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 55-year-old woman is being managed on the surgical floor after having a total abdominal hysterectomy as a definitive treatment for endometriosis. On day 1 after the operation, the patient complains of fevers. She has no other complaints other than aches and pains from lying in bed as she has not moved since the procedure. She is currently receiving ondansetron, acetaminophen, and morphine. Her temperature is 101°F (38.3°C), blood pressure is 127/68 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 94% on room air. Her abdominal exam is within normal limits and cardiopulmonary exam is only notable for mild crackles. Which of the following is the most likely etiology of this patient’s fever?

Inflammatory stimulus of surgery

A 42-year-old woman, gravida 3, para 3 comes to the physician because of a 14-month history of prolonged and heavy menstrual bleeding. Menses occur at regular 28-day intervals and last 7 days with heavy flow. She also feels fatigued. She is sexually active with her husband and does not use contraception. Vital signs are within normal limits. Pelvic examination shows a firm, irregularly-shaped uterus consistent in size with a 16-week gestation. Her hemoglobin concentration is 9 g/dL, hematocrit is 30%, and mean corpuscular volume is 92 μm3. Pelvic ultrasound shows multiple intramural masses in an irregularly enlarged uterus. The ovaries appear normal bilaterally. The patient has completed childbearing and would like definitive treatment for her symptoms. Operative treatment is scheduled. Which of the following is the most appropriate next step in management?

Progestin-only contraceptive pills

Levonorgestrel-releasing intrauterine device

Estrogen-progestin contraceptive pills

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 30-year-old woman, gravida 1, para 0, at 30 weeks' gestation is brought to the emergency department because of progressive upper abdominal pain for the past hour. The patient vomited once on her way to the hospital. She said she initially had dull, generalized stomach pain about 6 hours prior, but now the pain is located in the upper abdomen and is more severe. There is no personal or family history of any serious illnesses. She is sexually active with her husband. She does not smoke or drink alcohol. Medications include folic acid and a multivitamin. Her temperature is 38.5°C (101.3°F), pulse is 100/min, and blood pressure is 130/80 mm Hg. Physical examination shows right upper quadrant tenderness. The remainder of the examination shows no abnormalities. Laboratory studies show a leukocyte count of 12,000/mm3. Urinalysis shows mild pyuria. Which of the following is the most appropriate definitive treatment in the management of this patient?

Laparoscopic removal of ovarian cysts

Intramuscular ceftriaxone followed by cephalexin

A 67-year-old woman with endometrial cancer undergoes robotic-assisted staging surgery. Final pathology reveals grade 2 endometrioid adenocarcinoma with 60% myometrial invasion, positive pelvic lymph nodes (2/15), negative para-aortic nodes (0/8), and lymphovascular space invasion. No cervical or adnexal involvement. The tumor care team debates adjuvant treatment. Evaluate which combination of pathologic features most significantly impacts treatment recommendations?

Positive pelvic nodes and negative para-aortic nodes

Grade 2 histology and depth of myometrial invasion

Number of positive nodes and total nodes removed

Lymphovascular space invasion and myometrial invasion depth

Absence of cervical involvement and patient age

Myomectomy procedures for USMLE Step 2 CK: High-Yield Surgery Lessons

✂️ Clinical - Fertility-Sparing Fibroid Fix

Goal: Excise leiomyomas, preserving the uterus for future fertility.
Indications: Symptomatic fibroids (abnormal uterine bleeding, bulk symptoms, recurrent pregnancy loss) in women desiring pregnancy.
Pre-op: GnRH agonists (e.g., leuprolide) can ↓ fibroid size and correct anemia.
Surgical Approach Decision:
Key Risks: Hemorrhage, adhesions.

⭐ Counsel on ↑ risk of uterine rupture during future labor. Cesarean delivery is strongly recommended if the uterine cavity was entered.

🗺️ Anatomy - Location, Location, Location!

A fibroid's (leiomyoma) location is the key determinant for choosing the surgical approach. The FIGO classification system provides a detailed map.

Submucosal (FIGO 0-2): Protrude into the uterine cavity. Ideal for hysteroscopic resection.
Intramural (FIGO 3-5): Contained within the myometrium. Often require laparoscopy or laparotomy.
Subserosal (FIGO 6-7): Protrude from the external uterine surface. Amenable to laparoscopy or laparotomy.

FIGO Classification of Uterine Fibroids

⭐ Submucosal fibroids are most implicated in heavy menstrual bleeding (menorrhagia) and impaired fertility (infertility, recurrent pregnancy loss) due to endometrial cavity distortion.

🔪 Surgical Strategy Selection

Primary Goal: Symptom relief (e.g., bleeding, bulk symptoms) while preserving the uterus for patients desiring future fertility.
The surgical approach is tailored based on fibroid size, number, and location (FIGO classification).

Hysteroscopic: Ideal for intracavitary lesions causing abnormal uterine bleeding. Outpatient, low morbidity.
Laparoscopic/Robotic: Minimally invasive for subserosal/intramural types. Requires skilled suturing for multi-layer closure to ensure uterine integrity.
Abdominal (Laparotomy): Gold standard for very large (>10 cm), numerous, or difficult-to-access fibroids. Allows for optimal uterine reconstruction but has higher morbidity (blood loss, adhesions, longer recovery).

⭐ High-Yield: Any myomectomy that breaches the uterine cavity or requires deep myometrial incision (laparoscopic or abdominal) increases the risk of uterine rupture in subsequent pregnancies. This often necessitates a planned Cesarean delivery.

FIGO classification of leiomyomas

⚠️ Complications - Post-Op Perils

Intra-op & Early Post-op:
- Hemorrhage: Most common. Requires meticulous hemostasis (e.g., vasopressin, tourniquets).
- Organ Injury: Bladder, ureter, bowel.
- Hysteroscopy-Specific: Fluid overload (hyponatremia), uterine perforation, gas embolism.
Delayed & Long-term:
- Adhesion Formation: Can cause chronic pain, infertility, small bowel obstruction. Risk varies by surgical approach.
- Infection: Endometritis, pelvic cellulitis, abscess.
- Uterine Rupture in Future Pregnancy: Critical risk, especially with deep intramural incisions.
⭐ Counsel patients on planned Cesarean delivery for subsequent pregnancies, typically at 36-37 weeks, to avoid labor and potential rupture.
- Undiagnosed Sarcoma: Risk of morcellating an occult leiomyosarcoma (~1 in 350).

⚡ Biggest Takeaways

Myomectomy is the uterus-sparing surgery for symptomatic fibroids in women desiring fertility preservation.

Procedure choice depends on fibroid location: hysteroscopic (submucosal), laparoscopic (intramural/subserosal), or abdominal (large/multiple).

The most feared long-term complication is uterine rupture during a future pregnancy.

Patients require counseling on the high likelihood of needing a cesarean section for future deliveries.

Major risks include intraoperative hemorrhage and postoperative fibroid recurrence.

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