Obstetrics and Gynecology

Match each gynecologic or gestational neoplasm with its characteristic clinical tumor marker and classic histologic or clinical finding.

A patient in her second pregnancy, having had one previous uncomplicated term birth, presents to the labor and delivery unit at 38 weeks and 4 days of gestation. She is experiencing regular, painful uterine contractions. Her vital signs are within normal limits. Cervical examination reveals 7 cm of dilation and 100% effacement with the fetal vertex at 0 station. External electronic fetal monitoring displays a baseline heart rate of 140/min with moderate variability. Over the next 20 minutes, the tracing shows recurrent, abrupt drops in the fetal heart rate to 90/min, each lasting approximately 40 seconds before returning rapidly to baseline. These drops vary in their timing relative to the peaks of the uterine contractions. What is the most appropriate next step in management for this patient?

An otherwise healthy 27-year-old nulliparous woman arrives at the emergency department with severe, worsening lower abdominal pain and subjective fevers over the past three days. She also reports a foul-smelling vaginal discharge. Her temperature is 39.2°C (102.6°F), blood pressure is 108/68 mmHg, and pulse is 114/min. On physical examination, she exhibits marked cervical motion tenderness and guarding in the bilateral lower quadrants. Bimanual examination reveals a severely tender, fluctuant 6-cm mass in the left adnexa. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for the standard evaluation and step-wise management of this patient, from initial triage to intervention for potential medical failure.

A 28-year-old multiparous patient experiences severe hemorrhage and hypovolemic shock immediately following the vaginal delivery of a $4,100\text{ g}$ neonate. During the third stage of labor, aggressive umbilical cord traction was applied before complete placental separation. Physical examination reveals a firm, round, red mass protruding through the vaginal introitus, and the uterine fundus is no longer palpable in the lower abdomen. Profuse vaginal bleeding is ongoing.

Arrange the following management steps for this obstetric emergency in the correct chronological sequence.

A 67-year-old G1P1 is evaluated for a two-week history of mild pelvic cramping and scant, brownish vaginal discharge. Her last menstrual period was 15 years ago. Her medical history includes severe osteoporosis, for which she takes raloxifene, and hypothyroidism, for which she takes levothyroxine. Her BMI is 22 kg/m². On speculum examination, the vaginal mucosa appears pale and thin, with a small amount of old blood in the vaginal vault and at the cervical os. Bimanual examination reveals a small, anteverted uterus and no adnexal masses. Transvaginal ultrasonography demonstrates a homogeneously thickened endometrium measuring 6 mm. Which of the following is the most appropriate next step in management?

A 28-year-old woman presents to the clinic for a routine well-woman examination. She had a levonorgestrel-releasing intrauterine device (IUD) placed two years ago and reports being highly satisfied with the method. During the speculum examination, the physician is unable to visualize the IUD strings at the external cervical os. The patient is completely asymptomatic, reporting no abdominal pain, fever, or unexpected vaginal bleeding. Arrange the following diagnostic and management steps in the most appropriate chronological sequence to address the missing IUD strings.

A 24-year-old primigravid woman at 39 weeks gestation is in the second stage of labor. The fetus is in a vertex, occiput anterior presentation. As the fetal head navigates through the maternal bony pelvis, it undergoes a series of predictable, adaptive positional changes. Arrange the following cardinal movements of labor in the correct chronological order as they typically occur.

A 29-year-old nulliparous woman at 39 weeks gestation is evaluated in the labor and delivery unit due to a concerning fetal heart rate tracing. Her pregnancy has been uncomplicated. She was admitted in active labor and her cervix is currently 7 cm dilated and 100% effaced, with the fetal presenting part at +1 station. Uterine contractions are occurring every 2 to 3 minutes, each lasting approximately 60 seconds. Spontaneous rupture of membranes occurred 2 hours ago, revealing clear fluid. The continuous electronic fetal monitor demonstrates a baseline heart rate of 135/min with moderate variability. With each of the last four contractions, there is an abrupt decrease in the fetal heart rate to 85/min that reaches its nadir in 15 seconds and resolves quickly as the contraction subsides. The decelerations last approximately 45 seconds each. The patient is promptly repositioned to the left lateral decubitus position and administered an intravenous fluid bolus. However, the subsequent three contractions demonstrate the exact same fetal heart rate pattern. Maternal blood pressure is 118/76 mm Hg and pulse is 88/min. Which of the following is the most appropriate next step in management?

A $33$-year-old woman, G3P2, at $36$ weeks gestation is brought to the emergency department after a high-speed motor vehicle collision. She complains of severe, constant abdominal pain. She is fully conscious but extremely anxious and reiterates her religious objection to receiving any blood products, providing a signed advance directive that explicitly refuses transfusions under all circumstances. Her blood pressure is $82/50$ mm Hg, heart rate is $128$/min, and respiratory rate is $22$/min. Abdominal examination reveals a rigid, exquisitely tender uterus, and fetal parts are easily palpable just beneath the maternal abdominal wall. A focused assessment with sonography for trauma (FAST) exam shows a large amount of free fluid in the hepatorenal recess. Arterial blood gas on room air shows a pH of $7.44$, pCO $_2$ of $29$ mm Hg, pO $_2$ of $98$ mm Hg, and HCO $_3^-$ of $20$ mEq/L. Hemoglobin is $10.4$ g/dL. Fetal heart tracing shows a baseline of $170$/min, absent variability, and recurrent late decelerations. Which of the following is the most appropriate next step in management?

A 10-year-old girl is brought to the clinic by her mother for a routine well-child visit. The mother asks about what to expect regarding her daughter's physical development over the next few years. The physician explains the typical progression of female puberty. Arrange the following physiological milestones of normal female puberty in their typical chronological sequence of occurrence, from earliest to latest.

A 26-year-old pregnant woman, currently at 35 weeks of gestation, arrives at the emergency department via ambulance after being the restrained driver in a high-speed motor vehicle collision. She complains of severe, unremitting abdominal pain and reports a sudden onset of dark vaginal bleeding. Her past medical history is unremarkable. Her blood pressure is $82/50 \text{ mmHg}$, heart rate is $132/\text{min}$, and respiratory rate is $24/\text{min}$. Physical examination reveals a rigid, diffusely tender, and "woody" uterus. Initial laboratory studies show a hemoglobin level of $8.5 \text{ g/dL}$. Continuous electronic fetal monitoring demonstrates a baseline heart rate of $95/\text{min}$ with absent variability and recurrent late decelerations. Which of the following is the most appropriate next step in the management of this patient?

A $61$-year-old female presents to the physician with a chief complaint of vaginal spotting that began $2$ days ago. She experienced menopause at age $51$. Her medical history includes hypertension, obesity, and type 2 diabetes mellitus. A speculum examination demonstrates a normal-appearing vagina and cervix, with a small amount of blood exiting the external cervical os. Pelvic sonography is performed and reveals an endometrial stripe thickness of $9 \text{ mm}$. Which of the following is the most appropriate next step in management?

A 36-year-old woman comes to the clinic for evaluation of severe vulvar itching and vaginal burning that began 5 days ago. Over the past year, she has had four similar episodes. Each prior episode was treated with a single dose of oral fluconazole, which provided only transient partial relief before her symptoms recurred. Her medical history includes type 2 diabetes mellitus. Current medications include metformin and sitagliptin, though she admits to frequently missing doses. Her most recent hemoglobin A1c is 9.4%. Vital signs are temperature 37.0°C (98.6°F), blood pressure 122/78 mmHg, heart rate 78/min, and respiratory rate 14/min. Pelvic examination demonstrates pronounced vulvar erythema and edema with visible excoriations. A moderate amount of thick, white, adherent discharge is present in the vaginal vault. The cervix is visually normal with no bleeding or discharge from the external os, and bimanual examination is unremarkable with no cervical motion tenderness. Vaginal pH is 4.3. Wet mount microscopy with 10% potassium hydroxide preparation reveals numerous small budding yeast cells but is notably negative for pseudohyphae. Which of the following is the most appropriate next step in management for this patient?

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

A 28-year-old nulligravid woman presents to the clinic with a 4-month history of rapidly worsening facial hair growth, deepening of her voice, and male-pattern baldness. She has not had a menstrual period for the past 5 months. Previously, her menses were regular, occurring every 28 days. Her body mass index is 23 kg/m2. Vital signs are within normal limits. Pelvic examination reveals clitoromegaly and a normal-sized, non-tender uterus. Which of the following is the most appropriate next step in the management of this patient?

Match each patient's clinical presentation, laboratory findings, and histologic description with the most likely corresponding ovarian neoplasm.

Match each clinical presentation of third-trimester obstetric complications with its most likely diagnosis.

A 61-year-old woman, gravida 3, para 3, presents to the gynecology clinic reporting a three-day history of light vaginal spotting. Her last menstrual period occurred 10 years ago, and she denies any postmenopausal bleeding prior to this episode. Her medical history is significant for type 2 diabetes mellitus, chronic hypertension, and obesity (BMI 38 kg/m^2). Current medications include metformin, lisinopril, and a daily multivitamin. Vital signs are within normal limits. Pelvic examination demonstrates pale, thinned vaginal mucosa with decreased rugosity. A small amount of dark blood is visible at the external cervical os. Bimanual examination reveals a normal-sized, mobile uterus without adnexal masses. A transvaginal ultrasound reveals an endometrial echo complex measuring 9 mm in thickness. Which of the following is the most appropriate next step in the management of this patient?

A 31-year-old nulliparous patient at 41 weeks gestation is admitted to the labor and delivery unit for induction of labor due to postterm pregnancy. She is currently receiving an intravenous oxytocin infusion. Her temperature is 37.0°C (98.6°F), blood pressure is 122/78 mmHg, and pulse is 88/min. Cervical examination reveals 5 cm dilation, 80% effacement, and -1 station. The external fetal monitor displays a baseline heart rate of 135/min with moderate variability. Over the past 40 minutes, the tracing reveals recurrent, gradual decreases in the fetal heart rate that begin consistently after the peak of each uterine contraction and do not return to baseline until the contraction has ended. Which of the following is the most appropriate next step in management?

Seeking evaluation for bilateral pelvic discomfort, a female patient in her early thirties is seen at an ambulatory care clinic. The pain has steadily worsened over the past three days and is associated with a thick, yellow vaginal discharge. She has no significant past medical history and takes no daily medications other than a combined oral contraceptive pill. Her vital signs include a blood pressure of $118/76$ mmHg, a heart rate of $88$/min, and a temperature of $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$). Abdominal examination reveals mild lower quadrant tenderness without guarding or rebound. Pelvic examination demonstrates mucopurulent discharge at the cervical os. Bimanual examination elicits significant pain upon manipulation of the cervix as well as bilateral adnexal tenderness. A point-of-care urine pregnancy test is negative. She is able to tolerate oral fluids in the clinic without nausea. Which of the following is the most appropriate next step in the pharmacologic management of this patient?