Obstetrics and Gynecology

A $24$-year-old primigravida at $41$ weeks gestation is undergoing induction of labor for a post-term pregnancy. She is currently $5$ cm dilated, $100\%$ effaced, and the fetal presenting part is at $0$ station. Artificial rupture of membranes was performed one hour ago, releasing a small amount of clear fluid. Uterine contractions are occurring every $3$ minutes. The fetal heart rate tracing demonstrates a baseline of $135$/min with moderate variability. However, with nearly every contraction, there is an abrupt decrease in the fetal heart rate to $70$ to $80$/min that lasts for $40$ to $50$ seconds before rapidly returning to the baseline. The patient's vital signs include a blood pressure of $118/76$ mmHg, a heart rate of $92$/min, and a respiratory rate of $22$/min. She reports intense pain during contractions. The nursing staff has already changed the patient's position and administered an intravenous fluid bolus, but the abnormal fetal heart rate pattern persists. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical presentation of peripartum complications to the most accurate diagnostic etiology.

A 62-year-old female presents to the physician reporting two episodes of scant, brownish vaginal discharge over the past month. She achieved menopause at age 51. Her past medical history is notable for colon cancer treated with a right hemicolectomy at age 48, and genetic testing at that time confirmed an $MLH1$ gene mutation. She currently takes no daily medications. On pelvic examination, the external genitalia and vagina appear pale with loss of rugae. The cervix is flush with the vaginal vault and appears visually normal. A transvaginal ultrasound is performed in the office, revealing a homogeneous endometrial echo complex measuring $3$ mm in thickness, with normal-appearing bilateral ovaries. Which of the following is the most appropriate next step in management?

Pharmacotherapy and targeted interventions are mainstays in the management of various pelvic floor disorders, including overactive bladder, urgency urinary incontinence, and neurogenic bladder. Match each pharmacological agent or intervention with its most critical clinical contraindication or adverse effect profile.

For each patient scenario involving a potential or confirmed gynecologic malignancy, select the most appropriate evidence-based next step in clinical management.

A 31-year-old gravida 4, para 3 at 39 weeks of gestation delivers a 4300-g neonate via spontaneous vaginal delivery. Five minutes after the delivery of an intact placenta, she develops profuse vaginal bleeding. The uterus is palpated as soft and boggy at the level of the umbilicus. Her blood pressure is 95/55 mm Hg, and her pulse is 115/min. Bimanual uterine massage is performed, and a rapid intravenous infusion of oxytocin is started, but the hemorrhage persists. Assuming each subsequent step fails to arrest the bleeding, arrange the following management interventions in the correct chronological sequence from first to last.

Pair the following maternal and fetal clinical presentations with the correct obstetric complication.

A 32-year-old pregnant patient, gravida 2, para 1, presents to the obstetric triage unit at 38 weeks gestation reporting painful uterine contractions. The pregnancy has been notable for an anatomy ultrasound at 20 weeks showing a succenturiate placental lobe. Her temperature is 37.0 C (98.6 F), blood pressure is 112/70 mm Hg, and pulse is 86/min. The initial fetal heart rate baseline is 145/min with moderate variability and no decelerations. Cervical examination shows 5 cm dilation and intact membranes. Three hours into her admission, the patient experiences spontaneous rupture of membranes, accompanied by a moderate amount of bright red vaginal bleeding. Immediately following this event, the fetal heart rate tracing demonstrates a prolonged deceleration that evolves into a sinusoidal pattern with a baseline of 90/min. Uterine resting tone is normal, and contractions are occurring every 3 minutes. Which of the following is the most appropriate next step in management of this patient?

A 48-year-old woman comes to the clinic reporting a 3-week history of constant, small-volume urine leakage. She states that she never experiences a sudden urge to void, nor does the leakage worsen exclusively with coughing or laughing. However, she frequently feels that her bladder is full and reports a weak, hesitant urinary stream. The patient was diagnosed with multiple sclerosis five years ago and has had two prior exacerbations involving lower extremity weakness. Vital signs are within normal limits. Abdominal examination reveals a palpable, non-tender suprapubic mass. Neurologic examination shows symmetrically increased deep tendon reflexes in the lower extremities. Urinalysis is negative for leukocyte esterase and nitrites. A bladder ultrasound demonstrates a post-void residual volume of 450 mL.

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

A 68-year-old woman is brought to the clinic for evaluation of blood-tinged vaginal discharge that started 3 weeks ago. She attained menopause at age 52. Her medical history is significant for hypertension, obesity, and estrogen receptor-positive breast cancer diagnosed 3 years ago, for which she was treated with a lumpectomy and radiation therapy. She is currently taking tamoxifen. Pelvic examination reveals a small amount of dark blood in the vaginal vault. The cervix appears flush with the vagina and is severely stenotic. A transvaginal ultrasound shows an endometrial thickness of 14 mm with multiple small cystic spaces. An attempt to perform an in-office endometrial biopsy is unsuccessful because the sampling device cannot pass through the external cervical os, despite the use of a tenaculum and misoprostol preparation. Which of the following is the most appropriate next step in management?

A 16-year-old girl is brought to the clinic for evaluation of absent menarche. Her medical history is unremarkable. She is at the 10th percentile for height and 50th percentile for weight. Physical examination reveals absent breast development (Tanner stage I) and normal external female genitalia. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological sequence for the evaluation and management of this patient.

An 18-year-old college student presents to the emergency department complaining of progressive pelvic heaviness and a sudden exacerbation of sharp right lower abdominal pain that began 12 hours ago. A transabdominal ultrasound demonstrates a 14-cm complex right ovarian mass featuring prominent solid components. Her urine pregnancy test is negative. Arrange the following interventions in the most appropriate chronological sequence for the standard diagnostic workup and definitive management of this patient.

A multiparous patient in her late fifties reports involuntary loss of urine that occurs exclusively when she sneezes, coughs, or participates in high-impact aerobics. Physical examination confirms the diagnosis without evidence of concurrent urgency symptoms or significant pelvic organ prolapse. According to standard urogynecologic protocols for this specific condition, arrange the following therapeutic interventions in the correct order of clinical escalation, starting with the least invasive initial recommendation and progressing to definitive surgical treatments.

A $31$-year-old woman, gravida $0$, presents to the clinic for evaluation of a $14$-month history of inability to conceive. The patient and her partner have been engaging in regular, unprotected intercourse. Menarche occurred at age $12$. Her menses were previously regular, occurring every $28$ days, but over the past year, they have become irregular, occurring every $45$ to $60$ days. The patient has also noticed new, coarse dark hairs on her chin and upper lip. She reports feeling unusually fatigued recently, which she attributes to stress at her job, and has gained $6 \text{ kg}$ ($13.2 \text{ lbs}$) over the past $6$ months despite no changes in her diet.

Vital signs show a temperature of $36.6^\circ\text{C}$ ($97.9^\circ\text{F}$), blood pressure of $112/74 \text{ mmHg}$, and heart rate of $58\text{/min}$. Her body mass index (BMI) is $32 \text{ kg/m}^2$. Physical examination reveals coarse facial hair and dry skin. Pelvic examination is unremarkable.

Laboratory evaluation reveals the following:

Follicle-stimulating hormone (FSH): $5 \text{ mIU/mL}$
Luteinizing hormone (LH): $6 \text{ mIU/mL}$
Prolactin: $48 \text{ ng/mL}$ (Normal: $<20 \text{ ng/mL}$)
Thyroid-stimulating hormone (TSH): $14.5 \text{ \mu IU/mL}$ (Normal: $0.4-4.0 \text{ \mu IU/mL}$)
Free thyroxine (T4): $0.6 \text{ ng/dL}$ (Normal: $0.8-1.8 \text{ ng/dL}$)

A urine pregnancy test is negative.

Which of the following is the most appropriate initial management for this patient's inability to conceive?

A 27-year-old female patient seeks medical evaluation because she has been unable to conceive for the past year and a half. She notes that her menses are infrequent, occurring only 5 to 6 times per year. She also reports progressive, unwanted hair growth on her face and abdomen over the last four years. She has no other medical conditions and does not take any prescription medications. Her body mass index is 30 kg/m2 and blood pressure is 118/76 mm Hg. On physical examination, terminal hairs are noted on her chin, upper lip, and lower abdomen. No clitoromegaly or purple striae are observed. Transvaginal ultrasonography reveals polycystic morphology in both ovaries. Serum levels of prolactin and thyroid-stimulating hormone are within normal reference ranges. Which of the following is the most appropriate test to perform next to establish the etiology of her symptoms?

Concerned by a complete cessation of her menstrual cycles over the past six months, a female in her late twenties visits a specialist. She and her partner have been having regular, unprotected intercourse for the past 14 months without a pregnancy. The patient expresses significant distress regarding a recent, rapid increase in coarse hair growth on her chin, chest, and lower abdomen, as well as a noticeable deepening of her voice. She has no chronic medical conditions and takes no medications. Her blood pressure is 122/78 mmHg, and her body mass index is 24 kg/m². Physical examination reveals temporal hair thinning, severe nodulocystic acne, and prominent clitoromegaly. Bimanual pelvic examination is unremarkable. Transvaginal ultrasonography reveals normal-sized ovaries lacking any cystic changes or solid masses. A urine pregnancy test is negative. Which of the following is the most appropriate next step in the evaluation of this patient?

Match each clinical and laboratory presentation of secondary amenorrhea to the most likely underlying etiology.

Match each of the following clinical scenarios describing patients presenting for fertility evaluation to the most appropriate primary therapeutic intervention or assisted reproductive technology.

A 24-year-old nulliparous woman at 40 weeks gestation is evaluated in the labor and delivery unit due to painful uterine contractions. She has no significant past medical history, and her prenatal care has been routine. On admission, her blood pressure is 118/76 mm Hg and her pulse is 78/min. Cervical examination shows 5 cm dilation and 90% effacement. The fetal head is engaged. A lumbar epidural is placed for pain control. Twenty minutes later, the patient complains of dizziness and nausea. Repeat maternal vital signs show a blood pressure of 82/45 mm Hg and a pulse of 105/min. The continuous fetal monitor displays a baseline heart rate of 125/min, minimal variability, and symmetric decreases in the fetal heart rate that nadir after the peak of the uterine contractions. Uterine contractions are occurring every 3 to 4 minutes and lasting 60 seconds.

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

Match each clinical presentation of an obstetric complication with its most likely diagnosis.