Obstetrics and Gynecology

A 28-year-old primigravida comes to the office for an initial prenatal visit at 10 weeks gestation. The patient reports feeling well and denies any vaginal discharge, pruritus, dysuria, or pelvic pain. Her medical history is unremarkable, and she takes no medications other than a prenatal vitamin. Vital signs are within normal limits. A pelvic examination is performed, during which a small amount of thin, homogeneous, grayish fluid is noted in the vaginal vault. The cervix appears normal and closed, with no cervical motion tenderness. Point-of-care testing of the vaginal fluid reveals a pH of 5.5, and a prominent amine odor is noted upon the addition of potassium hydroxide. Microscopic evaluation of a wet mount shows numerous squamous epithelial cells with margins completely obscured by small bacteria. Which of the following is the most appropriate next step in management?

Match each patient's clinical presentation with its most likely underlying pathophysiological mechanism.

A 27-year-old woman, gravida 1, para 1, experiences brisk vaginal bleeding immediately following an uncomplicated vaginal delivery of a 4100-g (9-lb) neonate. The placenta delivers intact 5 minutes later. On physical examination, her blood pressure is 100/60 mm Hg and pulse is 110/min. The uterus is soft, boggy, and palpated above the umbilicus. Arrange the following management steps in the correct sequential order from initial first-line intervention to definitive treatment for this patient's complication.

A 39-year-old woman comes to the clinic reporting heavy, continuous vaginal bleeding for the past 18 days. She states that her menstrual cycles have been highly unpredictable since menarche, typically occurring every 3 to 6 months. Over the last two years, she has gained 15 kg (33 lbs). She also notes increased facial hair growth for which she occasionally uses laser hair removal. Her medical history includes type 2 diabetes mellitus, which is managed with metformin. She does not use any contraception. Her temperature is 37.0°C (98.6°F), blood pressure is 132/84 mmHg, pulse is 82/min, and respirations are 14/min. Her BMI is 38 kg/m². Pelvic examination reveals normal external genitalia. The vagina contains dark red blood. The uterus is normal in size, smooth, and mobile. No adnexal masses are palpated. A urine pregnancy test is negative. Which of the following is the most appropriate next step in the management of this patient?

A $27$-year-old G1P0 woman at $39$ weeks gestation is admitted to the labor and delivery unit in active labor. Her pregnancy has been uncomplicated. On admission, she provides a legally documented advance directive explicitly refusing a cesarean delivery under any circumstances, which she verbally confirms with the attending physician while demonstrating full decisional capacity.

Laboratory studies obtained on admission show:
Hemoglobin: $10.6$ g/dL
Platelets: $185,000/\text{mm}^3$
Leukocytes: $11,500/\text{mm}^3$

An epidural catheter is placed for analgesia. Fifteen minutes later, the patient experiences a syncopal episode and is temporarily unresponsive. Her blood pressure is $82/48$ mmHg and her pulse is $98$/min. The uterus is soft between contractions with no apparent vaginal bleeding. The fetal heart rate tracing, which was previously reassuring, now demonstrates a prolonged deceleration to $85$/min that has persisted for $3$ minutes with minimal variability. The cervix is $5$ cm dilated and $100\%$ effaced. Her husband, present at the bedside, is extremely anxious and urges the medical team to 'do whatever it takes to save the baby, including surgery.'

Based on the clinical presentation, which of the following is the most appropriate next step in management?

A 32-year-old G3P3 woman experiences heavy vaginal bleeding 15 minutes after the spontaneous vaginal delivery of a 4200 g (9 lb 4 oz) neonate. The placenta delivered intact. On physical examination, her blood pressure is 100/60 mm Hg and pulse is 110/min. Active bleeding is noted from the vagina, and the uterine fundus is soft, boggy, and palpated above the umbilicus. Two large-bore intravenous lines are established. Arrange the following interventions in the most appropriate sequential order for the management of this patient's condition, proceeding from initial steps to definitive last-resort measures.

A 63-year-old postmenopausal woman presents to the clinic complaining of new-onset vaginal spotting. Arrange the following steps in the standard evidence-based sequence for the evaluation and management of this patient, assuming each diagnostic step yields abnormal results culminating in a diagnosis of early-stage endometrial cancer.

A $62$-year-old obese woman with a history of type $2$ diabetes reports several weeks of vaginal spotting, $10$ years after her natural menopause. A recent transvaginal ultrasound demonstrated an endometrial stripe thickness of $14 \text{ mm}$. Arrange the following interventions in the standard chronological sequence for her evaluation and definitive management, assuming each step confirms an early-stage endometrial malignancy.

A 24-year-old primigravid patient at 40 weeks gestation is evaluated on the labor and delivery unit. She has been in the second stage of labor and actively pushing for the past 2 hours under continuous epidural analgesia. Until recently, the fetal heart rate tracing demonstrated a baseline of 140/min, moderate variability, and positive accelerations without decelerations. However, 4 minutes ago, the fetal heart rate suddenly decreased to 80/min and has remained at this rate. Uterine contractions are occurring every 3 minutes and lasting 45 seconds. Maternal repositioning to the left lateral decubitus position, administration of a rapid intravenous fluid bolus, and discontinuation of oxytocin were immediately performed, but the fetal heart rate remains at 80/min. Cervical examination reveals complete dilation and 100% effacement. The fetus is in a vertex presentation, the position is direct occiput anterior, and the station is +3. The estimated fetal weight is 3,300 g. Which of the following is the most appropriate next step in management?

A 26-year-old woman, gravida 1 para 0, at 39 weeks gestation is in the second stage of labor. She has been pushing for 2 hours and has functioning epidural anesthesia. Her temperature is 37.1°C (98.8°F), blood pressure is 112/72 mm Hg, and pulse is 88/min. Uterine contractions are occurring every 3 minutes and palpate strong. The fetal heart rate baseline was previously 135/min with moderate variability and no decelerations. Seven minutes ago, the fetal heart rate abruptly decreased to 75/min. Maternal repositioning to the left lateral decubitus position, administration of an intravenous fluid bolus, and initiation of supplemental oxygen were performed immediately, but the fetal heart rate remains at 75/min. Cervical examination shows complete dilation and 100% effacement. The fetal head is in the direct occiput anterior position at +3 station. Which of the following is the most appropriate next step in management?

Match each clinical presentation of a gynecologic infection with the most likely etiologic pathogen and its appropriate first-line pharmacotherapy.

A 24-year-old woman comes to the clinic reporting three days of intense vaginal itching and a thick, white vaginal discharge. She denies abdominal pain, fever, or dysuria. Two weeks ago, she completed a 10-day course of amoxicillin-clavulanate for acute bacterial sinusitis. She is sexually active with one male partner and uses oral contraceptives. Vital signs are within normal limits. Pelvic examination reveals significant vulvar erythema and edema, along with thick, cottage cheese-like adherent vaginal discharge. The cervix appears normal with no motion tenderness. Vaginal pH is 4.0. Microscopic evaluation of the vaginal fluid with 10% potassium hydroxide (KOH) preparation reveals budding yeast and pseudohyphae. Which of the following is the most appropriate next step in management?

A 28-year-old primigravida at 39 weeks gestation is undergoing an induction of labor for gestational hypertension. She currently receives a continuous intravenous infusion of oxytocin. The patient's blood pressure is 134/82 mm Hg, and her pulse is 88/min. She has continuous epidural analgesia. Over the past 30 minutes, the tocodynamometer records 6 to 7 uterine contractions in every 10-minute window. The fetal heart rate baseline is 135/min with minimal variability and recurrent late decelerations. The nursing staff promptly stops the oxytocin infusion, repositions the patient to the left lateral decubitus position, and provides an intravenous fluid bolus. Ten minutes later, the frequency of contractions remains unchanged, and the late decelerations persist on the monitor. Which of the following is the most appropriate next step in management for this patient?

A 29-year-old primigravida at 32 weeks gestation is admitted to the labor and delivery unit for the management of preeclampsia with severe features. Her admission blood pressure was $172/112$ mmHg. She was immediately started on an intravenous magnesium sulfate infusion for seizure prophylaxis and received a dose of intravenous hydralazine. Three hours later, she complains of sudden-onset, severe shortness of breath and a cough producing pink, frothy sputum. Her temperature is $37.0^{\circ}\text{C}$ ($98.6^{\circ}\text{F}$), blood pressure is $165/105$ mmHg, pulse is $122$/min, and respirations are $28$/min. Pulse oximetry shows $87\%$ on room air. Physical examination reveals bibasilar crackles extending to the mid-lung fields. Deep tendon reflexes are 2+ bilaterally. The fetal heart rate tracing shows a baseline of $140$/min with moderate variability and no decelerations. Which of the following is the most appropriate next step in the management of this patient's acute respiratory symptoms?

Match each postpartum clinical vignette with the most appropriate next step in management.

Match each clinical presentation of a patient with a gynecologic infection to the most appropriate next best step in management.

A 24-year-old nulligravid woman presents to the office reporting that she has not had a menstrual period for the past 8 months. Menarche occurred at age 13, and her menses were previously regular, occurring every 28 to 30 days and lasting 5 days. She reports no headaches, visual changes, nipple discharge, heat intolerance, or weight changes. She is not taking any medications and does not use illicit substances. Vital signs are within normal limits. Her BMI is 22 kg/m $^2$. Physical examination reveals a normal thyroid gland, normal breast development without galactorrhea, and a normal pelvic examination with no clitoromegaly or virilization.

Arrange the following diagnostic steps in the most appropriate sequential order for evaluating this patient's secondary amenorrhea, from the absolute first step to subsequent evaluations.

A 24-year-old woman, gravida 1 para 0, at 28 weeks gestation is evaluated in the labor and delivery triage for a sudden gush of clear vaginal fluid 18 hours ago, followed by the onset of lower abdominal pain and chills over the past 4 hours. Her prenatal course has been uncomplicated. Her temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $112/72\text{ mmHg}$, pulse is $118/\text{min}$, and respiratory rate is $18/\text{min}$. Physical examination reveals a uterus that is diffusely tender to palpation. Speculum examination shows pooling of purulent fluid in the posterior vaginal fornix; the fluid turns nitrazine paper blue. Cervical examination reveals 1 cm dilation, 20% effacement, and -3 station. Fetal heart rate monitoring shows a baseline of $175/\text{min}$ with moderate variability and no decelerations. Tocodynamometry shows irregular uterine contractions every 8 to 10 minutes. Which of the following is the most appropriate next step in management for this patient?

Match each patient's clinical profile with the most appropriate contraceptive method based on the WHO Medical Eligibility Criteria and non-contraceptive benefits.

A 24-year-old G1P0 woman at 39 weeks gestation is admitted to the labor and delivery unit in active labor. Six hours after admission, her cervix is 8 cm dilated and 100% effaced, with the fetal vertex at 0 station. Spontaneous rupture of membranes occurred 4 hours ago, yielding clear fluid. Uterine contractions are occurring every 3 to 4 minutes and are of adequate intensity. The continuous fetal heart rate monitor demonstrates a baseline of 145/min and moderate variability. However, abrupt decreases in the fetal heart rate to 80/min are noted with nearly every contraction. The onset to nadir of these decelerations takes approximately 15 seconds, and they last for 30 to 45 seconds before rapidly returning to baseline. Maternal repositioning to the left lateral decubitus position and administration of an intravenous fluid bolus are performed, but the decelerations persist. Maternal vital signs remain within normal limits. Which of the following is the most appropriate next step in management?