Which one of the following is associated with galactorrhea?
Correct Answer A:
Galactorrhea, or inappropriate lactation, is a relatively common problem with multiple causes. Systemic disease is one cause, the most common being hypothyroidism. Low levels of thyroid hormone result in increased levels of thyrotropin releasing hormone (TRH), which increases prolactin secretion. Galactorrhea and symptoms of hypothyroidism abate with thyroid hormone replacement therapy.
→ This condition is not associated with breast cancer (choice B) or fibrocystic disease of the breast (choice C).
→ Cushing’s disease, rather than adrenal insufficiency (choice D), is associated with galactorrhea.
→ In Grave's disease (choice E), there are high levels of circulating thyroid hormone (hyperthyroidism).
A 34-year-old female who delivered a healthy infant 18 months ago complains of a milky discharge from both nipples. She reports that normal periods have resumed since cessation of breastfeeding 6 months ago. She takes ethinyl estradiol/norgestimate (Ortho Tri-Cyclen) for birth control and red clover for immune system and appetite suppression, as advised by her sister. A complete review of systems is otherwise negative. Her complete blood test results show no abnormalities.
The most likely cause of the discharge is:
This patient has galactorrhea, which is defined as a milk-like discharge from the breast in the absence of pregnancy in a non-breastfeeding patient who is more than 6 months post partum. It is more common in women ages 20-35 and in women who are previously parous. It also can occur in men. Medication side effect is the most common etiology.
Galactorrhea can be caused by numerous medications and some herbs. The most common pharmacologic cause of galactorrhea is oral contraceptives. Oral contraceptives that contain estrogen can both suppress prolactin inhibitory factor and stimulate the pituitary directly, both of which can cause galactorrhea. Other medications that can cause galactorrhea include metoclopramide, cimetidine, risperidone, methyldopa, codeine, morphine, verapamil, SSRIs, butyrophenones, dopamine-receptor blockers, tricyclics, phenothiazines, and thioxanthenes; herbs: Anise, Blessed thistle, Fennel, Fenugreek seed, Marshmallow, Red clover, Red raspberry.
→ Breast cancer is unlikely to present with a bilateral milky discharge. The nipple discharge associated with cancer is usually unilateral and bloody.
→ Pituitary tumors are a pathologic cause of galactorrhea due to the hyperprolactinemia that is caused by the blockage of dopamine from the hypothalamus, or by the direct production of prolactin. However, patients often have symptoms such as headache, visual disturbances, temperature intolerance, seizures, disordered appetite, polyuria, and polydipsia. Patients with prolactinomas often have associated amenorrhea. These tumors are associated with marked levels of serum prolactin, often > 200 ng/mL.
→ Hypothalamic lesions such as craniopharyngioma, primary hypothalamic tumor, metastatic tumor, histiocytosis X, tuberculosis, sarcoidosis, and empty sella syndrome are significant but infrequent causes of galactorrhea, and generally cause symptoms similar to those of pituitary tumors, particularly headache and visual disturbances.
→ It is rare for primary hypothyroidism to cause galactorrhea in adults. Symptoms that would be a clue to this diagnosis include fatigue, constipation, menstrual irregularity, weight changes, and cold intolerance.
A G1P0 woman comes to the labor and delivery department with regular painful contractions. On exam, a footling presentation found.
What is the appropriate management?
Correct Answer C:
When a gravid woman goes into labor her baby can be in a variety of positions.
Of these the most appropriate for delivery is the vertex face position.
Occasionally we see one of the other presentations. A footling presentation is seen here:
This is a presentation with the feet entering the birth canal ahead of any other part of the body. This may occur with two feet (double footling) or a single foot (single footling). Most often one leg is extended while the other is flexed at the knee. It is usually safer to deliver this kind of baby by a Cesarean section early in labor or before labor begins. If a footling breech is delivered vaginally, there is a risk that the head may not easily pass through the birth canal.
A G2P1 with history of previous Cesareans for cephalo-pelvic disproportion presents with onset of labor. As the nurses are getting ready to start helping the patient with pushing, a gush of blood is seen coming out from vagina. She is in a tremendous amount of pain.
What is the likely cause?
Correct Answer D: Uterine rupture is a concern in women who have had prior cesarean deliveries, and the risk of rupture does rise with the number of previous cesarean deliveries. It is of particular concern if the woman is in labor.
A bloody show would not be this dramatic. Placenta previa is implantation of the placenta over or near the internal os of the cervix. Typically, bright red painless vaginal bleeding occurs during late pregnancy.
Which one of the following is the most reliable clinical symptom or sign of uterine rupture?
Correct Answer D:
Fetal distress has been found to be the most reliable presenting clinical symptom of uterine rupture. The “classic” signs of uterine rupture such as sudden, tearing uterine pain, vaginal hemorrhage, and loss of uterine tone of cessation of uterine are not reliable and are often absent. Pain and bleeding occur in as few as 10% of cases. Even ruptures monitored with an intrauterine pressure catheter fail to show loss of uterine tone.
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