Obstetrics and Gynecology

Match each normal obstetrical finding or clinical milestone to the earliest gestational age at which it is typically expected during a normal, uncomplicated pregnancy.

A 39-year-old nulligravid female presents to the physician reporting eight months of heavy, unpredictable vaginal bleeding. Her menstrual cycles were previously regular, occurring every $28$ to $30$ days and lasting $5$ days. Over the past eight months, bleeding episodes have occurred at irregular intervals ranging from $15$ to $45$ days, with menses lasting up to $10$ days and requiring her to change super-absorbency pads every two hours on heavy days. Medical history is significant for type 2 diabetes mellitus, chronic hypertension, and morbid obesity. Current medications include metformin and lisinopril. Vital signs show a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $148/92\text{ mm Hg}$, pulse of $82/\text{min}$, and a body mass index (BMI) of $42\text{ kg/m}^2$. Pelvic examination reveals normal external genitalia, a normal-appearing cervix, and a bulky but non-tender uterus. A urine pregnancy test is negative. Laboratory studies show a hemoglobin level of $10.2\text{ g/dL}$. Which of the following is the most appropriate next step in the management of this patient?

An established $34$-year-old patient presents to the gynecology clinic reporting relentless vulvovaginal pruritus and burning that has persisted for the past month. She states that a three-dose course of oral fluconazole prescribed four weeks ago provided almost no symptom relief. Her past medical history is notable for poorly controlled type 2 diabetes mellitus with a recent hemoglobin A1c of $9.2\%$. On speculum examination, the vulvar and vaginal mucosae are intensely erythematous, and there is a thick, white, clumpy discharge adherent to the vaginal sidewalls. Vaginal fluid pH is $4.2$. Microscopic evaluation of the discharge prepared with $10\%$ potassium hydroxide reveals numerous budding yeast cells, but a complete absence of pseudohyphae or true hyphae. Which of the following is the most appropriate pharmacotherapy for this patient's condition?

A 29-year-old G1P0 at 39 weeks gestation undergoes an emergent cesarean delivery. She presented to the labor triage unit 20 minutes prior with painful uterine contractions and a history of a sudden gush of fluid at home. Upon admission, her cervix was 6 cm dilated, and the fetal heart rate was found to be persistently in the 60s, prompting immediate surgical intervention. A male neonate is delivered and requires positive pressure ventilation.

Umbilical artery blood gas analysis is obtained immediately after delivery:

Which of the following is the most likely primary mechanism for this neonate's acid-base derangement?

A 30-year-old nulliparous woman presents to the clinic for preconception counseling. She plans to discontinue her oral contraceptives and attempt pregnancy in the coming months. The patient is highly detail-oriented and requests a comprehensive timeline of the routine medical evaluations she should expect once she conceives. The physician explains the standard sequence of prenatal care milestones. Assuming she achieves an uncomplicated, spontaneous singleton pregnancy and establishes care early in the first trimester, arrange the following routine prenatal screening evaluations in the correct chronological order from earliest to latest in gestation.

A $29$-year-old woman, G1P1, is evaluated on postpartum day $3$ for a new-onset fever, chills, and lower abdominal pain. Three days ago, she underwent a primary low transverse cesarean delivery due to active phase arrest. Her membranes had been ruptured for $22$ hours prior to delivery. Her temperature is $39.0^\circ\text{C}$ ($102.2^\circ\text{F}$), blood pressure is $112/72\text{ mmHg}$, pulse is $112/\text{min}$, and respirations are $18/\text{min}$. Physical examination reveals soft, non-tender breasts without erythema. Her abdomen is soft. The cesarean incision is clean, dry, and intact, with no erythema, induration, or purulent drainage. Palpation of the uterine fundus elicits severe tenderness. Pelvic examination reveals a normal-appearing cervix with moderate, foul-smelling lochia. Which of the following is the most appropriate next step in the management of this patient?

A 22-year-old woman presents to the outpatient clinic reporting a 5-day history of yellowish vaginal discharge and spotting after intercourse. Her last menstrual period was 6 weeks ago, and she reports inconsistent condom use with a new male partner. Her temperature is 37.2°C (99.0°F), blood pressure is 110/70 mm Hg, and pulse is 82/min. Speculum examination reveals a friable cervix with mucopurulent exudate. Bimanual examination demonstrates mild cervical motion tenderness without uterine or adnexal tenderness. Arrange the following steps in the most appropriate chronological sequence for the clinical and public health management of this patient.

A 26-year-old primigravid patient at 40 weeks gestation is admitted to the labor and delivery unit in active spontaneous labor. Her prenatal course was uncomplicated. Spontaneous rupture of membranes occurred 4 hours ago, revealing thick meconium-stained amniotic fluid. Her temperature is 37.1°C (98.8°F), blood pressure is 118/76 mmHg, and pulse is 82/min.

Pelvic examination demonstrates the cervix is 6 cm dilated, 100% effaced, and the fetal vertex is at 0 station. No structures are palpable ahead of the presenting part.

Continuous external fetal monitoring over the last 30 minutes shows a baseline heart rate of 140/min and moderate variability. There are recurrent, abrupt decreases in the fetal heart rate to 80/min that last for 45 to 60 seconds before returning rapidly to baseline. These decreases do not have a consistent temporal relationship with the uterine contractions. The contractions are occurring every 3 to 4 minutes and last 60 seconds.

The nurse assists the patient into the left lateral, right lateral, and hands-and-knees positions, and administers a 500 mL intravenous bolus of lactated Ringer solution. Despite these resuscitative maneuvers, the fetal heart rate pattern remains unchanged for the next 20 minutes. A repeat cervical examination shows no change in dilation.

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

Match each patient's clinical profile with the most appropriate contraceptive method based on the Medical Eligibility Criteria for Contraceptive Use.

A 24-year-old primigravid woman at 39 weeks gestation is evaluated in the labor and delivery unit. She was admitted 22 hours ago in active labor, at which time spontaneous rupture of membranes occurred. Her current temperature is 39.2°C (102.6°F), blood pressure is 110/70 mmHg, and heart rate is 118/min. Physical examination reveals a diffusely tender uterine fundus. Pelvic examination shows the cervix is 6 cm dilated, 100% effaced, and the fetal vertex is at 0 station. Purulent fluid is noted in the vaginal vault. The fetal heart rate tracing demonstrates a baseline of 175/min with moderate variability and no decelerations. Maternal laboratory studies show a leukocyte count of $18,000/\text{mm}^3$ and a hemoglobin of $10.4 \text{ g/dL}$. Which of the following is the most appropriate next step in the management of this patient?

During a scheduled mid-trimester visit at $20$ weeks gestation, a $32$-year-old multigravida reports feeling generally well, with only mild fatigue and occasional urinary frequency. Her blood pressure is $115/75$ mmHg and pulse is $82$/min. Physical examination reveals a fundal height consistent with dates and normal fetal heart tones. Routine laboratory screening is performed with the following results:

Hemoglobin: $11.2$ g/dL
Leukocyte count: $12,500$/mm $^3$
Serum creatinine: $1.1$ mg/dL
Alkaline phosphatase: $195$ U/L
Urinalysis: Trace glucose, negative for protein and nitrites

Which of the following laboratory findings in this patient is abnormal and warrants further diagnostic evaluation?

A healthy pregnant patient at $28$ weeks of gestation comes to the obstetric clinic for a scheduled evaluation. She is $24$ years old and this is her first pregnancy. The patient mentions occasionally feeling as though she cannot take in a full breath, especially when resting. She confirms she has no chest pain, cough, or difficulty speaking in full sentences, and she continues to walk her dog daily without limitation. Vital signs reveal a heart rate of $85$/min, respiratory rate of $16$/min, blood pressure of $112/68$ mmHg, and an oxygen saturation of $99\%$ on room air. Pulmonary auscultation reveals clear breath sounds bilaterally. A comprehensive metabolic panel and arterial blood gas analysis are drawn as part of a voluntary physiologic study she enrolled in. Which of the following profiles most accurately reflects the expected acid-base status in this patient?

A 24-year-old woman comes to the clinic for evaluation of a newly identified right breast lump. She first noticed the mass 2 weeks ago while showering. The patient is otherwise healthy, takes no medications, and has no family history of breast cancer. Her menstrual cycles are regular, and her last menstrual period was 3 weeks ago. Vital signs are normal. On physical examination, there is a 2-cm, firm, mobile, and non-tender mass in the upper outer quadrant of the right breast. There is no overlying skin dimpling, nipple retraction, or axillary lymphadenopathy. Which of the following is the most appropriate next step in management of this patient?

A $25$-year-old primigravida at $41$ weeks gestation is admitted to the labor and delivery unit for induction of labor due to postterm pregnancy. A continuous intravenous oxytocin infusion is initiated. Her cervix is $5\text{ cm}$ dilated and $80\%$ effaced. Uterine contractions are occurring every $3$ to $4$ minutes. The fetal heart rate baseline is $135/\text{min}$ with moderate variability. Over the past $30$ minutes, the fetal heart rate tracing demonstrates recurrent, symmetric decreases in the heart rate that begin after the peak of each contraction, reach their nadir after the contraction ends, and then gradually return to baseline. Maternal vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure $118/76\text{ mmHg}$, and heart rate $84/\text{min}$. Laboratory studies show a leukocyte count of $14,500/\text{mm}^3$ and hemoglobin of $10.8\text{ g/dL}$. Which of the following is the most appropriate next step in management?

A physician is evaluating a 62-year-old patient who reports highly distressing urinary symptoms that have persisted for the past eight months. She states that she frequently experiences an abrupt, overwhelming need to urinate, which is often followed by a large volume of urine loss before she can reach the bathroom. These episodes occur 4 to 5 times daily. There is no history of leakage associated with physical exertion, sneezing, or coughing. Her medical history includes well-controlled hypertension, narrow-angle glaucoma, and severe chronic idiopathic constipation that requires daily osmotic laxatives. Pelvic examination reveals normal vaginal rugae without erythema or atrophy, and there is no evidence of pelvic organ prolapse. The cough stress test is negative. Postvoid residual volume is 25 mL. Urinalysis shows no abnormalities. The patient has diligently completed an 8-week behavioral therapy program, including timed voiding and pelvic floor muscle training, with minimal improvement. Which of the following pharmacologic mechanisms is most appropriate to target for symptom relief in this patient?

A 65-year-old G3P3 patient is evaluated in the urogynecology clinic prior to a scheduled surgical procedure. She has a symptomatic, advanced anterior vaginal wall prolapse that causes daily pelvic pressure and a bothersome vaginal bulge. The patient explicitly denies any current involuntary loss of urine, urinary urgency, or dysuria, stating that her bladder control is completely normal. Her medical history includes obesity, well-controlled hypertension, and a total abdominal hysterectomy for benign fibroids 12 years ago. Pelvic examination confirms a large cystocele protruding 4 cm beyond the hymenal ring during a Valsalva maneuver. The posterior vaginal wall and vaginal apex are well supported. Urinalysis is unremarkable, and postvoid residual volume is 25 mL. The patient is scheduled to undergo an anterior colporrhaphy next week. To prevent a common postoperative complication, which of the following is the most appropriate next diagnostic step to guide this patient's surgical plan?

A 31-year-old G3P3 woman experiences massive postpartum hemorrhage immediately following a spontaneous vaginal delivery of a 4200g neonate. Physical examination reveals a soft, enlarged, and boggy uterus. Initial management with continuous bimanual uterine massage, aggressive intravenous fluid resuscitation, and high-dose intravenous oxytocin has failed to arrest the bleeding. Her past medical history is significant for chronic hypertension and poorly controlled asthma. Arrange the following interventions in the most appropriate stepwise order of escalation for managing this patient's ongoing hemorrhage.

A 31-year-old woman, gravida 2 para 1, at 37 weeks and 4 days gestation, presents to the emergency department reporting unremitting lower back pain for the past three hours. She has not experienced any vaginal bleeding, leakage of fluid, or recent trauma. Her medical history is significant for chronic hypertension managed with oral labetalol. Vital signs are temperature 37.1°C, pulse 115/min, blood pressure 152/92 mm Hg, and respirations 18/min. Physical examination reveals a firm, tense uterus that is tender to deep palpation. There is no visible blood in the vaginal vault on speculum examination, and the cervix is closed. Continuous electronic fetal monitoring demonstrates a baseline heart rate of 165/min, absent baseline variability, and repetitive late decelerations. The tocodynamometer shows high-frequency, low-amplitude uterine contractions occurring every 1 to 2 minutes with an elevated resting tone. Initial laboratory studies show a hemoglobin of 10.4 g/dL, platelet count of 105,000/mm³, and fibrinogen of 190 mg/dL. Which of the following is the most appropriate next step in management?

A $72$-year-old woman, gravida $2$, para $2$, comes to the gynecologist reporting a vulvar lesion that she first noticed $4$ months ago. She states that the area is occasionally pruritic and bleeds slightly when wiped. Her past medical history is notable for lichen sclerosus, which was diagnosed $10$ years ago and is managed with intermittent topical clobetasol. Menopause occurred at age $51$. On physical examination, the vagina and cervix appear atrophic. On the right labium majus, approximately $4$ cm lateral to the midline, there is a $2.5$ cm, firm, ulcerated, unifocal nodule. There are no palpable inguinal lymph nodes. A punch biopsy of the nodule confirms invasive squamous cell carcinoma with a depth of invasion of $3.5$ mm. Which of the following is the most appropriate next step in management?

A 58-year-old woman presents to the clinic with a 3-week history of continuous, thin, watery vaginal discharge that occasionally leaves pink stains on her undergarments. She reached menopause at age 51. Her medical history is notable for estrogen receptor-positive breast cancer diagnosed 4 years ago, which was treated with a lumpectomy and radiation therapy. She has been taking anastrozole for the past 3 years. Since starting the medication, she reports significant vaginal dryness and dyspareunia. Her vital signs are within normal limits. Speculum examination reveals pale, thin, and dry vaginal mucosa with a loss of rugation. There are no lacerations in the vaginal vault, but a small amount of dark red fluid is noted pooling at the external cervical os. Bimanual examination demonstrates a small, mobile, non-tender uterus without adnexal masses. Which of the following is the most appropriate next step in the management of this patient?