A 24-year-old female presents with a complaint of mild fullness in the neck. A review of systems is negative, except for some poor sleep related to the care of her 4-month-old infant, and mild palpitations at times when she is tired. Her pregnancy was uneventful, and breastfeeding is going well. Findings on examination are normal except for enlargement of the thyroid. Her TSH level is 0.1 µU/mL (N 0.3-5.0).
Which one of the following would be most appropriate at this point?
Correct Answer A:
Postpartum thyroiditis is a common condition, occurring after 3%-16% of pregnancies. It is thought to be a variation of Hashimoto’s disease and can present in several ways. It can cause hyperthyroidism, beginning 1-4 months after delivery and lasting for 2-8 weeks. Thyroid function then either returns to normal or the patient develops transient or permanent hypothyroidism. Another possible manifestation is hypothyroidism beginning 2-6 months after delivery, which again can either be transient or become permanent. A third possibility is that the patient can develop a euthyroid goiter.
As in this case, the symptoms are usually mild, and can be confused with the typical feelings of a new mother. Since the symptoms are mild and the hyperthyroid stage is brief, treatment is not necessary in the majority of cases. The hyperthyroid symptoms should be explained to the patient, and she should also be made aware of the symptoms of hypothyroidism, since it is a common development after the hyperthyroid stage has passed and may be permanent. Breastfeeding was going well in this patient, and should be continued. Propranolol is not needed unless the palpitations worsen. Propylthiouracil is used for Graves’ disease, to counteract overproduction of thyroid hormone. With postpartum thyroiditis, as with other types of thyroiditis, thyroid hormone is released from the gland as a result of autoimmune injury, but production of thyroid hormone is actually low. Propylthiouracil has no place in the treatment of thyroiditis.
Radioactive thyroid scanning is not necessary unless symptoms are significant and are not resolving, in which case Graves’ disease masquerading as thyroiditis must be ruled out. Thyroiditis would cause low uptake, but this has no bearing as to whether thyroid hormone needs to be given. Thyroid hormone is used in postpartum thyroiditis if the person is found to be hypothyroid (with high levels of TSH), with symptoms significant enough to require treatment. Treatment would be continued for 1-2 months and then stopped, and the TSH level rechecked 1 month later to see if the hypothyroid condition has resolved.
A 28-year-old female presents 2 weeks post partum complaining of palpitations, diarrhea, weight loss, and being “jumpy.” Her examination is normal except for a slightly enlarged and tender thyroid gland. Her TSH level is 0.02 µU/mL (N 0.5-5.5), with a higher than normal level of free T3.
Which one of the following would be the most appropriate treatment?
Correct Answer C:
This patient presents with signs, symptoms, and laboratory evidence of postpartum thyroiditis. This is an autoimmune attack of the thyroid gland that occurs in 5%-10% of all mothers within a year of delivery. The transient increase of thyroid hormone that results is often unnoticed but can cause clinical hyperthyroidism. A ß-blocker is recommended to reduce heart irregularities and other symptoms related to high levels of circulating thyroid hormone. Propylthiouracil prevents the production of new thyroid hormone and is not indicated because this condition results only in a release of thyroid hormone that has already been created. Up to one-third of women with this condition will become chronically hypothyroid and will require regular thyroid replacement. This patient is not currently hypothyroid, so she would not benefit from replacement with levothyroxine.
In a woman with mild persistent asthma, which one of the following agents is thought to be the best choice for maintenance therapy during pregnancy?
Inhaled corticosteroids (choice A) are currently the recommended maintenance agent for pregnant patients with mild persistent asthma. They have proven efficacy with a relatively low risk profile.
→ Cromolyn (choice B) has a good safety record but somewhat disappointing results. Its effectiveness is limited compared to that of inhaled corticosteroids.
→ Long-acting beta-agonists (choice C) with inhaled corticosteroids are more often used in more severe persistent asthma, as they decrease the frequency of attacks. There is some controversy about their effect on mortality.
→ Leukotriene receptor antagonists (choice D) are probably a reasonable add-on therapy for asthma in pregnancy. They are not as effective as inhaled corticosteroids, however, and do not have as long a track record of safety.
→ Leukotriene synthesis inhibitors (choice E) are not recommended for use in pregnancy.
A 19-year-old primigravida at approximately 40 weeks gestation comes to the hospital with painful contractions. She has received no prenatal care. Examination reveals that her cervix is 4 cm dilated and 85% effaced at -1 station. Her blood pressure is 164/111 mm Hg and a urine dipstick shows 3+ protein. She reports that she has had severe headaches for 3 days and has noticed a lot of swelling in her legs and feet. Moments after blood is drawn and intravenous access is obtained, she has a generalized tonic-clonic seizure and fetal heart tones drop to 60 beats/min.
Which one of the following is the most appropriate immediate course of action?
This patient has eclampsia. When an eclamptic seizure occurs, the first priority is to control the convulsions and prevent their recurrence with a 4- to 6-g intravenous or intramuscular loading dose of magnesium sulfate given over 15-20 minutes, followed by a drip at 2 g/hr. Although the only cure for eclampsia is delivery, the patient should be stabilized first.
→ Fetal bradycardia is an expected occurrence during an eclamptic seizure and does not necessitate an emergency cesarean section unless it fails to resolve within a few minutes.
→ Lorazepam is frequently used to control seizures in nonpregnant patients, but magnesium sulfate is the agent of choice for an eclamptic seizure. [note: benzodiazepine or phenytoin can be used for seizures that are not responsive to magnesium sulfate].
→ A fetal scalp electrode can be helpful to confirm fetal heart tones, but should not take precedence over trying to control the seizure.
→ Terbutaline is a tocolytic agent that does not have a role in the acute management of an eclamptic seizure.
A 33-year-old female presents with 3 months of irregular vaginal bleeding. Prior to this her menstrual periods were normal.
Which one of the following is the most appropriate initial laboratory test for this patient?
Correct Answer E:
In women of childbearing age, the most likely cause of abnormal vaginal bleeding is pregnancy; thus, the most appropriate initial test would be an hCG level. Once pregnancy has been excluded, patient history would guide further testing. Iatrogenic causes, usually resulting from certain medicines or supplements, are the next most common cause in this age group, followed by systemic disorders. Hemoglobin and hematocrit would be appropriate only if the patient seemed acutely anemic due to the abnormal bleeding.
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