Obstetrics and Gynecology

A 34-year-old G3P2 at 40 weeks gestation is in the second stage of labor. The fetal head delivers but then tightly retracts against the maternal perineum (turtle sign). Routine gentle downward traction fails to deliver the anterior shoulder. The obstetrician immediately calls for nursing and neonatal assistance and instructs the patient to stop pushing. Arrange the following subsequent management steps in the correct sequential order, starting with the most appropriate initial maneuver and ending with the maneuver of last resort.

A 29-year-old woman presents to the outpatient clinic to discuss contraception and to be evaluated for absent menstrual periods. Her last menstrual period was 8 months ago. Previously, her cycles were regular, occurring every 28 days. She reports feeling excessively tired, frequently cold, and having gained 6 kg (13 lb) over the past year despite active exercise. She also notes occasional clear fluid expression from her breasts.

Her medical history is notable for migraine headaches accompanied by visual scintillating scotomas, for which she takes sumatriptan as needed. She does not smoke or use illicit drugs.

Vital signs are:
Blood pressure: 105/65 mm Hg
Pulse: 56/min
Respirations: 14/min
Temperature: 36.1 °C (97.0 °F)
BMI: 27 kg/m2

Physical examination reveals a delayed relaxation phase of the deep tendon reflexes. Breast examination confirms bilateral non-bloody galactorrhea. The pelvic examination is normal.

Urine beta-hCG test is negative.

Serum laboratory studies show:
Thyroid-stimulating hormone (TSH): 1.2 mIU/L (Normal: 0.5–5.0 mIU/L)
Free thyroxine (T4): 0.5 ng/dL (Normal: 0.9–1.7 ng/dL)
Prolactin: 65 ng/mL (Normal: < 20 ng/mL)
Follicle-stimulating hormone (FSH): 3.2 mIU/mL (Normal follicular: 3–10 mIU/mL)

The patient requests a prescription for combined oral contraceptive pills to regulate her cycle and prevent pregnancy. Which of the following is the most appropriate next step in management?

A 64-year-old woman with a body mass index of 37 kg/m² and a history of type 2 diabetes mellitus presents for evaluation of new-onset vaginal spotting. She underwent natural menopause twelve years ago. Arrange the following clinical actions and events in the correct chronological sequence for the standard diagnostic and therapeutic management of her condition.

An outpatient gynecology clinic is evaluating several women for contraceptive counseling. Match each patient's clinical profile with the most appropriate primary contraceptive method according to the United States Medical Eligibility Criteria (US MEC) for Contraceptive Use.

A female in her late sixties seeks medical advice for a bothersome urinary symptom. She describes a sudden, intense need to urinate that she cannot suppress, frequently leading to urine loss before she can reach a toilet. She has no history of neurological disorders, and a urinalysis is negative for infection. The patient is inquiring about the long-term treatment strategy for her condition. Arrange the following therapeutic interventions in the standard, evidence-based sequence of escalation for this patient's diagnosis, progressing from initial management to therapies reserved for refractory cases.

A 32-year-old woman comes to the clinic seeking highly effective contraception. She recently started a new relationship and does not wish to conceive. The patient also reports a 7-month history of secondary amenorrhea, accompanied by severe fatigue, a 5-kg (11-lb) weight gain, and bilateral milky breast discharge. Her medical history is notable for a deep vein thrombosis 4 years ago following an orthopedic surgery, as well as migraines with visual aura. She currently smokes 10 cigarettes daily. A urine pregnancy test is negative.

Vital signs include a heart rate of 54/min and a blood pressure of 118/76 mm Hg. Her BMI is 24 kg/m². Physical examination shows a delayed relaxation phase of the deep tendon reflexes.

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

A 64-year-old woman, G3P3, presents to the outpatient clinic reporting a 2-week history of intense vulvovaginal itching, burning, and a malodorous, yellow-green vaginal discharge. During this time, she has also noticed intermittent, light vaginal bleeding. Her last menstrual period was 12 years ago. She recently became sexually active with a new male partner. Her past medical history includes hypertension and type 2 diabetes mellitus. Vital signs are within normal limits. Pelvic examination reveals a pale, thin vaginal mucosa with a loss of rugae. There is a copious, frothy, yellow-green discharge in the vaginal vault, and the cervix demonstrates punctate macular hemorrhages. A wet mount preparation of the discharge reveals abundant motile, flagellated, pear-shaped organisms and numerous polymorphonuclear leukocytes. Which of the following is the most appropriate next step in the management of this patient?

A 56-year-old woman, G2P2, comes to the office to discuss the results of her recent cervical cancer screening. She reached menopause 5 years ago and reports no vaginal bleeding, discharge, or pelvic pain. Her medical history includes hypertension and type 2 diabetes mellitus. Her body mass index is $36 \text{ kg/m}^2$. Her cervical cytology (Pap test) results show atypical glandular cells (AGC), and human papillomavirus (HPV) testing is positive. A transvaginal ultrasound performed today shows a thin, homogeneous endometrial stripe measuring $3 \text{ mm}$ and normal adnexa. Which of the following is the most appropriate next step in management?

A 28-year-old primiparous woman experiences significant vaginal bleeding immediately following the vaginal delivery of a 4100-g neonate. The delivery was complicated by a prolonged second stage, and aggressive umbilical cord traction was applied before complete placental separation. On physical examination, a firm, beefy-red mass is visualized protruding through the vaginal introitus, and the uterine fundus is no longer palpable transabdominally. The patient's blood pressure is 78/40 mmHg and her heart rate is 132/min. Intravenous fluid resuscitation and massive transfusion protocols are initiated.

Assuming each conservative measure fails to achieve resolution, arrange the following interventions in the correct chronological sequence for the optimal management of this patient's condition.

A 28-year-old G2P2 woman at 39 weeks gestation undergoes an uncomplicated spontaneous vaginal delivery of a healthy neonate. During the immediate postpartum period, her vital signs are blood pressure 110/70 mm Hg, heart rate 85/min, and temperature 37.1 C (98.8 F). Match the following potential clinical presentations during the third and fourth stages of labor to their most likely underlying etiology.

Seeking evaluation for increasingly erratic menstrual cycles, a 37-year-old nulligravid woman presents for a consultation. Over the last 14 months, her menses have occurred at unpredictable intervals of 45 to 70 days, accompanied by heavy flow lasting up to two weeks. During this time, she has also noticed new, coarse hair growth on her chin and chest. Her medical history is notable for asthma, obesity, and episodes of visual scotomata that precede severe, throbbing unilateral headaches. She currently takes no medications. She desires a reliable method of contraception as she anticipates becoming sexually active soon. Vital signs include a blood pressure of $138/88$ mmHg and a body mass index (BMI) of $37$ kg/m $^2$. A point-of-care urine pregnancy test is negative. Pelvic examination is limited by body habitus but reveals normal external genitalia and no palpable adnexal masses. Laboratory evaluation shows a normal serum thyroid-stimulating hormone (TSH) level and a normal serum prolactin concentration. Which of the following is the most appropriate next step in management?

Following a prolonged second stage of labor, a multiparous patient at term delivers a 4300g (9 lb 8 oz) neonate vaginally. The placenta delivers spontaneously and intact ten minutes later. Within minutes, the patient experiences heavy vaginal bleeding with large clots. Her blood pressure drops to 90/55 mmHg, and her heart rate rises to 118/min. Abdominal palpation reveals a soft, boggy uterus located above the umbilicus. Arrange the following interventions in the correct sequential management algorithm for this obstetric emergency, progressing from the most appropriate initial step to definitive last-resort therapy.

An 19-year-old female college student visits the student health clinic reporting a three-day history of a persistent, unpleasant vaginal odor and a newly developed thin discharge. She recently became sexually active with a new male partner and uses oral contraceptives consistently. Her temperature is 37.1°C (98.8°F), blood pressure is 110/70 mm Hg, and pulse is 76/min. Abdominal examination reveals no tenderness or guarding. Pelvic examination demonstrates a thin, homogeneous, grayish-white discharge pooling in the posterior fornix without underlying vulvovaginal erythema. The cervix is visually unremarkable, and bimanual examination elicits no cervical motion or adnexal tenderness. The vaginal pH is measured at 5.5. Microscopic evaluation of the vaginal fluid mixed with normal saline demonstrates squamous epithelial cells with blurred, stippled borders. Which of the following is the most appropriate next step in the management of this patient?

A $39$-year-old nulligravid woman presents to the clinic complaining of highly unpredictable and heavy menstrual bleeding for the past $8$ months. She states that her menstrual cycles vary from $20$ to $65$ days in length, with bleeding often lasting up to $14$ days and requiring her to use double protection with both a tampon and a thick pad. She has a medical history significant for type $2$ diabetes mellitus and hypertension. Current medications include metformin and lisinopril. Her body mass index is $38 \text{ kg/m}^2$. Blood pressure is $138/86 \text{ mmHg}$. A urine pregnancy test obtained in the clinic is negative. Pelvic examination reveals normal external genitalia, a visually normal cervix, and a normal-sized, non-tender, mobile uterus. Which of the following is the most appropriate next step in the management of this patient?

A 22-year-old woman presents to the emergency department with a 2-day history of worsening lower abdominal pain, nausea, and fever. Her temperature is 38.6°C (101.5°F). She is sexually active with a new partner and does not use barrier contraception. Arrange the following steps in the most appropriate clinical sequence for her diagnostic workup and management, culminating in the treatment of complicated pelvic inflammatory disease.

A 72-year-old woman with severe chronic obstructive pulmonary disease presents with progressive abdominal distension, early satiety, and dyspnea. CT imaging of the chest, abdomen, and pelvis demonstrates an 8-cm complex right adnexal mass, extensive omental caking, massive ascites, and a large right-sided pleural effusion. A multidisciplinary tumor board determines she is an unacceptably high-risk candidate for upfront primary cytoreductive surgery due to her severe pulmonary comorbidities and the massive extent of her disease. Arrange the following steps in the standard evidence-based sequence for the evaluation and management of this patient.

A 38-year-old woman comes to the clinic to discuss long-term contraceptive options. She recently started a new relationship and does not desire pregnancy. Her medical history is significant for a deep vein thrombosis (DVT) in her right leg 3 years ago after a long-haul flight, for which she completed a 6-month course of oral anticoagulation. She currently takes no medications. She has a 15-pack-year smoking history and continues to smoke one pack of cigarettes daily. Her blood pressure is 122/78 mm Hg, heart rate is 76/min, and body mass index is 27 kg/m². Physical examination reveals normal findings with no leg swelling or tenderness. A urine human chorionic gonadotropin test is negative. She requests a highly effective contraceptive method. Which of the following is the most appropriate contraceptive option for this patient?

Match each clinical presentation involving a potential gynecologic oncologic condition with the most appropriate next step in management.

A 28-year-old primigravida at 10 weeks of gestation is evaluated during her first prenatal visit. She feels well and reports no vaginal discharge, pelvic pain, or dysuria. Her past medical history is unremarkable, and she takes a daily prenatal vitamin. Vital signs are within normal limits. A pelvic examination demonstrates a normal-appearing cervix with no evidence of inflammation or abnormal discharge. Routine prenatal laboratory screening is performed. The nucleic acid amplification test (NAAT) from a vaginal swab is positive for *Chlamydia trachomatis* and negative for *Neisseria gonorrhoeae*. Which of the following is the most appropriate next step in the management of this patient?

A 24-year-old nulligravid woman presents to the emergency department reporting three days of sharp, right-sided abdominal pain that intensifies when she takes a deep breath. She also describes a mild, dull, bilateral lower pelvic ache for the past week and new-onset vaginal spotting between her menses. Her temperature is 38.4°C (101.1°F), blood pressure is 118/76 mm Hg, and pulse is 98/min. Physical examination reveals tenderness to deep palpation in the right upper quadrant, but no rebound tenderness or guarding. Bowel sounds are normoactive. Laboratory studies show a leukocyte count of 14,000/mm³. Serum aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase levels are within normal limits. Right upper quadrant ultrasonography reveals a normal-appearing gallbladder without gallstones, normal biliary ducts, and a trace amount of perihepatic free fluid. Which of the following is the most appropriate next step in the evaluation of this patient?