A 30-year-old G5P3 has undergone a repeat cesarean delivery. She wants to breastfeed. Her past medical history is significant for hepatitis B infection, hypothyroidism, depression, and breast reduction. She is receiving intravenous antibiotics for endometritis. The baby latches on appropriately and begins to suckle.
The patient asks you about the pros and cons of breastfeeding.
Which of the following is an accurate statement regarding breastfeeding?
According to the American Academy of Pediatrics, some of the benefits of nursing include a decrease in infant diarrhea, urinary tract infections, ear infections, and death from sudden infant death syndrome. Human milk is the ideal food for neonates. It provides species- and age-specific nutrients for the baby. It has immunological factors and antibacterial properties, and contains factors that act as biological signals to promote cellular growth. Breastfeeding can delay the resumption of ovulation and menses but should not be considered contraception.
The patient returns to see you in 6 weeks for a routine postpartum visit. She has been nursing her baby without any major problems, and wants to continue to do so for at least 9 months. She is ready to resume sexual activity and wants to know what her options are for contraception. She is a nonsmoker, and her only other medication is a prenatal vitamin.
Which of the following methods may decrease her milk supply?
The use of an IUD, barrier methods, and hormonal contraceptive agents containing only progestins are all appropriate methods of birth control for breastfeeding women. It is best for nursing mothers to avoid estrogen-containing contraceptives because estrogen preparations can inhibit lactation or decrease milk supply.
On postpartum day 2 after a vaginal delivery, a 32-year-old G2P2 develops acute shortness of breath and chest pain. Her vital signs are: blood pressure 120/80 mm Hg, pulse 130 beats per minute, respiratory rate 32 breaths per minute, and temperature 37.6°C (99.8°F). She has new onset of cough. She appears to be in mild distress. Lung examination reveals clear bases with no rales or rhonchi. The chest pain is reproducible with deep inspiration. Cardiac examination reveals tachycardia with 2/6 systolic ejection murmur. Pulse oximetry shows an oxygen saturation of 88% on room air, and oxygen supplementation is initiated.
Which of the following is the best diagnostic tool to confirm the diagnosis?
The patient most likely has a pulmonary embolism (PE). All three components of Virchow’s triad are present during pregnancy and the postpartum period: venous stasis, endothelial injury, and a hypercoaguable state. The reported incidence of venous thromboembolism during pregnancy is 1 in 500 to 1 in 2000. PE is the seventh leading cause of maternal mortality, responsible for 9% of maternal deaths, and therefore, rapid diagnosis and treatment are critical. The classic triad—hemoptysis, pleuritic chest pain, and dyspnea—appears in only 20% of cases. The most common sign on physical examination is tachypnea (> 16 breaths/min). Ventilationperfusion scans with large perfusion defects and ventilation mismatches support the putative diagnosis of PE, but this finding can also be seen with atelectasis or other disorders of lung aeration. Conversely, a normal ventilation-perfusion scan suggests that massive PE is not the etiology of the clinical symptoms. To confirm the diagnosis, a CT pulmonary angiography is the best diagnostic tool in this setting, and has high sensitivity and specificity for the diagnosis of PE. An arterial blood gas will confirm hypoxia, but not confirm PE as the cause. A chest x-ray could be done to rule out other causes such as pulmonary edema or pneumonia, but will not make the diagnosis of PE.
A 26-year-old G1P1 is now postoperative day (POD) 6 after a lowtransverse cesarean delivery for arrest of active phase. On POD 2, the patient developed a fever of 39°C (102.2°F) and was noted to have uterine tenderness and foul-smelling lochia. She was started on broad-spectrum antibiotic coverage for endometritis. The patient states she feels fine now and wants to go home, but continues to spike fevers each evening. Her lung, breast, and cardiac examinations are normal. Her abdomen is nontender with a firm, nontender uterus below the umbilicus. On pelvic examination, her uterus is appropriately enlarged, but nontender. The adnexa are nontender without masses. Her lochia is normal. Her white blood cell count is 12 with a normal differential. Blood, sputum, and urine cultures are all negative for growth after 3 days. Her chest x-ray is negative.
Which of the following statements accurately describes this patient’s condition?
The patient described has SPT. SPT may involve the ovarian vein, or other deep pelvic veins. The clinical presentation is usually that of pain and fever; therefore, it is usually diagnosed as endometritis, and antibiotic therapy is started. Following antimicrobial therapy, clinical symptoms usually resolve, but fever spikes persist. Patients typically do not appear clinically ill between fevers. The diagnosis of ovarian vein thrombosis is made by computerized tomography (CT) or magnetic resonance imaging (MRI). Deep septic pelvic thrombophlebitis that does not involve the ovarian vein is usually a diagnosis of exclusion, and should be suspected in patients with persistent postpartum fever despite antibiotics, with normal imaging. The treatment of choice is anticoagulation. There are no studies documenting the optimal time for anticoagulation, but most institutions recommend 6 weeks.
A 24-year-old who delivered her first baby 5 weeks ago calls your office and asks to speak to you. She states that she is feeling very overwhelmed and anxious about taking care of her newborn son. She feels she cannot do anything right, and feels sad throughout the day. She tells you that she cries on most days, and is having difficulty sleeping at night. She also states she doesn’t feel like eating or doing any of her normal activities. She reports no suicidal or homicidal ideation.
Which of the following is the most likely diagnosis?
This patient is exhibiting classic symptoms of postpartum depression. Postpartum depression develops in about 8% to 15% of women, and generally is characterized by an onset about 2 weeks to 12 months postdelivery, with an average duration of 3 to 14 months. Perinatal depression includes major and minor depressive episodes that occur during pregnancy or in the first 12 months after delivery, and is one of the most common medical complications during pregnancy or the postpartum period. It often goes unrecognized, because changes in sleep, appetite, and libido may be attributed to normal pregnancy and postpartum changes. Women with postpartum depression may display irritability, labile mood, difficulty sleeping, phobias, and anxiety. About 50% of women experience postpartum blues within 3 to 6 days after delivering. This mood disturbance is thought to be precipitated by progesterone withdrawal following delivery, and usually resolves in 10 to 14 days. Postpartum blues is characterized by mild insomnia, tearfulness, fatigue, irritability, poor concentration, and depressed effect. Postpartum psychosis usually has its onset within a few days of delivery and is characterized by confusion, disorientation, and loss of touch with reality. Postpartum psychosis is very rare and occurs in only 1 to 4 in 1000 births. Bipolar disorder or manic-depressive illness is a psychiatric disorder characterized by episodes of depression followed by mania.
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