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 accurately describes this patient’s condition?
Patients at high risk for postpartum depression often have a history of depression or postpartum depression. They are more likely to be primiparous or older; they may have had a long interval between pregnancies or an unplanned pregnancy or be without a supportive partner. Other risk factors include experiencing a stressful life event during pregnancy or early postpartum period, a traumatic birth experience, having a baby in the neonatal intensive care unit, or breastfeeding problems. ACOG recommends that all women be screened during the perinatal period with a validated, standardized assessment tool such as the Edinburgh Postnatal Depression Scale. Recent evidence suggests that collaborative care models improve long-term patient outcomes; this may involve medical therapy, social work, psychotherapy, and support under the supervision of a mental health specialist. Prenatal intervention must include the obstetric team, with family or peer support when possible. Postpartum depression is variable in duration, but occasionally will not resolve without intervention such as therapy, medication, or in rare cases, hospitalization.
A 35-year-old G3P3 presents to your office 3 weeks after an uncomplicated vaginal delivery. She has been successfully breastfeeding. She reports chills and a fever up to 38.3°C (101°F) at home. She states that she feels like she has flu, but has not had any sick contacts. She has no medical problems, prior surgeries, or allergies to medications. On examination, she has a temperature of 38°C (100.4°F) and generally appears in no distress. Head, ear, throat, lung, cardiac, abdominal, and pelvic examinations are all normal. A triangular area of erythema and tenderness is noted in the upper outer quadrant of the left breast. No masses or axillary lymphadenopathy are noted.
Which of the following is the best option for treatment of this patient?
Puerperal mastitis may be subacute, but is often characterized by chills, fever, and breast tenderness. If undiagnosed, it may progress to suppurative mastitis with abscess formation that requires drainage. The most common causative organism is Staphylococcus aureus, which is probably transmitted from the infant’s nose and throat. Initial antibiotic therapy should be directed at this organism, and should consist of either dicloxacillin 500 mg orally four times a day, or cephalexin 500 mg orally four times a day, for a total of 10 to 14 days. In penicillin-allergic patients, clindamycin 300 mg orally three times a day is recommended. If a mass is palpable, an abscess should be suspected. Incision and drainage is recommended for a breast abscess. Milk production should not be suppressed, and the patient should continue to breastfeed or pump on the affected breast. Symptomatic relief with ibuprofen and ice packs may also be of benefit.
A 22-year-old G1 at 34 weeks is tested for tuberculosis because her father, with whom she lives, was recently diagnosed with tuberculosis. Her skin test is positive and her chest x-ray demonstrates a granuloma in the upper left lobe.
Which of the following is true concerning infants born to mothers with active tuberculosis?
The goal of management in the infant born to a mother with active tuberculosis is prevention of early neonatal infection. Congenital infection, acquired either by a hematogenous route or by aspiration of infected amniotic fluid, is rare. Most neonatal infections are acquired by postpartum maternal contact. The risk of active disease during the first year of life may approach 50% if prophylaxis is not instituted. BCG vaccination and daily isonicotinic acid hydrazide (isoniazid, INH) therapy are both acceptable means of therapy. BCG vaccination may be easier because it requires only one injection; however, the ability to perform future tuberculin skin testing is lost.
A 23-year-old G2P1 develops chorioamnionitis during labor and is started on ampicillin and gentamicin. She requires a cesarean delivery for arrest of active phase labor.
What is the most optimal way to reduce her chance of developing postoperative endometritis?
Postpartum endometritis is much more common after cesarean delivery, and the infection is commonly polymicrobial. Fever is the most common criteria for the diagnosis. The addition of anaerobic coverage to the primary antibiotic regimen of ampicillin and gentamicin has reduced the rates of postcesarean endometritis. Ideally, this should be given preincision as part of antibiotic prophylaxis for cesarean delivery, and should consist of either clindamycin 900 mg IV or metronidazole 500 mg IV. There is not conclusive evidence regarding the optimal duration of therapy postpartum; however, based on limited studies, it is reasonable to continue antibiotics for one more postpartum dose following delivery.
A 21-year-old G2P2 calls her physician 7 days postpartum because she is concerned that she is still experiencing vaginal bleeding. She describes the bleeding as light pink to bright red, and less heavy than the first few days postdelivery. She reports no fever or pain. On examination, she is afebrile and has an appropriately sized, nontender uterus. The vagina contains about 10 cc of old, dark blood. The cervix is closed.
Which of the following is the most appropriate treatment?
The bleeding this patient describes is normal. Bloody lochia can persist for up to 2 weeks without indicating an underlying pathology; however, if heavy bleeding continues beyond 2 weeks, it may indicate placental site subinvolution, retention of small placental fragments, or both. At that point, appropriate diagnostic and therapeutic measures should be initiated. The physician should first estimate the blood loss and then perform a pelvic examination in search of uterine subinvolution or tenderness. Excessive bleeding or tenderness should lead the physician to suspect retained placental fragments or endometritis. A larger than expected but otherwise asymptomatic uterus supports the diagnosis of subinvolution.
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