Obstetrics and Gynecology

A 23-year-old nulligravid woman presents to the emergency department with a 3-day history of progressively worsening lower abdominal pain, high fever, and nausea. Her temperature is 39.2°C (102.6°F), blood pressure is 112/72 mmHg, and pulse is 114/min. Abdominal examination reveals marked bilateral lower quadrant tenderness with voluntary guarding. Arrange the following steps in the most appropriate sequence for the evaluation and management of this patient's suspected complicated pelvic inflammatory disease.

A healthy 26-year-old primigravida presents to the clinic for her first obstetric evaluation at 8 weeks of gestation. Vital signs are within normal limits, with a blood pressure of 108/68 mm Hg, a heart rate of 76/min, and a body mass index (BMI) of 23 kg/m $^2$. Her medical history is unremarkable. During the consultation, she expresses curiosity about the timeline of the physical and internal changes her body will undergo in the coming months. The physician explains the expected progression of normal maternal physiological adaptations. Arrange the following physiological and anatomical milestones of a normal pregnancy in the correct chronological sequence of their occurrence or peak, from earliest in gestation to latest.

Seeking medical advice for the absence of her menstrual periods over the past eight months, an unmarried twenty-six-year-old nulligravida arrives at the outpatient clinic. Her prior menstrual cycles occurred regularly every thirty days. She reports feeling profoundly fatigued and has noticed a $5$-kg ($11$-lb) weight gain over the past year despite maintaining her usual diet. Recently, she began experiencing intermittent morning headaches.

Vital signs are blood pressure $108/70$ mm Hg, pulse $56$/min, and BMI $27$ kg/m $^2$. Physical examination shows delayed relaxation of the deep tendon reflexes and bilateral galactorrhea upon breast expression. There is no facial hirsutism or acne. A point-of-care urine pregnancy test is negative.

Laboratory studies reveal the following:

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

A gravida 1 para 0 at 39 weeks and 5 days of gestation is admitted to the labor and delivery unit in active labor. Her prenatal course was uncomplicated. Her temperature is 37.1°C (98.8°F), blood pressure is 122/78 mm Hg, and pulse is 88/min. The estimated fetal weight is 3,200 g (7 lb 1 oz). Cervical examination shows 6 cm dilation, 90% effacement, and 0 station. Spontaneous rupture of membranes occurred 3 hours ago, revealing clear amniotic fluid. Uterine contractions are occurring every 3 to 4 minutes and palpate as strong. Continuous external fetal monitoring demonstrates a baseline heart rate of 145/min with moderate variability. There are recurrent, abrupt decreases in the fetal heart rate to 90/min that last for 45 to 60 seconds before rapidly returning to baseline; these decreases occur with almost every contraction. Maternal repositioning to the left lateral decubitus position and administration of an intravenous fluid bolus were performed 15 minutes ago, but the fetal heart rate pattern remains unchanged. Which of the following is the most appropriate next step in management?

A 48-year-old female presents to the gynecology clinic reporting a 3-month history of postcoital bleeding and foul-smelling vaginal discharge. She has not received regular medical care or cancer screening for over a decade. Pelvic examination reveals a 5-centimeter friable, exophytic mass replacing the cervix and extending into the upper third of the vaginal wall. There is nodularity in the bilateral parametria on rectovaginal examination. Arrange the following steps in the correct chronological order for the optimal diagnosis, staging, and definitive management of this patient's condition.

An otherwise healthy 26-year-old woman presents to the ambulatory care center complaining of pelvic pain and abnormal vaginal discharge that began 3 days ago. She describes the pain as a dull, continuous ache in her lower abdomen that worsens with intercourse. She denies any nausea, vomiting, or subjective fever. Her medical history is unremarkable, and she has been using a levonorgestrel-releasing intrauterine device for contraception over the past two years. Her last menstrual period was three weeks ago. She reports having a new male sexual partner as of two months ago. Vital signs show a temperature of 37.6 C (99.7 F), blood pressure of 112/74 mm Hg, and a heart rate of 84/min. Abdominal palpation elicits mild tenderness in the bilateral lower quadrants but no rebound tenderness or guarding. On pelvic examination, the intrauterine device strings are visible at the cervical os. Purulent material is seen exuding from the endocervical canal. Bimanual examination demonstrates pronounced cervical motion tenderness and bilateral adnexal tenderness without discrete masses. A urine pregnancy test is negative. Which of the following is the most appropriate next step in management?

A 32-year-old woman, gravida 3, para 2, at 36 weeks gestation is evaluated in the clinic for a routine prenatal visit. Her pregnancy has been uncomplicated. While lying flat on the examination table for fundal height measurement, she suddenly complains of dizziness, nausea, and shortness of breath. She appears pale and diaphoretic. Her blood pressure is 82/50 mm Hg, and her heart rate is 115/min. Upon rolling onto her left side, her symptoms resolve within a few minutes. Her repeat blood pressure is 112/70 mm Hg with a heart rate of 82/min. Which of the following is the most likely mechanism responsible for this patient's initial presentation?

Review the following patient clinical histories and epidemiological profiles. Identify the specific gynecologic malignancy that each patient is at the highest statistical risk of developing.

A 56-year-old woman, gravida 2, para 2, comes to the office due to a 1-month history of intermittent vaginal spotting and new-onset breast tenderness. Her last menstrual period was 5 years ago. She has no significant past medical history and takes no medications. Vital signs are within normal limits. Body mass index is $23 \text{ kg/m}^2$. Pelvic examination reveals normal external genitalia and vagina. The cervix appears grossly normal. Bimanual examination is notable for an $8 \text{ cm}$, mobile, non-tender right adnexal mass. The uterus is of normal size and mobility. Transvaginal ultrasound demonstrates an $8.5 \text{ cm}$ complex, multiloculated solid and cystic right ovarian mass. The endometrial stripe thickness is $14 \text{ mm}$. Which of the following is the most appropriate next step in management?

A 26-year-old woman, G1P0, at 40 weeks and 2 days gestation, is currently in the active phase of the first stage of labor. Cervical examination reveals 7 cm dilation, complete effacement, and +1 station. Spontaneous rupture of membranes occurred four hours ago, revealing clear fluid. The patient is receiving an epidural for analgesia and an intravenous oxytocin drip to optimize uterine contractility. Maternal vital signs are within normal limits. The continuous fetal monitor shows a baseline heart rate of 142/min with moderate variability. The tracing also reveals gradual, symmetric drops in the fetal heart rate that consistently start after the peak of each uterine contraction, with the lowest point of the drop occurring after the contraction resolves. These drops are observed with more than half of the contractions. Which of the following is the most appropriate next action in the care of this patient?

Routine cervical cancer screening is performed on a 44-year-old patient during her annual health maintenance visit. The patient has a medical history significant for type 2 diabetes mellitus and a body mass index of $33 \text{ kg/m}^2$. She reports that her menstrual cycles occur every 28 days and last for 5 days with moderate flow. She has two children delivered vaginally at term. The laboratory reports the cytology results as atypical glandular cells. Speculum examination reveals a parous cervix with no visible lesions. Bimanual examination demonstrates a normal-sized, mobile uterus and no adnexal tenderness. Which of the following is the most appropriate next step in the management of this patient?

An uncomplicated pregnant patient presents for evaluation at $28$ weeks of gestation for her scheduled obstetric follow-up. The $25$-year-old nulliparous woman reports feeling well, with only mild generalized fatigue and occasional lower back pain. She explicitly denies abdominal pain, nausea, vomiting, or skin itchiness. Her blood pressure is $112/70$ mm Hg, and her pulse is $82$/min. Physical examination reveals a gravid uterus consistent with dates and no right upper quadrant tenderness. The skin shows no excoriations or jaundice.

Routine laboratory results are as follows:

Hemoglobin: $11.2$ $g/dL$
Platelet count: $195,000/\mu L$
Aspartate aminotransferase (AST): $24$ $U/L$
Alanine aminotransferase (ALT): $28$ $U/L$
Alkaline phosphatase: $285$ $U/L$ (Reference: $40-120$ $U/L$)
Total bilirubin: $0.6$ $mg/dL$

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

A 15-year-old girl is brought to the clinic by her parents due to the absence of menarche. She reports no cyclical lower abdominal pain. A urine beta-hCG test obtained in the clinic is negative. Her height is at the 5th percentile for her age, and her weight is at the 40th percentile. Vital signs are within normal limits. Physical examination reveals Tanner stage 1 breast development and Tanner stage 1 pubic hair. She has a broad chest with widely spaced nipples and a low posterior hairline. Arrange the following diagnostic steps in the most appropriate sequential order to evaluate and manage this patient's condition.

A $26$-year-old woman, gravida $1$, para $0$, presents to the obstetrics clinic to establish prenatal care. Her vital signs are within normal limits, and her medical history is unremarkable. She reports irregular menstrual cycles and is uncertain of her last menstrual period. Her physician explains how pregnancy progression is tracked using early ultrasound findings followed by standardized physical examination landmarks. Arrange the following expected clinical and sonographic milestones for this patient in the correct chronological sequence from the earliest gestational age to the latest.

Match each clinical and laboratory profile of a patient presenting with primary amenorrhea to the most likely underlying diagnosis.

A 29-year-old woman, who delivered a healthy infant four weeks ago, is evaluated for sudden-onset fever, chills, and left-sided breast pain. She has been exclusively breastfeeding since delivery. Her temperature is $38.4^\circ$ C ($101.1^\circ$ F), blood pressure is $112/70$ mm Hg, and pulse is $98$/min. Physical examination of the left breast reveals a focal, wedge-shaped area of erythema, warmth, and induration in the upper outer quadrant that is markedly tender to palpation. There is no palpable fluctuance, skin retraction, or purulent nipple discharge. The right breast is unremarkable. Which of the following is the most appropriate next step in management?

For her annual well-woman examination, a twenty-seven-year-old female is evaluated in the ambulatory care center. She is seeking advice on initiating a highly reliable form of birth control, having recently entered a new sexual relationship. Her medical background is notable for polycystic ovary syndrome (PCOS), currently managed solely through lifestyle modifications, with menses occurring unpredictably every 6 to 8 weeks. Additionally, eight weeks ago, she developed an unprovoked right lower extremity deep vein thrombosis (DVT) and is presently anticoagulated with oral apixaban. Her vital signs are within normal limits, though her body mass index is 31.5 kg/m². A bimanual pelvic exam demonstrates a normal-sized, mobile uterus with no adnexal masses. A urine pregnancy test is negative. In light of her complex medical history, which of the following represents the optimal choice for preventing pregnancy in this individual?

Match each patient's clinical presentation to the most likely underlying breast disorder.

A 29-year-old woman, gravida 1, para 0, at 40 weeks gestation is admitted to the labor and delivery unit in spontaneous labor. Her pregnancy has been uncomplicated. Four hours after admission, her cervical examination reveals 6 cm dilation, 90% effacement, and -1 station. She is currently receiving an intravenous oxytocin infusion for labor augmentation due to inadequate cervical progression. Her temperature is 37.1°C (98.8°F), blood pressure is 120/78 mm Hg, and pulse is 88/min. Continuous fetal monitoring shows a baseline heart rate of 145/min with moderate variability. Over the last 30 minutes, there is an average of 7 contractions in a 10-minute window. The fetal heart rate tracing demonstrates symmetric, gradual decreases in the fetal heart rate that begin after the peak of the contraction and return to baseline after the contraction ends. These decelerations are occurring with nearly every contraction. Which of the following is the most appropriate next step in management?

A 44-year-old woman presents to the emergency department on postoperative day 8 following an uncomplicated total abdominal hysterectomy for symptomatic adenomyosis. She reports a 2-day history of worsening lower abdominal pain, severe chills, and foul-smelling vaginal discharge. Her temperature is 39.2°C (102.6°F), blood pressure is 102/68 mm Hg, heart rate is 112/min, and respiratory rate is 18/min. Physical examination reveals localized lower abdominal tenderness with guarding and purulent discharge pooling at the vaginal cuff. Arrange the following management steps in the most appropriate chronological sequence for this patient.