Exam 5: Obstetrics & Gynecology

A 25-year-old woman, gravida 2 para 1, at 8 weeks gestation comes to the physician to initiate prenatal care.  Her blood type is O negative and the father's blood type is O positive.  Her first pregnancy was significant for placental abruption at the time of delivery.  She received the standard dose of anti-D immune globulin at 28 weeks during her first pregnancy and again 1 day postpartum.  The patient has no medical problems and no history of blood transfusions.  Her anti-D antibody titer is currently 1:32.  Which of the following is the most likely explanation for this patient's finding?

A 27-year-old nulliparous woman comes to the office due to left pelvic pain over the past 8 months.  She has constant pelvic pressure exacerbated by exercise and sexual activity.  The patient stopped taking combined oral contraceptives 2 years ago with the intention of having children but has not yet conceived.  Her last menstrual period was 2 weeks ago.  The patient's menstrual cycles are regular, occurring every 27 days with 4 days of bleeding.  She was treated for trichomoniasis at age 20.  Temperature is 37.2 C (99 F) and blood pressure is 120/72 mm Hg.  Pelvic examination shows a normal-sized uterus with no abnormal cervical discharge.  Bimanual examination reveals left adnexal tenderness.  A unilocular mass with homogeneous, low-level echoes on the left ovary is seen on ultrasound.  Which of the following is the most likely diagnosis in this patient?

A 29-year-old woman, gravida 1 para 0, at 16 weeks gestation comes to the office for prenatal care.  The patient was hospitalized at 7 weeks gestation for hyperemesis gravidarum.  Since the hospitalization, she has received intravenous hydration several times in the emergency department due to dehydration from persistent nausea and vomiting.  She is able to tolerate prenatal vitamins, which she takes with metoclopramide.  However, despite taking antiemetics frequently, the patient is unable to eat or drink much.  Blood pressure is 90/50 mm Hg.  Prepregnancy BMI was 18 kg/m².  Weight is 50 kg (110.2 lb), a decrease of 2 kg (4.4 lb) from prepregnancy weight.  Fetal heart tones are normal by Doppler.  The patient is concerned about her weight loss and whether it will affect the baby.  The fetus is at greatest risk for which of the following complications?

A 54-year-old woman, gravida 2 para 2, comes to the office due to several months of irregular vaginal spotting.  The patient has had intermittent spotting with wiping after urination and has noticed some blood stains on her underwear, but she has had no large clots or abnormal vaginal discharge.  Menopause occurred over a year ago and was complicated by severe hot flashes and night sweats.  The patient was prescribed a transdermal estrogen patch and cyclic progesterone-only pills.  She has been using the estrogen patches consistently but stopped taking the progesterone-only pills due to severe nausea.  The patient has no chronic medical conditions and has had no surgeries.  A Pap test 2 years ago was normal.  Family history is noncontributory.  She does not use tobacco, alcohol, or illicit drugs.  Vital signs are normal.  BMI is 23 kg/m².  On speculum examination, there are no cervical or vaginal lesions and there is no blood in the vagina.  Bimanual examination reveals a small, mobile uterus and no adnexal masses.  Which of the following is the best next step in management of this patient?

A 22-year-old woman comes to the office for routine annual examination.  The patient has regular menses typically lasting 4 or 5 days with minimal cramping on the first day.  Her last menstrual period was 3 weeks ago.  She normally has no midcycle pain, but for 2 days she has had a mild, sharp pain in her left lower abdomen.  The patient has had no nausea, vomiting, dysuria, or changes in bowel movements.  She has no chronic medical conditions or previous surgeries.  The patient is sexually active and uses a copper-containing intrauterine device (IUD) for contraception.  She does not use tobacco, alcohol, or illicit drugs.  Vital signs are normal.  BMI is 22 kg/m².  The abdomen is mildly tender over the left lower quadrant.  On speculum examination, the cervix appears normal and without lesions.  The IUD strings are visualized at the external cervical os.  The uterus is small and mobile, and a 4-cm nontender mass is palpable in the left adnexa.  Pelvic ultrasonography reveals a 4-cm simple left ovarian cyst with normal Doppler flow.  Urine pregnancy test is negative.  Which of the following is the best next step in management of this patient?

A 41-year-old woman, gravida 1 para 0, at 21 weeks gestation comes to the emergency department due to several hours of vaginal spotting.  She has also had increased vaginal discharge and pelvic pressure over the past few days but no cramping or leakage of fluid.  The patient first felt fetal movement last week and has an occasional headache without visual changes or epigastric pain.  She has chronic hypertension and type 2 diabetes mellitus.  The patient had an abnormal Pap test in her 20s that required a cone biopsy.  She has a 20-pack-year smoking history but quit 2 years ago.  Temperature is 36.7 C (98.1 F), blood pressure is 130/84 mm Hg, and pulse is 78/min.  BMI is 24 kg/m².  The abdomen is soft and nontender with no palpable contractions.  On pelvic examination, minimal blood is present in the vaginal vault.  The cervix is visibly dilated to 2 cm, with smooth, shiny membranes bulging through the os.  Deep tendon reflexes are 2+ at the knees.  Transabdominal ultrasound reveals the fetus in a cephalic presentation with a low-lying anterior placenta.  Fetal heart rate is 150/min.  Urinalysis shows no protein.  Which of the following is the most likely contributing factor to this patient's clinical presentation?

A 19-year-old woman comes to the office for evaluation of dyspareunia.  The patient became sexually active with her boyfriend 4 months ago but has been avoiding intercourse for the past month because it has become too painful.  She has tried using a water-based lubricant during intercourse, but it has not relieved her pain.  The patient is using condoms for contraception.  She has regular menses with 3-4 days of heavy bleeding and lower abdominal cramping.  There has been an increase in cramping over the past 2 months but no abnormal vaginal discharge.  The patient has type 1 diabetes mellitus and uses an insulin pump; her most recent hemoglobin A1c was 7.2%.  Vital signs are normal.  BMI is 21 kg/m².  On pelvic examination, the vulva and cervix appear noninflamed.  Speculum examination reveals a laterally displaced cervix.  Bimanual examination reveals a small uterus with cervical motion tenderness.  Which of the following is the most likely cause of this patient's dyspareunia?

A 24-year-old woman, gravida 2 para 1, at 20 weeks gestation, comes to the office for a routine fetal anatomy ultrasound.  The patient feels well and has had no contractions, vaginal bleeding, or leakage of fluid.  Fetal movement is normal.  Her prior pregnancy was uncomplicated and ended in a vaginal delivery at 41 weeks gestation after labor induction for a postterm pregnancy.  She has no chronic medical conditions, and her only medication is a daily prenatal vitamin.  The patient does not use tobacco, alcohol, or illicit drugs.  Temperature is 36.7 C (98 F), blood pressure is 110/80 mm Hg, and pulse is 72/min.  The uterine fundus is at the umbilicus and is nontender.  Ultrasound reveals a singleton fetus in breech presentation with a heart rate of 148/min.  The lower edge of the placenta is 3 cm from the internal cervical os, and cervical length is 1.8 cm (normal: >2.5).  Amniotic fluid index is 18 cm.  Which of the following is the best next step in management of this patient?

A 42-year-old woman comes to the office after a positive home pregnancy test.  The patient has a history of irregular menses and had a positive home pregnancy test after she went 6 months without a menstrual period.  Her medical conditions include chronic hypertension, for which she takes multiple medications, and type 2 diabetes mellitus, for which she stopped taking metformin a few months ago due to side effects.  BMI is 38 kg/m².  Temperature is 37.6 C (100 F), blood pressure is 138/88 mm Hg, and pulse is 90/min.  The abdomen is soft and without rebound or guarding.  The uterus is nontender and fundal height measures 24 cm.  Ultrasound findings show a singleton fetus at 24 weeks gestation with bilateral small, underdeveloped kidneys and a bladder with minimal urine.  The amniotic fluid index is 4 cm (normal: >5 cm).  Which of the following is the most likely cause of this fetal presentation?

A 56-year-old woman comes to the office for a routine health maintenance examination.  She has been postmenopausal for 4 years and is not using hormone therapy.  The patient had a normal screening mammogram last year.  Pap testing 3 years ago was normal, but human papillomavirus testing was not performed.  The patient has well-controlled hypertension and hyperlipidemia.  She had 2 cesarean deliveries and a tubal ligation with her last delivery at age 30.  Blood pressure is 130/90 mm Hg and pulse is 72/min.  BMI is 38 kg/m².  Physical examination is normal.  Speculum examination shows no cervical abnormalities.  Her Pap test shows endometrial cells and no cervical intraepithelial lesions.  Which of the following is the best next step in management of this patient?

A 23-year-old woman, gravida 2 para 1, at 37 weeks gestation comes to the labor and delivery unit due to contractions and leakage of fluid for the last 8 hours.  She had routine prenatal care until 20 weeks gestation but has not had an appointment since moving across the country.  Her prior pregnancy was a term vaginal delivery complicated by intraamniotic infection.  Her infant spent 3 weeks in the neonatal intensive care unit for early-onset neonatal sepsis.  Temperature is 37.5 C (99.5 F), blood pressure is 120/80 mm Hg, and pulse is 84/min.  The patient has grossly ruptured membranes with clear fluid, and the cervix is 3 cm dilated and 30% effaced with the fetal vertex at −1 station.  Leukocyte count is 13,000/mm³, hematocrit is 33%, and platelets are 189,000/mm³.  Which of following is the indication for intrapartum group B Streptococcus (GBS) prophylaxis in this patient?

A 39-year-old woman, gravida 4 para 4, comes to the office for emergency contraception.  The patient stopped breastfeeding a month ago and has not restarted her oral contraceptives because her husband is scheduled for a vasectomy in a few weeks.  She had unprotected intercourse last night and is concerned she might get pregnant.  The patient has no chronic medical conditions and takes no medications.  She does not use tobacco, alcohol, or illicit drugs.  Her last menstrual period was 9 days ago.  Vital signs and physical examination are normal.  Urine pregnancy test is negative.  Which of the following is the best emergency contraceptive option for this patient?

A 32-year-old woman, gravida 3 para 2, at 35 weeks gestation comes to the hospital due to frequent, painful uterine contractions.  The patient started to have contractions an hour ago but has had no vaginal bleeding or leakage of fluid.  She was incidentally diagnosed with a shortened cervix on routine anatomy ultrasound at 20 weeks gestation, for which she uses vaginal progesterone.  The patient has no chronic medical conditions and has had no previous surgeries.  Her prior pregnancies ended in term vaginal deliveries.  Blood pressure is 120/70 mm Hg, and pulse is 80/min.  Fetal heart tracing is normal.  The tocodynamometer shows contractions every 6 minutes.  A visibly dilated cervix is noted on speculum examination with no evidence of membrane rupture.  On digital cervical examination, the cervix is 4 cm dilated and 90% effaced with the fetus at −3 station.  Ultrasound examination reveals the fetus in vertex presentation.  Which of the following is the best next step in management of this patient?

A 28-year-old primigravida woman is admitted to the hospital at 10 weeks gestation.  Temperature is 36.7 C (98 F), pulse is 96/min, and respirations are 12/min.  Arterial blood gas laboratory results are as follows: Which of the following is the most likely cause of this patient's abnormal arterial blood gas?

A 29-year-old woman, gravida 2 para 1, at 10 weeks gestation comes to the emergency department for vaginal bleeding with passage of large clots and intense lower abdominal cramping.  The bleeding began 3 hours ago and she reports worsening dizziness on standing.  The patient initiated prenatal care a week ago and an ultrasound at that time revealed a 9-week gestation with a normal fetal heart rate.  Today, temperature is 37 C (98.7 F), blood pressure is 90/65 mm Hg, pulse is 110/min, and respirations are 17/min.  Large clots of blood are evacuated from the vagina during pelvic examination, after which active bleeding from an open cervical os is noted.  Blood type is AB negative.  Hemoglobin is 8.0 g/dL.  A bedside transvaginal ultrasound reveals a 9-week-size fetus in the lower uterine segment with no cardiac activity.  Intravenous fluids are begun.  Which of the following is the most appropriate next step in management of this patient?

A 27-year-old woman, gravida 2 para 1, at 32 weeks gestation comes to the emergency department due to abdominal pain.  A few hours ago, the patient developed a sudden onset of constant abdominal pain that has not resolved with rest.  For the last 30 minutes, the pain has increased and become unbearable.  She has had light vaginal bleeding but no passage of clots or fluid.  The patient has no chronic medical conditions, and her only surgery is a cesarean delivery in her last pregnancy due to preterm labor and fetal malpresentation.  She smokes a pack of cigarettes daily but does not use alcohol or illicit drugs.  Temperature is 36.7 C (98.1 F), blood pressure is 130/80 mm Hg, pulse is 100/min, and respirations are 18/min.  Fetal heart tracing shows a baseline of 170/min and occasional late decelerations.  The uterus is tender to palpation and has frequent palpable, painful contractions.  Speculum examination shows a closed cervix with minimal bleeding.  Ultrasound reveals a fundal placenta, a singleton fetus in transverse presentation, and a normal amniotic fluid index.  There is a 5-cm (1.97-in) pedunculated uterine fibroid and bilateral normal adnexae.  Which of the following factors in this patient's history most likely increased the risk for this clinical presentation?

A 28-year-old nulliparous woman being evaluated for infertility comes to the office due to clear vaginal discharge for the past 2 days.  The patient and her partner have intercourse every other day and have been trying to conceive for the past 7 months.  Menstrual cycles occur every 29 days with 4 days of flow.  Last week, she took penicillin for a sore throat.  The patient has no medical issues and has had no surgeries.  She takes a daily prenatal vitamin.  Pelvic examination shows clear mucus at the cervical os.  Which of the following is the most likely explanation for this patient's discharge?

Despite starting the recommended therapy, the patient's 2-hour postprandial blood glucose levels remain >140 mg/dL.  At 37 weeks gestation, ultrasound examination reveals an estimated fetal weight of 4 kg (8 lb 13 oz).  At 38 weeks gestation, the patient comes to the hospital in spontaneous labor and has a protracted labor course, pushing for 3 hours.  Following delivery of the fetal head, the anterior shoulder cannot be delivered.  A tight nuchal cord is palpated.  She is instructed not to push.  Which of the following is the best next step in management of this patient?

A 36-year-old woman, gravida 3 para 2, at 35 weeks gestation comes to the emergency department due to leakage of fluid and painless vaginal bleeding.  The patient had rupture of membranes 30 minutes ago; the fluid was initially clear but became bloody a few minutes later.  She had normal fetal movement earlier today.  The patient has not received prenatal care this pregnancy; her 2 previous pregnancies resulted in term cesarean deliveries.  She has hypertension but stopped taking her medication when she became pregnant.  Temperature is 36.1 C (97 F), blood pressure is 140/96 mm Hg, and pulse is 92/min.  The uterus is nontender.  Speculum examination confirms rupture of membranes; the cervical os is 1 cm dilated with minimal vaginal bleeding.  Doppler ultrasound is unable to detect fetal heart tones.  Which of the following is the most likely cause of this patient's presentation?

A 25-year-old woman, gravida 2 para 2, comes to the office for a postpartum visit and to discuss contraception.  Two weeks ago, the patient had a vaginal delivery at 36 weeks gestation.  She is breastfeeding exclusively with no issues.  Her lochia has decreased, and she has no pelvic pain.  The patient would like to start reliable contraception as soon as possible because she conceived while breastfeeding after her first pregnancy.  She takes a daily iron supplement for iron deficiency anemia due to heavy menstrual bleeding.  The patient has no other chronic medical conditions and takes no medications.  Vital signs are normal.  Pelvic examination is deferred.  Which of the following is the best contraceptive option for this patient?