A 24-year-old White (G1P1001) female presents to your office 6 weeks after a normal spontaneous vaginal delivery at term. She reports that she has been unable to breast-feed her baby despite helpfrom her pediatrician and a lactation consultant. On further questioning, you elicit that she has also experienced nausea, weakness, and weight loss. In addition, she reports dizziness when getting out of bed in the morning. On your examination, she has a waxy texture to her skin and periorbital edema. You also note decreased axillary and pubic hair, which she reports is a change for her.
This condition is most commonly associated with which of the following?
A. obesity and increased facial hair
B. postpartum hemorrhage
C. acute thrombosis
D. no specific association is known, this condition is idiopathic
E. serotonin imbalance
Correct Answer: B Section: (none)
Explanation:
Sheehan syndrome is also known as postpartum pituitary necrosis. It is associated with severe blood loss during the early postpartum period. The patient with this syndrome may present acutely with hypotension and shock due to adrenal insufficiency, though often it presents as in this case, with the more gradual onset of symptoms. The most common initial presentation is the inability to lactate. Other symptoms may occur over months to years with the classic patient presenting with failure of lactation, rapid breast involution, amenorrhea, failure to regrow pubic and axillary hair, skin depigmentation, anorexia and nausea, lethargy, weakness, and weight loss. Signs and symptoms may present years after the event. Additionally, on physical examination, patients may have waxy skin, periorbital edema, and decreased skin pigmentation. Sheehan syndrome usually involves the anterior pituitary but can sometimes cause ischemia of the posterior pituitary. With posterior pituitary involvement, vasopressin secretion is diminished resulting in diabetes insipidus. Most cases involve the selective loss of hormone secretion of the anterior pituitary hormones, and the loss is usually incomplete. The clinical manifestation depends on the degree of deficiency and the hormones that are affected. GH deficiency is seen in the majority of patients with Sheehan syndrome followed by ACTH deficiency, hypogonadism, and hypothyroidism
Question 322:
A 24-year-old White (G1P1001) female presents to your office 6 weeks after a normal spontaneous vaginal delivery at term. She reports that she has been unable to breast-feed her baby despite helpfrom her pediatrician and a lactation consultant. On further questioning, you elicit that she has also experienced nausea, weakness, and weight loss. In addition, she reports dizziness when getting out of bed in the morning. On your examination, she has a waxy texture to her skin and periorbital edema. You also note decreased axillary and pubic hair, which she reports is a change for her. She most likely has which of the following diagnoses?
A. postpartum depression
B. normal postpartum changes
C. Sheehan syndrome
D. PCOS
E. medication reaction
Correct Answer: C Section: (none)
Explanation:
Sheehan syndrome is also known as postpartum pituitary necrosis. It is associated with severe blood loss during the early postpartum period. The patient with this syndrome may present acutely with hypotension and shock due to adrenal insufficiency, though often it presents as in this case, with the more gradual onset of symptoms. The most common initial presentation is the inability to lactate. Other symptoms may occur over months to years with the classic patient presenting with failure of lactation, rapid breast involution, amenorrhea, failure to regrow pubic and axillary hair, skin depigmentation, anorexia and nausea, lethargy, weakness, and weight loss. Signs and symptoms may present years after the event. Additionally, on physical examination, patients may have waxy skin, periorbital edema, and decreased skin pigmentation. Sheehan syndrome usually involves the anterior pituitary but can sometimes cause ischemia of the posterior pituitary. With posterior pituitary involvement, vasopressin secretion is diminished resulting in diabetes insipidus. Most cases involve the selective loss of hormone secretion of the anterior pituitary hormones, and the loss is usually incomplete. The clinical manifestation depends on the degree of deficiency and the hormones that are affected. GH deficiency is seen in the majority of patients with Sheehan syndrome followed by ACTH deficiency, hypogonadism, and hypothyroidism
Question 323:
A 30-year-old (G2P0101) female presents to the clinic for a new obstetric visit. She has an unknown LMP. She reports that she discovered she was pregnant when she took a urine pregnancy test at home a month ago. She vaguely recalls having a period about 2 months ago, but is not sure exactly when that occurred. She reports that she is generally healthy. She had a previous delivery at 36 weeks EGA, though she reports her doctor was not really sure about her due date in that pregnancy. She reports that she had a normal spontaneous vaginal delivery in her previous pregnancy, and the child is healthy. Her postpartum course was complicated by depression, which has since resolved and not recurred. She denies history of sexually transmitted diseases or abnormal pap smears. She has no surgical history. She does not smoke, drink alcohol, or use illicit drugs. She does not have any family history of hypertension, diabetes, twins, or congenital anomalies. She does report that her mother has a history of depression Postpartum psychosis is a serious disorder that can occur in the early postpartum period. Patients with which of the following medical conditions are at increased risk of postpartum psychosis?
A. multiparity
B. anxiety disorder
C. thyroid disease
D. bipolar disorder
E. advanced maternal age
Correct Answer: D Section: (none)
Explanation:
The pelvic ultrasound is the most reliable measurement of fetal gestational age in the absence of accurate dating by LMP. A first trimester sonogram is thought to be reliable ±7 days. Given the patient's history, she is likely at least 2 months pregnant. hCG level at this gestation can be variable and is not a useful method of pregnancy dating. A pelvic examination is useful to help confirm likely dating, but is not a reliable means of determining EDD. FSH and LH levels have no role in determining pregnancy dating.
The risk of postpartum major depression is estimated at 820% in all postpartum patients. In those with a previous history of postpartum depression, the risk is thought to be 50100%. In patients who have had previous depression not associated with pregnancy, the risk of postpartum depression is 2030%. Maternity blues is a milder psychological reaction that can occur in the early postpartum period and is thought to occur in 70+ % of all postpartum patients. Patients with a history of bipolar disease have a igher risk of recurrence in the postpartum period, and these patients often present with postpartum psychosis symptoms.
Question 324:
A 30-year-old (G2P0101) female presents to the clinic for a new obstetric visit. She has an unknown LMP. She reports that she discovered she was pregnant when she took a urine pregnancy test at home a month ago. She vaguely recalls having a period about 2 months ago, but is not sure exactly when that occurred. She reports that she is generally healthy. She had a previous delivery at 36 weeks EGA, though she reports her doctor was not really sure about her due date in that pregnancy. She reports that she had a normal spontaneous vaginal delivery in her previous pregnancy, and the child is healthy. Her postpartum course was complicated by depression, which has since resolved and not recurred. She denies history of sexually transmitted diseases or abnormal pap smears. She has no surgical history. She does not smoke, drink alcohol, or use illicit drugs. She does not have any family history of hypertension, diabetes, twins, or congenital anomalies. She does report that her mother has a history of depression
Given the patient's history of postpartum depression as well as her family history of depression, her risk of postpartum depression after this pregnancy is approximately what percentage?
A. 50% or greater
B. 5%
C. 10%
D. 20%
E. less than 1%
Correct Answer: A Section: (none)
Explanation:
The pelvic ultrasound is the most reliable measurement of fetal gestational age in the absence of accurate dating by LMP. A first trimester sonogram is thought to be reliable ±7 days. Given the patient's history, she is likely at least 2 months pregnant. hCG level at this gestation can be variable and is not a useful method of pregnancy dating. A pelvic examination is useful to help confirm likely dating, but is not a reliable means of determining EDD. FSH and LH levels have no role in determining pregnancy dating.
The risk of postpartum major depression is estimated at 820% in all postpartum patients. In those with a previous history of postpartum depression, the risk is thought to be 50100%. In patients who have had previous depression not associated with pregnancy, the risk of postpartum depression is 2030%. Maternity blues is a milder psychological reaction that can occur in the early postpartum period and is thought to occur in 70+ % of all postpartum patients. Patients with a history of bipolar disease have a igher risk of recurrence in the postpartum period, and these patients often present with postpartum psychosis symptoms.
Question 325:
A 30-year-old (G2P0101) female presents to the clinic for a new obstetric visit. She has an unknown LMP. She reports that she discovered she was pregnant when she took a urine pregnancy test at home a month ago. She vaguely recalls having a period about 2 months ago, but is not sure exactly when that occurred. She reports that she is generally healthy. She had a previous delivery at 36 weeks EGA, though she reports her doctor was not really sure about her due date in that pregnancy. She reports that she had a normal spontaneous vaginal delivery in her previous pregnancy, and the child is healthy. Her postpartum course was complicated by depression, which has since resolved and not recurred. She denies history of sexually transmitted diseases or abnormal pap smears. She has no surgical history. She does not smoke, drink alcohol, or use illicit drugs. She does not have any family history of hypertension, diabetes, twins, or congenital anomalies. She does report that her mother has a history of depression.
Which of the following tests will provide the most useful information to determine this patient's EDD?
A. pelvic examination
B. serum FSH and LH
C. serum quantitative -hCG level
D. measurement of fundal height
E. pelvic ultrasound
Correct Answer: E Section: (none)
Explanation:
The pelvic ultrasound is the most reliable measurement of fetal gestational age in the absence of accurate dating by LMP. A first trimester sonogram is thought to be reliable ±7 days. Given the patient's history, she is likely at least 2 months pregnant. hCG level at this gestation can be variable and is not a useful method of pregnancy dating. A pelvic examination is useful to help confirm likely dating, but is not a reliable means of determining EDD. FSH and LH levels have no role in determining pregnancy dating.
The risk of postpartum major depression is estimated at 820% in all postpartum patients. In those with a previous history of postpartum depression, the risk is thought to be 50100%. In patients who have had previous depression not associated with pregnancy, the risk of postpartum depression is 2030%. Maternity blues is a milder psychological reaction that can occur in the early postpartum period and is thought to occur in 70+ % of all postpartum patients. Patients with a history of bipolar disease have a igher risk of recurrence in the postpartum period, and these patients often present with postpartum psychosis symptoms.
Question 326:
A 19-year-old (G2P1001) female at 354/7 weeks EGA presents for a routine prenatal visit. Her pregnancy has been uncomplicated. She reports good fetal movement and denies vaginal bleeding, loss of fluid, or contractions. She is excited about the arrival of her baby and is planning to breast-feed. Her past medical history is significant for chlamydia that was treated approximately 1 year ago. She is otherwise healthy. Her blood pressure today is 110/60. Fundal height is appropriate. UA is negative.
The patient wants to know what complications she might experience from breast-feeding. You tell her that the most common complication of breast-feeding is mastitis. If she were to develop mastitis, which of the following treatments would be recommended?
A. dicloxacillin by mouth plus discontinuation of breast-feeding
B. discontinuation of breast-feeding only
C. Flagyl by mouth plus discontinuation of breast-feeding
D. dicloxacillin by mouth with continued breast-feeding
E. no treatment is required for mastitis
Correct Answer: D Section: (none)
Explanation:
The patient would be best served by a progesterone-only pill as it will be less likely to interfere with breast milk production. The rhythm method cannot be reliably used in the early postpartum period as normal menstrual cycles may not have resumed. An IUD would be contraindicated in this patient because of her recent history of chlamydia infection. Patients may not ovulate during breastfeeding but should not rely on breast-feeding alone as a form of contraception, as pregnancy can occur while breast-feeding.
Mastitis is a common complication of breast-feeding. It is characterized by fever, myalgias, and redness with pain in the affected breast. Antibiotic options include penicillin V, ampicillin, or dicloxacillin. Studies show that patients may continue to breast-feed while undergoing treatment for mastitis
Question 327:
A 19-year-old (G2P1001) female at 354/7 weeks EGA presents for a routine prenatal visit. Her pregnancy has been uncomplicated. She reports good fetal movement and denies vaginal bleeding, loss of fluid, or contractions. She is excited about the arrival of her baby and is planning to breast-feed. Her past medical history is significant for chlamydia that was treated approximately 1 year ago. She is otherwise healthy. Her blood pressure today is 110/60. Fundal height is appropriate. UA is negative.
The patient would like to discuss options for postpartum birth control. Which of the following would be an appropriate and effective option for postpartum birth control for this patient?
A. combined OCP
B. intrauterine device (IUD)
C. progesterone-only pill
D. no birth control is necessary as the patient will be breast-feeding
E. rhythm method
Correct Answer: C Section: (none)
Explanation:
The patient would be best served by a progesterone-only pill as it will be less likely to interfere with breast milk production. The rhythm method cannot be reliably used in the early postpartum period as normal menstrual cycles may not have resumed. An IUD would be contraindicated in this patient because of her recent history of chlamydia infection. Patients may not ovulate during breastfeeding but should not rely on breast-feeding alone as a form of contraception, as pregnancy can occur while breast-feeding.
Mastitis is a common complication of breast-feeding. It is characterized by fever, myalgias, and redness with pain in the affected breast. Antibiotic options include penicillin V, ampicillin, or dicloxacillin. Studies show that patients may continue to breast-feed while undergoing treatment for mastitis
Question 328:
A34-year-old Black (G1) female presents to your clinic for an obstetric visit at 16 weeks estimated gestational age (EGA). She has a sure LMP and her estimated date of delivery (EDD) is in December. She is generally healthy and has not had any surgeries. She denies history of sexually transmitted diseases or abnormal pap smears. She has no significant family history. She does not smoke or use alcohol or illicit drugs. She works as an administrative assistant. Her prenatal labs are as follows: blood type O+, antibody screen negative; hepatitis B surface antigen negative; HIV antibody negative; Rubella nonimmune; rapid plasma regain (RPR) nonreactive; pap smear within normal limits; urine culture negative. Based on her laboratory results and history, you recommend that she receive which of the following injections during her pregnancy?
A. measles, mumps, and rubella (MMR) vaccine
B. influenza vaccine
C. hepatitis B vaccine series
D. RhoGAM injection
E. poliomyelitis vaccine
Correct Answer: B Section: (none)
Explanation:
Influenza vaccination is recommended to all women who will be in the second or third trimester of pregnancy during the flu season. Poliomyelitis vaccination is not recommended for women in the United States unless they have some increased risk due to travel or exposure. MMR vaccination is contraindicated in pregnancy secondary to a theoretic risk of teratogenicity from the rubella vaccine. MMR should be given to this patient postpartum. RhoGAM is recommended routinely during pregnancy in Rh negative women who are unsensitized to Rh factor. In this case the patient is Rh positive.
Question 329:
A 22-year-old female (G3P0020) presents to your office for an initial obstetric visit in her third pregnancy. She reports a sure LMP date approximately 6 weeks ago, with a history of regular cycles. Her two previous pregnancies ended in spontaneous abortions. She denies any significant medical or surgical history. She denies use of alcohol, tobacco, or illicit drugs, though she does report a history of IV drug use as a teenager. She is a full-time student. She reports that twins run in her family, but she does not have any family history of diabetes, hypertension, or congenital anomalies. On review of her prenatal labs that have already been drawn, you find that her human immunodeficiency virus (HIV) antibody test (enzyme-linked immunosorbent assay [ELISA]) is positive. Her test results are otherwise normal
Which of the following is recommended to reduce the risk of perinatal transmission of HIV from mother to infant?
A. A scheduled cesarean delivery can reduce the risk of transmission if the maternal viral load is greater than 1000 copies/mL.
B. All pregnant women with HIV should receive highly active antiretroviral therapy regardless of severity of HIV infection.
C. No treatment is required; the risk of perinatal transmission of HIV is quite low.
D. All patients with HIV should be required to have a cesarean delivery.
E. Treatment of opportunistic infections such as Pneumocystis carinii pneumonia in the mother is most important in reducing the perinatal transmission of HIV.
Correct Answer: A Section: (none)
Explanation:
Screening for HIV should be offered to all pregnant women as part of routine prenatal care. Screening for HIV infection is done using an enzyme immunoassay (EIA). If the screening test is positive, it may be repeated. Once the screening test is determined to be positive, a Western blot assay or immunofluorescent antibody assay (IFA) is done as a confirmatory test. If the confirmatory test is positive, the patient is then considered to be infected with HIV. Pregnant patients should be treated for HIV by the same standards as any other adult with HIV, though some consideration is given to selection of antiretroviral medications that are safest in pregnancy. Appropriate HIV-related care should not be deferred because of pregnancy. For patients with significant HIV disease, the combination of elective scheduled cesarean and antiretroviral therapy has been shown to be more effective than antiretrovirals alone at reducing perinatal transmission of HIV. In the absence of any therapy, the risk of vertical transmission is estimated at 25%. With zidovudine therapy, the risk is decreased to approximately 58%. When zidovudine is given in combination with elective cesarean for appropriate patients, the risk is decreased to approximately 2%. In a recent meta-analysis, perinatal transmission occurred in only 1% of treated women with RNA viral loads less than 1000 copies/ mL. Given the low risk of transmission in this group, it is unclear whether cesarean delivery would provide additional benefit. After reviewing this data, the American College of Obstetricians and Gynecologists Committee on Obstetric Practice has issued a Committee Opinion concerning route of delivery, recommending consideration of scheduled cesarean delivery for HIV-1-infected pregnant women with HIV1 RNA levels >1000 copies/mL near the time of delivery.
Question 330:
A 22-year-old female (G3P0020) presents to your office for an initial obstetric visit in her third pregnancy. She reports a sure LMP date approximately 6 weeks ago, with a history of regular cycles. Her two previous pregnancies ended in spontaneous abortions. She denies any significant medical or surgical history. She denies use of alcohol, tobacco, or illicit drugs, though she does report a history of IV drug use as a teenager. She is a full-time student. She reports that twins run in her family, but she does not have any family history of diabetes, hypertension, or congenital anomalies. On review of her prenatal labs that have already been drawn, you find that her human immunodeficiency virus (HIV) antibody test (enzyme-linked immunosorbent assay [ELISA]) is positive. Her test results are otherwise normal. Which of the following indicates how you counsel the patient?
A. This result is a false positive due to pregnancy, and she does not need any further testing.
B. She is infected with HIV and will need to begin treatment right away.
C. She will require an additional, confirmatory test to determine whether or not she has HIV.
D. She may have HIV, but she should wait until after she delivers her baby to have further testing.
E. Because it has been years since she participated in high-risk behaviors, she is unlikely to have HIV.
Correct Answer: C Section: (none)
Explanation:
Screening for HIV should be offered to all pregnant women as part of routine prenatal care. Screening for HIV infection is done using an enzyme immunoassay (EIA). If the screening test is positive, it may be repeated. Once the screening test is determined to be positive, a Western blot assay or immunofluorescent antibody assay (IFA) is done as a confirmatory test. If the confirmatory test is positive, the patient is then considered to be infected with HIV. Pregnant patients should be treated for HIV by the same standards as any other adult with HIV, though some consideration is given to selection of antiretroviral medications that are safest in pregnancy. Appropriate HIV-related care should not be deferred because of pregnancy. For patients with significant HIV disease, the combination of elective scheduled cesarean and antiretroviral therapy has been shown to be more effective than antiretrovirals alone at reducing perinatal transmission of HIV. In the absence of any therapy, the risk of vertical transmission is estimated at 25%. With zidovudine therapy, the risk is decreased to approximately 58%. When zidovudine is given in combination with elective cesarean for appropriate patients, the risk is decreased to approximately 2%. In a recent meta-analysis, perinatal transmission occurred in only 1% of treated women with RNA viral loads less than 1000 copies/ mL. Given the low risk of transmission in this group, it is unclear whether cesarean delivery would provide additional benefit. After reviewing this data, the American College of Obstetricians and Gynecologists Committee on Obstetric Practice has issued a Committee Opinion concerning route of delivery, recommending consideration of scheduled cesarean delivery for HIV-1-infected pregnant women with HIV1 RNA levels >1000 copies/mL near the time of delivery.
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