All of the following may occur as a result of postpartum pituitary necrosis (Sheehan syndrome), except:
Correct Answer B:
Prolactin deficiency reduces or eliminates a woman's ability to produce breast milk after childbirth. One cause of low prolactin levels and deficiency of other pituitary hormones is Sheehan's syndrome, a rare complication of childbirth. Sheehan's syndrome typically develops because of excessive blood loss and shock during childbirth, which results in partial destruction of the pituitary gland. Symptoms include fatigue, loss of pubic and underarm hair, and inability to produce breast milk. Prolactin deficiency has no known ill effects in men.
A woman who delivers after a prolonged labor presents to you after 2 days. All of the following suggest endometritis, except:
Correct Answer C:
Puerperal endometritis is uterine infection, typically caused by bacteria ascending from the lower genital or GI tract. Symptoms are abdominal tenderness and pain, fever, malaise, and sometimes discharge. Diagnosis is clinical, rarely aided by culture. Treatment is with broad-spectrum antibiotics (eg, clindamycin plus gentamycin).
Typically, the first symptoms are lower abdominal pain and uterine tenderness, followed by fever - most commonly within the first 24 to 72 hours postpartum. Chills, headache, malaise, and anorexia are common. Sometimes the only symptom is a low-grade fever.
Pallor, tachycardia, and leukocytosis usually occur, and the uterus is soft, large, and tender. Lochia may be decreased or profuse and malodorous. When parametria are affected, pain and pyrexia are severe; the large, tender uterus is indurated at the base of the broad ligaments, extending to the pelvic walls or posterior cul-de-sac. Pelvic abscess may present as a palpable mass separate from and adjacent to the uterus.
Which one of the following intravenous antibiotic regimens is most appropriate for the treatment of postpartum endometritis?
Correct Answer D:
The usual recommendation is to treat postpartum endometritis with clindamycin and gentamycin. This combination covers anaerobes, group B Streptococcus, and gram-negative organisms. Extended-spectrum cephalosporins or imipenem-cilastatin or ampicillin-sulbactam are frequently used; however, the clindamycin/gentamycin regimen remains the gold standard when endometritis is suspected.
A sexually active woman presents with dysuria and vaginal discharge. All the following can cause this condition, except:
Correct Answer D: Gonorrhea, Chlamydia and Trichomoniasis are all sexually transmitted diseases that can cause dysuria and vaginal discharge.
Genital warts (condylomata acuminata) are growths in or around the vagina, penis, or rectum caused by sexually transmitted papillomaviruses. Many people have no symptoms from the warts, but some feel occasional burning pain. The warts usually appear 1 to 6 months after infection with papillomavirus, beginning as tiny, soft, moist, pink or red swellings. They grow rapidly and appear as rough, irregular bumps, which sometimes grow out from the skin on narrow stalks. Groups of warts often grow in the same area, and their rough surfaces give them the appearance of a small cauliflower.
A 23-year-old multipara has been in active labor for the last 8 hours. Her cervix is dilated to 8 cm and the fetal vertex is at plus 2 station. The fetus is of average size and she has had a prior uneventful 9 lb (4.08 kg) fetus deliver vaginally. Recently, her contractions have been augmented by an oxytocin intravenous infusion. Membranes are ruptured and the amniotic fluid is clear. The patient is afebrile and normotensive. She has not required any medication for pain control. Her nurse has notified you of a recent change in the character of the fetal heart tracing. On arrival at the patient’s bedside, you note repetitive late decelerations on fetal heart tracing.
Which of the following is the most appropriate next step?
Correct Answer D: These are examples of repetitive late decelerations. Late decelerations are felt to be consistent with uteroplacental insufficiency. This can be due to a number of reasons, including the following: the maternal circulation is not adequately perfusing the placental bed; maternal hypoxia; inadequate exchange across the placental bed (abruption, infarct); and also inadequate fetal perfusion of the placenta. Since this is a recent change in the prior character of the fetal heart tracing and since the patient is on oxytocin infusion, allowing intrauterine resuscitation would be the most optimal choice. Should no improvement in the fetal condition occur, then the next step after this would be delivery.
→ Instrumented vaginal delivery (choice A) is never indicated before the cervix is completely dilated.
→ Cesarean delivery (choice B) would be indicated if measures to allow intrauterine resuscitation are unsuccessful (left lateral position, supplemental oxygen to the mother, discontinue contractions).
→ Amnioinfusion (choice C) is appropriate for repetitive variable decelerations must be evaluated and measures undertaken to improve the fetal heart tracing.
→ It is possible in the future, with the use of fetal pulse oximetry, that in some conditions this heart tracing can be further observed without intervention (choice E).
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