Obstetrics and Gynecology

Several patients present to a women's health clinic requesting initiation of a highly effective, reversible contraceptive method. Review their clinical histories and match each patient with the single most appropriate contraceptive option based on the Medical Eligibility Criteria and the patient's specific requests.

A 54-year-old postmenopausal woman comes to the clinic due to a 3-month history of an itchy, flaking rash on her left nipple and areola. She states that the rash initially began as a small red patch but has gradually spread and thickened. She applied an over-the-counter hydrocortisone cream twice daily for 4 weeks with no improvement. She has no personal or family history of breast cancer. On physical examination, there is a unilateral, well-demarcated, erythematous, scaly plaque confined to the left nipple-areolar complex with small areas of superficial crusting and ulceration. The nipple appears slightly flattened. Palpation of the left breast yields no distinct masses. Axillary lymph nodes are not palpable. Bilateral diagnostic mammography reveals no abnormalities. Which of the following is the most appropriate next step in management?

A 24-year-old woman comes to the office after discovering a lump in her right breast while showering 3 days ago. She has not noticed any nipple discharge, skin changes, or breast pain. Her menstrual periods occur every 28 days and last for 4 to 5 days. Her last menstrual period ended 2 weeks ago. Her medical history is unremarkable, and she takes no medications. She has no family history of breast or ovarian cancer. Vital signs are within normal limits. On physical examination, there is a 2.5-cm, firm, mobile, non-tender, well-circumscribed mass in the upper outer quadrant of the right breast. There is no overlying skin erythema, dimpling, or nipple retraction. No axillary or supraclavicular lymphadenopathy is appreciated. Which of the following is the most appropriate next step in management?

Match each gynecologic surgical procedure step or scenario with the most likely clinical presentation of its associated iatrogenic complication.

A 28-year-old nulligravid woman comes to the clinic reporting severe, cyclic lower pelvic pain for the past 4 months. She states the pain lasts for 4 to 5 days each month and is accompanied by breast tenderness and bloating, but she has not had any vaginal bleeding during these episodes. Her last normal menstrual period was 6 months ago. Five months ago, the patient underwent a loop electrosurgical excision procedure (LEEP) for high-grade cervical intraepithelial neoplasia (CIN 3). She has a negative home pregnancy test. Her BMI is $24 \text{ kg/m}^2$. Vital signs are within normal limits. Pelvic examination reveals normal external genitalia. Speculum examination shows a scarred, flush cervix without a visible external os. Bimanual examination reveals a symmetrically enlarged, globular, and very tender uterus. Bilateral adnexa are normal. A transvaginal ultrasound demonstrates a distended uterine cavity filled with $45 \text{ mL}$ of echogenic fluid. Which of the following is the most appropriate next step in management?

Evaluate the following clinical scenarios encountered in an outpatient women's health clinic. Select the most accurate diagnosis that corresponds to each patient's specific presentation.

A 33-year-old gravid 3, para 2 woman at 38 weeks of gestation is evaluated in the labor unit. She was admitted in active labor 2 hours ago. Her past medical history is notable for a laparoscopic myomectomy three years ago that required extensive entry into the uterine cavity. She has been comfortable on continuous epidural analgesia until 10 minutes ago, when she reports the sudden onset of severe, tearing lower abdominal pain that radiates to her left shoulder. Her blood pressure is $82/48$ mm Hg, and her pulse is $132$/min. The tocodynamometer reveals a sudden cessation of previously regular uterine contractions. Fetal heart rate monitoring demonstrates an abrupt deceleration to $80$/min that has persisted for 4 minutes without recovery. On sterile vaginal examination, the fetal presenting part has receded from $0$ station to $-3$ station. Which of the following is the most appropriate next step in management?

A 28-year-old woman comes to the office with her partner for evaluation of an inability to conceive for the past 14 months. She has a history of irregular menstrual cycles occurring every 35 to 90 days. Her last menstrual period was 10 weeks ago. Recently, she has felt unusually fatigued and has experienced mild nausea upon awakening. She takes a daily prenatal vitamin. Blood pressure is $112/70 \text{ mm Hg}$, and pulse is $88/\text{min}$. BMI is $27 \text{ kg/m}^2$. Physical examination shows mild facial acne. Pelvic examination reveals a soft, slightly enlarged globular uterus and a bluish discoloration of the cervix. Laboratory studies obtained at a health fair last week show:

Thyroid-stimulating hormone (TSH): $0.1 \text{ mU/L}$ (N: $0.4-4.0 \text{ mU/L}$)
Total thyroxine (T4): $13.5 \text{ \mu g/dL}$ (N: $5.0-12.0 \text{ \mu g/dL}$)
Prolactin: $35 \text{ ng/mL}$ (N: $< 20 \text{ ng/mL}$)

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

A reproductive endocrinology clinic utilizes various pharmacotherapy regimens to treat patients with anovulatory and anatomical infertility. For each clinical scenario describing a patient receiving an infertility treatment, match the appropriate intervention with its primary pathophysiological mechanism of action.

An expectant mother at 37 weeks of gestation presents to the triage unit complaining of profound, full-body itching that has progressively worsened over the last week. The sensation is particularly unbearable at night and is concentrated on the palms of her hands and the soles of her feet. She has no prior history of dermatologic conditions, and no visible rash or lesions are observed on physical examination. Her blood pressure is 118/76 mm Hg, and her temperature is 37.1°C (98.8°F).

Laboratory results are as follows:

A continuous fetal heart rate tracing reveals a baseline of 140/min, moderate variability, and periodic shallow decreases in the heart rate that begin and end exactly symmetrically with the patient's spontaneous mild uterine contractions.

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

A $31$-year-old woman comes to the clinic due to an $18$-month history of inability to conceive. She and her partner have been having regular, unprotected intercourse. Her menstrual periods, previously regular, now occur every $50$ to $60$ days. The patient also reports a $5\text{-kg}$ ($11\text{-lb}$) weight gain, sluggishness, and increased sensitivity to cold over the past year. Her BMI is $28\ \text{kg/m}^2$. Vital signs show a temperature of $36.1^\circ\text{C}$ ($97.0^\circ\text{F}$) and a pulse of $56\text{/min}$. Physical examination reveals an enlarged, firm, and non-tender thyroid gland, as well as bilateral milky discharge from the nipples. A urine pregnancy test is negative.

Laboratory results:
Thyroid-stimulating hormone (TSH): $22.5\ \mu\text{U/mL}$ (Normal: $0.4$ – $4.0\ \mu\text{U/mL}$)
Free thyroxine (T4): $0.5\ \text{ng/dL}$ (Normal: $0.9$ – $1.7\ \text{ng/dL}$)
Prolactin: $68\ \text{ng/mL}$ (Normal: $4$ – $23\ \text{ng/mL}$)

Which of the following is the most likely pathophysiologic mechanism responsible for this patient's infertility?

A 27-year-old woman presents to the reproductive endocrinology clinic with her partner because they have been unable to conceive for the past 15 months despite regular unprotected intercourse. She reports that her menstrual periods have been unpredictable since menarche, typically occurring only 3 or 4 times a year. Her medical history is unremarkable, and she takes no medications. Vital signs include a blood pressure of 122/78 mmHg and a body mass index (BMI) of 33 kg/m $^2$. Physical examination reveals dark, thickened, velvety plaques on the posterior neck and axillae, as well as coarse, dark hair on her upper lip, chin, and chest. Laboratory evaluation shows an elevated serum free testosterone level, a normal thyroid-stimulating hormone (TSH) level, a normal prolactin level, and a normal early morning 17-hydroxyprogesterone level. A pelvic ultrasound demonstrates bilaterally enlarged ovaries with multiple small, peripherally arranged cysts. Which of the following pathophysiologic mechanisms is the primary driver of this patient's anovulatory infertility?

A 19-year-old woman comes to the emergency department complaining of sudden-onset, sharp right upper quadrant abdominal pain that worsens with deep inspiration. She also reports a 5-day history of lower pelvic discomfort and spotting between her menstrual periods. She recently became sexually active with a new male partner. Her only medication is an oral contraceptive. Her temperature is 38.3°C (101.0°F), blood pressure is 112/68 mmHg, pulse is 98/min, and respirations are 18/min. Physical examination shows marked right upper quadrant tenderness without guarding or rebound. Murphy sign is negative. There is also bilateral lower quadrant tenderness. Pelvic examination reveals a mucopurulent cervical discharge and pronounced cervical motion tenderness.

A urine pregnancy test is negative. Right upper quadrant ultrasound demonstrates a normal gallbladder without stones, sludge, or wall thickening.

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

A $44$-year-old woman, G $3$ P $3$, comes to the office due to a $1$-week history of continuous, involuntary watery vaginal discharge. Four weeks ago, she underwent a complicated total abdominal hysterectomy for severe endometriosis and large uterine leiomyomas. Her postoperative course was notable for right-sided back pain and a fever of $38.3^\circ\text{C}$ ($101.0^\circ\text{F}$) on postoperative day $14$. She was evaluated at an urgent care clinic where urinalysis was inconclusive, and she was advised to follow up. Her pain and fever spontaneously resolved a week later, which precisely coincided with the onset of the constant vaginal leakage. The patient notes that despite the continuous leakage, she still feels the urge to urinate and voids normally in the toilet every $3$ to $4$ hours. Vital signs today are within normal limits. On pelvic examination, the vaginal cuff appears well-healed with no erythema, but there is pooling of clear fluid in the vaginal vault. A tampon is placed in the vagina, and a dilute methylene blue solution is instilled directly into the bladder via a urethral catheter. Thirty minutes later, the patient is asked to walk around the clinic. The tampon is then removed and shows no blue staining. Which of the following is the most appropriate next step in evaluation?

An otherwise healthy 36-year-old female patient presents to the outpatient clinic reporting a 3-week history of spontaneous, unilateral breast discharge. She notes finding small, blood-stained spots on the inside of her bra on the left side. The patient denies any localized breast pain, fever, recent trauma, or palpable lumps. Her menstrual cycles are regular, and she is currently nulliparous. She takes no daily medications and has no family history of breast cancer. On physical examination, visual inspection shows normal breast symmetry without overlying skin changes or nipple retraction. Careful palpation of all quadrants yields no discrete masses, and there is no axillary lymphadenopathy. Gentle pressure applied around the left areola produces a single drop of bloody fluid from a single duct opening. Which of the following is the most likely diagnosis?

A 72-year-old woman comes to the office due to a 6-month history of increasingly severe, involuntary urinary leakage. She describes the urine as "just dripping out" when she transitions from sitting to standing or when walking around her home. The patient underwent a transobturator tape procedure 12 years ago that initially resolved her symptoms, but the leakage has recurred and is now worse. She reports no dysuria, hematuria, or pelvic pain. Medical history includes hypertension, osteoporosis, and well-controlled type 2 diabetes mellitus. Body mass index is $26 \text{ kg/m}^2$. Pelvic examination reveals a well-supported vaginal apex with no anterior or posterior vaginal wall prolapse. A cotton swab (Q-tip) test demonstrates a resting angle of $5^\circ$ and a maximal straining angle of $15^\circ$ from the horizontal. Urodynamic evaluation shows a Valsalva leak point pressure of $45 \text{ cm H}_2\text{O}$ and a post-void residual volume of $20 \text{ mL}$. Detrusor overactivity is absent during cystometry. Urinalysis is unremarkable. Which of the following is the most appropriate next step in management?

A physician is evaluating a 61-year-old female patient who reports a six-month history of increasingly frequent urges to urinate, often resulting in involuntary leakage before she can reach a restroom. She notes having to wake up two to three times per night to void. The patient also mentions progressive vaginal dryness and discomfort during intercourse. She has no history of fevers, hematuria, or dysuria. Her last menstrual period was 10 years ago. Her medical history includes hypertension, for which she takes amlodipine. Vital signs are within normal limits. On physical examination, the vulvar and vaginal tissues appear pale, thin, and lack normal rugation. The urethral meatus is slightly retracted. A midstream urinalysis is negative for nitrites and leukocyte esterase, with 0-1 leukocytes/hpf. Which of the following is the most appropriate next step in management?

A 35-year-old nulliparous woman is brought to the emergency department 5 days after undergoing an uncomplicated laparoscopic left ovarian cystectomy with fulguration of pelvic endometriosis. For the past 24 hours, she has experienced progressive, severe generalized abdominal pain accompanied by nausea and multiple episodes of emesis. Her temperature is 39.2°C (102.6°F), blood pressure is 86/54 mm Hg, and pulse is 128/min. She appears toxic and diaphoretic. Physical examination reveals a rigid, significantly distended abdomen with diffuse rebound tenderness and involuntary guarding. Bowel sounds are absent. Laboratory studies show a leukocyte count of 22,000/mm³ with a marked left shift. Which of the following is the most appropriate next step in management?

A $71$-year-old woman comes to the office due to a $4$-month history of urinary dribbling, frequent small voiding, and pelvic pressure. The patient says, 'I feel like a ball is falling out of my vagina.' She also notes occasional faint pink spotting on her underwear after wiping, which she attributes to the bulge rubbing against her clothing. She does not take any medications and has never used hormone therapy. Vital signs are within normal limits. Pelvic examination reveals a large anterior vaginal mass extending $2$ cm beyond the hymenal ring with the Valsalva maneuver. The mucosal surface of the prolapsed tissue is thinned, erythematous, and has a superficial $1$-cm abrasion that is oozing a minute amount of blood. Post-void residual volume is $350$ mL. Urinalysis shows trace leukocyte esterase but is negative for nitrites. Which of the following is the most appropriate initial management for this patient?

A 38-year-old woman presents to the urogynecology clinic complaining of an 8-month history of continuous postvoid dribbling, dysuria, and pelvic pressure. She also reports deep dyspareunia. Over the past year, she has visited urgent care clinics on three separate occasions for presumed urinary tract infections; each time, she received a short course of oral antibiotics which provided temporary relief of her dysuria. Her past medical history is notable for a spontaneous vaginal delivery $4$ years ago complicated by a prolonged second stage of labor. Vital signs are within normal limits. Pelvic examination reveals normal external genitalia. Speculum examination demonstrates a $3$ cm, exquisitely tender, fluctuant, cystic mass located on the anterior vaginal wall. Gentle palpation of this mass expresses a small amount of purulent discharge from the urethral meatus. Urinalysis demonstrates $15$-$20$ leukocytes per high-power field, positive leukocyte esterase, and negative nitrites. Which of the following is the most appropriate next step in management?