A 22-year-old G1P1 is brought to the emergency department by EMS after having a seizure at home. She is 2 weeks’ postpartum after an uncomplicated spontaneous vaginal delivery. She has no medical problems, and her pregnancy, labor, and immediate postpartum period were unremarkable. On arrival, her vitals were: blood pressure 165/95 mm HG, pulse 82 beats per minute, respiratory rate 20 breaths per minute.
What is the most appropriate next step in management?
This patient is most likely to have postpartum preeclampsia. This may present up to 6 weeks after delivery, and in greater than 50% of cases, follows a pregnancy and labor that were not complicated by hypertension. Although the differential diagnosis may include new onset seizure disorder, illicit drugs, and brain tumor, she is most likely to have postpartum preeclampsia, especially given her hypertension on arrival, and should be initially managed as such. The most appropriate first step is to begin magnesium therapy for seizure prophylaxis. The rest of the treatment is aimed at managing her blood pressure.
You are doing postpartum rounds on a 23-year-old G1P1 who is postpartum day 2 after an uncomplicated vaginal delivery. As you walk into the room, you note that she is crying. She states she can’t seem to help it. She says she does not feel sad or anxious. She has not been sleeping well because she is getting up every 2 to 3 hours to breastfeed her new baby. Her past medical history is unremarkable.
Which of the following is the most appropriate treatment recommendation?
Women experiencing postpartum blues usually do fine with reassurance alone, because this condition usually resolves spontaneously in a short period of time. Women with postpartum depression may need a referral to a psychiatrist who can administer psychotherapy and prescribe antidepressants. Haldol is an antipsychotic that might be administered in the treatment of postpartum psychosis. Sleep aids are not recommended. Electroconvulsive therapy would be used to treat depression only if a patient were unresponsive to pharmacologic therapy
A 20-year-old G1P1 is postpartum day 2 after an uncomplicated vaginal delivery of a 6-lb 10-oz baby boy. She is trying to decide whether to have you perform a circumcision on her newborn. The boy is in the well-baby nursery and is doing very well.
In counseling this patient, you tell her which of the following recommendations from the American Pediatric Association?
According to the American Academy of Pediatrics, current evidence indicates that health benefits of newborn male circumcision outweigh the risks, and that the procedure’s benefits justify access to this procedure for families who choose it. The American College of Obstetricians and Gynecologists has also adopted this statement. Specific health benefits include a decreased incidence of urinary tract infections, penile cancer, and some sexually transmitted infections, including HIV.
When performed by an experienced person on a healthy, stable infant, circumcisions are generally safe procedures, although potential complications include infection and bleeding. Although the health benefits are not great enough to recommend routine circumcision for all newborns, it is important for clinicians to counsel patients about the benefits and risks in an unbiased and accurate manner.
The parents ask if you will use analgesia during the circumcision.
What do you tell them regarding the recommendations for administering pain medicine for circumcisions?
Analgesia should always be provided to a newborn undergoing a circumcision procedure, because much evidence suggests that infants who undergo this procedure without pain medicine experience pain and stress. The administration of oral tylenol or sucrose is not adequate for operative pain relief. Topical lidocaine cream, dorsal penile nerve block, and subcutaneous ring block are all effective and safe modalities to achieve analgesia in newborns undergoing a circumcision procedure.
A 33-year-old G1P0 was induced for being postterm at 42½ weeks’ gestation. Immediately following the delivery, you examine the baby with the pediatricians and note the following on physical examination: a small amount of cartilage in the earlobe, occasional creases over the anterior two-thirds of the soles of the feet, 4-mm breast nodule diameter, fine and fuzzy scalp hair, and a scrotum with some but not extensive rugae.
Based on this physical examination, what is the approximate gestational age of this male infant?
An estimate of the gestational age of a newborn can be made rapidly by a physical examination immediately following delivery. Important physical characteristics that are evaluated are the sole creases, breast nodules, scalp hair, earlobes, and scrotum. In newborns who are 39 weeks’ gestational age or greater, the soles of the feet will be covered with creases, the diameter of the breast nodules will be at least 7 mm, the scalp hair will be coarse and silky, the earlobes will be thickened with cartilage, and the scrotum will be full with extensive rugae. In infants that are 36 weeks or less, there will be an anterior transverse sole crease only, the breast nodule diameter will be 2 mm, the scalp hair will be fine and fuzzy, the earlobes will be pliable and lack cartilage, and the scrotum will be small with few rugae. In infants of gestational age between 37 and 38 weeks, the soles of the feet will have occasional creases on the anterior two-thirds of the feet, the breast nodule diameter will be 4 mm, the scalp hair will be fine and fuzzy, the earlobes will have a small amount of cartilage, and the scrotum will have some but not extensive rugae.
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