Obstetrics and Gynecology

A 66-year-old G3P3 woman is evaluated on postoperative day 2 following a vaginal uterosacral ligament hysteropexy and anterior colporrhaphy for symptomatic stage III pelvic organ prolapse. She reports right-sided back pain, nausea, and mild vaginal spotting. The Foley catheter was removed yesterday, and she has been voiding spontaneously in adequate volumes.

Physical examination reveals marked right costovertebral angle tenderness. The vaginal vault is intact with minimal serosanguinous discharge.

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

A 71-year-old multiparous woman is evaluated in the urogynecology clinic for a persistent vaginal bulge and pelvic pressure that has progressively worsened over the past year. She also reports a single episode of scant, bright red vaginal spotting three weeks ago, which she attributed to the bulge rubbing against her clothing. She went through menopause at age 52 and has not seen a physician in over a decade. Her medical history includes well-controlled hypertension. On physical examination, there is stage III pelvic organ prolapse with the cervix protruding past the hymenal ring. A 1.5-cm superficial, non-bleeding erosion is noted on the dependent portion of the prolapsed cervix. A transvaginal ultrasound reveals a homogeneous endometrial stripe of 8 mm and normal-appearing adnexa. Which of the following is the most appropriate next step in the management of this patient?

An otherwise healthy 39-year-old woman presents to the reproductive endocrinology clinic to discuss her difficulty becoming pregnant. For the last 10 months, she and her male partner have engaged in regular, unprotected coitus targeting her fertile window. Her menstrual cycles occur regularly every 24 to 25 days, with menses lasting 4 days. She notes that in her early twenties, her cycles were consistently 28 days long. She reports mild, intermittent facial acne that she has had since her teenage years, as well as occasional night sweats occurring a few days prior to the onset of her period. Medical and surgical history are unremarkable. She takes a daily prenatal vitamin. Vital signs are within normal limits, and her body mass index is $22 \text{ kg/m}^2$. Bimanual pelvic examination reveals a normal-sized, mobile uterus with no adnexal masses. Her partner's semen analysis shows normal volume, concentration, and motility. Initial laboratory testing on the third day of her menstrual cycle reveals the following:

Which of the following is the most likely primary underlying mechanism for this patient's difficulty conceiving?

A 61-year-old woman is evaluated for a 1-year history of sudden, overwhelming urges to urinate accompanied by frequent, large-volume urinary leakage. She has no neurologic deficits, and a recent urinalysis was unremarkable. Post-void residual volume is 25 mL. Evaluation confirms non-neurogenic urgency urinary incontinence. According to standard clinical guidelines, arrange the following therapeutic interventions in the correct escalating sequence, starting from the initial first-line approach to the treatment of last resort for severely refractory symptoms.

A 26-year-old woman is undergoing a suction dilation and curettage for a missed abortion. During the procedure, the physician notes a sudden loss of resistance while advancing the suction curette. Upon withdrawing the instrument, yellow, fatty tissue is seen within the cannula. The patient is under monitored anesthesia care. Her blood pressure is 105/65 mm Hg and heart rate is 102/min.

Arrange the following management steps in the most appropriate chronological sequence for this patient's acute complication.

A 23-year-old nulliparous woman comes to the clinic because she found a lump in her right breast 2 weeks ago. She has no family history of breast cancer or other malignancies. Menarche was at age 12, and her menses are regular, occurring every 28 days. She takes no medications. On physical examination, her temperature is 37.0°C (98.6°F), blood pressure is 110/70 mm Hg, and pulse is 72/min. Breast examination reveals a 2-cm, firm, mobile, rubbery, well-circumscribed, non-tender mass in the upper outer quadrant of the right breast. There is no overlying skin erythema, dimpling, nipple retraction, or abnormal discharge. Examination of the axillae reveals no palpable lymphadenopathy. Which of the following is the most appropriate next step in evaluation?

A 31-year-old woman comes to the reproductive endocrinology clinic due to an inability to conceive for the past 14 months. Her menstrual periods were regular until two years ago, when they became irregular, and she has had no menses for the past 8 months. During this time, she has gained 8 kg (17.6 lb) and reports progressive fatigue, cold intolerance, and constipation. She also reports occasional clear, milky discharge from both nipples. Her BMI is 28.5 kg/m². Vital signs show a pulse of 54/min and a blood pressure of 105/65 mmHg. Physical examination reveals delayed relaxation of the deep tendon reflexes and bilateral galactorrhea. Pelvic examination is normal. A urine pregnancy test is negative.

Laboratory evaluation shows:
Follicle-stimulating hormone: 2.2 mIU/mL
Luteinizing hormone: 1.8 mIU/mL
Prolactin: 78 ng/mL (normal: 4-23 ng/mL)
Thyroid-stimulating hormone (TSH): 0.2 mU/L (normal: 0.5-5.0 mU/L)
Free thyroxine (T4): 0.4 ng/dL (normal: 0.9-1.7 ng/dL)

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

A 22-year-old woman presents to the emergency department with acute-onset, severe bilateral lower abdominal pain and a fever of 38.8°C (101.8°F). She is sexually active with a new partner and states her last menstrual period was 6 weeks ago. Her blood pressure is 110/70 mm Hg, and pulse is 108/min.

Arrange the following steps in the most appropriate chronological order for evaluating and managing this patient's condition, from first to last.

A 76-year-old woman comes to the clinic reporting a 6-month history of a vaginal bulge and pelvic pressure. She notes significant difficulty with bowel movements, frequently needing to press on the skin between her vagina and rectum to completely empty her bowels. Today, she noticed a few spots of blood on her undergarments. Her medical history is significant for severe chronic obstructive pulmonary disease requiring continuous home oxygen therapy, and a myocardial infarction 3 months ago. Her current medications include aspirin, metoprolol, atorvastatin, and a tiotropium inhaler. On pelvic examination, there is a prominent bulge of the posterior vaginal wall that extends 3 cm beyond the hymenal ring with the Valsalva maneuver. The cervix is flush with the vaginal vault and has no active bleeding or lesions. There is a superficial 3-mm mucosal ulceration on the dependent portion of the prolapsed posterior vaginal wall that oozes a small amount of blood when touched. Which of the following is the most appropriate next step in management?

A $34$-year-old gravida $3$, para $2$ at $37$ weeks gestation is brought to the labor and delivery triage complaining of a sudden onset of intense, constant abdominal pain accompanied by a moderate amount of dark red vaginal bleeding. Her medical history is significant for chronic hypertension. Her vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $168/105\text{ mmHg}$, heart rate of $112/\text{min}$, and respiratory rate of $18/\text{min}$. Physical examination reveals a uniformly rigid and exquisitely tender uterus. A bedside ultrasound confirms a live fetus in cephalic presentation but does not visualize a retroplacental hematoma. Laboratory studies display a hemoglobin level of $10.6\text{ g/dL}$ and a platelet count of $140,000/\text{mm}^3$. The continuous fetal monitor indicates a baseline heart rate of $105/\text{min}$, absent variability, and recurrent late decelerations. Which of the following is the most appropriate next step in the management of this patient?

During a routine health maintenance visit, a 61-year-old G2P2 complains of a three-month history of progressive abdominal bloating, early satiety, and pelvic heaviness. Her last menstrual period was 10 years ago, and she has never used hormone replacement therapy. Vital signs are within normal limits. Abdominal examination reveals fullness in the lower quadrants. Bimanual pelvic examination identifies a palpable, firm, irregular, and fixed mass in the right adnexa. Arrange the following steps in the most appropriate chronological sequence for the diagnostic workup and therapeutic management of this patient.

A 74-year-old woman is brought to the clinic by her son for evaluation of urinary incontinence that has worsened over the past 6 months. The patient experiences sudden, overwhelming urges to urinate and frequently leaks large amounts of urine before she can reach the bathroom. These episodes occur during both the day and night. She has attempted pelvic floor muscle exercises and timed voiding for the last 3 months with minimal benefit. The patient denies dysuria, hematuria, or abdominal pain. Her medical history is significant for hypertension, hyperlipidemia, and mild Alzheimer dementia. Her current medications are amlodipine, atorvastatin, and donepezil. Vital signs are within normal limits. Pelvic examination demonstrates healthy, well-estrogenized vaginal mucosa without evidence of pelvic organ prolapse. A bladder scan shows a post-void residual volume of 30 mL. Urinalysis is negative for leukocyte esterase, nitrites, and blood. Which of the following is the most appropriate next step in management?

A $68$-year-old nulliparous woman comes to the clinic for a $1$-month history of intermittent vaginal spotting. She went through menopause at age $52$. Her medical history is significant for obesity (BMI $36 \text{ kg/m}^2$), type 2 diabetes mellitus, and essential hypertension. She takes metformin and lisinopril. Vital signs are within normal limits. Pelvic examination reveals normal external genitalia and a small amount of dark blood at the cervical os. Bimanual examination is limited by body habitus. A transvaginal ultrasound demonstrates an endometrial stripe thickness of $14 \text{ mm}$ with a heterogeneous appearance. No adnexal masses are noted. An office endometrial biopsy is attempted, but the sampling catheter cannot be advanced past the internal cervical os due to severe cervical stenosis. The patient reports significant discomfort, and the procedure is aborted. Which of the following is the most appropriate next step in management?

Match each clinical presentation of a urogynecologic condition with the most appropriate therapeutic intervention, taking into account the patient's specific comorbidities.

A 34-year-old woman comes to the office to establish care. Her primary concern today is an intense, burning vaginal itch accompanied by a thick, white discharge that began five days ago. She is particularly distressed because this marks her fourth identical presentation in the past ten months. She notes that during each of the three prior occurrences, a clinician at a local urgent care prescribed a single antifungal tablet that provided complete relief within days, only for the symptoms to return a few months later. Her medical history is significant for type 2 diabetes mellitus, and her most recent hemoglobin A1c was 8.4%. On pelvic examination, there is marked erythema and edema of the vulva and vagina, with adherent, curd-like discharge in the vaginal vault. The vaginal pH is 4.2. A wet mount preparation with 10% potassium hydroxide reveals abundant budding yeast and pseudohyphae. Which of the following is the most appropriate pharmacologic management strategy for this patient?

Match each patient's clinical and urodynamic presentation with the most accurate underlying pathophysiologic diagnosis.

A multiparous 62-year-old patient comes to the physician seeking treatment for involuntary urinary leakage that has progressively worsened over the past year. She describes two distinct patterns: losing small amounts of urine during physical exertion (such as lifting groceries) and experiencing a sudden, overwhelming need to void that sometimes results in larger volume leakage before she can reach the toilet. She takes no daily medications. Pelvic examination reveals normal vaginal estrogenization and a positive cough stress test. Assuming the patient's symptoms persist and fail to improve adequately at each successive stage of treatment, arrange the following clinical interventions in the correct sequential order from initial presentation to definitive management.

An evaluation is requested for a 36-year-old female patient presenting with ongoing urinary difficulties. For the past four months, she has experienced sharp pain during micturition, significant discomfort during sexual intercourse, and involuntary fluid leakage. She specifically notes that small amounts of urine continuously dribble from her vagina immediately after she stands up from the toilet. Despite completing two separate courses of empirical oral antibiotics for presumed cystitis over the last half-year, her symptoms have not resolved. A urine culture obtained one week ago demonstrates no bacterial growth. Vital signs are within normal limits. On pelvic examination, the provider palpates a 3-cm, tender, fluctuant mass situated on the anterior vaginal wall. When gentle upward pressure is applied to this structure, a small volume of purulent fluid is expressed from the urethral meatus. Which of the following is the most appropriate next step in the management of this patient?

During an initial reproductive endocrinology consultation, a 27-year-old woman seeks evaluation for an inability to conceive over the past 16 months. She previously experienced regular 28-day menstrual cycles, but they became progressively infrequent and completely ceased 8 months ago. Detailed history reveals that over the past year, the patient transitioned to a strict ketogenic diet and began high-intensity training for an ultramarathon, resulting in an intentional 9-kg weight loss. She notes a recent increase in mild facial acne. Her current body mass index is $19.8 \text{ kg/m}^2$. Vital signs are within normal limits. Pelvic ultrasonography reveals a normal-appearing uterus and bilaterally enlarged ovaries, each containing 15 to 20 small, subcapsular follicles measuring 4 to 8 mm.

Laboratory studies show the following:
Follicle-stimulating hormone: 1.8 mIU/mL
Luteinizing hormone: 1.1 mIU/mL
Estradiol: 15 pg/mL
Prolactin: 9 ng/mL
Thyroid-stimulating hormone: 1.6 mU/L
Total testosterone: 25 ng/dL

Her partner's semen analysis is within normal limits. The patient strongly desires immediate pregnancy and strictly declines any modifications to her current diet or exercise regimen. Which of the following is the most appropriate pharmacologic intervention to induce ovulation in this patient?

Match each gynecologic procedure or intraoperative surgical step to its most classically associated complication or risk.