Obstetrics and Gynecology

A 32-year-old woman, gravida 2, para 1, at 39 weeks gestation is evaluated in the labor and delivery unit. She is in spontaneous active labor and attempting a trial of labor after cesarean (TOLAC), having had a primary low transverse cesarean delivery three years ago. Epidural analgesia was placed two hours ago and has provided excellent pain relief. Over the past 15 minutes, the patient reports the sudden onset of severe, continuous lower abdominal pain that radiates to her shoulder, which she describes as "breaking through" the epidural. Her temperature is 37.0°C (98.6°F), blood pressure is 88/50 mm Hg, and heart rate is 122/min. The fetal heart rate tracing previously demonstrated a baseline of 145/min with moderate variability but now shows profound and persistent bradycardia at 75/min. On vaginal examination, the cervix is 6 cm dilated and 90% effaced. The fetal presenting part is now palpated at -3 station; it was at 0 station on the previous examination an hour ago. Which of the following is the most appropriate next step in management?

A 32-year-old woman with a history of severe pelvic inflammatory disease and bilateral tubal occlusion is preparing to undergo in vitro fertilization (IVF). She and her partner are reviewing the upcoming treatment protocol with their reproductive endocrinologist. Arrange the following steps of a standard IVF cycle in the correct chronological order from first to last.

Match each third-trimester obstetric clinical presentation with its corresponding underlying pathophysiology.

A 26-year-old primigravid woman at 40 weeks gestation is evaluated in the labor and delivery unit. She was admitted earlier today for induction of labor due to oligohydramnios. The patient is currently receiving a continuous intravenous oxytocin infusion. Her cervix is 6 cm dilated, 100% effaced, and the fetal presenting part is at 0 station. Maternal temperature is 37.1°C (98.8°F), blood pressure is 122/78 mm Hg, and pulse is 88/min. Uterine contractions are occurring every 3 minutes. Continuous fetal heart rate monitoring demonstrates a baseline of 140/min with moderate variability. Over the past 20 minutes, there are recurrent, gradual decreases in the fetal heart rate; the nadir of each decrease consistently occurs after the peak of the associated uterine contraction, with a slow return to baseline. Which of the following is the most appropriate next step in the management of this patient?

Match the following causes of primary and secondary amenorrhea with their defining pathophysiologic mechanism.

Following an uncomplicated, precipitous vaginal delivery of a 4,300-g (9-lb 8-oz) neonate, a multiparous patient develops massive vaginal bleeding. The placenta was delivered intact 15 minutes ago. Physical examination reveals a maternal heart rate of 115/min and a blood pressure of 92/58 mm Hg. The uterus feels enlarged, soft, and poorly contracted on abdominal palpation. Arrange the following management steps for this patient's condition in the correct sequential order of escalation, from the most appropriate initial intervention to the definitive final procedure.

Accurate interpretation of serum hormone levels is a critical first step in evaluating patients presenting with ovulatory dysfunction and infertility. Match each distinct reproductive laboratory profile below with the most likely corresponding etiology.

An infertility evaluation is initiated for a couple who have been unable to achieve a pregnancy despite having regular, unprotected intercourse for the past $18$ months. The female partner is $27$ years of age. She reports that since discontinuing oral contraceptive pills a year and a half ago, she has not experienced a single menstrual period. Prior to starting oral contraceptives at age $18$, her menstrual cycles occurred irregularly every $3$ to $5$ months. She competes in triathlons and maintains a strict vegan diet. Her body mass index is $17.5 \text{ kg/m}^2$. Vital signs show a blood pressure of $90/60 \text{ mmHg}$ and a pulse of $50/min$. Physical examination reveals Tanner stage V breast development and normal pubic hair, with no hirsutism, acne, or thyromegaly. Pelvic ultrasound demonstrates a normal-appearing uterus with a thin endometrial stripe ($3 \text{ mm}$) and small, bilateral ovaries without cysts. Laboratory evaluation shows:

After $6$ months of concerted efforts at nutritional rehabilitation and exercise reduction, her body mass index remains $17.8 \text{ kg/m}^2$ and her amenorrhea persists. Which of the following is the most appropriate next step in medical management to help this patient conceive?

A hospitalized patient is evaluated in the labor unit. She is in her first pregnancy at 38 weeks of gestation and was admitted 3 hours ago in spontaneous active labor. Artificial rupture of membranes was performed shortly after admission, yielding a small amount of clear fluid. Her vital signs are temperature 37.0°C (98.6°F), blood pressure 118/72 mm Hg, and pulse 85/min. Uterine contractions are occurring every 3 to 4 minutes. Continuous electronic monitoring reveals a baseline fetal heart rate of 145/min with moderate variability. Coinciding with the majority of uterine contractions, the tracing shows recurrent, sudden drops in the heart rate to a nadir of 85/min. These decreases last for 30 to 50 seconds before rapidly recovering to the baseline rate. Which of the following is the most appropriate initial management for this patient?

A 32-year-old G2P1 woman at 35 weeks gestation is brought to the obstetric triage unit after experiencing a sudden gush of clear fluid from her vagina, followed immediately by moderate, painless vaginal bleeding. She recently immigrated and has not received regular prenatal care, missing her second-trimester anatomy ultrasound. Her temperature is 36.9°C (98.4°F), blood pressure is 112/72 mm Hg, pulse is 90/min, and respirations are 16/min. Speculum examination reveals clear fluid mixed with bright red blood pooling in the posterior vaginal fornix. The fetal heart rate tracing demonstrates a continuous, smooth, undulating baseline of 140/min with a wave frequency of 4 cycles per minute, absent short-term variability, and no accelerations or true decelerations. Which of the following is the most appropriate next step in management?

Paramedics bring a pregnant patient to the emergency department after she suffered a witnessed generalized tonic-clonic convulsion at home. The patient's partner reports that she has been experiencing severe headaches and visual changes for the past two days. She is currently at 37 weeks gestation. Upon arrival in the trauma bay, the patient is actively seizing. Her blood pressure is 176/114 mmHg. Oxygen saturation is 96% on room air, and her airway remains patent. Fetal heart rate monitoring is not yet established. Arrange the following acute management steps in the most appropriate chronological sequence for this patient.

An evaluation for secondary amenorrhea and secondary infertility is requested for a 32-year-old woman. She reports that she has not menstruated since the delivery of her first child 14 months ago. The patient's pregnancy was complicated by placental abruption at 37 weeks gestation, which resulted in hemorrhagic shock requiring the transfusion of six units of packed red blood cells. Following delivery, she experienced profound lactational failure despite multiple interventions by a lactation consultant. Over the past six months, she has also noted worsening lethargy, unintentional weight gain, and cold intolerance. Her body mass index is $22 \text{ kg/m}^2$. Vital signs show a blood pressure of $92/60 \text{ mmHg}$ and a heart rate of $56/\text{min}$. Physical examination reveals a loss of axillary and pubic hair, as well as a delayed relaxation phase of the deep tendon reflexes.

Laboratory studies are obtained with the following results:
- Thyroid-stimulating hormone (TSH): $0.1 \text{ \mu U/mL}$ (Normal: $0.4-4.0 \text{ \mu U/mL}$)
- Free thyroxine (T4): $0.5 \text{ ng/dL}$ (Normal: $0.9-1.7 \text{ ng/dL}$)
- Follicle-stimulating hormone (FSH): $2.0 \text{ mIU/mL}$ (Normal for follicular phase: $3-10 \text{ mIU/mL}$)
- Luteinizing hormone (LH): $1.1 \text{ mIU/mL}$ (Normal for follicular phase: $2-12 \text{ mIU/mL}$)
- Prolactin: $1.5 \text{ ng/mL}$ (Normal: $4-25 \text{ ng/mL}$)

Which of the following is the most likely underlying etiology of this patient's reproductive failure?

A $33$-year-old woman comes to the clinic due to a $14$-month history of inability to conceive. She and her husband have regular, unprotected intercourse. Menarche was at age $12$. Her menstrual cycles were previously regular, but they became irregular $2$ years ago. For the past $6$ months, she has had no menses. She reports intermittent episodes of sudden warmth and sweating, particularly at night. She has no significant past medical history and takes no medications. Vital signs are within normal limits. BMI is $22 \text{ kg/m}^2$. Pelvic examination shows pale, thin vaginal mucosa with loss of rugae. The uterus is of normal size and adnexa are nonpalpable.

Laboratory studies show the following:

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

A 29-year-old woman with a body mass index of $34 \text{ kg/m}^2$ and a known diagnosis of polycystic ovary syndrome (PCOS) presents for an infertility evaluation. She and her partner have been unable to conceive after 18 months of regular, unprotected intercourse. Her partner's semen analysis is normal, and a hysterosalpingogram confirms patent fallopian tubes bilaterally. Arrange the following management steps in the correct sequential order from the most appropriate initial intervention to the most advanced therapy.

Identify the most appropriate obstetric emergency for each of the following distinct clinical scenarios describing patients presenting to the labor and delivery triage unit.

A 31-year-old G2P1 woman at 39 weeks gestation is admitted to the labor and delivery unit for a trial of labor after a prior low transverse cesarean delivery. She is receiving an intravenous oxytocin infusion for labor augmentation. Her most recent cervical examination 1 hour ago showed 7 cm dilation, 90% effacement, and the fetal head at +1 station. The patient suddenly reports intense, tearing lower abdominal pain that radiates to her chest. The intrauterine pressure catheter shows a sudden loss of baseline uterine tone and the cessation of regular contractions. Continuous fetal heart rate monitoring demonstrates a prolonged deceleration to 75/min. On repeat pelvic examination, the cervix is unchanged, but the fetal presenting part is now ballotable at -2 station. Her blood pressure is 85/45 mm Hg, and her pulse is 125/min. Which of the following is the most appropriate next step in management?

A 26-year-old woman comes to the office due to an 8-month history of an inability to conceive and absent menses. Menarche occurred at age 13, and her menses were previously regular, occurring every 28 days. Over the past 6 months, she has noticed increased hair growth on her face and chest, severe acne, and a deepening of her voice. She and her husband have been having unprotected intercourse regularly for the past year. She has no significant past medical history and takes no medications. Vital signs are temperature $37.1 \ ^\circ\text{C} \ (98.8 \ ^\circ\text{F})$, blood pressure $118/74 \text{ mmHg}$, pulse $78\text{/min}$, and respirations $16\text{/min}$. BMI is $24 \text{ kg/m}^2$. Physical examination reveals moderate acne on the cheeks and jawline, as well as coarse, dark terminal hair on the upper lip, chin, and periareolar areas. Pelvic examination reveals clitoromegaly. Bimanual examination shows a normal-sized uterus, but is otherwise limited due to patient guarding. A urine pregnancy test is negative. Laboratory studies show a serum thyroid-stimulating hormone (TSH) level of $1.9 \ \mu\text{U/mL}$ and a serum prolactin level of $11 \text{ ng/mL}$. Which of the following is the most appropriate next step in evaluation?

A 27-year-old woman presents to the clinic with an 8-month history of absent menses. She previously had regular 28-day menstrual cycles. Her body mass index is 22 kg/m $^2$ and physical examination is unremarkable. A urine $\beta$-hCG test performed in the office today is negative. Arrange the following steps in the classic diagnostic algorithm for secondary amenorrhea in the correct chronological sequence, from initial evaluation to final definitive testing.

A 31-year-old woman and her husband come to the office to undergo evaluation for primary infertility. They have engaged in regular, unprotected intercourse for the past 15 months without achieving pregnancy. The patient reports that her menstrual periods have always been unpredictable, occurring approximately every 7 to 9 weeks. She has also struggled with persistent acne and the growth of thick hair on her chin and lower abdomen over the last few years. She does not report any deepening of her voice, increased muscle mass, or abnormal bruising. Her body mass index is 32 kg/m². Vital signs are normal. Physical examination reveals moderate facial hirsutism, but no clitoromegaly or purple striae are noted. A urine pregnancy test is negative. The physician suspects polycystic ovary syndrome but notes that a diagnosis requires excluding other conditions with a similar presentation. Along with thyroid-stimulating hormone and prolactin, which of the following laboratory tests is most necessary to definitively exclude a common mimicker of this patient's suspected condition?

Match each distinct clinical presentation of acute third-trimester or intrapartum bleeding with its most likely underlying obstetric complication.