Obstetrics and Gynecology

A 26-year-old woman, gravida 1 para 0, is evaluated in the labor and delivery unit at 40 weeks and 2 days of gestation. She was admitted 6 hours ago in active labor. Her prenatal course was uncomplicated. Admission laboratory values demonstrated a hemoglobin concentration of $10.4\text{ g/dL}$ and a leukocyte count of $11,500/\mu\text{L}$. Epidural analgesia was administered, and an artificial rupture of membranes was performed at 5 centimeters of cervical dilation, yielding clear fluid.

Currently, the patient's blood pressure is $118/76\text{ mmHg}$, pulse is $84/\text{min}$, and temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$). Uterine contractions occur every 3 to 4 minutes, lasting 50 seconds, with normal intensity upon palpation. Cervical examination reveals 8 centimeters of dilation, 100% effacement, and the fetal vertex at 0 station. Fetal monitoring demonstrates a baseline heart rate of $150/\text{min}$ with moderate variability and no accelerations. Over the last 40 minutes, the cardiotocograph has shown abrupt decreases in the fetal heart rate to $80/\text{min}$, lasting 45 to 60 seconds before rapidly returning to baseline. These decreases are noted during approximately 60% of the uterine contractions. Maternal repositioning to the left lateral decubitus position, an intravenous normal saline bolus, and supplemental oxygen administration have been implemented, but the fetal heart rate pattern remains unchanged.

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

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

Match the following clinical presentations of healthy pregnant patients with the primary underlying physiologic mechanism responsible for their findings.

An adolescent primigravida at 15 weeks gestation is evaluated in the outpatient clinic for a 3-day history of thick, yellow vaginal discharge and mild burning during urination. She denies lower abdominal discomfort, nausea, vomiting, or fever. Her vital signs are within normal limits. Speculum examination reveals a grossly erythematous cervix that bleeds easily upon contact with a swab. Copious mucopurulent exudate is visible at the external cervical os. Bimanual palpation elicits no cervical motion tenderness, and the adnexa are non-tender. Fetal heart tones are reassuring. A point-of-care urinalysis is unremarkable. The clinician prepares to send an endocervical sample for nucleic acid amplification testing. Which of the following is the most appropriate empiric management for this patient?

A $37$-year-old G3P3 woman presents to the clinic to discuss long-term contraception. She and her partner state that their family is complete, but they prefer a non-surgical option. Her menstrual periods occur every $28$ days, last for $7$ to $8$ days, and are exceptionally heavy, requiring her to change super-absorbent pads every $2$ hours during the first three days of menses. Her past medical history is significant for migraines that are consistently preceded by visual scintillating scotomas. She smokes $15$ to $20$ cigarettes per day. Vital signs show a blood pressure of $124/78 \text{ mmHg}$ and a heart rate of $72$/min. Body mass index is $28 \text{ kg/m}^2$. Pelvic examination is unremarkable. A urine pregnancy test is negative. Laboratory studies reveal a hemoglobin level of $10.2 \text{ g/dL}$. Which of the following is the most appropriate contraceptive method for this patient?

A 26-year-old woman comes to the physician due to a 5-month history of absent menstrual periods and increased facial hair growth. She also reports a recent deepening of her voice and increased muscle mass. Her menstrual cycles had previously occurred every 28 to 30 days and lasted 5 days. Her blood pressure is 112/72 mmHg, pulse is 78/min, and body mass index is 23 kg/m². Physical examination reveals severe acne on the face and back, coarse terminal hair growth on the upper lip and chin, temporal balding, and clitoromegaly. Pelvic examination shows no palpable adnexal masses. A urine pregnancy test is negative. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient?

Seeking to establish obstetric care, a patient at $10$ weeks gestation based on her last menstrual period presents to the clinic. Over the past three weeks, she has experienced progressive nausea, mild heat intolerance, and intermittent episodes where she feels her heart racing. She has no significant past medical history and takes only a daily prenatal vitamin. Vital signs demonstrate a blood pressure of $108/65$ mm Hg and a regular pulse of $98$/min. Physical examination reveals warm, moist skin. The neck examination shows a diffusely full, symmetrical thyroid gland without distinct nodules, bruit, or cervical lymphadenopathy. Eye examination is negative for proptosis or lid lag.

Initial serum laboratory investigations demonstrate the following:

Based on these findings, which of the following is the most appropriate next step in management?

A 29-year-old woman is brought to the emergency department due to a 2-week history of worsening shortness of breath, cough, and two episodes of coughing up blood. She also reports ongoing, irregular vaginal spotting for the past month. Six months ago, she had an uncomplicated spontaneous vaginal delivery of a healthy term infant. She has no significant past medical history and takes no medications. Her temperature is 37.2°C (99.0°F), blood pressure is 110/70 mm Hg, pulse is 112/min, and respiratory rate is 22/min. Pulse oximetry shows 94% on room air. Lung auscultation reveals bilateral crackles. Pelvic examination demonstrates a symmetrically enlarged, soft uterus and a 2-cm, dark red, highly vascular-appearing nodule on the posterior vaginal fornix. Chest radiography displays multiple bilateral, rounded pulmonary nodules. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient?

During a labor induction for preeclampsia with severe features, a patient at $38$ weeks and $2$ days gestation begins experiencing acute, severe shortness of breath and a cough producing pink-tinged sputum. The patient, who is $18$ years old and nulliparous, has been receiving continuous intravenous infusions of magnesium sulfate and oxytocin for the past eight hours. Her medical history is otherwise unremarkable, and she has not received regional anesthesia. Vital signs show a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $152/96\text{ mmHg}$, pulse of $118\text{ /min}$, and respirations of $28\text{ /min}$. Pulse oximetry indicates an oxygen saturation of $88\%$ on room air. Physical examination reveals $3+$ pitting edema of the lower extremities and bilaterally hyperactive ($3+$) patellar reflexes. Auscultation of the lungs reveals diffuse bilateral crackles extending to the apices. Pelvic examination indicates the cervix is $4\text{ cm}$ dilated and $80\%$ effaced. Fetal heart rate monitoring demonstrates a baseline of $140\text{ /min}$, moderate variability, and occasional variable decelerations that recover rapidly to baseline. Which of the following is the most appropriate next step in management?

Routine evaluation of a patient at $11$ weeks gestation is notable for her reporting a sensation of "not getting enough air." She has no history of asthma or cardiac disease, and her pregnancy has been uncomplicated. Current vital signs include a blood pressure of $112/70$ mm Hg, a pulse of $88$/min, and a respiratory rate of $18$/min. Pulse oximetry shows $99\%$ on room air. Auscultation of the chest reveals clear breath sounds bilaterally with no wheezes or crackles. Which of the following arterial blood gas profiles is most consistent with the expected physiologic adaptations in this patient?

Match each intrapartum clinical scenario and continuous fetal heart rate (FHR) tracing description to its corresponding diagnosis and underlying pathophysiology.

A 23-year-old nulligravid woman is evaluated in the emergency department for a 3-day history of progressively worsening lower abdominal pain, fever, and a malodorous vaginal discharge. Her temperature is 38.9°C (102.0°F), blood pressure is 110/70 mm Hg, and pulse is 112/min. Physical examination reveals exquisite cervical motion tenderness and a palpable, tender 6-cm fullness in the left adnexa. A urine pregnancy test is negative.

Arrange the following steps in the most appropriate chronological sequence for the optimal diagnosis and management of this patient's condition.

A 28-year-old nulliparous woman presents to the gynecologist complaining of an absence of menses for the past seven months. Her menarche occurred at age 13, and her menstrual cycles were previously regular, occurring every 28 days. Eight months ago, she underwent a dilation and curettage for an incomplete spontaneous abortion. She reports no hot flashes, headaches, visual changes, or galactorrhea. Her body mass index is $22 \text{ kg/m}^2$. Pelvic examination is unremarkable. Arrange the following diagnostic and management steps in the most appropriate sequential order for evaluating this patient's secondary amenorrhea.

A 45-year-old woman, gravida 3, para 3, presents to the clinic to discuss the results of her recent routine cervical cancer screening. Her Pap smear results are reported as "Atypical Glandular Cells, favor neoplastic" (AGC-neoplastic). She is asymptomatic, has regular 28-day menstrual cycles, and her pelvic examination is unremarkable. She underwent a bilateral tubal ligation 10 years ago and does not desire future fertility. Throughout the course of her care, subsequent evaluations confirm a final diagnosis of cervical adenocarcinoma in situ (AIS) with no evidence of invasive cancer. Arrange the following clinical interventions in the standard chronological sequence for the complete evaluation and definitive management of this patient.

A 28-year-old woman, gravida 1, para 0, at 36 weeks gestation presents for a routine prenatal visit. The pregnancy has been uncomplicated. To systematically determine the fetal lie, presentation, position, and engagement, the physician performs Leopold maneuvers. Arrange the distinct steps of the Leopold maneuvers in their standard sequential order, from the first maneuver to the fourth maneuver, as performed during an obstetric examination.

A 46-year-old G2P2 woman presents to the clinic with a 5-month history of heavy, irregular vaginal bleeding. She reports her menstrual periods occur unpredictably every 18 to 40 days, lasting up to 10 days, with the passage of large clots. She has a history of type 2 diabetes mellitus and hypertension. Her body mass index is $34 \text{ kg/m}^2$. Vital signs are stable. Pelvic examination reveals a normal-appearing cervix and a bulky, mobile uterus. Arrange the following steps in the most appropriate chronological order for the evaluation and management of this patient's abnormal uterine bleeding, assuming benign initial findings and a desire to avoid surgery if possible.

A $33$-year-old woman presents to the clinic complaining of an absence of menses for the past $9$ months. Her previously regular $28$-day menstrual cycles stopped completely, although she did experience a single episode of light vaginal spotting one week ago. Over the past year, the patient has also developed profound fatigue, cold intolerance, constipation, and occasional mild morning headaches. She recently noticed a spontaneous milky discharge from both breasts. She takes no medications and has no significant past medical history. Vital signs show a blood pressure of $110/70$ mm Hg and a heart rate of $56$/min. Body mass index is $24$ kg/m $^2$. Physical examination reveals dry skin and delayed relaxation of the deep tendon reflexes. Visual fields are full to confrontation. Pelvic examination is unremarkable.

Laboratory results are as follows:

Which of the following is the most likely diagnosis?

During a scheduled prenatal visit, a gravid patient at 18 weeks gestation reports experiencing severe vulvovaginal pruritus and a new onset of profuse, malodorous vaginal discharge for the past week. She has no uterine contractions, leakage of fluid, or vaginal bleeding. Her prenatal course has been uncomplicated thus far. On pelvic examination, the vaginal mucosa is erythematous, and a frothy, yellow-green discharge is pooled in the posterior fornix. The cervix appears inflamed with prominent punctate hemorrhages. Vaginal fluid pH testing yields a result of 6.0. Microscopic evaluation of a saline wet preparation reveals numerous polymorphonuclear leukocytes and pear-shaped, motile protozoa. Which of the following is the most appropriate management for this patient?

A 61-year-old nulliparous woman comes to the physician because of vaginal bleeding for the past 2 weeks. She reached menopause 9 years ago and had not experienced any bleeding until now. Over the past month, she has also noticed new-onset bilateral breast tenderness. She has no other medical conditions and takes no medications. Her body mass index is 23 kg/m^2. Vital signs are within normal limits. Pelvic examination reveals a normal-appearing vagina and cervix. Bimanual examination palpates a 7-cm, firm, mobile right adnexal mass. Transvaginal ultrasound shows a complex right ovarian mass with both solid and cystic components, along with an endometrial thickness of 14 mm. Which of the following is the most appropriate next step in management?

A 24-year-old primigravid woman at 39 weeks and 2 days gestation is evaluated in the labor and delivery unit due to a non-reassuring fetal heart rate tracing. The patient presented in spontaneous active labor 14 hours ago and has been pushing in the second stage of labor for 2.5 hours. Continuous epidural anesthesia provides excellent pain relief. Over the last 15 minutes, the continuous fetal monitor demonstrates a baseline heart rate of 155/min, absent baseline variability, and recurrent late decelerations. Uterine contractions occur every 3 minutes, last 60 seconds, and are palpated as firm. The nursing staff immediately repositioned the patient to the left lateral decubitus position, administered an intravenous fluid bolus, and applied 100% oxygen via a nonrebreather mask. Subsequent evaluation 10 minutes later shows no improvement in the fetal heart rate tracing. Maternal vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $118/74$ mm Hg, and pulse 92/min. On physical examination, the cervix is completely dilated and effaced. The fetal sagittal suture is palpable in the anteroposterior diameter with the posterior fontanelle directed anteriorly. The leading bony edge of the fetal skull is at $+3$ station. Which of the following is the most appropriate next step in management?