Obstetrics and Gynecology

Match each routine prenatal screening or evaluation milestone to its optimal gestational age window in an uncomplicated pregnancy, according to standard obstetric guidelines.

Match each clinical presentation of a gynecologic malignancy with its most likely specific diagnosis.

A 32-year-old multiparous woman at 40 weeks gestation with diet-controlled gestational diabetes is in the second stage of labor. Following the delivery of the fetal head, the head rapidly retracts tightly against the maternal perineum. Gentle downward traction fails to deliver the anterior shoulder. Arrange the following management steps in the correct sequential order according to standard stepwise escalation protocols for this obstetric emergency, proceeding from the initial response to maneuvers of last resort.

Accompanied by her sister, a $68$-year-old female comes to the outpatient clinic to establish care. While reviewing her symptoms, she casually notes seeing a pinkish discharge on her toilet tissue twice over the past month. She denies pelvic pain, weight loss, or dysuria. She reached natural menopause $16$ years ago and had no vaginal bleeding until this recent episode. Her medical history includes hypertension, type 2 diabetes mellitus, and osteoarthritis. Current medications include lisinopril and metformin. Vital signs are within normal limits, and her body mass index is $34\text{ kg/m}^2$. Pelvic examination reveals atrophic external genitalia and a pale vaginal vault with no gross lesions. A bedside transvaginal ultrasound reveals an endometrial thickness of $7\text{ mm}$. Which of the following is the most appropriate next step in the management of this patient?

Maternal physiology undergoes profound systemic adaptations during an uncomplicated pregnancy to support fetal development and prepare for childbirth. These changes frequently manifest as altered clinical exam findings or shifted laboratory reference ranges that might closely mimic pathological states in a non-pregnant individual. Evaluate the following physiological findings commonly encountered during routine prenatal care and match each to its primary underlying maternal or placental mechanism.

A patient at 40 weeks gestation (G1P0) is admitted to the labor and delivery unit for labor augmentation with intravenous oxytocin. She is 28 years old, and her prenatal course has been uncomplicated. She is utilizing epidural anesthesia for pain management. Her cervix is currently 5 cm dilated, 90% effaced, and at -1 station. Over the past 30 minutes, the fetal heart rate monitor displays a baseline of 150/min. The amplitude of the peak-to-trough fetal heart rate fluctuations is 3 to 5 beats per minute. There are recurrent, gradual decreases in the fetal heart rate that begin after the peak of each uterine contraction and return to baseline after the contraction ends. Tocodynamometry reveals 7 contractions per 10-minute period, averaged over the last 30 minutes, with each contraction lasting 60 to 80 seconds. In response to these findings, the oxytocin infusion is promptly discontinued, the patient is placed in the left lateral decubitus position, and a 500-mL intravenous bolus of lactated Ringer solution is administered. Fifteen minutes later, the contraction frequency remains unchanged, and the fetal heart rate tracing continues to demonstrate the same pattern of recurrent decelerations with minimal fluctuations. Maternal vital signs are blood pressure 118/76 mmHg, pulse 88/min, and temperature 37.1°C (98.8°F). Which of the following is the most appropriate next step in management?

A 46-year-old woman, G1P1, presents to the clinic with a 4-week history of heavy, erratic vaginal bleeding. Her previous menstrual cycles were unpredictable, occurring every 2 to 6 months. She has a history of type 2 diabetes mellitus and obesity. She also notes severe fatigue and cold intolerance over the past several months. Her BMI is $42 \text{ kg/m}^2$. Vital signs show a blood pressure of $135/85 \text{ mm Hg}$ and a heart rate of $62/\text{min}$. Pelvic examination reveals a normal-appearing cervix with dark blood in the vaginal vault, and no palpable adnexal masses. A urine beta-hCG test is negative.

Initial laboratory studies show:
Hemoglobin: $9.8 \text{ g/dL}$
Thyroid-stimulating hormone (TSH): $0.8 \text{ mU/L}$ (Normal: $0.5-5.0 \text{ mU/L}$)
Free thyroxine (T4): $0.5 \text{ ng/dL}$ (Normal: $0.9-1.7 \text{ ng/dL}$)

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

A 32-year-old woman with well-controlled type 2 diabetes mellitus presents to the clinic reporting her fifth episode of thick, white vaginal discharge and severe vulvar pruritus in the past 11 months. Previous episodes were treated empirically with short courses of over-the-counter topical miconazole with only temporary relief. Arrange the following clinical steps in the correct chronological sequence for the definitive, guideline-concordant management of this patient's recurrent vulvovaginal candidiasis.

A 27-year-old primigravida at 40 weeks gestation is undergoing induction of labor for oligohydramnios. She is currently receiving a continuous oxytocin drip and has a functioning epidural block. Her blood pressure is 118/76 mm Hg, pulse is 88/min, and temperature is 37.2°C (99.0°F). A cervical examination shows 5 cm dilation, 90% effacement, and -1 station. The fetal monitor records 7 uterine contractions per 10-minute window. The fetal heart rate baseline is 135/min with minimal variability and recurrent late decelerations. The oxytocin drip is immediately stopped, the patient is repositioned to her left side, and an intravenous fluid bolus is administered. Fifteen minutes later, the contraction frequency remains 7 per 10-minute window, and the fetal heart rate tracing is unchanged. Which of the following is the most appropriate next step in management?

Match each clinical presentation to the most appropriate diagnosis regarding hypertensive disorders of pregnancy.

Match each clinical presentation of postpartum febrile morbidity to its most likely underlying diagnosis based on the timing and specific physical exam findings.

Match each clinical presentation and characteristic biomarker profile with the most likely specific gynecologic malignancy.

Match each patient's clinical profile with the most appropriate contraceptive method based on the World Health Organization Medical Eligibility Criteria (WHO MEC) and specific non-contraceptive benefits.

A $31$-year-old woman, gravida $2$, para $1$, at $26$ weeks gestation is evaluated in the clinic for right-sided flank discomfort that began $5$ days ago. The pain is described as a dull, constant ache and is not exacerbated by movement. She denies dysuria, hematuria, fever, chills, or vaginal bleeding. Fetal movement is active. Her prior pregnancy was uncomplicated. Temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $112/72\text{ mm Hg}$, and pulse is $82/\text{min}$. Physical examination shows a gravid uterus consistent with gestational age. There is mild right costovertebral angle tenderness, but no abdominal guarding or rebound. Urinalysis reveals no leukocytes, nitrites, or erythrocytes. A right upper quadrant and renal ultrasound demonstrates mild dilation of the right renal pelvis and proximal ureter without evidence of shadowing calculi. The left kidney and ureter are unremarkable. Which of the following is the most appropriate next step in management of this patient?

A 39-year-old woman comes to the clinic reporting heavy, irregular vaginal bleeding for the past 6 months. Prior to the onset of this bleeding, she had not menstruated for 9 months. Menarche was at age 12, and her menses have historically occurred only 3 to 4 times per year. She has a history of severe facial acne and hirsutism. Her medical history is otherwise unremarkable, and she does not take any medications. Her BMI is $42 \text{ kg/m}^2$. Vital signs are within normal limits. Pelvic examination demonstrates normal external genitalia and a normal-appearing cervix. Bimanual examination reveals a normal-sized, mobile uterus and no adnexal masses. A urine pregnancy test is negative. Which of the following is the most appropriate next step in management?

A 28-year-old woman, gravida 3, para 2, at 36 weeks gestation is brought to the emergency department via ambulance following a severe motor vehicle collision. She complains of intense, unremitting abdominal pain and moderate dark red vaginal bleeding. Her temperature is 36.8°C (98.2°F), blood pressure is 88/54 mm Hg, pulse is 126/min, and respirations are 24/min. Physical examination reveals a rigid, exquisitely tender uterus with no palpable relaxation between contractions. Continuous fetal monitoring demonstrates a baseline of 175/min with absent variability and recurrent late decelerations. Initial laboratory evaluation reveals a hemoglobin level of 7.8 g/dL, a platelet count of 65,000/mm³, and an elevated international normalized ratio (INR). During the initial assessment, the nursing staff notes continuous, non-clotting blood oozing from the patient's peripheral intravenous catheter sites. Which of the following is the most appropriate next step in the management of this patient?

A 31-year-old female presents to the physician reporting a lack of menstrual periods for the past 5 months. Prior to this, her menses occurred regularly every 29 to 32 days. Over the same 5-month period, she has noticed rapid growth of thick hair on her chin and chest, a noticeable deepening of her voice, and an increase in muscle mass. She has no significant past medical history and takes no medications. Her vital signs include a blood pressure of $122/76$ mm Hg, heart rate of $74$/min, and respiratory rate of $14$/min. Her BMI is $22 \text{ kg/m}^2$. Physical examination reveals temporal hair thinning, coarse terminal hairs on the face and sternum, and significant clitoral enlargement. A point-of-care urine pregnancy test is negative. Which of the following is the most appropriate next step in the diagnosis of this patient?

Match each prenatal screening test or prophylactic intervention with its appropriate clinical indication and temporal timing during an uncomplicated pregnancy.

A 34-year-old gravida 2, para 2 woman comes to the office for a routine wellness examination. She has no current medical conditions and takes no daily medications. Her only form of contraception is a copper intrauterine device, which was placed three years ago. The patient reports normal, regular menstrual cycles and denies any vaginal discharge, pelvic pain, or dyspareunia. Vital signs are within normal limits. Pelvic examination reveals normal external genitalia and a healthy-appearing cervix. The intrauterine device strings are visible at the external cervical os. Bimanual examination shows a non-tender, anteverted uterus with no adnexal masses. A Papanicolaou test is performed. One week later, the cytology report indicates negative for intraepithelial lesion or malignancy, but notes the presence of Actinomyces-like organisms. Which of the following is the most appropriate next step in management?

A 24-year-old nulliparous woman is evaluated in the clinic for secondary amenorrhea. Her last menstrual period occurred $8$ months ago. Previously, she had predictable $28$-day cycles. Over the past $6$ months, she has become increasingly distressed by new-onset severe cystic acne, coarse hair growth on her chest and back, and a noticeable deepening of her voice. She has no significant past medical history and takes no medications. In the clinic, a urine human chorionic gonadotropin test is negative. Vital signs are normal with a body mass index of $22$ $kg/m^2$. Examination reveals temporal hair thinning, marked hirsutism, and clitoromegaly. Pelvic examination is otherwise unremarkable. Laboratory studies show:

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