Obstetrics and Gynecology

A 31-year-old woman comes to the office for evaluation of infertility. She and her husband have been trying to conceive for 12 months without success. Previously, her menstrual cycles occurred regularly every 28 days, but for the past 8 months, they have been irregular, occurring every 45 to 60 days. She also notes progressive fatigue, generalized muscle aches, and a 4.5-kg (10-lb) weight gain during this time. Vital signs are within normal limits. Physical examination reveals dry skin and delayed relaxation of the deep tendon reflexes. A urine pregnancy test is negative. Which of the following mechanisms best explains this patient's difficulty conceiving?

Match each clinical presentation of third-trimester bleeding or acute obstetric pain to the most likely diagnosis.

An 18-year-old nulligravid female is brought to the emergency department by her roommate due to excruciating lower abdominal pain that began yesterday. She has been unable to eat or drink due to severe nausea and three episodes of bilious emesis. Her last menstrual period was 6 weeks ago, which she states is 'normal for her irregular cycles.' Her temperature is 39.2°C (102.6°F), blood pressure is 105/68 mm Hg, and pulse is 112/min. Abdominal examination demonstrates marked guarding and rebound tenderness in both lower quadrants. A speculum examination reveals abundant yellow cervical exudate and mucosal friability. Bimanual examination elicits exquisite cervical motion tenderness and reveals a palpable, exquisitely tender, fluctuant 6-cm fullness in the left adnexa.

Arrange the following clinical interventions in the most appropriate chronological sequence for the diagnostic workup and management of this patient.

Following a prolonged induction of labor for severe preeclampsia, a patient at $39$ weeks gestation experiences a spontaneous vaginal delivery of a $4100$ g infant. She is $31$ years old and this is her first pregnancy. Ten minutes after the placenta is delivered, she develops brisk, steady vaginal hemorrhage. Her blood pressure is $155/100$ mm Hg, and her pulse is $112$/min. On physical examination, the uterine fundus is soft, boggy, and palpated at the level of the umbilicus. A continuous intravenous oxytocin infusion and bimanual uterine massage are immediately initiated, but the excessive bleeding persists. Two large-bore intravenous lines are secured, and aggressive fluid resuscitation is underway.

Arrange the following interventions in the most appropriate sequential order for the continued management of this patient's hemorrhage, proceeding from the most immediate next step to the final definitive measure.

A comprehensive infertility evaluation requires selecting targeted diagnostic investigations based on the patient's specific clinical history and physical examination findings. Match each suspected etiology of female infertility with its most appropriate initial diagnostic investigation or biomarker.

Molecular pathogenesis and unique histologic features dictate the behavior and origins of various gynecologic malignancies. Match each specific gynecologic neoplasm below to its characteristic molecular derangement, pathognomonic histologic finding, or primary clinical driver.

A 24-year-old woman, gravida 2, para 1, at 40 weeks gestation is admitted to the labor and delivery unit for an elective induction of labor. A continuous intravenous oxytocin infusion was started 12 hours ago. Her pain is well controlled with a functioning epidural catheter. A cervical examination reveals that she is 6 cm dilated, 90% effaced, and at -1 station. The fetal heart rate monitor demonstrates a baseline of 150/min, minimal variability, and symmetric, gradual decreases in the fetal heart rate that begin after the peak of the contractions and return to baseline after the contractions end. The tocodynamometer reveals 7 contractions every 10 minutes averaged over the last 30 minutes. The nursing staff immediately positions the patient in the left lateral decubitus position, administers a 500-mL intravenous fluid bolus of lactated Ringer solution, applies supplemental oxygen, and completely discontinues the oxytocin infusion. Reassessment 15 minutes later reveals that the contraction pattern remains at 7 contractions per 10 minutes, and the fetal heart rate tracing is unchanged. Which of the following is the most appropriate next step in management?

Match each classic clinical presentation and diagnostic finding with the most likely gynecologic infection.

A 65-year-old G3P3 woman presents to the clinic with a 2-month history of progressive abdominal bloating, early satiety, and vague pelvic fullness. Physical examination reveals a firm, irregular, fixed mass in the right adnexa and shifting dullness on abdominal percussion. Arrange the following steps in the most appropriate sequential order for the standard diagnostic evaluation and definitive management of this patient's condition.

A 29-year-old primiparous woman at $40$ weeks gestation undergoes a spontaneous vaginal delivery. The infant weighs $4100$ g. Active management of the third stage of labor is performed using controlled cord traction. Shortly after the placenta delivers, a firm, smooth, red mass is observed protruding from the vaginal introitus, accompanied by profuse hemorrhage. The patient becomes lethargic, and her blood pressure drops to $70/40$ mm Hg with a heart rate of $135$/min. Arrange the following steps in the correct chronological order for the optimal management of this complication.

A 31-year-old woman, gravida 3, para 2, at 35 weeks and 2 days of gestation presents to the obstetrical triage unit reporting a sudden gush of clear vaginal fluid that occurred 30 minutes ago. Shortly after her arrival, she experiences another gush of fluid, this time mixed with a moderate amount of bright red blood. The patient reports no uterine contractions or abdominal pain. Her temperature is 37.1°C (98.8°F), blood pressure is 112/72 mm Hg, and pulse is 88/min. Physical examination reveals a soft, non-tender uterus. A prenatal ultrasound at 20 weeks revealed an anterior placenta with a succenturiate lobe in the lower uterine segment. Continuous electronic fetal monitoring shows a baseline heart rate of 140/min that rapidly deteriorates into a smooth, undulating pattern with a frequency of 3 to 5 cycles per minute and absent variability. Which of the following is the most appropriate next step in the management of this patient?

An overweight 71-year-old female is brought to the clinic by her daughter for a routine wellness check. During the system review, the patient casually mentions noticing pink-tinged spots on her undergarments on three separate occasions over the prior month. She underwent natural menopause two decades ago and takes no hormone replacement therapy. Her medical history includes well-controlled hypertension and type 2 diabetes mellitus. Arrange the following interventions in the strictly correct chronological sequence for the definitive workup and comprehensive management of this patient's most likely diagnosis.

A pregnant patient, currently at 10 weeks of gestation, presents to her obstetrician complaining of worsening vaginal discomfort over the past five days. She describes persistent vulvovaginal pruritus and a copious, foul-smelling, yellow-green discharge. She has no abdominal pain, fever, or chills. On pelvic examination, the vulva is edematous and erythematous. The cervix exhibits patchy macular erythema. The vaginal pH is 6.2. Wet mount preparation of the discharge reveals abundant polymorphonuclear leukocytes and motile, flagellated protozoa. Which of the following is the most appropriate next step in management?

A 30-year-old gravid 2, para 1 at 40 weeks gestation is admitted to the labor and delivery unit for induction of labor due to diet-controlled gestational diabetes mellitus. Her cervix is 5 cm dilated, 90% effaced, and the fetal head is at -1 station. Over the last 30 minutes, the electronic fetal monitor has recorded an average of 7 uterine contractions per 10-minute window. The fetal heart rate baseline is 145/min with minimal variability, featuring recurrent decelerations that begin after the peak of each contraction and reach their nadir following the contraction's conclusion.

Recognizing the abnormal tracing, the clinical team immediately terminates the oxytocin infusion, repositions the patient into the left lateral decubitus position, and administers an intravenous isotonic fluid bolus. Fifteen minutes later, the physician reevaluates the patient. The uterine contraction frequency remains unchanged at 7 per 10-minute window, and the fetal heart rate continues to exhibit the same deceleration pattern. The patient's blood pressure is 118/76 mm Hg, and her pulse is 92/min. Which of the following is the most appropriate next step in management?

A $26$-year-old woman comes to the office due to a $7$-month history of absent menses. Her menarche was at age $12$, and her menses were previously regular, occurring every $28$ days. She reports feeling excessively tired over the last few months, along with new-onset constipation and an unintended $4.5$-kg ($10$-lb) weight gain. She has no headaches, visual changes, or nipple discharge. Vital signs show a blood pressure of $110/70$ mm Hg, a pulse of $56$/min, and a body mass index (BMI) of $25$ kg/m $^2$. Physical examination reveals normal secondary sexual characteristics, delayed relaxation of deep tendon reflexes, and no hirsutism or acne. A urine pregnancy test is negative. Which of the following is the most appropriate next step in the evaluation of this patient?

A 27-year-old G1P1 experiences a sudden gush of vaginal bleeding and severe lower abdominal pain immediately following the delivery of the placenta. The patient is tachycardic at 122/min, and her blood pressure is 85/50 mmHg. On physical examination, the uterine fundus is absent from the periumbilical region, and a smooth, round, beefy red mass is visualized protruding through the vaginal introitus. An initial attempt at immediate manual replacement is unsuccessful due to a tightly contracted lower uterine segment.

Arrange the following management steps in the most appropriate chronological sequence for this patient.

Correlate each complex clinical presentation of a lower reproductive tract infection with its most appropriate, evidence-based management strategy.

A 67-year-old woman is brought to the office by her daughter, who recently noticed blood stains on the patient's undergarments. The patient has moderate Alzheimer dementia and cannot provide a detailed history, but she denies any pelvic pain. Her last menstrual period was 15 years ago. Current medications include donepezil. Vital signs are within normal limits. Pelvic examination reveals thin, pale vaginal mucosa and a small amount of dark blood at the cervical os. There are no vulvar or vaginal lesions. Transvaginal ultrasound demonstrates an endometrial thickness of 8 mm. Which of the following is the most appropriate next step in management?

A $29$-year-old woman, gravida $2$, para $1$, at $31$ weeks gestation is evaluated in the antepartum unit. She was admitted $2$ days ago after a sudden gush of vaginal fluid, and evaluation confirmed preterm premature rupture of membranes (PPROM). At admission, she was started on expectant management with a course of betamethasone and prophylactic ampicillin and erythromycin. She now reports chills and lower abdominal pain. Her temperature is $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), blood pressure is $105/65\text{ mmHg}$, and heart rate is $116\text{/min}$. Physical examination reveals a uterus that is exquisitely tender to palpation. The fetal heart rate tracing demonstrates a baseline of $175\text{/min}$, minimal variability, and no decelerations. The cervix is $2\text{ cm}$ dilated and $70\%$ effaced. Which of the following is the most appropriate next step in the management of this patient?

A 21-year-old woman is evaluated in the outpatient clinic for increasingly irregular menstrual periods and bothersome facial hair growth. Over the last 18 months, she has only had three menstrual bleeding episodes. She is frustrated by the recent onset of thick, dark hair on her chin and chest. Her medical history is unremarkable, and she takes no medications. Her body mass index is 29 kg/m². Her blood pressure and other vital signs are normal. Physical examination confirms the presence of hirsutism and acne. There is no evidence of temporal balding, deepening of the voice, or clitoral enlargement. A point-of-care urine pregnancy test is negative. The clinician suspects polycystic ovary syndrome but wishes to exclude other conditions that can present similarly. In addition to checking thyroid-stimulating hormone and prolactin levels, which of the following is the most appropriate next laboratory test to order for this patient?