Obstetrics and Gynecology

During a routine wellness check, a patient reports noticing small amounts of dark blood on her toilet tissue over the past week. Review of her medical record confirms she is nulliparous, has a body mass index of $34 \text{ kg/m}^2$, and experienced her final menstrual period eight years ago. A pelvic examination reveals a small amount of blood in the vaginal vault with a visually normal cervix and no vaginal lacerations. Which of the following is the most appropriate next step in the management of this patient?

A 59-year-old woman comes to the office due to a 3-month history of continuous urinary dribbling. She says, "I never feel like my bladder is fully empty, and urine just constantly leaks out all day." She has a 20-year history of type 2 diabetes mellitus that is poorly controlled, with a recent hemoglobin A1c of 9.2%. Her current medications include metformin, glipizide, and insulin glargine. On pelvic examination, the vaginal mucosa is pink and well-rugated, and there is no evidence of pelvic organ prolapse. Neurologic examination shows decreased sensation to monofilament testing over the plantar surface of both feet. Which of the following is the most appropriate next step in the evaluation of this patient's urinary symptoms?

Match each clinical vignette describing an adverse reaction during the management of postpartum hemorrhage to the underlying mechanism of action of the responsible pharmacologic agent.

An academic medical center runs a specialized complex contraception clinic. Four patients present seeking highly effective, reversible contraception. Match each patient's presentation and medical history with the single most appropriate contraceptive method based on the World Health Organization Medical Eligibility Criteria (WHO MEC) and potential secondary clinical benefits.

A 68-year-old woman presents to the clinic reporting recurrent, light vaginal bleeding for the past 4 months. Three months ago, she was evaluated at an outside facility for the initial onset of this symptom. At that time, a transvaginal ultrasound was performed, demonstrating a homogeneous endometrial stripe of 2.6 mm and normal-appearing ovaries. A Pap test was negative for intraepithelial lesion or malignancy. She was diagnosed with genitourinary syndrome of menopause and prescribed vaginal estrogen therapy. The patient has been using the estrogen cream twice weekly as directed, but reports that the intermittent spotting has persisted. She takes no other medications and has no history of abnormal Pap smears. Vital signs are within normal limits. Pelvic examination reveals a well-rugated, moist vaginal mucosa. The cervix appears nulliparous and grossly normal, with a small amount of dark blood noted at the external os. The uterus is small, mobile, and non-tender, with no palpable adnexal masses. Which of the following is the most appropriate next step in management?

A 28-year-old nulligravid woman presents to the clinic alongside her partner, reporting an inability to conceive after 12 months of regular, unprotected intercourse. She previously experienced predictable 28-day menstrual cycles, but over the past eight months, she has had only two episodes of light vaginal bleeding. The patient notes a generalized lack of energy and an unintentional 8-kg (17.6-lb) weight gain during this period. She also reports the recent appearance of dark, coarse hair on her chin. Her body mass index is 31 kg/m $^2$. Vital signs show a heart rate of 56/min and blood pressure of 112/74 mmHg. Pelvic examination is unremarkable. Transvaginal ultrasonography reveals symmetrically enlarged ovaries, each containing 15 to 20 small subcapsular follicles.

Laboratory studies show the following:
- $\beta$-hCG: negative
- Total testosterone: 65 ng/dL (Reference: 15-70 ng/dL)
- Prolactin: 48 ng/mL (Reference: < 20 ng/mL)
- Thyroid-stimulating hormone (TSH): 11.2 $\mu$ U/mL (Reference: 0.4-4.0 $\mu$ U/mL)
- Free thyroxine (T4): 0.6 ng/dL (Reference: 0.9-1.7 ng/dL)
- Follicle-stimulating hormone (FSH): 4 mIU/mL
- Luteinizing hormone (LH): 3 mIU/mL

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

A 24-year-old woman comes to the clinic for a follow-up visit regarding persistent vaginal discharge and spotting after intercourse. Three weeks ago, she presented with similar symptoms and was diagnosed with cervicitis. A nucleic acid amplification test (NAAT) at that time was positive for *Chlamydia trachomatis* and negative for *Neisseria gonorrhoeae*. She was prescribed a 7-day course of oral doxycycline, which she completed. Her new male sexual partner was also treated, and they abstained from sexual activity for 10 days. Today, her vital signs are within normal limits. Pelvic examination reveals an erythematous, friable cervix with mucopurulent discharge. No cervical motion tenderness or adnexal tenderness is appreciated. A repeat NAAT for *C. trachomatis* and *N. gonorrhoeae* is negative. Wet mount microscopy shows numerous polymorphonuclear leukocytes but no clue cells, trichomonads, or pseudohyphae. Which of the following is the most appropriate next step in management?

A primigravid patient at $36$ weeks gestation comes to the emergency department reporting a $6$-hour history of severe, persistent pain in her right upper abdomen accompanied by nausea. The $29$-year-old reports typical fetal movement and no fluid leakage or uterine contractions. Vital signs include a blood pressure of $162/105\text{ mm Hg}$, a heart rate of $92/\text{min}$, and a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$). On physical examination, there is noticeable swelling of the hands and face, along with significant tenderness in the right upper abdominal quadrant. The fetal heart rate tracing is Category I, showing a baseline of $145/\text{min}$, moderate variability, and positive accelerations.

Laboratory results are as follows:

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

A $34$-year-old woman, who has never been pregnant, comes to the physician due to a $4$-month history of rapidly progressing facial hair growth and severe acne. Her menstrual periods, previously regular every $28$ days, have completely stopped during this time. The patient has also noted that her voice sounds deeper than usual over the past few weeks. She has no significant past medical history and takes no medications. Her body mass index is $23 \text{ kg/m}^2$. Vital signs show a blood pressure of $124/82 \text{ mmHg}$ and a heart rate of $76/\text{min}$. Physical examination shows significant terminal hair growth on the chin, upper lip, and chest. Pelvic examination demonstrates clitoromegaly and normal vaginal rugae; bimanual examination reveals a normal-sized uterus, but the adnexa are difficult to palpate.

Laboratory studies show:
- $\beta$-hCG: negative
- Prolactin: $14 \text{ ng/mL}$ (Normal: $< 20 \text{ ng/mL}$)
- Thyroid-stimulating hormone: $2.2 \text{ } \mu\text{U/mL}$
- Total testosterone: $210 \text{ ng/dL}$ (Normal: $15-70 \text{ ng/dL}$)
- Dehydroepiandrosterone sulfate (DHEAS): $2.5 \text{ } \mu\text{g/mL}$ (Normal: $0.5-4.0 \text{ } \mu\text{g/mL}$)

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

An obstetric rapid response is called for a patient at $36\text{ weeks}$ of gestation who presents to the triage unit with a $2\text{-day}$ history of worsening jaundice, persistent nausea, and severe lethargy. She has no significant past medical history, and her prenatal course was previously unremarkable. Upon evaluation, she appears visibly confused and is difficult to arouse. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $132/84\text{ mm Hg}$, and heart rate is $108/\text{min}$. Physical examination reveals scleral icterus and right upper quadrant abdominal tenderness. The uterus is soft, and pelvic examination shows a closed cervix. A continuous fetal monitor is placed, demonstrating a baseline heart rate of $145/\text{min}$ with moderate variability and spontaneous accelerations; there are no decelerations.

Initial laboratory studies are obtained and reveal the following:

Hemoglobin: $10.8\text{ g/dL}$
Platelet count: $88,000/\text{mm}^3$
Leukocyte count: $16,500/\text{mm}^3$
Glucose: $42\text{ mg/dL}$
Aspartate aminotransferase (AST): $740\text{ U/L}$
Alanine aminotransferase (ALT): $820\text{ U/L}$
Total bilirubin: $5.6\text{ mg/dL}$
Creatinine: $1.8\text{ mg/dL}$
Prothrombin time: $22\text{ seconds}$ (Reference: $11-14\text{ seconds}$)
Activated partial thromboplastin time: $54\text{ seconds}$ (Reference: $25-40\text{ seconds}$)

Intravenous dextrose is immediately administered, and the patient becomes fully oriented. Blood products are typed and crossmatched. Which of the following is the most appropriate next step in the management of this patient?

Paramedics bring a $30$-year-old patient at $37$ weeks of pregnancy to the trauma bay after a severe motor vehicle collision. Her obstetric history is notable for one prior uncomplicated vaginal delivery at term. She complains of unrelenting, severe lower abdominal pain and reports a small amount of dark red vaginal bleeding.

Vital signs show a blood pressure of $86/52$ mmHg, a heart rate of $128$/min, and a respiratory rate of $22$/min. Physical examination reveals a rigid, board-like uterus that is extremely tender to palpation. Pelvic examination demonstrates the cervix is $1$ cm dilated and $50\%$ effaced.

Continuous fetal heart rate monitoring displays a baseline of $105$/min with absent beat-to-beat variability and recurrent late decelerations occurring with every spontaneous uterine contraction. Laboratory analysis reveals a hemoglobin of $9.2$ g/dL and a normal platelet count.

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

A $32$-year-old female, currently in her second pregnancy (G2P1) at $34$ weeks of gestation, is evaluated in the emergency department for shortness of breath and leg swelling. She states that the breathlessness has gradually developed over the past few weeks and is most noticeable when she lies flat in bed. She denies chest pain, cough, or pain in her legs. Her medical history is unremarkable, and her pregnancy has been uncomplicated.

Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $112/70\text{ mmHg}$, pulse of $86\text{/min}$, and respirations of $16\text{/min}$. Oxygen saturation is $99\%$ on ambient air.

Physical examination demonstrates 1+ symmetric, bilateral pitting edema extending to the ankles. The maximum circumference of the right calf is $35.0\text{ cm}$ and the left calf is $35.5\text{ cm}$. Cardiac auscultation reveals a grade 2/6 early systolic murmur at the left sternal border. The lungs are clear to auscultation bilaterally.

Laboratory analysis reveals the following:

Hemoglobin: $10.6\text{ g/dL}$
Platelet count: $145,000\text{/mm}^3$
D-dimer: $920\text{ ng/mL}$ (Reference: $< 500\text{ ng/mL}$)

Arterial blood gas analysis on ambient air:
pH: $7.44$
PaO $_2$: $104\text{ mmHg}$
PaCO $_2$: $29\text{ mmHg}$
HCO $_3^-$: $19\text{ mEq/L}$

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

A primigravid patient at $37$ weeks of gestation is currently in the labor and delivery unit. She was admitted $24$ hours ago for induction of labor due to preeclampsia with severe features. She is receiving continuous intravenous oxytocin, labetalol, and magnesium sulfate. Over the past $4$ hours, her total urine output has been $45\text{ mL}$. The nurse calls the physician because the patient has become increasingly somnolent and difficult to arouse. Current vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure $135/85\text{ mmHg}$, pulse $82/\text{min}$, and respiratory rate $8/\text{min}$. Oxygen saturation is $90\%$ on room air. Neurologic examination reveals absent deep tendon reflexes at the patella and biceps. The continuous fetal heart rate tracing demonstrates a baseline of $145/\text{min}$, minimal variability, and no decelerations. Which of the following is the most appropriate initial step in management?

During a routine health maintenance visit, a 54-year-old G2P2 patient reports experiencing two days of light vaginal spotting the previous week. She underwent natural menopause at age 51. Her past medical history is significant for estrogen receptor-positive, node-negative breast cancer, for which she was treated with a lumpectomy and radiation therapy three years ago. Since completing her primary surgical and radiation treatment, she has been maintained on tamoxifen. Her body mass index is 26 kg/m^2. Vital signs are within normal limits. Pelvic examination demonstrates normal external genitalia, a small and mobile uterus, and no palpable adnexal masses. Speculum examination shows a small amount of dark red blood in the vaginal vault, but no active bleeding or visible cervical lesions. Which of the following is the most appropriate next step in management?

An obstetric team is attending the delivery of a macrosomic infant at 40 weeks gestation. After the fetal head emerges, it immediately retracts tightly against the mother's perineum. The anterior shoulder remains impacted behind the pubic symphysis despite routine gentle downward traction. Arrange the following management steps in the correct standard sequence of escalation to resolve this complication, from the immediate first response to the maneuver of last resort.

An adolescent primigravida at 39 weeks gestation is currently in the active phase of labor following spontaneous rupture of membranes 24 hours ago. Over the last hour, she has developed a new-onset fever. She is currently receiving continuous epidural analgesia. Her temperature is 39.2°C (102.6°F), blood pressure is 112/70 mm Hg, pulse is 115/min, and respirations are 18/min. Physical examination reveals a uterus that is tender to palpation between contractions. Pelvic examination shows the cervix is 6 cm dilated and 90% effaced, with the fetal presenting part at +1 station. Uterine contractions are occurring every 5 to 6 minutes. Continuous fetal monitoring displays a baseline heart rate of 175/min with moderate variability and occasional early decelerations. Which of the following is the most appropriate next step in the management of this patient?

A 30-year-old nulliparous woman at 40 weeks and 1 day of gestation is managed on the labor unit. She was admitted 8 hours ago in spontaneous active labor. Four hours ago, her cervical examination revealed 6 cm dilation, 100% effacement, and 0 station. Spontaneous rupture of membranes occurred around that time, and the amniotic fluid was clear. An intrauterine pressure catheter was subsequently placed. Over the last four hours, she has consistently had 4 to 5 uterine contractions every 10 minutes, generating a total of 240 to 260 Montevideo units. Re-evaluation of her cervix just now shows no change from the prior examination. The maternal vital signs are within normal limits. The fetal heart rate tracing exhibits a baseline of 140/min, moderate baseline variability, the presence of accelerations, and no decelerations. Which of the following is the most appropriate next step in management?

A 22-year-old female is evaluated in the emergency department for three days of worsening right-sided abdominal pain and lower pelvic discomfort. The abdominal pain is sharp, exacerbated by deep inspiration, and accompanied by nausea. She has a past medical history of asthma and a severe allergic reaction to amoxicillin during childhood that resulted in anaphylaxis and endotracheal intubation. Her temperature is 38.9°C (102.0°F), blood pressure is 112/72 mmHg, and pulse is 114/min. Physical examination reveals right upper quadrant tenderness with a palpable friction rub over the anterior costal margin, as well as profound bilateral lower abdominal tenderness. Pelvic examination demonstrates a friable cervix with mucopurulent discharge at the cervical os and exquisite pain on cervical motion. Laboratory studies show a leukocyte count of 16,800/mm³. Liver aminotransferases and alkaline phosphatase levels are within normal limits. A right upper quadrant ultrasound demonstrates no biliary abnormalities and no pericholecystic fluid. Which of the following is the most appropriate initial pharmacologic management for this patient?

A 32-year-old woman, gravida 2, para 2, experiences sudden, massive vaginal bleeding shortly after a spontaneous vaginal delivery at 39 weeks gestation. The placenta delivered spontaneously 5 minutes ago with gentle cord traction. Her blood pressure is 78/40 mmHg and her pulse is 135/min. On physical examination, the uterine fundus cannot be palpated in the abdomen. Pelvic examination reveals a red, fleshy, globular mass protruding through the external cervical os. Arrange the following management steps in the correct sequential order for this patient's condition.

A 64-year-old female presents to the gynecology clinic evaluating intermittent vaginal bleeding that has been ongoing for the past two months. She notes that the bleeding is particularly noticeable after intercourse. She reached menopause at age 52 and takes no medications. Her last gynecologic examination and cervical cancer screening were over two decades ago. Vital signs are within normal limits. Speculum examination reveals a 3.5-cm friable, ulcerated mass on the anterior lip of the cervix that bleeds on contact. Bimanual examination demonstrates a normal-sized, mobile uterus with no adnexal masses. A transvaginal ultrasound shows an endometrial stripe of 2.5 mm. Which of the following is the most appropriate next step in the management of this patient?