A 25-year-old woman is 17 weeks pregnant. Her pas medical history is positive for genital herpes simplex virus infection.
Which one of the following is the current best management of this patient?
Correct Answer C: Genital herpes can be transmitted to the neonate during delivery, particularly if women have visible herpetic lesions or known infection with prodromal symptoms or if herpes infection first occurs during the late 3rd trimester (when the virus is likely to be excreted from the cervix at delivery). In such cases, delivery by cesarean section is preferred.
If visible lesions or prodrome is absent, even in women with recurrent infections, risk is low, and vaginal delivery is possible. If women are asymptomatic, serial antepartum cultures do not help identify those at risk of transmission. If women have recurrent herpes infections during pregnancy but no other risk factors for transmission, delivery can sometimes be induced to occur between recurrences. When delivery is vaginal, cervical and neonatal herpes virus cultures are done. Acyclovir (oral and topical) appears to be safe during pregnancy.
Breast engorgement in a woman eager to breastfeed is best managed by:
Correct Answer A: Breast milk usually "comes in" sometime during the first week after delivery. This means the milk changes from colostrum, or early milk, to mature milk. The body may make more than a baby needs during this period and it is easy to become overly full.
It is important to tell patients that to prevent engorgement: nurse frequently, about 8-12 times per day. Make sure the baby latches-on well so he/she will empty the breasts effectively. Do not skip feedings or give formula feedings during the first several weeks.
A mother is nearing the end of maternity leave. She asks for your advice regarding breastfeeding her infant after she returns to work.
Which one of the following would be accurate advice?
Correct Answer A:
Physicians commonly counsel women on how to continue breastfeeding after maternity leave. Breastfeeding should be well established by 4 weeks postpartum. Pumping may allow a woman to continue to provide breast milk while not physically available. Refreezing breast milk destroys valuable proteins and is not recommended. Separation of breast milk, in the refrigerator or at room temperature, is normal; the milk just needs to be shaken to re-emulsify the fat. The Occupational Safety and Health Administration (OHSA) states that exposure to breast milk does not constitute an occupational hazard. Breast milk should never be thawed in boiling water or in the microwave; this destroys valuable proteins. Breast milk may be stored in either glass or plastic bags or bottles. In addition, transparent plastic containers or bottles that contain bisphenol A should be avoided because exposure to bisphenol A may be associated with impairment of infant development. These containers often are marked with the recycling number 7 or the letters PC, which stand for "polycarbonate" plastic.
A previously healthy 22-year-old female presents for her regular prenatal checkup at 38 weeks gestation. She has a blood pressure of 145/95 mm Hg today and this is unchanged 1 hour later. Her blood pressure was normal before pregnancy. She is otherwise feeling well. She has moderate edema at the ankles and 3+ reflexes at the knees and ankles. A urinalysis for protein is normal.
Given this presentation, which one of the following is the most likely diagnosis?
Correct Answer D:
This patient has gestational hypertension. This condition is diagnosed when elevated blood pressure without proteinuria develops after 20 weeks gestation and blood pressure returns to normal within 12 weeks of delivery.
The new criteria for preeclampsia specify a new onset of hypertension (systolic blood pressure > 140 mm Hg or diastolic pressure > 90 mm Hg) after 20 weeks gestation, along with 300 mg protein in a 24-hour urine specimen. A certain amount of increase in blood pressure is no longer a criterion. Edema is also no longer a criterion. Elevated uric acid levels are no longer considered necessary for the diagnosis of preeclampsia.
Chronic hypertension can only be diagnosed if present before pregnancy, or if it does not resolve by 12 weeks post partum. Essential hypertension is the most common cause of chronic hypertension. HELLP syndrome is a serious, but relatively rare, form of pregnancy-related hypertension associated with hemolysis, elevated liver enzymes, and low platelets.
A 25-year-old black female at 32 weeks gestation is found to have a blood pressure of 170/100 mm Hg during a prenatal visit. Previously, her blood pressure had been normal. Although her blood pressure remains elevated during the remainder of her pregnancy, she denies any headaches, visual symptoms, chest pain, dyspnea, or abdominal pain. She develops edema, but does not have proteinuria. Her delivery is uneventful, and her blood pressure at her first postpartum visit is 124/78 mm Hg.
This patient most likely had:
Correct Answer C: Hypertension may be diagnosed for the first time during pregnancy. Gestational hypertension (choice C) is defined as systolic blood pressure (SBP) > 140 mm Hg or diastolic blood pressure (DBP) > 90 mm Hg on at least two occasions during a pregnancy. Chronic hypertension is diagnosed if blood pressure elevation persists ≥ 12 weeks postpartum. Transient hypertension of pregnancy is diagnosed if blood pressure returns to normal by 12 weeks postpartum.
→ The presence of hypertension and proteinuria (> 300 mg/24 hours) indicates preeclampsia (choice A).
→ Criteria for severe preeclampsia (choice B) include an SBP ≥ 160 mm Hg or a DBP ≥ 110 mm Hg; proteinuria ≥ 5 g/24 hrs; oliguria; cerebral or visual symptoms; pulmonary edema; epigastric or right upper quadrant abdominal pain; impaired liver function; thrombocytopenia; and intrauterine growth retardation.
→ Eclampsia (choice D) is the new occurrence of seizures in women with preeclampsia. Edema is no longer part of the diagnostic criteria for preeclampsia. Pre-hypertension is defined as an SBP of 130-140 mm Hg or a DBP of 80-90 mm Hg.
→ The HELLP syndrome (choice E) consists of hemolysis, elevated liver enzymes, and thrombocytopenia.
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