Obstetrics and Gynecology

A series of pregnant patients present to the obstetric triage unit during their first trimester for evaluation of potential pregnancy loss. Match each clinical and ultrasonographic presentation to the most accurate diagnosis.

Match each intrapartum clinical scenario to the most likely obstetric diagnosis.

A 29-year-old multiparous patient at 39 weeks gestation undergoes a spontaneous vaginal delivery. During the third stage of labor, excessive traction is applied to the umbilical cord before placental separation. The patient suddenly develops severe lower abdominal pain and profuse vaginal bleeding. On physical examination, a firm, beefy-red mass is protruding from the introitus, and the uterine fundus is not palpable transabdominally. The patient is tachycardic and hypotensive.

Arrange the following management steps in the optimal chronological sequence, assuming each initial intervention is unsuccessful until surgical resolution is required, followed by standard post-correction care.

A pregnant patient, gravida 3, para 2, at 39 weeks gestation is admitted to the labor unit following the spontaneous onset of contractions. Her prenatal course has been entirely uncomplicated. Cervical examination upon admission reveals 5 cm dilation and 90% effacement. The patient requests pain management, and a continuous lumbar epidural is successfully placed. Twenty minutes later, the patient reports feeling sudden onset lightheadedness and nausea. Her blood pressure is now 82/45 mmHg, representing a significant drop from her admission baseline of 118/76 mmHg. Simultaneously, the external fetal heart rate monitor demonstrates a baseline of 125/min with minimal variability and recurrent late decelerations. The nursing staff immediately places the patient in the left lateral decubitus position and initiates a rapid intravenous infusion of lactated Ringer solution. After five minutes of these interventions, her blood pressure remains 84/48 mmHg and the fetal decelerations persist. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical vignette describing a third-trimester obstetric complication with its primary underlying pathophysiologic mechanism.

Match each clinical presentation of a pregnant patient with the most accurate diagnosis regarding her hypertensive disorder.

A $31$-year-old woman is evaluated in the outpatient clinic for secondary amenorrhea. Her last menstrual period was $7$ months ago. Previously, her menstrual cycles were regular, occurring every $28$ days. She also reports a $3$-month history of bilateral milky nipple discharge, worsening fatigue, cold intolerance, and a $5.5$-kg ($12$-lb) weight gain. The patient has a $4$-year history of bipolar I disorder, which has been stable on a regimen of lithium and risperidone.

Physical examination reveals a body mass index (BMI) of $29$ kg/m $^2$. Vital signs show a temperature of $36.4^\circ$ C ($97.5^\circ$ F), blood pressure of $118/78$ mmHg, and a pulse of $56$/min. Cardiopulmonary examination is unremarkable. Breast examination reveals bilateral, non-bloody, milky discharge that is easily expressed from multiple ducts. Pelvic examination is normal.

A urine pregnancy test is negative.

Laboratory studies show the following results:

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

Match each clinical scenario describing an acute intrapartum or puerperal event to the most likely underlying diagnosis.

Match each intrapartum fetal heart rate (FHR) tracing description and its accompanying maternal clinical scenario with the most appropriate targeted intervention.

A primigravid patient at 33 weeks gestation is evaluated in the obstetric clinic due to concerns about her breathing and mild swelling. She reports a frequent sensation of needing to take deeper breaths that began a few weeks ago, but she states that she can still maintain her daily exercise routine of walking a mile without limitation. She denies chest pain, orthopnea, cough, or calf pain. Her pregnancy has been uncomplicated. Her vital signs are temperature 37.0°C (98.6°F), blood pressure 110/68 mm Hg, pulse 88/min, and respiratory rate 16/min. Pulse oximetry is 99% on room air. Physical examination demonstrates clear lungs bilaterally. Cardiovascular examination reveals a regular rate and rhythm with a grade 2/6 systolic ejection murmur at the left upper sternal border. Trace bilateral dependent edema is present.

Laboratory results are as follows:
Leukocyte count: 12,500/mm³
Hemoglobin: 11.2 g/dL
Platelet count: 220,000/mm³

Based on these findings, 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 World Health Organization Medical Eligibility Criteria (WHO MEC) and the patient's personal preferences.

Match each patient's clinical presentation of secondary amenorrhea with the most likely underlying pathophysiologic mechanism.

During a health maintenance visit, a $54$-year-old woman (G2P2) returns to the clinic to discuss the results of her recent cervical cancer screening. Two weeks prior, she underwent a routine Pap test and reported a self-resolving episode of brownish vaginal spotting. She reached menopause at age $50$ and does not take hormone replacement therapy. Her past medical history is notable for obesity with a body mass index of $32$ and well-controlled hypertension. The cytology report indicates atypical glandular cells (AGC), and high-risk human papillomavirus (HPV) co-testing is negative. Pelvic examination demonstrates a parous, normal-appearing cervix without visible lesions, and bimanual examination reveals a mobile, non-tender uterus of normal size. Which of the following is the most appropriate next step in the diagnostic workup for this patient?

Seeking contraceptive counseling, a 25-year-old nulligravid woman presents to the gynecology clinic. She is in a monogamous relationship and desires to prevent pregnancy for at least the next five years. Her medical history is significant for Wilson disease, which is currently well-managed with trientine. She also reports a longstanding history of heavy menstrual bleeding that has previously required intermittent oral iron supplementation for mild anemia. Her current medications include trientine and a daily multivitamin. Vital signs are within normal limits, and her body mass index is 24 kg/m $^2$. A point-of-care urine pregnancy test is negative. The patient requests a highly effective, long-acting reversible contraceptive (LARC) method. Which of the following is the most appropriate recommendation for this patient?

A 29-year-old woman, gravida 3, para 2, is evaluated on the labor and delivery unit at 38 weeks of gestation. She reports a sudden gush of clear vaginal fluid occurring 20 minutes ago, followed by the onset of strong, painful uterine contractions. Her previous deliveries were full-term, uncomplicated vaginal births. Her temperature is 37.1 C (98.8 F), blood pressure is 112/70 mm Hg, and pulse is 85/min. On pelvic examination, the cervix is 5 cm dilated and 80% effaced. The fetal presenting part is ballottable at a -3 station, and a smooth, pulsatile, rope-like mass is palpated in the vaginal vault extending through the cervical os. Simultaneously, continuous electronic fetal monitoring demonstrates an abrupt decrease in the fetal heart rate to 80/min that has lasted for the past 90 seconds. Which of the following is the most appropriate next step in the management of this patient?

A 31-year-old woman is evaluated on the maternity ward on postpartum day 2 for new-onset fever and pelvic pain. She delivered a full-term neonate via low transverse cesarean delivery following a diagnosis of active phase arrest. Her membranes were ruptured for 18 hours prior to the procedure. Over the last few hours, she has developed chills and worsening lower abdominal discomfort. Vital signs show a temperature of 39.2°C (102.6°F), blood pressure of 115/72 mm Hg, and heart rate of 110/min. Physical examination reveals clear lungs and soft, non-tender breasts. Abdominal examination demonstrates a soft abdomen with a well-approximated surgical incision that is free of erythema or induration. Deep palpation of the suprapubic region elicits marked uterine tenderness. The perineal pad contains a moderate amount of malodorous, purulent lochia. Urinalysis is unremarkable. Which of the following is the most appropriate next step in management?

A 29-year-old multiparous patient at 40 weeks gestation is in the second stage of labor. Following the delivery of the fetal head, it retracts tightly against the maternal perineum ('turtle sign'). Gentle downward traction fails to deliver the anterior shoulder. Arrange the following steps in the most appropriate sequence of escalation for managing this obstetric emergency according to standard protocols.

Match each patient's clinical presentation with the characteristic histopathological finding expected on biopsy or surgical excision of their adnexal mass.

Following a presentation of severe, bilateral lower pelvic pain and high-grade fever ($38.9^\circ\text{C}$), a $32$-year-old female is evaluated in the emergency department. She reports having a copper intrauterine device (IUD) inserted four years prior. On physical examination, marked cervical motion tenderness and purulent cervical exudate are noted. Pelvic ultrasonography confirms the IUD is properly situated within the endometrial cavity and reveals bilateral fallopian tube thickening consistent with severe pelvic inflammatory disease (PID), but no tubo-ovarian abscess is visualized. The patient is admitted to the inpatient ward for complicated PID.

Arrange the following diagnostic and therapeutic interventions in the most appropriate chronological sequence according to current clinical guidelines.

Match each clinical presentation and diagnostic finding to the most appropriate next step in management or definitive treatment.