$ mmHg. Which of the following pathophysiologic processes is most directly responsible for this patient's secondary amenorrhea and infertility?

A $32$-year-old woman is evaluated in the clinic for a $2$-year history of inability to conceive. She has never been pregnant. She and her partner have been engaging in frequent, unprotected intercourse. Over the past $18$ months, her menstrual cycles have lengthened to $45$ to $60$ days, and she has noticed increased dark hair growth on her upper lip and chin, requiring her to shave twice a week. She also reports a $12\text{-kg}$ ($26\text{-lb}$) weight gain during this period, predominantly in her abdominal area, and says she feels profoundly weak when trying to climb the stairs to her apartment. She takes a daily multivitamin. Vital signs show a blood pressure of $154/96 \text{ mm Hg}$, pulse of $82\text{/min}$, and BMI of $33 \text{ kg/m}^2$. Physical examination reveals a rounded, plethoric face and broad, violaceous stretch marks over the lower abdomen. Pelvic examination is unremarkable. Pelvic ultrasonography demonstrates bilaterally enlarged ovaries with multiple peripherally oriented small cysts. Which of the following is the most appropriate initial diagnostic step to ascertain the underlying cause of this patient's ovulatory dysfunction?

A 31-year-old primigravida at 38 weeks gestation is admitted to the labor and delivery triage unit for evaluation of severe preeclampsia. While speaking with the physician, she suddenly loses consciousness and begins exhibiting generalized tonic-clonic movements. Her blood pressure was recorded as 174/112 mm Hg five minutes prior to this event. Arrange the following steps in the most appropriate sequential order for the acute management of this patient's condition.

A 25-year-old nulliparous woman at 40 weeks and 2 days gestation is admitted to the labor and delivery unit for induction of labor. An intravenous oxytocin infusion is initiated. Six hours later, the patient is reporting significant pain but is coping well with epidural anesthesia. Her temperature is 37.4°C (99.3°F), blood pressure is 118/76 mmHg, and pulse is 92/min. The cervix is 6 cm dilated, 90% effaced, and the fetal head is at 0 station. Review of the external tocodynamometer over the past 30 minutes shows 7 uterine contractions per 10-minute window, with each contraction lasting 60 to 80 seconds. The continuous fetal heart rate monitor demonstrates a baseline of 130/min, minimal variability, and visually apparent, gradual decreases in the fetal heart rate that nadir after the peak of the contractions and return to baseline after the contractions conclude. The patient's hemoglobin is 10.8 g/dL with a normal mean corpuscular volume. Which of the following is the most appropriate next step in management?

A married couple visits a reproductive endocrinology specialist to discuss their inability to conceive over the past $14$ months. The female partner, who is $30$ years old, reports that her menstrual periods ceased entirely $8$ months ago. Prior to this, her cycles occurred predictably every $28$ days. Recently, she has been troubled by disrupted sleep, sudden episodes of warmth over her chest, and dyspareunia. Her past medical history is unremarkable. Family history is significant for her sister's $6$-year-old son, who was recently diagnosed with global developmental delay, autism spectrum disorder, and large protruding ears. The patient's body mass index is $22 \text{ kg/m}^2$. Pelvic examination shows thin, pale vaginal mucosa. A urine pregnancy test is negative. Laboratory studies demonstrate a serum follicle-stimulating hormone (FSH) level of $72 \text{ mIU/mL}$ and a luteinizing hormone (LH) level of $45 \text{ mIU/mL}$.

Which of the following pathophysiologic mechanisms best explains this patient's current condition?

A 30-year-old nulligravid woman comes to the clinic for infertility evaluation. She and her husband have been unable to conceive after 18 months of regular, unprotected intercourse. She has irregular menstrual cycles occurring every 45 to 90 days and was diagnosed with polycystic ovary syndrome (PCOS) three years ago. Her body mass index (BMI) is 34 kg/m². A recent hysterosalpingogram demonstrates bilateral tubal patency, and her husband's semen analysis is within normal limits. Arrange the following therapeutic interventions in the most appropriate stepwise order for managing this patient's infertility, from initial management to advanced treatments.

A multiparous patient (G3P2) at $39$ weeks of gestation is evaluated in the labor unit. She is experiencing painful uterine contractions every $3$ minutes. Her pregnancy has been uncomplicated. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $118/76\text{ mmHg}$, and pulse is $82\text{/min}$. The baseline fetal heart rate is $140\text{/min}$ with moderate variability and no decelerations. A cervical examination reveals $6\text{ cm}$ dilation, $80\%$ effacement, and the fetal vertex is at a $-2$ station. The physician performs an artificial rupture of membranes to augment labor. Immediately following the procedure, the continuous electronic fetal monitor reveals an abrupt decrease in the fetal heart rate to $70\text{/min}$ that persists for $3$ minutes. A repeat digital pelvic examination identifies a soft, compressible, pulsatile mass in the vaginal vault ahead of the fetal presenting part. Which of the following is the most appropriate next step in the management of this patient?

A 27-year-old woman comes to the office for evaluation of infertility. She and her husband have been trying to conceive for 14 months without success. Her last menstrual period was 7 months ago; prior to that, her menses occurred irregularly every 40 to 60 days. The patient reports a 4-kg (8.8-lb) weight gain over the past year, generalized fatigue, and occasional morning headaches. She notes mild worsening of facial acne. She takes no medications and has no other medical conditions. Her BMI is $24 \text{ kg/m}^2$. Blood pressure is $110/70 \text{ mmHg}$ and pulse is $62/\text{min}$. Physical examination shows a few open comedones on her chin but no hirsutism, clitoromegaly, or galactorrhea. Pelvic examination is unremarkable.

Laboratory results are as follows:

Human chorionic gonadotropin: negative
Follicle-stimulating hormone: $2.2 \text{ mIU/mL}$
Luteinizing hormone: $1.8 \text{ mIU/mL}$
Prolactin: $18 \text{ ng/mL}$
Thyroid-stimulating hormone (TSH): $1.0 \text{ mIU/L}$ (normal: 0.5–5.0)
Free thyroxine (T4): $0.5 \text{ ng/dL}$ (normal: 0.9–1.7)
Total testosterone: $35 \text{ ng/dL}$ (normal: 15–70)

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

A 21-year-old university student is brought to the outpatient clinic by her older sister because she has not had a menstrual period in 8 months. She experienced menarche at 13 years of age and subsequently had regular 29-day cycles. Over the past year, she has been training intensively for a regional triathlon and adhering to a strict, calorie-restricted vegan diet. She reports feeling occasionally fatigued but denies headaches, visual disturbances, or hot flashes. She takes no medications and is not sexually active. Her temperature is 36.6°C (97.9°F), blood pressure is 96/60 mm Hg, and pulse is 48/min. Her BMI is 16.8 kg/m2. Physical examination shows a very thin woman with fine, soft hair over her arms and back. Pelvic examination is unremarkable, and a urine pregnancy test is negative. Which of the following serum hormone profiles is most likely to be found in this patient?

A 34-year-old G1P0 woman at $37$ weeks of gestation is currently hospitalized and receiving an intravenous magnesium sulfate infusion for the management of severe preeclampsia. During a routine clinical assessment, the nurse notes that the patient has become increasingly somnolent and difficult to arouse. Her vital signs show a blood pressure of $152/98\text{ mmHg}$, a heart rate of $88\text{ /min}$, a respiratory rate of $8\text{ /min}$, and an oxygen saturation of $86\%$ on room air. Continuous fetal heart rate monitoring demonstrates a baseline of $130\text{ /min}$ with minimal variability and no decelerations. Neurological examination reveals bilaterally absent patellar reflexes. Urine output has been $40\text{ mL}$ over the last $4$ hours. Arrange the following acute management steps in the most appropriate chronological sequence for this patient.

An evaluation is requested for a 15-year-old adolescent who has not yet experienced menarche or any breast development. She is significantly shorter than her peers, with her height charting at the 2nd percentile for age. Examination demonstrates a broad chest with widely spaced nipples and a low posterior hairline. Pelvic examination reveals normal prepubertal female external genitalia. Arrange the following diagnostic and management steps in the most appropriate chronological order for this patient.

Match each patient's clinical presentation and laboratory profile with the most likely underlying etiology of her infertility or amenorrhea.

A 29-year-old woman, gravida 0, seeks medical advice for a 9-month history of secondary amenorrhea and infertility. During the past 4 months, she has also noted severe cystic acne, increased terminal hair growth on her face and chest, and a noticeable deepening of her voice. She has no history of medical conditions and takes no medications. Her blood pressure is 126/80 mm Hg, pulse is 76/min, and BMI is 24 $kg/m^2$. Physical examination demonstrates temporal balding, pronounced facial hirsutism, and clitoromegaly. Pelvic examination is limited by patient guarding, and no distinct adnexal masses are palpated. A urine $\beta$-hCG test is negative. Laboratory evaluation reveals the following:

Total testosterone: 195 $ng/dL$ (normal: 15-70 $ng/dL$)
Dehydroepiandrosterone sulfate (DHEAS): 210 $\mu g/dL$ (normal: 35-430 $\mu g/dL$)
Prolactin: 14 $ng/mL$ (normal: 4-23 $ng/mL$)
Thyroid-stimulating hormone: 2.1 $\mu U/mL$

Which of the following is the most appropriate next step in the evaluation of this patient?

A married couple presents to the reproductive endocrinology clinic seeking assistance with conception after actively trying for 16 months without success. The female partner, who is 32 years of age, states that her menstrual cycles were previously regular but have occurred only three times in the past year. During this period, she has developed significant, dark hair growth on her face, chest, and lower abdomen. She is particularly distressed because she recently noticed a distinct deepening of her voice and a receding hairline. Physical examination reveals a body mass index of 22 kg/m². Pelvic examination demonstrates marked clitoromegaly. A urine β-hCG test is negative. Which of the following is the most appropriate initial laboratory evaluation for this patient?

Match each patient's clinical presentation with the most likely corresponding serum laboratory profile. All patients present with secondary amenorrhea or oligomenorrhea.

A 34-year-old man and his 31-year-old female partner present to the reproductive endocrinology clinic for evaluation of infertility after 2 years of unsuccessful attempts to conceive. The female partner's evaluation, including ovulation assessment and hysterosalpingography, is completely normal. The male partner provides a semen sample, and the initial semen analysis demonstrates severe oligospermia with a sperm concentration of 3 million/mL (normal > 15 million/mL). He is otherwise healthy and has no history of cryptorchidism, genitourinary trauma, or sexually transmitted infections. Arrange the following subsequent steps in the most appropriate sequential order for the comprehensive evaluation and management of this male partner's severe oligospermia.

A 27-year-old woman comes to the clinic seeking evaluation for primary infertility. She and her male partner have been having regular, unprotected intercourse for 14 months without conception. The patient notes that her menstrual cycles have always been unpredictable, occurring roughly every 45 to 90 days. She also reports bothersome dark hair growth on her chin, upper lip, and chest, which she removes weekly. She has no history of sexually transmitted infections or pelvic pain. Her body mass index is 29 kg/m², and her blood pressure is 118/76 mmHg. Physical examination reveals terminal hairs in a male-pattern distribution and mild facial acne, but there is no deepening of the voice, temporal balding, or clitoromegaly. Striae and proximal muscle weakness are absent. Pelvic ultrasound shows bilaterally enlarged ovaries, each containing over 15 small peripheral cysts. Morning laboratory tests obtained on day 3 of a progestin-induced withdrawal bleed show the following:

Which of the following is the most likely diagnosis?