Obstetrics and Gynecology

During a routine third-trimester visit, a patient at 33 weeks gestation reports feeling increasingly winded after walking up the stairs at her home. She also notes that her shoes feel tight by the evening. The pregnancy has been uncomplicated thus far. Her current vital signs include a blood pressure of 112/68 mm Hg, a heart rate of 96/min, and a respiratory rate of 18/min. On physical examination, the physician notes a grade 2/6 systolic ejection murmur along the left sternal edge, accompanied by an early diastolic extra heart sound (S3). There is trace bilateral pitting edema of the ankles. Pulmonary auscultation reveals clear breath sounds in all fields, and the jugular venous pulse is not elevated. A rhythm strip demonstrates normal sinus rhythm with left axis deviation. What is the most appropriate action at this time?

While performing a routine evaluation on the antepartum unit, a physician responds to a patient who has suddenly become unresponsive. The patient, who was admitted earlier that day for induction of labor at 39 weeks gestation due to severe features of preeclampsia, is exhibiting generalized, rhythmic jerking of her extremities and a clenched jaw. Her last recorded blood pressure 15 minutes prior was 172/114 mm Hg. Arrange the following management steps in the most appropriate sequential order to stabilize and treat this acute obstetric emergency.

Match each of the following major obstetric emergencies during labor and the puerperium with its classic physical examination or clinical presentation.

A $30$-year-old healthy nulligravid woman presents for a preconception evaluation. She asks detailed questions regarding early pregnancy development. To accurately explain the normal progression of fetal and placental development, arrange the following physiological milestones in the correct chronological order from earliest to latest based on estimated gestational age.

A $30$-year-old woman, gravida 1, para 0, at $38$ weeks gestation is admitted to the labor and delivery unit for induction of labor due to preeclampsia with severe features. She is receiving continuous intravenous infusions of oxytocin and magnesium sulfate. Maintenance intravenous fluids are running concurrently at $125\text{ mL/hr}$. Approximately $12$ hours into her induction, she reports the sudden onset of severe shortness of breath, anxiety, and a cough productive of pink, frothy sputum.

Vital signs are:
- Temperature: $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$)
- Blood pressure: $152/100\text{ mmHg}$
- Heart rate: $118/\text{min}$
- Respiratory rate: $28/\text{min}$
- Oxygen saturation: $86\%$ on room air

Physical examination reveals prominent jugular venous distension and diffuse, bilateral crackles on lung auscultation. Deep tendon reflexes are $2+$ and symmetric bilaterally. Urine output has been $50\text{ mL}$ over the last $2$ hours. The fetal heart rate tracing demonstrates a baseline of $145/\text{min}$ with moderate variability and no decelerations. Supplemental oxygen is administered via a non-rebreather mask.

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

A 16-year-old female presents to the gynecology clinic reporting that she has never had a menstrual period. She became sexually active six months ago and uses condoms inconsistently. She has no chronic medical conditions and takes no medications. Physical examination reveals normal external genitalia, Tanner stage 4 breast development, and Tanner stage 4 pubic hair. Her body mass index (BMI) is 22 kg/m². Arrange the following diagnostic steps in the most appropriate sequential order for evaluating this patient's primary amenorrhea.

During a routine health maintenance visit, a 42-year-old G0P0 patient receives the results of a recent cervical cancer screening. She currently feels well and reports regular, 28-day menstrual cycles. Her medical history is notable for obesity (BMI $33 \text{ kg/m}^2$) and diet-controlled type 2 diabetes mellitus. The cytology report reveals atypical glandular cells (AGC). Concurrent testing for high-risk human papillomavirus (HPV) is negative. A subsequent pelvic examination is completely normal, with a grossly normal cervix and no palpable adnexal masses. Which of the following is the most appropriate next step in the diagnosis of this patient?

An uncomplicated first-time mother, 22 years of age, is evaluated in the labor and delivery ward at term (38 weeks and 5 days). She was admitted earlier today in spontaneous labor. Her membranes ruptured naturally two hours ago with clear fluid noted. Her current vital signs are within normal limits.

Pelvic examination reveals a cervix that is 7 cm dilated and fully effaced, with the fetal vertex at 0 station. An internal intrauterine pressure catheter and a fetal scalp electrode are placed. Contractions are adequate, occurring every 3 minutes and lasting 60 seconds.

Review of the electronic fetal monitoring tracing over the past 30 minutes shows a baseline heart rate of 135/min with moderate beat-to-beat variability. Frequent, sudden drops in the fetal heart rate to 75/min are observed. These drops reach their nadir in less than 30 seconds, last for approximately 45 seconds, and are not consistently synchronized with the onset of uterine contractions.

Nursing staff has already assisted the patient into a left-lateral resting position and administered a 500 mL intravenous bolus of lactated Ringer's, yet the fetal heart rate pattern persists without improvement.

Based on the clinical presentation, which of the following is the most appropriate next step in management?

A $29$-year-old woman, gravida $2$, para $1$, at $36$ weeks gestation presents to the clinic for a routine prenatal visit. Her pregnancy has been uncomplicated. She reports normal fetal movement and denies uterine contractions, vaginal bleeding, or leakage of fluid. Her first pregnancy was complicated by early-onset neonatal sepsis in the infant; blood cultures from the newborn grew *Streptococcus agalactiae*. The patient has a medical history significant for a severe allergic reaction to amoxicillin during childhood, which resulted in anaphylaxis and required epinephrine administration. During the current pregnancy, a midstream urine culture obtained at $12$ weeks gestation showed no growth. Her vital signs and physical examination today are unremarkable. The fetal heart rate is $145$/min. Which of the following is the most appropriate next step regarding the prevention of early-onset neonatal infection in this patient?

Following the spontaneous onset of regular contractions, a multiparous patient at 38 weeks gestation is admitted to the delivery unit. She is 31 years old (gravida 2, para 1). Her prenatal history is significant for a mid-trimester anatomy ultrasound demonstrating a low-lying placenta; however, a follow-up transvaginal ultrasound at 32 weeks confirmed that the placental edge had migrated 4 cm away from the internal cervical os. Her vital signs upon admission are temperature 37.0°C (98.6°F), blood pressure 118/76 mm Hg, and heart rate 84/min.

Cervical examination demonstrates 6 cm dilation, 100% effacement, and 0 station with a tense, bulging amniotic sac. The baseline fetal heart rate is 140/min with moderate variability and no decelerations. Ten minutes later, the patient's membranes spontaneously rupture. Immediately following the rupture, a large gush of blood-tinged fluid is observed, rapidly followed by frank, bright red vaginal bleeding. The patient's uterine tone remains soft between contractions, and she explicitly denies any new, sudden, or tearing abdominal pain. Simultaneous evaluation of the fetal monitor reveals a precipitous drop in the fetal heart rate to 60/min. Three minutes later, the bradycardia persists without any sign of recovery.

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

An uncomplicated pregnancy in a primigravid patient progresses to spontaneous labor at $38$ weeks and $2$ days of gestation. Upon admission to the obstetric triage unit, maternal vital signs are stable, and the cervix is dilated to $5\text{ cm}$ and $100\%$ effaced. Uterine contractions occur every $3$ minutes. Shortly after admission, the amniotic membranes spontaneously rupture, revealing a large amount of bright red vaginal bleeding. Concurrent evaluation of the cardiotocogram reveals a smooth, undulating fetal heart rate baseline of $140/\text{min}$, oscillating with an amplitude of $15/\text{min}$ and a frequency of $4$ cycles per minute. Baseline variability is otherwise absent, and no accelerations or decelerations are visualized. The patient has not received any systemic opioids or local anesthetics. Which of the following is the most appropriate next step in management?

Review the following patient scenarios involving complex medical histories. Select the most appropriate contraceptive method for each patient based on the World Health Organization Medical Eligibility Criteria (WHO MEC) and clinical efficacy.

A 28-year-old primigravid woman presents for her first prenatal visit at 7 weeks gestation. She has no significant past medical history and takes only prenatal vitamins. A transvaginal ultrasound confirms a viable intrauterine pregnancy consistent with her last menstrual period. The physician outlines the schedule of routine prenatal testing and evaluations she will undergo throughout her pregnancy. Arrange the following routine prenatal interventions in the correct chronological order in which they should be performed, from earliest in the pregnancy to latest.

Match the following clinical and laboratory findings of female genital tract infections to their most appropriate first-line pharmacotherapy and partner management strategy.

An otherwise healthy $25$-year-old woman, gravida $1$, para $0$, is evaluated in the clinic at $30$ weeks gestation for a scheduled prenatal check-up. She mentions noticing puffiness around her ankles by the end of the day, which generally resolves after a night's sleep. She denies headaches, blurred vision, or abdominal pain. Vital signs show a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $112/68\text{ mm Hg}$, heart rate of $86/\text{min}$, and respiratory rate of $16/\text{min}$. Physical examination reveals trace, bilateral dependent edema of the lower extremities but is otherwise unremarkable. A urine dipstick shows no protein or glucose.

The patient is highly anxious regarding laboratory results from her previous visit at $28$ weeks gestation, which she reviewed online. The results are as follows:

Hemoglobin: $11.5\text{ g/dL}$
Leukocyte count: $14,200/\text{mm}^3$
Platelet count: $220,000/\text{mm}^3$
Serum creatinine: $0.5\text{ mg/dL}$

Based on the clinical presentation and laboratory findings, which of the following is the most appropriate next step in management?

A $26$-year-old woman, gravida $2$, para $1$, at $39$ weeks gestation undergoes an uncomplicated vaginal delivery of a $3800$ g neonate. During the third stage of labor, excessive umbilical cord traction is applied before complete placental separation. Shortly after, a firm, purple, globular mass is noted protruding from the introitus, and the uterine fundus is no longer palpable in the abdomen. The patient experiences sudden, severe vaginal bleeding and her blood pressure drops to $85/50$ mmHg. Arrange the following steps in the optimal chronological order for the acute management of this obstetric emergency.

A $33$-year-old woman comes to the clinic reporting the absence of menses for the past $9$ months. Her menarche occurred at age $12$, and her menstrual cycles were regular every $28$ days until $9$ months ago. She also reports progressive fatigue, feeling cold constantly, and a $6\text{-kg}$ ($13\text{-lb}$) weight gain over the past year despite no changes in her diet or exercise routine. She occasionally notices a milky white discharge from her breasts. The patient has no headaches, visual field deficits, or abnormal facial hair growth. She takes no medications and uses condoms for contraception. Vital signs show a blood pressure of $110/70\text{ mm Hg}$, pulse of $58/\text{min}$, and temperature of $36.5^\circ\text{C}$ ($97.7^\circ\text{F}$). Her body mass index is $26\text{ kg/m}^2$. The thyroid gland is not palpable. Breast examination reveals bilateral, non-bloody, milky discharge that is easily expressible on palpation. Neurologic examination shows a delayed relaxation phase of the patellar reflexes. Visual fields are full to confrontation. A urine pregnancy test is negative.

Laboratory studies show the following:
Prolactin: $68\text{ ng/mL}$ (Normal: $4$ - $23\text{ ng/mL}$)
Thyroid-stimulating hormone (TSH): $0.2\text{ } \mu\text{U/mL}$ (Normal: $0.5$ - $5.0\text{ } \mu\text{U/mL}$)
Free thyroxine (T4): $0.4\text{ ng/dL}$ (Normal: $0.9$ - $2.4\text{ ng/dL}$)

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

An asymptomatic 26-year-old pregnant woman, gravida 2, para 1, is evaluated at the clinic during her 10th week of gestation for a routine prenatal visit. Her medical history is unremarkable, and her prior pregnancy ended in an uncomplicated full-term vaginal delivery. The patient reports no pelvic pain, dysuria, vaginal itching, or abnormal discharge. Vital signs are within normal limits. During a speculum examination performed for routine cervical cancer screening, a scant amount of thin, homogeneous, grayish fluid is noted in the vaginal vault. Point-of-care testing of the fluid reveals a pH of 5.0. Microscopic evaluation of a wet mount preparation demonstrates rare leukocytes and multiple squamous epithelial cells studded with coccobacilli that obscure the cell borders. An amine odor is appreciated upon the addition of 10% potassium hydroxide to the sample. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical presentation during routine prenatal care with its most appropriate next step in management based on standard obstetric protocols.

Match the characteristic histopathologic finding with the most likely associated gynecologic neoplasm.