Obstetrics and Gynecology

A 31-year-old G2P1 woman at 39 weeks gestation is admitted to the labor and delivery unit in active labor. Her most recent cervical examination shows 5 cm dilation, 80% effacement, and the fetal vertex at -2 station. Shortly after admission, the patient experiences spontaneous rupture of membranes with a large gush of clear amniotic fluid. Immediately following this event, the continuous fetal heart rate monitor demonstrates a sudden, prolonged deceleration, with the heart rate dropping to 60/min and remaining there. A prompt sterile vaginal examination is performed, which reveals a pulsating, rope-like structure palpable in the vaginal canal ahead of the fetal presenting part. Which of the following is the most appropriate next step in management?

Match each gestational age window or prenatal visit timing with the most appropriate routine screening test indicated at that time for an average-risk, uncomplicated pregnancy.

Match each obstetric patient presentation with the most appropriate indicated management or screening plan.

A 26-year-old G1P0 woman at 39 weeks gestation is evaluated in the labor and delivery unit for active labor. Her pregnancy has been uncomplicated. Her membranes spontaneously ruptured 4 hours ago, yielding clear fluid. Her temperature is 37.1°C (98.8°F), blood pressure is 120/78 mm Hg, and pulse is 88/min. Laboratory studies show a hemoglobin concentration of 10.5 g/dL. The cervix is 7 cm dilated, 100% effaced, and the fetal vertex is at 0 station. Uterine contractions occur every 3 minutes and are of moderate intensity. Fetal heart rate monitoring demonstrates a baseline of 140/min with moderate variability. Over the last 45 minutes, there are recurrent, abrupt decreases in the fetal heart rate to 80-90/min, lasting for 45-60 seconds, which occur with approximately 60% of the contractions. The decelerations rapidly return to the baseline. Maternal repositioning to the left lateral decubitus position, administration of oxygen, and an intravenous fluid bolus are performed, but the fetal heart rate pattern remains unchanged over the next 15 minutes. Which of the following is the most appropriate next step in management?

A 45-year-old woman, gravida 3, para 3, comes to the clinic complaining of involuntary urine leakage for the past 4 months. She states that the leakage typically occurs when she coughs, sneezes, or laughs heartily. She does not experience a sudden, overwhelming urge to urinate prior to the leakage and does not wake up at night to void. Her medical history is unremarkable, and she had three uncomplicated vaginal deliveries. Physical examination reveals a positive cough stress test with leakage of urine from the urethra. Urinalysis is normal, and postvoid residual volume is 25 mL. Which of the following is the most appropriate initial management for this patient?

A 64-year-old woman, G2P2, comes to the office due to a 2-week history of vaginal bleeding. She describes the bleeding as spotting that occasionally requires a panty liner. Her last menstrual period was 12 years ago, and she did not receive hormone replacement therapy. She has a medical history of obesity, essential hypertension, and type 2 diabetes mellitus. Her current medications include lisinopril and metformin. Vital signs are within normal limits. Pelvic examination shows a normal-appearing vagina and cervix with no visible lesions. A small amount of dark blood is noted in the posterior vaginal fornix. Which of the following is the most appropriate next step in management?

A 62-year-old woman comes to the office due to a 3-week history of episodic vaginal bleeding. She reached menopause at age 52 and has not had any vaginal bleeding since then. Her medical history is significant for obesity, type 2 diabetes mellitus, and hypertension. Current medications include metformin and lisinopril. Her body mass index (BMI) is 34 kg/m². Pelvic examination shows normal external genitalia and a nulliparous cervix without visible lesions. Bimanual examination reveals a normal-sized, mobile uterus with no adnexal masses. A transvaginal ultrasound is performed and shows an endometrial stripe thickness of 7 mm. Which of the following is the most appropriate next step in management?

A 24-year-old woman comes to the clinic because she has not had a menstrual period for the past 3 months. Menarche occurred at age 12, and her menses had previously occurred at regular 28-day intervals. She has no other symptoms such as headaches, visual changes, or nipple discharge. She takes no daily medications and has no chronic medical conditions. She is sexually active with a male partner and relies on the withdrawal method for contraception. Vital signs include a temperature of 37.0°C (98.6°F), blood pressure of 118/76 mm Hg, pulse of 74/min, and BMI of 23 kg/m². Physical examination shows normal breast development, no hirsutism or acne, and a normal pelvic examination. Which of the following is the most appropriate initial step in evaluating this patient's condition?

A 64-year-old woman, gravida 0, presents to the clinic reporting a two-week history of intermittent vaginal spotting. She reached menopause at age 52. Past medical history includes type 2 diabetes mellitus, chronic hypertension, and obesity. Her body mass index is 38 kg/m². Pelvic examination reveals a small amount of dark blood in the vaginal vault. The cervix appears grossly normal, and the uterus is non-tender and mobile. A transvaginal ultrasound shows an endometrial thickness of 9 mm. An office endometrial biopsy is performed; however, the pathology report returns as 'scant cellular material, composed primarily of blood and mucus, insufficient for diagnosis.' Which of the following is the most appropriate next step in management?

A $64$-year-old woman, G2P2, comes to the office due to a $3$-month history of intermittent vaginal bleeding and new-onset breast fullness. Menopause occurred at age $52$. She has no other medical conditions and takes no medications. Vital signs are within normal limits. Pelvic examination reveals a normal-appearing vagina and cervix. Bimanual examination demonstrates a mobile, $8$-cm, solid mass in the right adnexa and a globally enlarged, soft uterus. Transvaginal ultrasonography shows an $8$-cm right ovarian mass with solid and cystic components, and an endometrial stripe thickness of $14$ mm. Which of the following is the most appropriate next step in management?

A 28-year-old woman, nulligravida, comes to the clinic reporting an absence of menstruation for the past 6 months. Prior to this, her menstrual cycles were regular, occurring every 28 to 30 days. Over the same 6-month period, she has noticed rapid growth of coarse, dark hair on her upper lip, chin, and lower abdomen. She also reports that her voice has deepened, and she has experienced thinning of the hair on her scalp. She has no significant past medical history and takes no medications. Her body mass index (BMI) is 22 kg/m². Vital signs are within normal limits. Physical examination reveals temporal balding and significant facial hirsutism. Pelvic examination demonstrates a normal-sized, mobile uterus and distinct clitoromegaly. A urine pregnancy test is negative. Which of the following is the most appropriate next step in diagnosis?

A 26-year-old woman presents to the clinic requesting emergency contraception. She reports having condomless vaginal intercourse 115 hours ago. Her last menstrual period began 16 days ago, and she usually has regular 28-day cycles. Her past medical history is significant for Wilson disease, which is well-controlled on oral D-penicillamine. She takes no other medications. She states she would also like to initiate a highly effective, long-acting reversible contraceptive method today to prevent future unintended pregnancies.

Vital signs include a blood pressure of 118/76 mmHg, a heart rate of 78/min, and a respiratory rate of 14/min. Her body mass index (BMI) is $34 \text{ kg/m}^2$. Physical examination reveals a normal thyroid gland, clear lungs, and a soft, non-tender abdomen. Neurologic examination is unremarkable, with no resting tremor or ataxia. A urine pregnancy test obtained in the clinic is negative.

Which of the following is the most appropriate emergency contraceptive method for this patient?

A $28$-year-old G1P0 at $39$ weeks gestation is evaluated in the labor and delivery unit. At $10:00\text{ AM}$, her cervical examination reveals $6\text{ cm}$ dilation, $100\%$ effacement, and the fetal head at $0$ station. Artificial rupture of membranes is performed, yielding clear fluid. Due to a previous period of slow cervical change, an intrauterine pressure catheter (IUPC) is placed and an intravenous oxytocin infusion is started.

By $2:00\text{ PM}$ ($4$ hours later), her cervical examination remains completely unchanged at $6\text{ cm}$ dilation, $100\%$ effacement, and $0$ station. Review of the IUPC tracing over the last hour shows $5$ contractions per $10$ minutes. The contractions have peak pressures of $65\text{ mm Hg}$ and a resting tone of $15\text{ mm Hg}$. The fetal heart rate tracing shows a baseline of $140\text{/min}$, moderate variability, and no decelerations. Which of the following is the most appropriate next step in management?

A $21$-year-old woman is brought to the emergency department with a $3$-day history of progressively worsening lower abdominal pain, high fevers, and multiple episodes of vomiting. She is unable to keep any oral fluids down. Her temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $98/60$ mmHg, and pulse is $112$/min. She is sexually active with a new partner and does not use contraception. Arrange the following steps in the optimal sequence for the evaluation and management of this patient's condition.

A 29-year-old primigravida at 40 weeks gestation is evaluated in the labor and delivery unit during the active phase of labor. Her pregnancy has been uncomplicated. Her cervix is 6 cm dilated, 90% effaced, and the fetal head is at -1 station. Uterine contractions are occurring every 3 to 4 minutes and are of moderate intensity. Thirty minutes after admission, the patient requests and receives continuous epidural anesthesia for pain relief.

Fifteen minutes later, the patient reports feeling lightheaded and nauseated. Her blood pressure is 82/45 mm Hg, and her heart rate is 105/min. The continuous fetal heart rate monitoring previously showed a baseline of 145/min with moderate variability and positive accelerations. The tracing now reveals minimal variability and gradual, symmetric decreases in the fetal heart rate from the baseline to a nadir of 125/min. The onset, nadir, and recovery of the decelerations occur after the beginning, peak, and end of the uterine contractions, respectively. These decelerations occur with more than 50% of contractions.

The nurse immediately turns the patient onto her left side and administers a bolus of intravenous lactated Ringer solution. Ten minutes later, the patient's blood pressure remains 86/48 mm Hg, and the fetal heart rate tracing is unchanged.

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

A 16-year-old phenotypic female is brought to the gynecology clinic by her mother for evaluation of primary amenorrhea. She has never had a menstrual period. On physical examination, her blood pressure is 110/70 mm Hg, heart rate is 76/min, and BMI is 21 kg/m². Breast development is Tanner stage 4, but axillary and pubic hair are Tanner stage 1. Examination of the external genitalia reveals a normal-appearing clitoris and a shortened vaginal vault. Assuming each successive test or intervention directs the next step according to standard guidelines, arrange the following diagnostic and management steps in the correct chronological sequence to appropriately evaluate and treat this patient.

Match each clinical presentation of postpartum hemorrhage to its most likely underlying etiology.

During a busy shift on the labor and delivery unit, a 28-year-old primigravida at 39 weeks gestation is evaluated for labor progression. Her prenatal course was unremarkable. Recent routine laboratory studies showed a hemoglobin level of $10.5 \text{ g/dL}$ and a serum bicarbonate of $20 \text{ mEq/L}$.

She is currently receiving an oxytocin infusion for labor augmentation. Vital signs show a blood pressure of $118/76 \text{ mmHg}$, heart rate of $88/\text{min}$, and a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$). Uterine contractions are occurring every 3 minutes and are strong to palpation.

Review of the continuous fetal monitor reveals a baseline heart rate of $130/\text{min}$ with absent variability. Symmetrical, gradual decreases in the fetal heart rate to a nadir of $100/\text{min}$ are noted, consistently beginning after the peak of each uterine contraction and resolving only after the contraction has ended. There are no spontaneous accelerations.

The nursing staff has already repositioned the patient to the left lateral decubitus position, administered an intravenous normal saline bolus, and discontinued the oxytocin infusion. Reassessment 20 minutes later shows no improvement in the fetal heart rate tracing. Cervical examination demonstrates dilation at $5 \text{ cm}$, $90\%$ effacement, and the fetal vertex at a $-1$ station.

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

A 26-year-old woman presents to the clinic with a 7-month history of absent menstrual periods. She previously had regular 29-day cycles. She is sexually active and uses barrier contraception inconsistently. She denies headaches, visual changes, weight fluctuations, or galactorrhea. Her temperature is 37.0°C (98.6°F), blood pressure is 112/72 mm Hg, pulse is 72/min, and BMI is 23 kg/m². Pelvic examination shows normal female external genitalia and a normal-sized uterus. Assuming each successive test yields normal or negative results, arrange the following diagnostic steps in the most appropriate chronological sequence for evaluating this patient's secondary amenorrhea.

Match each specific gynecologic ovarian neoplasm with its most characteristic serum tumor marker used for clinical diagnosis and disease monitoring.