Obstetrics and Gynecology

A physician is evaluating a menopausal patient who reports a recent onset of unprovoked vaginal spotting. The patient's last menstrual cycle occurred $4$ years ago. Her past medical history is significant for a localized, hormone-receptor-positive invasive ductal carcinoma of the breast, which was treated with a lumpectomy and radiation therapy $3$ years ago. Since completing radiation, she has been maintained on daily tamoxifen therapy. She denies pelvic pain, dyspareunia, and weight loss. Vital signs are within normal limits. On speculum examination, the vaginal mucosa appears pale and thin, and the cervix is grossly normal without visible lesions. A trace amount of dark blood is noted in the vaginal vault. Transvaginal ultrasonography demonstrates a symmetrically thickened endometrial stripe measuring $8$ mm, with scattered subendometrial cystic spaces. Which of the following is the most appropriate next step in the management of this patient?

A 26-year-old woman, gravida 1, para 0, presents to the clinic for a scheduled prenatal evaluation at 26 weeks gestation. She has no complaints other than mild, intermittent fatigue. The patient is taking a daily prenatal vitamin containing iron and folic acid. Her vital signs are temperature 36.8°C (98.2°F), blood pressure 110/70 mm Hg, heart rate 82/min, and respiratory rate 14/min. Fetal heart tones are 145/min.

Laboratory studies obtained today show the following:

At her initial visit at 9 weeks gestation, her hemoglobin was 12.8 g/dL. Which of the following is the most likely primary mechanism responsible for this patient's current hematologic findings?

During her active phase of labor, a $28$-year-old nulliparous woman at $40$ weeks gestation experiences a change in fetal monitoring patterns. She is currently receiving a continuous oxytocin infusion to augment labor. Her cervix is $6$ cm dilated and $90\%$ effaced. The external fetal monitor shows a baseline heart rate of $135$/min with moderate variability. Following the peak of several recent uterine contractions, the fetal heart rate gradually drops to $110$/min and slowly returns to the baseline after the contractions have completely ended. The maternal blood pressure is $120/75$ mm Hg and temperature is $36.8^{\circ}$ C ($98.2^{\circ}$ F). Which of the following is the most appropriate next step in the management of this patient?

Match the following normal expected clinical findings during pregnancy with their primary physiological mechanism.

A $28$-year-old woman, gravida $1$, para $0$, at $34$ weeks gestation is brought to the emergency department after being the restrained driver in a high-speed motor vehicle collision. She complains of severe, continuous lower abdominal pain and dark red vaginal bleeding. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $82/50\text{ mmHg}$, pulse is $130/\text{min}$, and respirations are $24/\text{min}$. Physical examination reveals a rigid, hypertonic uterus that is exquisitely tender to palpation. Fetal monitoring reveals a baseline heart rate of $105/\text{min}$ with minimal variability and recurrent late decelerations. Which of the following is the most appropriate next step in management?

During standard prenatal care, a clinician monitors various clinical and developmental landmarks to ensure a normal trajectory of fetal growth and maternal adaptation. Arrange the following expected clinical milestones in the chronological order they typically occur during a normal, uncomplicated pregnancy, from earliest to latest gestational age.

Match each postoperative clinical presentation following a gynecologic procedure to the most likely underlying surgical complication or injured structure.

Match each patient's clinical presentation with the most likely corresponding pathophysiologic mechanism or urodynamic diagnostic finding.

Correlate each specific clinical scenario involving a gynecologic infection (or related incidental finding) with its most appropriate, guideline-concordant next step in management.

A 28-year-old primigravida at 39 weeks gestation is admitted to the labor and delivery unit in active labor. Her prenatal course was uncomplicated. Currently, her blood pressure is 118/76 mm Hg, heart rate is 82/min, and temperature is 37.1°C (98.8°F). Vaginal examination reveals that the cervix is dilated to 6 cm, 90% effaced, with the fetal head at +1 station. External fetal monitoring shows a baseline fetal heart rate of 140/min with moderate variability. During uterine contractions, there are recurrent, symmetric decreases in the fetal heart rate to 130/min. The onset, nadir, and recovery of each fetal heart rate decrease precisely align with the beginning, peak, and end of the respective uterine contraction. Which of the following is the most appropriate next step in management?

A 24-year-old primigravida at 39 weeks gestation is admitted to the labor and delivery unit in active labor. Her pregnancy has been uncomplicated. Her temperature is 37.1°C (98.8°F), blood pressure is 118/76 mm Hg, and pulse is 82/min. Epidural anesthesia is placed for pain management, and an oxytocin infusion is started to augment labor. Two hours later, a cervical examination reveals that the cervix is 6 cm dilated, 90% effaced, and the fetal head is at -1 station. Uterine contractions are occurring every 2 to 3 minutes and palpate as strong. The fetal heart rate tracing shows a baseline of 140/min with moderate variability. There are recurrent, gradual decreases in the fetal heart rate that begin after the peak of each uterine contraction and return to baseline after the contraction ends. Which of the following is the most appropriate next step in management?

Match the following fetal heart rate (FHR) tracing patterns observed during labor to their classic underlying physiological or pathological etiologies.

A 34-year-old woman, gravida 4, para 3, is evaluated in the obstetrical triage unit at 37 weeks and 4 days gestation. She complains of a sudden onset of severe, unremitting lower abdominal and back pain that started 90 minutes ago. The patient reports normal fetal movement earlier in the day but denies any vaginal bleeding, leakage of fluid, or recent trauma. Her prenatal course was notable only for mild diet-controlled gestational diabetes. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $112/68\text{ mm Hg}$, and pulse is $118\text{/min}$. On physical examination, the uterus is extremely firm, rigid, and exquisitely tender to light palpation. Pelvic examination reveals a long, closed, and posterior cervix with no visible blood in the vaginal vault. Initial laboratory studies demonstrate a hemoglobin of $10.6\text{ g/dL}$ and a platelet count of $152,000/\text{mm}^3$. Tocodynamometry shows high-frequency, low-amplitude uterine contractions occurring every 1 to 2 minutes with a persistently elevated resting tone. Fetal heart rate monitoring reveals a baseline of $105\text{/min}$, absent variability, and recurrent late decelerations. Which of the following is the most appropriate next step in management?

A 29-year-old woman presents to the office due to the absence of menstruation for the past 8 months. She previously had regular 29-day menstrual cycles since menarche at age 12. She reports no recent changes in weight, strenuous exercise habits, nipple discharge, headaches, or visual disturbances. Her past medical history is unremarkable, and she takes no daily medications. She is sexually active with a male partner and uses condoms inconsistently. Vital signs include blood pressure 110/70 mm Hg, pulse 72/min, and BMI 24 kg/m². Physical examination demonstrates normal breast development, appropriate body hair distribution, and a normal appearing cervix and vaginal vault.

Arrange the following diagnostic steps in the most appropriate sequential order for evaluating this patient's secondary amenorrhea.

A 24-year-old nulligravid woman is evaluated in the hospital on the third day of admission for pelvic inflammatory disease complicated by a 4-cm left tubo-ovarian abscess. On admission, she presented with a temperature of 38.9°C (102.0°F), severe lower abdominal pain, and a leukocyte count of 18,500/mm³. She was started on intravenous cefoxitin and oral doxycycline. Today, she reports feeling much better. Her temperature is 37.1°C (98.8°F), blood pressure is 118/76 mm Hg, pulse is 78/min, and respirations are 14/min. Abdominal examination shows significantly decreased tenderness with no rebound or guarding. Pelvic examination reveals markedly improved cervical motion tenderness and a stable left adnexal fullness. She is tolerating a regular diet, and her leukocyte count has decreased to 9,200/mm³. Which of the following is the most appropriate next step in management?

A $29$-year-old primigravid patient at $37$ weeks and $5$ days gestation presents to the obstetric triage unit reporting a sudden gush of clear vaginal fluid occurring $1$ hour ago. Over the past $20$ minutes, she has noticed the fluid becoming increasingly blood-tinged, followed by active, painless vaginal bleeding. She denies abdominal pain or uterine contractions. Her prenatal course was notable for a second-trimester ultrasound showing a velamentous umbilical cord insertion. Temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $122/78$ mm Hg, and pulse is $88$/min. The maternal abdomen is soft and non-tender. Speculum examination confirms active bleeding from the external cervical os. Continuous fetal monitoring initially showed a baseline of $145$/min with moderate variability, but now demonstrates a sudden, prolonged deceleration to $70$/min lasting for the past $4$ minutes. Which of the following is the most appropriate next step in management?

A 68-year-old woman presents to the clinic reporting a 6-month history of troublesome urinary symptoms. She describes experiencing a sudden, overwhelming need to urinate that is difficult to defer, often resulting in urinary leakage before she can reach the bathroom. She voids approximately 10 times during the day and wakes up 3 times at night to urinate. The patient denies any leakage when coughing, laughing, or lifting heavy objects. She also denies dysuria or hematuria. Over the past two months, she has tried limiting her caffeine intake and following a timed voiding schedule, but her symptoms have not improved. Her medical history is unremarkable. Pelvic examination reveals healthy-appearing vaginal mucosa and no evidence of pelvic organ prolapse. Postvoid residual volume is 30 mL, and a urinalysis is completely normal. Which of the following is the most appropriate next step in management for this patient?

Review the following microscopic descriptions of vaginal secretions prepared with normal saline or potassium hydroxide. Associate each distinct microscopic finding with the most likely corresponding gynecologic infection.

During a routine health maintenance visit, a $34$-year-old woman (G3P3) requests a reliable method of contraception. She also reports that her menstrual periods have become increasingly burdensome over the past $8$ months. Her menses occur regularly every $28$ days but now last for $9$ to $10$ days with the passage of large clots. She must change a super-absorbency pad every $1$ to $2$ hours during the heaviest flow and complains of persistent fatigue. Her medical history is notable for a deep vein thrombosis in her right leg $3$ years ago following an international flight, for which she completed a $6$-month course of anticoagulation. Additionally, she underwent a Roux-en-Y gastric bypass $18$ months ago; her body mass index subsequently decreased from $43 \text{ kg/m}^2$ to $27 \text{ kg/m}^2$. Vital signs are normal. Pelvic examination reveals a normal-sized, mobile uterus with no adnexal masses.

Laboratory evaluation reveals:
Hemoglobin: $9.2 \text{ g/dL}$
Mean corpuscular volume: $74 \text{ fL}$
Thyroid-stimulating hormone: $2.1 \mu\text{U/mL}$
Urine pregnancy test: negative

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

A 29-year-old G2P2 is evaluated in the outpatient setting for secondary amenorrhea that has persisted for 9 months. Her last pregnancy concluded 14 months prior via a spontaneous vaginal delivery, which was immediately complicated by significant uterine atony. This resulted in a massive obstetric hemorrhage necessitating a 4-unit packed red blood cell transfusion. In the postpartum period, the patient noted a complete inability to breastfeed her newborn. Over the most recent six-month interval, she has developed worsening fatigue, an inability to tolerate cold temperatures, and an unintended weight loss of 4 kg (8.8 lb). Before her last pregnancy, her menstrual cycles were highly predictable, occurring every 28 days. Vital signs today show a blood pressure of 92/58 mm Hg and a heart rate of 58/min. Physical examination is remarkable for dry, cool skin and a noticeable delay in the relaxation phase of her deep tendon reflexes. A urine beta-hCG assay is negative. Which of the following laboratory test result patterns is most likely to be present in this patient?