A 24-year-old gravida 3 para 1 is admitted to the hospital at 29 weeks gestation with a high fever, flank pain, and an abnormal urinalysis. You order blood and urine cultures, a CBC, electrolyte levels, and a serum creatinine level. You also start her on intravenous fluids and intravenous cefazolin. After 24 hours of antibiotic treatment she is clinically improved but continues to have fever spikes.
What would be the most appropriate management at this time?
Correct Answer A:
Pyelonephritis is the most common serious medical problem that complicates pregnancy. Infection is more common after mid-pregnancy, and is usually caused by bacteria ascending from the lower tract. Eschericia coli is the offending bacteria in approximately 75% of cases. About 15% of women with acute pyelonephritis are bacteremic. A common finding is thermoregulatory instability, with very high spiking fevers sometimes followed by hypothermia. Almost 95% of women will be afebrile by 72 hours. However, it is common to see continued fever spikes up until that time. Thus, further evaluation is not indicated (choice A) unless clinical improvement at 48-71 hours is lacking. If this is the case, the patient should be evaluated for urinary tract obstruction, urinary calculi and an intrarenal or perinephric abscess. Ultrasonography, plain radiography, and modified intravenous pyelography are all acceptable methods, depending on the clinical setting.
A patient, who is 8 weeks pregnant, has been using a copper-containing intrauterine device. On vaginal examination, the string is seen.
Which one of the following would be the most appropriate management of this patient?
Correct Answer E:
Following insertion of either device, a follow-up appointment should be planned after the next menses to address any concerns or adverse effects, ensure the absence of infection, and check the presence of the strings.
The most common adverse effects of IUDs are cramping, abnormal uterine bleeding, and expulsion. Adverse effects related specifically to the hormone-releasing IUD include amenorrhea, acne, depression, weight gain, decreased libido, and headache.
If the IUD threads are ever not present, a pregnancy test should be performed. When the results are negative, a cytobrush can be inserted gently into the cervical canal to locate the threads. If this method is unsuccessful, radiography or ultrasonography may be used to locate the IUD.
When the results of the pregnancy test are positive, an ectopic implantation must be ruled out. If the strings are visible and the pregnancy is early, the IUD can be removed but with a risk of pregnancy loss. If the strings are not visible, ultrasonography should be performed to identify the IUD for removal.
The main contraceptive action of the copper-based intrauterine device is:
Correct Answer D:
The main mechanism of the contraceptive action of copper bearing IUDs in the human is as a spermicide. The presence of a device in the uterus prompts the release of leukocytes and prostaglandins by the endometrium. These substances are hostile to both sperm and eggs; the presence of copper increases the spermicidal effect. Because of the spermicidal action of the copper IUD, few, if any, sperm reach the oviduct, and the ovum usually does not become fertilized.
→ Although there is a local inflammatory reaction, the main effect is spermicidal.
→ No effect on ovulation occurs from the copper IUD since it is non-hormonal.
→ See the answer to A.
→ No change in serum copper level occurs.
A copper Intra-Uterine Device (IUD) has a contraception efficacy rate of:
Effectiveness of contraceptive methods:
General efficacy of methods:
Based on these statistics: if abstinence or surgery are undesirable options, practitioners should promote “patient-independent” modes of contraception (i.e. methods that do not rely on the patient’s preparedness (e.g. condom) or memory (daily pills)…etc. Implantable hormones such as Implanon (available in the US) or IUDs (e.g. Mirena) would be such options.
PEARL: Abstinence & IUDs show greater contraception efficacy compared to the typical use of other methods.
A 28-year-old gravida 2 para 2 notes bilateral milky discharge from her breasts. She delivered her last child 2 years ago, and breastfed exclusively for 8 months and at night for a few more months. She totally stopped breastfeeding several months ago, but she can still express milk from both breasts daily. She takes no medications, and uses a diaphragm for contraception. The physical examination is unremarkable except that a milky discharge is easily expressible from both nipples.
The most likely diagnosis is:
Correct Answer E: The causes of galactorrhea are multiple, including intraductal papillomatosis, mammary duct ectasia, empty sella syndrome, hyperprolactinemia, hypothyroidism, and illicit drug ingestion.
However, bilateral galactorrhea, or milk production, can be physiologic for up to 2 years after breastfeeding an infant. It is also more likely if there continues to be breast stimulation, such as this woman’s daily expression of milk.
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