Obstetrics and Gynecology

Appropriate maternal weight gain during pregnancy is an essential component of routine prenatal care to optimize maternal and fetal outcomes. Based on the Institute of Medicine (IOM) guidelines for singleton pregnancies, match each patient's pre-pregnancy Body Mass Index (BMI) presentation with the most appropriate recommended total gestational weight gain range.

During a routine health maintenance visit, a thirty-four-year-old patient reports that she has not menstruated for the past nine months. Her menarche occurred at age $12$, and previously she experienced predictable $28$-day cycles. Over the last several months, she has been struggling with unexpected mood fluctuations, poor sleep, and sudden, intense episodes of upper body warmth accompanied by sweating. She is nulligravid, has no history of chronic medical conditions, and does not take any medications. Vital signs are within normal limits, with a BMI of $24 \text{ kg/m}^2$. On physical examination, her secondary sexual characteristics are appropriately developed. Pelvic examination reveals a pale vaginal mucosa with diminished rugae, but no adnexal masses are palpated. The thyroid gland is normal to palpation, and there is no evidence of galactorrhea or hirsutism. Arrange the following clinical interventions in the correct chronological sequence to appropriately evaluate and manage this patient's condition.

A 28-year-old primigravida at $41$ weeks gestation is admitted to the labor and delivery unit for induction of labor. Following cervical ripening, a continuous intravenous oxytocin infusion is started. Twelve hours later, the patient reports intense and continuous abdominal pain. Her temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $122/78\text{ mm Hg}$, and pulse is $92/\text{min}$. A sterile vaginal examination reveals the cervix is $6\text{ cm}$ dilated and $90\%$ effaced, with the fetal vertex at $0$ station. The external tocodynamometer records $7$ uterine contractions in a $10$-minute period, averaged over the last $30$ minutes. The continuous fetal heart rate tracing demonstrates a baseline of $145/\text{min}$, moderate variability, and symmetric decreases in the heart rate that begin after the peak of each contraction and slowly return to baseline after the contraction ends. Repositioning the patient to the left lateral decubitus position and providing a rapid intravenous fluid bolus do not resolve the fetal heart rate findings. Which of the following is the most appropriate next step in management?

A 39-year-old woman, G0, comes to the clinic due to a three-week history of continuous, heavy vaginal bleeding. She states that she has soaked through a thick maxi pad every 3 hours for the past week. The patient has a history of irregular menstrual cycles, with periods occurring unpredictably every 2 to 6 months since menarche. Medical history is notable for hypertension, for which she takes amlodipine. She does not use tobacco or alcohol. Her blood pressure is $138/88 \text{ mm Hg}$, pulse is $88/\text{min}$, and BMI is $38 \text{ kg/m}^2$. Physical examination reveals dark, velvety patches of skin on the posterior neck and axillae. Pelvic examination shows active bleeding from the cervical os; the uterus is normal in size and non-tender. A urine pregnancy test is negative. Complete blood count shows a hemoglobin of $10.4 \text{ g/dL}$ and a platelet count of $250,000/\text{mm}^3$. Thyroid-stimulating hormone level is within normal limits. Which of the following is the most appropriate next step in management?

A $31$-year-old woman, gravida $2$, para $1$, presents to the clinic for her initial prenatal visit at $11$ weeks gestation. She reports mild nausea and breast tenderness but otherwise feels well. She has no significant past medical history and takes only a daily prenatal vitamin. Her blood pressure is $112/70\text{ mm Hg}$ and pulse is $84/\text{min}$. Physical examination reveals a normal-sized thyroid gland without palpable nodules or tenderness. Pelvic examination is consistent with an $11$-week gestation. Routine initial prenatal laboratory studies are obtained, and the results of a reflexively drawn thyroid panel are as follows:

Thyroid-stimulating hormone (TSH): $0.15\ \mu\text{U/mL}$ (Reference: $0.4\text{--}4.0\ \mu\text{U/mL}$)
Total thyroxine (T4): $14.8\ \mu\text{g/dL}$ (Reference: $5.0\text{--}12.0\ \mu\text{g/dL}$)
Free thyroxine (T4): $1.6\text{ ng/dL}$ (Reference: $0.8\text{--}1.8\text{ ng/dL}$)

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

A 24-year-old primigravida presents to the clinic at 10 weeks gestation reporting severe nausea, vomiting, and dark red vaginal spotting for the past two days. Her blood pressure is 142/90 mmHg, and her heart rate is 105/min. Physical examination reveals a uterus that is palpably enlarged to the level of the umbilicus, which is consistent with a 20-week gestation. A bedside urine pregnancy test is positive. She has no significant past medical history.

Arrange the following steps in the most appropriate chronological sequence for the diagnosis, definitive management, and standard follow-up of this patient's condition.

A healthy 24-year-old primigravida in her second trimester visits the clinic after noticing a painless, indurated ulcer on her labia majora. Her medical history is notable for a severe anaphylactic reaction, characterized by respiratory distress and hypotension, following amoxicillin exposure during childhood. Arrange the following clinical steps in the most appropriate chronological order to accurately diagnose and definitively manage this patient's condition.

A 27-year-old multiparous patient at 39 weeks gestation has just delivered a 4,150 g (9 lb 2 oz) neonate vaginally. During the delivery of the placenta, the resident applies continuous umbilical cord traction while the uterus is flaccid. The patient suddenly cries out in severe lower abdominal pain, followed by a massive gush of vaginal blood. Her blood pressure is 76/40 mm Hg, and her pulse is 134/min. Physical examination reveals a beefy red, globular mass protruding through the vaginal introitus. The uterine fundus is not palpable on transabdominal examination. An initial attempt to manually push the mass back into the pelvis is unsuccessful because the lower uterine segment and cervix are firmly contracted around the prolapsed tissue. Arrange the following steps in the most appropriate sequential order to manage this patient's condition.

Evaluate the following four individuals presenting to the gynecology clinic for evaluation of absent menses. Pair their distinct physical, historical, and laboratory findings with the correct pathophysiologic diagnosis.

A 28-year-old woman, gravida 1, para 0, presents for her initial prenatal visit at 10 weeks gestation. She reports mild fatigue and frequent urination but otherwise feels well. Her medical history is unremarkable. She works as a kindergarten teacher. Temperature is 37.0°C (98.6°F), blood pressure is 110/70 mm Hg, pulse is 84/min, and respiratory rate is 18/min.

Laboratory results show:
- Hemoglobin: 11.2 g/dL
- Mean corpuscular volume: 88 $\mu$ m³
- Leukocyte count: 8,500/mm³
- Urine dipstick: positive for leukocyte esterase, negative for nitrites
- Urine culture: $10^5$ CFU/mL of *Escherichia coli*

Antibiotic susceptibilities for the isolate show sensitivity to amoxicillin, cephalexin, and levofloxacin.

The patient is concerned about catching the flu from her students and requests the intranasal influenza vaccine today. When told she needs treatment for her urinary findings, she states she is afraid to take antibiotics because she read they might harm the baby.

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

Seeking medical care for an unexpected return of vaginal bleeding, a 71-year-old retired teacher arrives at the gynecology office. She reports noticing red spotting on her undergarments and toilet tissue over the past two weeks. The patient transitioned through menopause 20 years ago and has not experienced any vaginal bleeding since. Her past medical history is significant for well-controlled type 2 diabetes mellitus, essential hypertension, and obesity. Current medications include metformin and lisinopril. On physical examination, her blood pressure is $138/82 \text{ mmHg}$, and her body mass index is $33 \text{ kg/m}^2$. Speculum examination shows pale, dry vaginal walls without lacerations, but a small pool of dark blood is visible at the posterior fornix. Bimanual examination reveals a mobile, non-tender, anteverted uterus that is normal in size for her age. A transvaginal ultrasound is performed in the office, demonstrating an endometrial thickness of $11 \text{ mm}$ with cystic changes. The adnexa are unremarkable bilaterally. Which of the following is the most appropriate next step in the clinical management of this patient?

A 24-year-old woman returns to the clinic to review laboratory results. Three days ago, she presented with new-onset dyspareunia and an increased yellowish vaginal discharge. At that time, her temperature was 37.1°C (98.8°F), blood pressure was 112/70 mm Hg, and pulse was 76/min. Pelvic examination revealed a markedly friable cervix with mucopurulent exudate, but no cervical motion or adnexal tenderness. A cervical swab was sent for testing, and the patient opted to defer empiric antibiotic therapy until a definitive diagnosis was made. Today, her nucleic acid amplification test (NAAT) results return positive for *Neisseria gonorrhoeae* and negative for *Chlamydia trachomatis*. Her medical history is significant for a severe allergic reaction to ceftriaxone, characterized by hypotension and respiratory distress requiring epinephrine. Based on current guidelines, which of the following is the most appropriate pharmacotherapy for this patient?

A healthy nulliparous patient at 6 weeks gestation by last menstrual period presents to the obstetrics clinic to establish care following a positive home pregnancy test. She is 27 years old, has an unremarkable medical history, and takes only a daily prenatal vitamin. The patient is eager to understand the timeline of her upcoming evaluations. Arrange the following routine prenatal assessments and interventions in the correct chronological sequence they should be performed throughout an uncomplicated pregnancy.

Match each patient's clinical presentation with the most appropriate next step in diagnosis or management.

A 24-year-old nulliparous patient presents to the labor unit at 39 weeks and 4 days of gestation with painful uterine contractions. Her prenatal course was unremarkable. On admission, her cervical examination demonstrates 5 cm of dilation, 90% effacement, and -1 station. Two hours later, she requests neuraxial analgesia, and a continuous epidural infusion is successfully initiated. Shortly after the procedure, the patient complains of dizziness and nausea. Her blood pressure drops to 80/45 mm Hg from a baseline of 118/74 mm Hg, and her heart rate increases to 112/min. Concurrently, the continuous fetal monitor demonstrates a sudden decrease in the fetal heart rate baseline from 145/min to 85/min, which persists for 4 minutes with minimal variability. The nursing staff immediately places the patient in the left lateral decubitus position and administers a rapid intravenous bolus of isotonic crystalloid, but her blood pressure only marginally improves to 84/48 mm Hg. The fetal heart rate remains at 85/min. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical presentation of a suspected gynecologic infection to the most appropriate initial pharmacologic management based on current guidelines.

Review the following clinical assessments of labor progress. According to current American College of Obstetricians and Gynecologists (ACOG) guidelines, match each clinical scenario to its correct diagnostic classification.

Standard prenatal care involves a strict schedule of laboratory evaluations and prophylactic interventions based on gestational age to optimize maternal and fetal outcomes. Match each clinical presentation during a routine, uncomplicated pregnancy with the most appropriate next step in prenatal screening or management.

A 27-year-old nulliparous woman at 15 weeks gestation comes to the clinic for a scheduled prenatal visit. She reports feeling well and has no current health concerns. Upon specific questioning, she denies any vaginal itching, burning, malodor, or pelvic pain. Her vital signs are within normal limits. Speculum examination reveals a normal-appearing, closed cervix and a moderate amount of thin, homogenous, grayish-white vaginal discharge pooling in the posterior fornix. The patient states this discharge has been present for several weeks but does not bother her. Point-of-care testing of the vaginal fluid demonstrates a pH of 5.5. Addition of 10% potassium hydroxide to the fluid produces a strong amine odor. Microscopic evaluation of a saline wet mount reveals numerous sloughed squamous epithelial cells with their margins completely obscured by adherent coccobacilli. Which of the following is the most appropriate next step in management?

A $24$-year-old woman, gravida $1$, para $0$, at $30$ weeks gestation comes to the clinic reporting a sensation of breathlessness. The patient states she feels like she "cannot take a deep enough breath," especially when sitting quietly. She denies cough, wheezing, chest pain, or leg swelling. Her medical history is unremarkable, and her only medication is a daily prenatal vitamin. Blood pressure is $112/68$ mm Hg, pulse is $88$/min, respirations are $16$/min, and pulse oximetry is $99\%$ on room air. Physical examination reveals clear lungs bilaterally and no heart murmurs. The fundal height is $30$ cm. If an arterial blood gas were obtained from this patient, which of the following sets of values would most likely be expected?