A 37-year-old G4P3 presents to her physician at 20 weeks gestation for routine prenatal care. Currently, she has no complaints; however, in the first trimester she was hospitalized due to acute pyelonephritis and was treated with cefuroxime. All her past pregnancies required cesarean deliveries for medical indications. Her history is also significant for amenorrhea after weight loss at 19 years of age and a cervical polypectomy at 30 years of age. Today, her vital signs are within normal limits and a physical examination is unremarkable. A transabdominal ultrasound shows a normally developing male fetus without morphologic abnormalities, anterior placement of the placenta in the lower uterine segment, loss of the retroplacental hypoechoic zone, and visible lacunae within the myometrium. Which of the following factors present in this patient is a risk factor for the condition she has developed?

Genitourinary infections during pregnancy

Intake of antibiotics in the first trimester

A 31-year-old female presents to her gynecologist with spotting between periods. She reports that her menses began at age 11, and she has never had spotting prior to the three months ago. Her medical history is significant for estrogen-receptor positive intraductal carcinoma of the breast, which was treated with tamoxifen. An endometrial biopsy is performed, which shows endometrial hyperplasia with atypia. She reports that she and her husband are currently trying to have children. What is the next best step?

Partial, cervix-sparing hysterectomy

Observation with annual endometrial biopsies

Start combination estrogen and progestin therapy

Total abdominal hysterectomy with bilateral salpingo-oophorectomy

A 27-year-old female presents to her OB/GYN for a check-up. During her visit, a pelvic exam and Pap smear are performed. The patient does not have any past medical issues and has had routine gynecologic care with normal pap smears every 3 years since age 21. The results of the Pap smear demonstrate atypical squamous cells of undetermined significance (ASCUS). Which of the following is the next best step in the management of this patient?

Perform a Loop Electrosurgical Excision Procedure (LEEP)

A 38-year-old woman presents to her primary care physician concerned about her inability to get pregnant for the past year. She has regular menstrual cycles and has unprotected intercourse with her husband daily. She is an immigrant from Australia and her past medical history is not known. She is currently taking folic acid and multivitamins. The patient's husband has had a sperm count that was determined to be within the normal range twice. She is very concerned about her lack of pregnancy and that she is too old. Which of the following is the most appropriate next step in management for this patient?

Assess ovulation with an ovulation calendar

Advise against pregnancy given the patient's age

Continue regular intercourse for 1 year

A 32-year-old man is brought to the emergency department after a skiing accident. The patient had been skiing down the mountain when he collided with another skier who had stopped suddenly in front of him. He is alert but complaining of pain in his chest and abdomen. He has a past medical history of intravenous drug use and peptic ulcer disease. He is a current smoker. His temperature is 97.4°F (36.3°C), blood pressure is 77/53 mmHg, pulse is 127/min, and respirations are 13/min. He has a GCS of 15 and bilateral shallow breath sounds. His abdomen is soft and distended with bruising over the epigastrium. He is moving all four extremities and has scattered lacerations on his face. His skin is cool and delayed capillary refill is present. Two large-bore IVs are placed in his antecubital fossa, and he is given 2L of normal saline. His FAST exam reveals fluid in Morison's pouch. Following the 2L normal saline, his temperature is 97.5°F (36.4°C), blood pressure is 97/62 mmHg, pulse is 115/min, and respirations are 12/min. Which of the following is the best next step in management?

Upper gastrointestinal endoscopy

A 39-year-old man presents with painless swelling of the right testis and a sensation of heaviness. The physical examination revealed an intra-testicular solid mass that could not be felt separately from the testis. After a thorough evaluation, he was diagnosed with testicular seminoma. Which of the following group of lymph nodes are most likely involved?

Superficial inguinal lymph nodes (lateral group)

Superficial inguinal lymph nodes (medial group)

Fertility-preserving surgical techniques for USMLE Step 2 CK: High-Yield Surgery Lessons

👶 Saving Future Families

Goal: Preserve uterine and/or ovarian function for future pregnancy in select gynecologic conditions.
Prerequisites:
- Strong desire for future fertility.
- Early-stage, low-grade malignancy or benign disease.
- Comprehensive counseling on risks (recurrence, further surgery).

Condition	Fertility-Sparing Surgery
Uterine Fibroids	Myomectomy
Benign Ovarian Cyst	Ovarian Cystectomy
Ectopic Pregnancy	Salpingostomy (if unruptured)
Early Ovarian Cancer	Unilateral Salpingo-oophorectomy
Early Cervical Cancer	Trachelectomy / Cone Biopsy

⭐ Radical trachelectomy for early-stage cervical cancer preserves the uterine fundus, allowing for future pregnancy, which typically requires delivery via Cesarean section.

Ovarian Transposition (Oophoropexy): Surgically moves ovaries out of the radiation field prior to pelvic radiotherapy.

хирургический_инструментарий The Surgical Toolbox

Myomectomy: Excision of uterine leiomyomas (fibroids) while preserving the uterus.
- Approaches: Hysteroscopic (submucosal), Laparoscopic/Robotic (intramural, subserosal), or Laparotomy (large/multiple fibroids).
Ovarian Cystectomy: Removal of an ovarian cyst (e.g., endometrioma, dermoid) while preserving ovarian tissue.
- Typically laparoscopic; preferred over oophorectomy in premenopausal women.
Unilateral Salpingo-oophorectomy (USO): For early-stage, unilateral epithelial ovarian or germ cell tumors.
Trachelectomy (Radical): For early-stage cervical cancer (e.g., Stage IA2, IB1) in patients desiring fertility.
- Removes cervix, upper vagina, and parametria; uterine body is reattached to the vagina.

⭐ Pearl: A key requirement for radical trachelectomy is a tumor size typically <2 cm and no evidence of lymphovascular space invasion (LVSI) or nodal metastasis. Post-procedure, delivery must be via Cesarean section.

⚠️ Complications - Bumps in the Road

General Risks: Hemorrhage, infection, visceral injury (bladder, ureter, bowel), and postoperative adhesion formation leading to pain or secondary infertility.
Myomectomy:
- Risk of uterine rupture in subsequent pregnancy.
- Future deliveries require Cesarean section.
Ovarian Cystectomy:
- ↓ Diminished Ovarian Reserve (DOR) due to removal of healthy tissue.
- Potential for premature ovarian insufficiency (POI).
Radical Trachelectomy:
- Cervical incompetence → ↑ risk of preterm labor.
- Cervical stenosis, dysmenorrhea.
- Requires Cesarean delivery.

⭐ After myomectomy where the uterine cavity is entered, subsequent pregnancies are high-risk for uterine rupture. A planned Cesarean section before labor onset (typically 37-38 weeks) is mandatory.

⚡ Biggest Takeaways

Myomectomy removes fibroids, preserving the uterus; risk of uterine rupture in future pregnancy.

Ovarian cystectomy for benign cysts (e.g., endometriomas) conserves ovarian tissue and function.

Radical trachelectomy for early cervical cancer removes the cervix but preserves the uterine fundus.

Unilateral salpingo-oophorectomy for early, unilateral ovarian cancer (germ cell, epithelial).

High-dose progestins can treat endometrial hyperplasia/carcinoma in young patients desiring fertility.

Ovarian transposition (oophoropexy) moves ovaries away from the pelvic radiation field.

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