Obstetrics and Gynecology

A 27-year-old woman, gravida 1, para 0, is admitted to the hospital at 39 weeks gestation in active labor. Her prenatal course was uncomplicated. Epidural analgesia is initiated for pain management when her cervical dilation is 5 cm. Fifteen minutes after the epidural placement, the patient complains of sudden dizziness and nausea. Her blood pressure drops to 88/55 mm Hg, and her pulse increases to 105/min. The external fetal monitor reveals a baseline fetal heart rate of 145/min with moderate variability. There are recurrent, symmetric, gradual decreases in the fetal heart rate that reach their nadir after the peak of each uterine contraction; the heart rate returns to baseline only after the contraction has ended. Which of the following is the most appropriate initial step in the management of this patient?

A 29-year-old multiparous patient develops heavy vaginal bleeding shortly after an uncomplicated vaginal delivery of a macrosomic infant. Examination reveals a boggy uterus positioned above the umbilicus. Arrange the following management steps for this patient's condition in the correct escalating sequence, from first-line intervention to the definitive final treatment.

An otherwise healthy 23-year-old primigravida presents to the labor and delivery unit at 39 weeks gestation reporting regular, painful uterine contractions. Her prenatal course was unremarkable. On admission, her cervix is dilated to 6 cm and 90% effaced, with the fetal vertex at -1 station. Continuous electronic fetal monitoring is initiated. The fetal heart rate tracing demonstrates a baseline of 140/min with moderate variability. There are recurrent, gradual decreases in the fetal heart rate that begin simultaneously with the onset of each contraction. The decelerations reach their nadir exactly at the peak of the contraction, and the heart rate returns to baseline precisely as the contraction ends. Which of the following is the most appropriate next step in management?

A 24-year-old nulligravid woman presents to the emergency department with severe, progressively worsening bilateral lower abdominal pain and fever for 3 days. Her temperature is 39.1°C (102.4°F), blood pressure is 105/65 mmHg, and pulse is 112/min. Physical examination reveals exquisite bilateral lower quadrant tenderness with involuntary guarding. Pelvic examination demonstrates purulent cervical discharge, pronounced cervical motion tenderness, and a palpable, exquisitely tender, 7-cm fluctuant mass in the right adnexa. A urine pregnancy test is negative.

Assuming standard protocols and a lack of clinical improvement following initial medical interventions, arrange the following management steps in the correct chronological sequence, from initial emergency department evaluation to ultimate definitive intervention.

Match each patient profile with the most appropriate contraceptive method based on medical eligibility criteria and patient preferences.

Match each of the following gynecologic neoplasms with the serum tumor marker that is most characteristically elevated in affected patients.

A 56-year-old woman comes to the clinic for a well-woman examination. She feels well and has no current complaints. She experienced menopause at age 51 and denies any hot flashes, vaginal dryness, or postmenopausal bleeding. She takes no medications and has no significant past medical history. Her body mass index is 26 kg/m². Pelvic examination reveals normal external genitalia, a well-estrogenized vagina, and a grossly normal cervix without any visible lesions. A routine cervical cytology test is performed. Three days later, the cytology report indicates that the sample is negative for intraepithelial lesion or malignancy, but it notes the incidental presence of "benign-appearing endometrial cells." Which of the following is the most appropriate next step in management?

A 24-year-old primigravida at 10 weeks gestation presents to the emergency department with heavy vaginal bleeding and severe vomiting. Her blood pressure is 150/90 mmHg. Pelvic examination reveals a uterus sized consistent with a 16-week gestation. Transvaginal ultrasonography demonstrates a heterogeneous, complex intrauterine mass with multiple cystic spaces and no fetal parts. Quantitative serum $\beta$-hCG is 250,000 mIU/mL. Assuming this patient's clinical course subsequently progresses to non-metastatic gestational trophoblastic neoplasia, arrange the following management and surveillance steps in the optimal chronological order.

An obstetrics and gynecology consultation is requested for a 71-year-old female due to persistent perineal pruritus that has been refractory to medical management over the past 14 months. The patient reports intense, burning itchiness localized to the right labial region. She has independently applied various over-the-counter hydrocortisone and clotrimazole preparations without symptomatic relief. Her past medical history is significant for well-controlled type 2 diabetes mellitus and primary hypertension. She underwent a screening colonoscopy 11 years ago, which was normal, and her last mammogram was performed 4 years ago. Physical examination of the external genitalia reveals a 3.5-cm sharply demarcated, brightly erythematous plaque with a 'velvety' texture and scattered white, hyperkeratotic patches on the right labium majus. There are no palpable inguinal lymph nodes. A 4-mm punch biopsy of the affected area is obtained. Histopathologic analysis demonstrates large, round cells with abundant pale cytoplasm and prominent nucleoli situated within the epidermis. Immunohistochemical staining is positive for cytokeratin 7 (CK7) and periodic acid-Schiff (PAS), but negative for cytokeratin 20 (CK20) and S100. Based on these findings, what is the most appropriate next step in patient management?

A healthy 25-year-old female visits the gynecology clinic for a routine wellness check. She underwent insertion of a levonorgestrel-releasing intrauterine device (IUD) twelve months ago. She reports feeling well with no pelvic pain, and she has experienced expected light spotting. However, she notes that she cannot palpate the device's strings, which she previously checked monthly. The patient's vital signs are stable. During speculum examination, the threads are not visualized protruding from the cervical os. Arrange the following diagnostic and management steps in the correct chronological sequence to evaluate this finding.

During the active phase of labor at $39$ weeks of gestation, a primigravid patient requests pain relief. An epidural catheter is placed and a standard dose of local anesthetic is administered. Ten minutes later, the patient reports feeling lightheaded and nauseated. Her blood pressure has decreased from a baseline of $120/75\text{ mmHg}$ to $85/50\text{ mmHg}$, and her heart rate is $112/\text{min}$. Continuous electronic fetal monitoring, which previously demonstrated a baseline of $140/\text{min}$ with moderate variability and no decelerations, now reveals a sudden decrease in the fetal heart rate to $85/\text{min}$ that has persisted for $3$ minutes. Uterine contractions are occurring every $4$ minutes and are of normal intensity. Which of the following is the most appropriate next step in the management of this patient?

A 59-year-old female is evaluated in the primary care clinic for new-onset vaginal spotting that has occurred intermittently for the past three weeks. Her last menstrual period was 8 years ago. She has no significant past medical history except for well-controlled hypertension. Her body mass index is 33 kg/m2. Physical examination shows a normal appearing cervix and vaginal mucosa. Which of the following is the most appropriate next step in evaluating this patient's symptoms?

A 19-year-old woman visits the student health clinic reporting four days of dull, aching pain in her lower abdomen accompanied by new-onset spotting between her menstrual periods. She reports having a new sexual partner over the last month and admits to inconsistent use of barrier contraception. Her vital signs are within normal limits, including a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$). She is able to eat and drink without difficulty and does not appear acutely ill. On speculum examination, there is yellow, mucopurulent discharge visible at the cervical os. Bimanual examination demonstrates significant tenderness upon manipulation of the cervix, as well as bilateral adnexal tenderness. Urine pregnancy testing is negative. Which of the following represents the most appropriate initial treatment regimen for this patient?

A 27-year-old woman presents to her primary care physician because she has not menstruated for the past $6$ months. She achieved menarche at age 14, and her menses have historically been regular, with bleeding lasting 4 days every 29 days. She works as a software engineer and exercises moderately twice a week. She recently started a new relationship and uses condoms for birth control. She has not noticed any breast discharge, changes in voice, or abnormal hair growth. Her body mass index is $24 \text{ kg/m}^2$. Her vital signs are normal. Physical examination shows normal thyroid size and no skin findings suggestive of hyperandrogenism. A urine pregnancy test performed at the clinic is negative. Which of the following is the most appropriate next step in the evaluation of this patient?

Match each common gynecologic infection with its characteristic clinical presentation and microscopic findings.

A $35$-year-old woman, gravida $2$, para $1$, at $41$ weeks gestation is admitted to the labor and delivery unit for induction of labor due to a post-term pregnancy. An intravenous oxytocin infusion is started. Six hours later, her cervix is $5\text{ cm}$ dilated and $90\%$ effaced, with the fetal vertex at $-1$ station. Uterine contractions are occurring every $4\text{ minutes}$ and are of moderate intensity. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $120/75\text{ mmHg}$, and pulse is $88\text{/min}$. Laboratory studies from admission show a hemoglobin of $10.6\text{ g/dL}$ and a platelet count of $210,000\text{/mm}^3$. The fetal heart rate monitoring demonstrates a baseline of $135\text{/min}$ with minimal variability. Over the past $20\text{ minutes}$, the tracing reveals recurrent, gradual decreases in the fetal heart rate that begin after the peak of each contraction and take approximately $40\text{ seconds}$ to reach their nadir. The fetal heart rate returns to baseline only after the contraction has fully ended. Which of the following is the most appropriate next step in management?

A family planning clinic is evaluating multiple patients who are seeking reliable, reversible contraception. Each patient has distinct medical comorbidities that impact the safety of various contraceptive methods according to the World Health Organization Medical Eligibility Criteria (WHO MEC). Match each patient's clinical presentation with the single most appropriate contraceptive method.

Match each gynecologic malignancy with its most characteristic risk factor or pathogenetic association.

A 23-year-old nulligravid woman presents to the emergency department with severe, worsening right-sided pelvic pain. Three days ago, she was diagnosed with pelvic inflammatory disease (PID) at an urgent care clinic, where she received a single dose of intramuscular ceftriaxone and was prescribed oral doxycycline and metronidazole. She reports worsening pain, subjective fevers, and an inability to tolerate the oral medications due to severe nausea. Her temperature is 39.0°C (102.2°F). Pelvic examination reveals exquisite cervical motion tenderness and a palpable, tender 5-cm mass in the right adnexa. A point-of-care urine pregnancy test is negative. Arrange the following steps in the most appropriate, evidence-based sequence for the ongoing management of this patient.

A 25-year-old nulliparous woman at 40 weeks gestation presents in spontaneous labor. Following an uncomplicated first stage, she is fully dilated, effaced, and at +1 station. The patient begins active maternal expulsive efforts. During this phase, the fetus must perform specific biomechanical adaptations to successfully navigate the maternal pelvis. Arrange the following cardinal movements of labor in the correct chronological sequence for a fetus in a standard vertex presentation.