A full-term newborn, born 72 hours ago, is noted to be jaundiced. The pregnancy was uneventful and the delivery uncomplicated. The mother has type A-positive blood and the child has type O-positive. The child is breastfed and has lost 9 ounces from a birth weight of 8 lb. He is feeding for 20 minutes every 4 hours, and except for being icteric, has a normal examination.
Laboratory evaluation reveals a total serum bilirubin level of 16 mg/dL (N 1.4-8.7), with a conjugated bilirubin level of 1.0 mg/dL. His hemoglobin level is 17.8 g/dL (N 13.4-19.8), his hematocrit is 55% (N 41-65), and his reticulocyte count is 3% (N 3-7).
Appropriate management would include:
Correct Answer E:
Hyperbilirubinemia can occur in up to 60% of term newborns during the first week of life. Early guidelines on management of elevated bilirubin were based on studies of bilirubin toxicity in infants who had hemolytic disease. Current recommendations now support the use of less intensive therapy in term newborns with jaundice who are otherwise healthy. Phototherapy should be initiated when the bilirubin level is above 15 mg/dL for infants at age 29-48 hours old, at 18 mg/dL for infants 49-72, and at 20 mg/dL in infants older than 72 hours. Generally, this problem is not considered pathologic unless it presents during the first hours after birth and the total serum bilirubin rises by more than 5 mg/dL/day or is higher than 17 mg/dL, or if the infant has signs or symptoms suggestive of a serious underlying illness such as sepsis. Fortunately, very few term newborns with jaundice have serious underlying pathology.
Physiologic jaundice follows a pattern, with the bilirubin level peaking on the third or fourth day of life and then declining over the first week after birth. Infants with multiple risk factors may develop an exaggerated form of physiologic jaundice, with the total bilirubin level rising as high as 17 mg/dL. Breastfed infants are at an increased risk for exaggerated physiologic jaundice because of relative caloric deprivation in the first few days of life. Compared with formula-fed infants, those who are breastfed are six times more likely to experience moderate jaundice, with the bilirubin rising above 12 mg/dL.
For breastfed newborns who have an early onset of hyperbilirubinemia, the frequency of feeding should be increased to more than 10 times per day. If the newborn has a decrease in weight gain, delayed stooling, and continued poor intake, then formula supplementation may be necessary. Breastfeeding should be continued to maintain breast milk production. Supplemental water or dextrose and water should not be given, as this can decrease breast milk production and may place the infant at risk for iatrogenic hyponatremia.
The definition of a post-term pregnancy is a pregnancy that has reached:
Correct Answer C:
Postdate and post-term pregnancy are terms that are used interchangeably. The postdate pregnancy is defined as a pregnancy that has reached 42 weeks of amenorrhea. This is important because perinatal mortality doubles at 42 weeks gestational age. The diagnosis of postdate pregnancy depends heavily on accurate dating methods.
A 27-year-old white female has a 10 year history of significant premenstrual dysphoria. Her condition has significantly worsened in the past 3 years, to the point that it is endangering her marriage of 5 year. Her symptoms are worse for the 10 days prior to her menstrual period and are gone by day 2 of her period. She has tried several measures without success, including birth control pills, various herbal preparations, and counseling at a woman’s health center.
You recommend:
SSRIs are considered first-line treatment for premenstrual dysphoric disorder. Several randomized trials have shown that they are superior to placebo for this condition. Fluoxetine and sertraline have been studied the most.
→ There have been no controlled trials to support anecdotal reports of benefit from the reduction of caffeine or refined sugar.
→ Studies using alprazolam have shown it to be effective for premenstrual anxiety only.
→ Progesterone has not been proven more effective than placebo in clinical trials, and bupropion is less effective than agents that primarily boost serotonergic activity.
A 23-year-old Hispanic female at 18 weeks gestation presents with a 4 week history of a new facial rash. She has noticed worsening with sun exposure. Her past medical history and review of systems is normal. On examination, you note symmetric, hyperpigmented patches on her cheeks and upper lip. The remainder of her examination is normal.
The most likely diagnosis is:
Melasma or chloasma is common in pregnancy, with approximately 70% of pregnant women affected. It is an acquired hypermelanosis of the face, with symmetric distribution usually on the cheeks, nose, eyebrows, chin, and/or upper lip. The pathogenesis is not known. UV sunscreen is important, as sun exposure worsens the condition. Melasma often resolves or improves post partum. Persistent melasma can be treated with hydroquinone cream, retinoic acid, and/or chemical peels performed post partum by a dermatologist.
The facial rash of lupus is usually more erythematous, and lupus is relatively rare. Pemphigoid gestationis is a rare autoimmune disease with extremely pruritic, bullous skin lesions that usually spare the face. Prurigo gestationis involves involves pruritic papules on the extensor surfaces and is usually associated with significant excoriation by the uncomfortable patient.
At a routine 6 week postpartum visit, a tearful, despondent-appearing patient reports depressed mood, poor appetite, decreased sexual drive, fatigue, and loss of interest in her usual activities. She denies suicidal ideation.
Which one of the following should you do now?
Postpartum depression is a highly prevalent disorder with consequences that can be profound. The “postpartum blues” affect up to 85% of women and typically resolve by the tenth postpartum day, whereas the onset of postpartum depression may not occur until 6 months following delivery. Evidence regarding the benefit of hormonal therapy for patients with postpartum depression is lacking. Generally, postpartum depression can be managed on an outpatient basis unless the illness is severe. SSRIs are ideal first-line agents and should be used for similar periods of time and in dosages comparable to those prescribed to patients who suffer from nonpuerperal illness.
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