A 35-year-old white female presents with a 6-month history of irregular menstrual bleeding. Before this problem began, her periods occurred every 30 days and lasted 5 days. Now they occur every 20 days and last for 10 days, and are heavier than they were previously. A physical examination reveals no obvious anatomic source of bleeding, and a Papanicolaou (Pap) test is normal. A pregnancy test is negative and a blood workup for organic causes of irregular menses is also negative. She is on birth control pills and takes no other medications.
Which one of the following would be most appropriate at this point?
Correct Answer A:
Dysfunctional uterine bleeding is common, but the diagnosis is made by excluding other pathologies. Changes in bleeding pattern may be due to cervical pathology which will usually be seen on a Papanicolaou (Pap) smear; anatomic problems such as polyps which can be detected on examination; organic causes such as thyroid problems; prolactinemia, coagulopathy, hepatic dysfunction, or adrenal dysfunction, which can be detected by laboratory testing; and pregnancy. If these conditions are ruled out, endometrial evaluation is important to exclude cancer, especially when any risk factors are present. Risk factors include age over 35, a history of anovulatory cycles, obesity, nulliparity, a history of tamoxifen use, and diabetes mellitus.
Ultrasonography is recommended to evaluate the thickness at the endometrial lining and to look for other uterine causes of bleeding such as polyps or fibroids. In this patient an endometrial biopsy is not mandatory given her age and lack of other risk factors.
A 36-year-old gravida 4 para 4 presents to your office due to irregular vaginal bleeding. Her last delivery was 2 years ago and uncomplicated. Since then, she has had two normal periods, but only intermittent spotting and bleeding for the last 7 months. Pelvic exam demonstrates a normal sized uterus and adnexa. You perform an endometrial biopsy to rule out the possibility of a malignancy.
The biopsy finding is most likely to show:
Correct Answer D:
The most common cause of abnormal uterine bleeding is anovulation. Since she had a vaginal delivery 2 years ago, she has not had a prolonged exposure to unopposed estrogen, so the likelihood of an endometrial malignancy is very low. The most common finding is proliferative endometrium in this case.
→ There have been only 2 years since her last delivery. It is unlikely that she has developed an estrogen induced neoplasia in that time frame.
→ An Arias Stella reaction is found in pregnancy; it is the hypersecretory gland appearance seen on histopathology.
An 18-year-old primigravida at 38 weeks gestation complains of a headache. Her blood pressure is 130/92 mm Hg. The fetal heart rate is 140 beats/min. A urine dipstick shows 2 + protein.
Laboratory Findings:
A nonstress test is reactive and the amniotic fluid index is 9.4 (N 8.0 - 20.0). The patient is admitted for further testing. After 24 hours repeat testing shows the following:
Which one of the following would be the most appropriate course of action at this point?
This patient has hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome and needs to be delivered. HELLP syndrome is a form of severe preeclampsia. There is no reason to delay delivery in a term pregnancy.
If the patient has a favorable cervical examination, labor induction with oxytocin is appropriate. If the cervix is unfavorable, cesarean delivery should be considered to expedite delivery.
In the past, Cesarean delivery was the most common way for delivery of women dealing with HELLP syndrome. But it is now recommended that women, who are at least 34 weeks gestation and have a favorable cervix, should be given a “trial of labor”. HELLP syndrome does not cause reason for an automatic cesarean and in some situations, operative surgery may cause more complications due to the possibility of blood clotting problems related to low platelet counts.
The laboratory abnormalities in HELLP syndrome typically worsen after delivery and then begin to resolve by three to four days postpartum.
The two most common indicators for transcervical amnioinfusion in labor are:
Correct Answer B:
Transcervical amnioinfusion is an effective treatment for severe variable decelerations in labor. Controlled prospective trials have established that it relieves variable decelerations in a majority of cases and allows the parturient to continue in labor. Its use for preventing meconium aspiration is less well established, but a Cochrane review recently favored its use for the patient in labor with a thick meconium.
The procedure is not indicated for oligohydramnios or fetal growth restriction, although pregnancies with these complications have a higher risk of developing indications for amnioinfusion. Umbilical cord prolapse and amniotic fluid embolism may be complications of amnioinfusion, but this is not fully established. Late decelerations, placental abruption, hypertonic labor, and low fetal scalp pH are all contraindications to the use of amnioinfusion.
A 28-year-old gravida 2 para 1 at 32 weeks gestation presents with severe itching. She denies fever or vomiting. Her physical examination is remarkable for jaundice, but is otherwise benign. Laboratory studies reveal a normal CBC, normal platelets, normal glucose and serum creatinine levels, normal transaminase levels, and a bilirubin level of 68.4 µmol/L.
Which one of the following is the most likely diagnosis?
Intrahepatic cholestasis of pregnancy is rare, occurring in 0.01% of pregnancies. It usually presents in the third trimester. Approximately 80% of patients present with pruritus alone, and another 20% with jaundice and pruritis. Laboratory results usually reveal normal or minimal elevation in transaminase levels, elevated bilirubin (usually < 85 µmol/L), and occasional elevations in cholesterol and triglyceride levels. It is important to recognize and diagnose this entity, as it is associated with prematurity, fetal distress, and increased perinatal mortality.
Acute viral hepatitis is a common cause of jaundice in pregnancy; however, it usually does not present with severe pruritus, and transaminase levels are markedly elevated. Acute fatty liver of pregnancy is another rare condition occurring in the third trimester and is usually associated with preeclampsia (50%-100% of cases). It presents with nausea and vomiting, anorexia, jaundice, abdominal pain, headache, and neurologic abnormalities. Transaminase levels are moderately elevated, PT and PTT are prolonged, and profound hypoglycemia and renal failure are usually present. Pruritic urticarial papules and plaques of pregnancy (PUPPP) is more common in women that present with severe pruritus. However, jaundice and liver function abnormalities are absent. HELLP syndrome is an uncommon but serious condition which presents in the third trimester with hemolysis, elevated transaminases, and low platelet count.
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