Exam 5: Obstetrics & Gynecology

A 35-year-old woman, gravida 3 para 0 aborta 3, comes in for evaluation of recurrent pregnancy loss.  The patient has had 3 first-trimester spontaneous abortions in the last year and is becoming increasingly worried that she will never carry a pregnancy to full term.  She has regular, monthly menses with 4-5 days of moderate bleeding and cramping.  The patient has no chronic medical conditions and takes a daily prenatal vitamin.  Family history is noncontributory.  Vital signs are normal.  BMI is 24 kg/m².  On pelvic examination, the uterus is small, anteverted, and nontender.  There are no adnexal masses.  Urine pregnancy test is negative.  Transvaginal ultrasound reveals a 2-cm submucosal fibroid at the uterine fundus.  Thrombophilia workup is negative.  Which of the following is the most appropriate treatment for this patient's recurrent pregnancy loss?

A 14-year-old girl is brought to the office by her parents to discuss her menstrual periods.  The patient was born at 25 weeks gestation and spent 4 months in the neonatal intensive care unit.  She has cerebral palsy and her mobility is limited due to spasticity.  She has no intellectual disability.  The patient started menstruating 1 year ago and has monthly bleeding for 8 days with passage of clots.  Her parents often need to change the patient's pads every hour during menses.  She has mild intermittent asthma and migraines with aura.  On examination, the patient is wheelchair-bound and has multiple contractures in the bilateral lower extremities that cause minimal active and passive range of motion.  The abdomen is soft, nontender, and has no palpable masses.  Pelvic examination is deferred.  Which of the following is the best treatment option for this patient?

A 42-year-old woman comes to the office for a routine health examination.  She is sexually active with a male partner and underwent a tubal ligation for contraception.  The patient has had no abnormal bleeding or recent changes in weight.  Menses are regular and last 3-5 days; her last menstrual period was 3 weeks ago.  Ten years ago, the patient had genital warts successfully treated by laser ablation.  Pap tests have been normal to date.  She has had no other serious medical illness or surgeries and takes no medications.  She has a family history of hypertension but no history of cancer.  Pelvic examination shows a normal cervix without any visible lesions, a small anteverted uterus, and no adnexal masses.  The Pap test shows atypical glandular cells.  Which of the following is the next best step in management of this patient?

A 22-year-old woman, gravida 1 para 1, is evaluated in the postpartum unit for lower abdominal pressure and pain.  The patient underwent an induction of labor at 41 weeks gestation due to oligohydramnios.  She received epidural anesthesia and had a forceps-assisted vaginal delivery due to prolonged second stage of labor.  A second-degree perineal laceration was repaired after delivery, and she had a postpartum hemorrhage that resolved with uterotonic medications.  The patient is now 6 hours postpartum; she has been unable to void since delivery and has persistent urine dribbling while lying in bed.  Temperature is 37.2 C (99 F), blood pressure is 100/60 mm Hg, and pulse is 92/min.  BMI is 33 kg/m².  Physical examination reveals a firm uterine fundus and diffuse lower abdominal tenderness to palpation.  The perineal repair is intact and there is moderate lochia.  Deep tendon reflexes are normal.  Which of the following is the most likely cause of this patient's urinary symptoms?

A 32-year-old primigravida at 28 weeks gestation comes to the emergency department due to painful contractions that began 2 hours ago and are now occurring every 5 minutes.  She has had no leakage of fluid or vaginal bleeding; fetal movement is normal.  The patient was last seen in the office a few days ago for a routine prenatal visit; she had some increasing pelvic pressure, but her pregnancy has otherwise been uncomplicated.  She has no chronic medical conditions, and her only medications are a daily prenatal vitamin and folate supplement.  Temperature is 37 C (99 F), blood pressure is 114/60 mm Hg, and pulse is 80/min.  The fetal heart rate tracing has moderate variability, multiple accelerations, and no decelerations.  Tocodynamometry shows contractions every 5 minutes.  On digital pelvic examination, the cervix is 3 cm dilated and 90% effaced with the fetus in vertex presentation.  Betamethasone and indomethacin are administered.  Which of the following is the best next step in management of this patient?

A 26-year-old primigravid patient at 8 weeks gestation comes to the office to establish prenatal care.  She has felt intermittently nauseous for the past 2 weeks, resulting in vomiting once every morning.  Her appetite is unpredictable; at times, she does not eat breakfast or lunch and then eats more than she intended for dinner.  The patient shares that she has noticed that she already looks pregnant, and that she recently had to switch to wearing maternity clothing.  She does not use tobacco, alcohol, or illicit drugs.  The patient takes a prenatal vitamin every morning.  Vital signs are normal.  Weight has decreased by 2 kg (4.4 lb) compared to her prepregnancy weight; BMI is 21 kg/m².  Physical examination shows no abnormalities.  Transvaginal ultrasound shows a single intrauterine gestation with a heart rate of 150/min.  Complete blood count and comprehensive metabolic panel are normal.  Urinalysis is negative for ketones.  Which of the following is the best next step in management of this patient's vomiting?

A 29-year-old woman, gravida 2 para 1, at 41 weeks gestation comes to the office for a routine prenatal visit.  The patient has had no abdominal pain, leakage of fluid, or vaginal bleeding.  Fetal movement is normal.  The patient has had an uncomplicated pregnancy.  An anatomy ultrasound at 20 weeks gestation was normal.  Group B Streptococcus screening at 37 weeks gestation was negative.  Her prior pregnancy ended in a post-term vaginal delivery.  The patient has no chronic medical conditions and does not use tobacco, alcohol, or illicit drugs.  Blood pressure is 120/70 mm Hg and pulse is 72/min.  BMI is 29 kg/m².  Fundal height is 37 cm.  Nonstress test shows moderate variability, multiple accelerations, and no decelerations.  Ultrasound reveals a fetus in vertex presentation, and the single deepest pocket of amniotic fluid is 1.2 cm.  Which of the following is the best next step in management of this patient?

A 67-year-old woman comes to the office with severe vulvar itching and burning for the past 6 months.  The patient has tried over-the-counter, topical lubricants for her symptoms without relief.  She is no longer sexually active because vaginal penetration is not possible due to pain.  Medical history includes type 1 diabetes mellitus that is well controlled with insulin.  The patient had a total vaginal hysterectomy at age 48 for adenomyosis.  She previously had no abnormal Pap tests and has not had cervical cancer screening since the hysterectomy.  Vital signs are normal.  Physical examination shows thin, dry, white, plaque-like vulvar skin with loss of the labia minora.  There is clitoral hood retraction.  Excoriations are present bilaterally on the vulva. Which of the following is the best next step in evaluation of this patient?

A 34-year-old woman, gravida 2 para 1, at 14 weeks gestation comes to the office for a routine prenatal visit.  She is feeling well and has no concerns.  The patient had daily nausea and vomiting for the first few weeks of her pregnancy, but symptoms resolved 2 weeks ago.  She has had no pelvic pain or vaginal bleeding.  The patient has not yet felt fetal movement.  Her first pregnancy ended in a cesarean delivery at 30 weeks gestation due to breech presentation and preeclampsia with severe features.  The patient has no chronic medical conditions.  Her only medication is a daily prenatal vitamin and she has no medication allergies.  The patient does not use tobacco, alcohol, or illicit drugs.  Blood pressure is 112/74 mm Hg.  BMI is 24 kg/m².  Fetal heart tones are 155/min.  The uterus is gravid and nontender.  The remainder of the examination is unremarkable.  Which of the following is the best next step in management of this patient?

A 26-year-old woman, gravida 1, para 0, comes to the physician for a prenatal visit.  She did not keep accurate records of her menstrual periods but the last one was approximately 7 months ago.  Early in the pregnancy, an ultrasound showed that she was at approximately 6 weeks gestation, giving her a current gestational age of 32 weeks.  The patient's blood pressure is 110/60 mm Hg and pulse is 90/min.  On examination, her fundal height is 26 cm.  Fetal heart tones by Doppler shows a rate of 140/min.  An ultrasound is performed and calculates the patient's gestational age as 28 weeks based on the fetal biparietal diameter and femur length.  The measured fetal abdominal circumference is consistent with a gestational age of 26 weeks.  Which of the following is the most accurate method for estimating the current gestational age?

A 27-year-old nulligravid woman comes to the office with her husband due to inability to conceive.  The patient and her husband stopped using barrier contraception a year ago and have intercourse every other day.  The patient has a period every 28 days that lasts 5 days with 2 days of heavy flow.  She has brief pelvic pain approximately 14 days after her period starts, but intercourse is not painful.  In her late teens, the patient was hospitalized for a pelvic infection; during that time she had pain with intercourse, discharge, and fever.  She has no other medical or surgical history.  Her sister has polycystic ovarian syndrome.  The patient's husband is age 31; he has no children, and his semen analysis is normal.  The patient's blood pressure is 128/76 mm Hg and pulse is 82/min.  Physical examination shows no abnormalities.  Which of the following is the best next step in management of this patient?

A 24-year-old woman, gravida 1 para 0, at 37 weeks gestation comes to the office for a routine prenatal visit.  The patient has no concerns today.  Her fetus is active, and she has no contractions, vaginal bleeding, or leakage of fluid.  The patient's pregnancy was dated by a first-trimester ultrasound, and her 18-week ultrasound revealed normal fetal anatomy.  At 26 weeks gestation, her 1-hour glucose screen was abnormal, but her 3-hour glucose tolerance test was normal.  The patient has no medical conditions and has had no surgeries.  Blood pressure is 112/68 mm Hg and pulse is 90/min.  Fundal height is 42 cm and fetal heart rate is 138/min.  Because of the uterine size-dates discrepancy, an ultrasound is performed, which reveals an intrauterine fetus in the cephalic position with an amniotic fluid index of 30 cm (normal: 8-24 cm).  Which of the following is the best next step in management of this patient?

A 19-year-old woman comes to the office for a routine physical examination.  She feels well and has no concerns.  The patient has had 2 sexual partners in the past 3 months and uses condoms for contraception.  She has no significant medical history, takes no medications, and has no drug allergies.  Temperature is 37.2 C (99 F), blood pressure is 120/72 mm Hg, and pulse is 72/min.  Pelvic examination shows normal external genitalia.  The cervix has no lesions, abnormal discharge, or friability.  On bimanual examination, the uterus is small and mobile and has no cervical motion or fundal tenderness.  A urine pregnancy test is negative.  A cervical swab sent for nucleic acid amplification testing is positive for Chlamydia trachomatis but negative for Neisseria gonorrhoeae.  The patient is still asymptomatic.  Which of the following is the most appropriate next step in management of this patient?

A 32-year-old nulliparous woman starts to experience more painful contractions as she transitions into active labor.  On admission, her blood pressure is 120/80 mm Hg.  Fetal heart rate tracing shows a baseline of 130/min, moderate variability, positive accelerations, and no decelerations.  Uterine contractions occur every 2-3 minutes.  Cervical examination shows 6 cm dilation, 75% effacement, and 0 station.  She requests epidural anesthesia for pain control.  After induction of anesthesia, she begins to feel light-headed and her blood pressure is 90/55 mm Hg, heart rate is 120/min, and respirations are 12/min.  The patient has normal strength and sensation of the upper extremities.  What is the most probable cause of her hypotension?

A 22-year-old nulligravid woman comes to the office for worsening acne on her face and body over the last 6 months.  She initially attributed the acne to her diet and has been eating healthier to improve the acne and lose weight.  The patient has lost 6.8 kg (15 lb) in the last 3 months, but the acne has not improved.  She has no chronic medical conditions and has had no surgeries.  The patient does not use tobacco, alcohol, or illicit drugs.  Her father has type 2 diabetes mellitus and her mother has hyperlipidemia.  Blood pressure is 138/86 mm Hg and pulse is 72/min.  BMI is 42 kg/m².  Coarse hair is noted on the chin and upper lip.  Nodulocystic acne is present on the face, chest, and back.  Pelvic examination shows an enlarged clitoris but otherwise normal external genitalia.  Bimanual examination is limited by body habitus.  Laboratory results reveal elevated total testosterone and normal dehydroepiandrosterone sulfate.  Which of the following is the most likely diagnosis in this patient?

A 33-year-old woman, gravida 2 para 2, comes to the office for evaluation of abnormal uterine bleeding.  Ten months ago, the patient had a spontaneous vaginal delivery complicated by a postpartum hemorrhage that required a blood transfusion and emergent suction curettage.  Since the delivery, the patient has had increasingly irregular menses and has been amenorrheic for the past 3 months.  She is bottle-feeding her infant and is not taking contraceptives.  The patient has lost 13.6 kg (30 lb) since the delivery and is now below her prepregnancy weight.  BMI is 22 kg/m².  Blood pressure is 110/60 mm Hg and pulse is 62/min.  Visual fields are intact.  The thyroid has no palpable masses.  Cardiopulmonary examination is unremarkable.  Pelvic examination shows a minimally rugated vagina; the uterus and cervix are small and nontender to palpation.  Urine pregnancy test is negative.  Serum TSH and prolactin levels are normal; FSH is elevated.  Pelvic ultrasound shows a uterus with a thin endometrium and no adnexal masses.  Which of the following is the most likely cause of this patient's presentation?

A 33-year-old woman, gravida 1 para 0, at 27 weeks gestation comes to the office for a prenatal visit.  She had an ultrasound at 8 weeks gestation for pregnancy confirmation but has had no other prenatal care.  Several weeks ago, the patient had a fever and a diffuse, nonpruritic, maculopapular rash that lasted 2 days and resolved without intervention.  She has no chronic medical conditions.  Vital signs are normal.  Fundal height is 23 cm.  Fetal heart rate is 160/min.  Fetal ultrasound reveals bilateral ventriculomegaly and multiple intracranial calcifications within the basal ganglia and at the gray-white matter junction.  Fetal ascites and hepatosplenomegaly are noted.  Estimated fetal weight is below the 5th percentile for gestational age.  This patient's presentation is most likely due to fetal infection from which of the following pathogens?

A 42-year-old woman comes to the office due to recurrent episodes of fatigue and hot flashes.  The patient's most recent symptoms began 4 days ago; she says she feels "extremely cranky."  She also has intermittent bloating, and her symptoms sometimes cause her to miss work.  Her last menstrual period was 3 weeks ago.  Menses occur every 30 days, with 2 days of heavy bleeding followed by 4 days of moderate flow.  The patient had 2 vaginal deliveries in her 30s and stopped taking combined oral contraceptives last year after undergoing bilateral tubal ligation.  She smokes cigarettes socially but does not use alcohol or illicit drugs.  She takes no medications and has no known drug allergies.  Vital signs and physical examination are normal.  Which of the following is the best next step in management for this patient?

A 37-year-old woman, gravida 4 para 0 aborta 3, comes to the labor and delivery department with painful contractions.  She has had no prenatal care this pregnancy, but states she is at 37 weeks gestation based on a first-trimester ultrasound performed in the emergency department.  The patient has had 3 elective pregnancy terminations with dilation and curettage.  On physical examination, the cervix is 6 cm dilated and 90% effaced with the fetal head at +1 station.  She dilates quickly to 10 cm and vaginally delivers a 4.5-kg (10-lb) male infant.  Following delivery of the infant, the umbilical cord avulses from the placenta, necessitating manual extraction.  The placenta is extracted in pieces, and the patient suddenly develops profuse vaginal bleeding.  The uterus is firm, and the bleeding is unresponsive to uterine massage and uterotonic medications.  Which of the following is the most likely cause of this patient's bleeding?

A 31-year-old woman, gravida 2 para 1, is brought to the emergency department by her husband due to heavy vaginal bleeding.  She is at 30 weeks gestation by a last menstrual period and has not received prenatal care.  The patient has had heavy vaginal bleeding for the past 2 hours, soaking through a pad every 30 minutes.  Her last pregnancy ended in an uncomplicated term vaginal delivery at home.  Vital signs and fetal heart rate tracing are normal.  A transvaginal ultrasound reveals a complete placenta previa.  After conservative management, the vaginal bleeding stops.  The findings and management, including a cesarean delivery, are discussed with the patient and her husband.  The patient says she does not want a cesarean delivery because she would like to deliver at home again.  Which of the following is the most appropriate response?