Obstetrics and Gynecology

A physician is evaluating a patient who reports intermittent pinkish spotting on her undergarments for the past $3$ weeks. The patient is $58$ years of age, and her last natural menstrual period occurred $7$ years ago. Her medical history is significant for well-controlled type $2$ diabetes mellitus. Her current body mass index is $34 \text{ kg/m}^2$. She takes metformin and daily low-dose aspirin. During the speculum examination, the vaginal mucosa appears pale, thinned, and lacks normal rugation. A scant amount of brownish fluid is pooled in the posterior vaginal fornix, but no active bleeding is observed. The bimanual examination shows a small, mobile uterus and no adnexal masses. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical presentation of a pregnant patient with the most appropriate routine screening test or intervention indicated at that specific gestational age.

A $32$-year-old nulliparous woman comes to the office due to heavy vaginal bleeding for the past $14$ days. She reports that since menarche at age $12$, she has only had three to four menstrual periods per year. Her weight has steadily increased since her early twenties, and she now has a body mass index of $37 \text{ kg/m}^2$. Medical history is significant for severe acne and type 2 diabetes mellitus. She takes metformin and uses condoms for contraception. Vital signs are within normal limits. Physical examination shows dark, velvety hyperpigmentation on the posterior neck and axillae. Pelvic examination reveals active bleeding from the cervical os. Bimanual examination shows a normal-sized, mobile uterus with no adnexal masses. A point-of-care urine pregnancy test is negative. She does not desire pregnancy at this time. Which of the following is the most appropriate next step in management?

A 28-year-old woman comes to the office due to a 3-day history of progressively worsening pain and swelling in her genital area. The pain is exacerbated by sitting, walking, and friction from her clothing. She denies having any fever, chills, dysuria, or abnormal vaginal discharge. She has no significant past medical history. Her vital signs are within normal limits. Pelvic examination reveals a 4.5-cm, exquisitely tender, fluctuant, erythematous mass located in the left posterior vaginal introitus at the 7 o'clock position. There is no surrounding induration or erythema extending beyond the margins of the mass, and no inguinal lymphadenopathy is present. Which of the following is the most appropriate next step in management for this patient?

A 31-year-old woman, gravida 1, para 0, at 27 weeks gestation comes to the office for a routine prenatal visit. She mentions feeling "short of breath" over the past two weeks, especially when resting or sitting down. She has no history of asthma or cardiopulmonary disease. She denies chest pain, cough, palpitations, or lightheadedness. Her current medications include a prenatal vitamin and iron supplementation. Vital signs show a blood pressure of $110/68$ mm Hg, a pulse of $84$/min, and respirations of $18$/min. Pulse oximetry is $99\%$ on room air. Physical examination shows a gravid uterus appropriate for gestational age. Lungs are clear to auscultation bilaterally. Cardiac examination shows a normal $S_1$ and $S_2$ with a grade $2/6$ systolic ejection murmur at the left upper sternal border. There is trace bilateral lower extremity edema. The physician reassures the patient that her symptoms are due to normal physiologic adaptations to pregnancy. If an arterial blood gas analysis were performed, which of the following sets of values would most likely be observed?

Match each patient's clinical presentation and biomarker profile with the most likely ovarian neoplasm diagnosis.

An ambulance brings a 31-year-old female to the resuscitation bay following the sudden onset of excruciating, diffuse abdominal pain that began two hours prior to arrival. Over the preceding five days, she had experienced progressive lower pelvic discomfort, high fevers, and a foul-smelling vaginal discharge. Her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $80/45\text{ mm Hg}$, and pulse is $132/\text{min}$. She appears lethargic and is profoundly diaphoretic. Following the rapid intravenous infusion of $2\text{ L}$ of normal saline, her blood pressure remains $84/48\text{ mm Hg}$. Physical examination reveals a rigid, board-like abdomen with severe diffuse tenderness, involuntary guarding, and rebound. Pelvic examination is limited by extreme pain but shows purulent exudate pooling at the cervical os. A bedside transvaginal ultrasound demonstrates a $7\text{-cm}$ complex, multiloculated right adnexal structure with a disrupted capsular margin, accompanied by a large volume of echogenic free fluid in the pelvis and right upper quadrant. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical vignette describing an obstetric emergency to the most likely underlying diagnosis. Evaluate the specific risk factors and clinical findings to determine the correct etiology.

Based on the World Health Organization Medical Eligibility Criteria (WHO MEC), which contraceptive method is most appropriate for each patient's clinical presentation?

A nulliparous patient at 39 weeks gestation is admitted to the labor unit and receives continuous lumbar epidural analgesia for pain control during the active phase of labor. Fifteen minutes after the epidural is activated, the patient reports feeling dizzy and nauseated. Her temperature is 37.0°C (98.6°F), blood pressure is 82/45 mm Hg, and heart rate is 112/min. The electronic fetal monitor reveals a baseline heart rate of 140/min, moderate variability, and recurrent gradual decreases in the fetal heart rate that reach their nadir after the peak of each uterine contraction. Uterine contractions are occurring every 4 minutes and lasting 60 seconds. The patient is immediately placed in the left lateral decubitus position, and a rapid bolus of intravenous lactated Ringer solution is administered. Five minutes later, her blood pressure is 84/48 mm Hg, and the fetal heart rate pattern remains unchanged. Which of the following is the most appropriate next step in management?

A medical student is reviewing maternal lower extremity neuropathies that can occur as complications of labor, operative positioning, or fetal descent. Match each classic postpartum clinical presentation with the specific compromised nerve.

A 25-year-old primigravida presents to the obstetric clinic at 8 weeks gestation for her initial prenatal visit. She has no significant past medical history, takes no medications other than a daily prenatal vitamin, and her physical examination is unremarkable. She wishes to undergo standard comprehensive prenatal care. Arrange the following routine prenatal screening tests and evaluations in the correct chronological sequence in which they are indicated during a normal pregnancy (from earliest to latest gestational age).

A 65-year-old woman comes to the clinic for a routine wellness visit. During the interview, she mentions that over the past two months, she has noticed occasional blood stains on her underwear. She attributed this to 'fragile skin' since she was recently diagnosed with vulvar lichen sclerosus and uses a prescribed topical corticosteroid ointment. Her last menstrual period was 14 years ago. She has a history of type 2 diabetes mellitus and hypertension. Her medications include metformin, lisinopril, and the topical steroid. Pelvic examination reveals white, parchment-like changes on the vulvar skin and a small anal fissure, but no active bleeding. Speculum examination demonstrates a normal-appearing cervix and vaginal vault without visible lesions. Bimanual examination is unremarkable. Transvaginal ultrasound shows a homogeneous endometrial echo complex of $9 \text{ mm}$. Which of the following is the most appropriate next step in management?

A 23-year-old woman is contacted by her physician regarding laboratory results. She was evaluated at the student health center two days ago for a one-week history of increased, yellow-tinged vaginal discharge and spotting after intercourse. At that visit, a pelvic examination revealed a friable cervix with mucopurulent exudate, but no cervical motion, uterine, or adnexal tenderness. A vaginal wet mount showed numerous leukocytes but no clue cells, motile trichomonads, or yeast. Nucleic acid amplification testing (NAAT) of an endocervical swab was sent. The results are now available and are positive for *Neisseria gonorrhoeae* and negative for *Chlamydia trachomatis*. The patient has no known drug allergies. Which of the following is the most appropriate pharmacologic intervention for this patient?

A $26$-year-old nulliparous woman comes to the clinic to discuss contraceptive options. She and her partner are sexually active and wish to avoid pregnancy for at least the next $3$ years. Her menstrual periods occur every $28$ days, last for $7$ to $8$ days, and are associated with heavy bleeding that requires changing a super-absorbent pad every $2$ hours on her heaviest days. Her past medical history is significant for episodic headaches that occur approximately once a month. These headaches are characteristically preceded by bilateral flashing lights and zig-zag lines, followed by throbbing unilateral head pain. She takes sumatriptan as needed with good relief. Her blood pressure is $118/76\text{ mmHg}$, heart rate is $72\text{/min}$, and body mass index is $24\text{ kg/m}^2$. A urine beta-hCG test is negative. Pelvic examination is unremarkable. Which of the following is the most appropriate contraceptive recommendation for this patient?

An asymptomatic patient at $10$ weeks gestation presents for her first prenatal visit. She reports mild nausea and breast tenderness over the past three weeks but no other symptoms. Her family history is significant for maternal Hashimoto thyroiditis, prompting the physician to order a baseline thyroid function panel. Physical examination reveals a normal-appearing, non-tender thyroid gland without palpable nodules. Vital signs show a heart rate of $82/\text{min}$ and blood pressure of $110/70\text{ mm Hg}$.

Laboratory studies reveal the following:
Thyroid-stimulating hormone (TSH): $0.1\text{ \mu U/mL}$ (reference: $0.4-4.0\text{ \mu U/mL}$)
Total thyroxine (Total T4): $14.2\text{ \mu g/dL}$ (reference: $5.0-12.0\text{ \mu g/dL}$)
Free thyroxine (Free T4): $1.4\text{ ng/dL}$ (reference: $0.8-1.8\text{ ng/dL}$)

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

A 24-year-old primigravida at 40 weeks and 3 days gestation is evaluated in the labor and delivery ward. She was admitted in spontaneous active labor 8 hours ago. Her temperature is 37.1°C (98.8°F), blood pressure is 118/74 mm Hg, and pulse is 82/min. The estimated fetal weight is 3300 g. A cervical examination shows 8 cm dilation, 100% effacement, and +1 station. Artificial rupture of membranes was performed 4 hours ago and revealed clear fluid. Uterine contractions are occurring every 2 to 3 minutes. Continuous fetal monitoring demonstrates a baseline heart rate of 145/min with moderate variability. During the last 45 minutes, the fetal heart rate has repeatedly shown abrupt decreases to 85/min that last for 40 to 60 seconds and occur with most contractions. The patient has been repositioned to the left lateral decubitus position, and an intravenous fluid bolus has been completed, but the decelerations persist. Which of the following is the most appropriate next step in management?

Match each patient's clinical presentation of biopsy-proven cervical carcinoma with the most appropriate primary management strategy.

A $36$-year-old nulligravid woman with a history of polycystic ovary syndrome (PCOS) and obesity (body mass index $41$) presents with frequent, heavy menstrual bleeding occurring every $14$ to $60$ days. She has not responded to an initial trial of combined oral contraceptives. The patient explicitly states a strong desire to have children in the near future.

Arrange the following steps in the most appropriate chronological sequence for the diagnosis, definitive management, and long-term follow-up of this patient.

A $28$-year-old woman, G1P1, presents to the gynecology clinic reporting an absence of menstrual periods for the past $8$ months. She delivered a healthy infant vaginally $10$ months ago. Her immediate postpartum course was complicated by severe hemorrhage that required emergent dilation and curettage. She formula-feeds her infant and has not experienced any galactorrhea, weight changes, hot flashes, or temperature intolerance. Vital signs are within normal limits. Pelvic examination shows a normal-appearing vagina and cervix with no adnexal masses. Arrange the following diagnostic steps in the most appropriate sequential order for evaluating this patient's secondary amenorrhea.