A 35-year-old G2P2 presents for her routine postpartum visit. Her pregnancy was complicated by gestational diabetes, which was diagnosed in the second trimester during routine screening. She has no other medical problems, and she has no family history of diabetes. She gained 25 pounds during her pregnancy, and her gestational diabetes was managed with diet modification.
How should this patient be managed postpartum?
It is estimated that 15% to 50% of women with gestational diabetes will develop type 2 diabetes later in life. Postpartum screening at 6 to 12 weeks is recommended to identify women with diabetes, impaired fasting glucose, or impaired glucose tolerance. Women with GDM have a sevenfold increased risk of developing type 2 diabetes when compared to women without GDM. Either a fasting plasma glucose or the 75-g oral glucose tolerance test may be ordered in the postpartum period. Offspring of mothers with gestational diabetes are at an increased risk for obesity later in life. There is some data that development of type 2 diabetes may be impacted by intrauterine exposure to hyperglycemia. Both types 1 and 2 diabetes have a large genetic component.
A 30-year-old G3P3, who is 8 weeks’ postpartum and regularly breastfeeding calls you and is very concerned because she is having pain with intercourse secondary to vaginal dryness.
Which of the following should you recommend to help her with this problem?
Intercourse can be painful in breastfeeding women because of an increase in vaginal dryness caused by hypoestrogenism. Water-soluble lubricants or estrogen cream applied topically to the vaginal mucosa can be helpful. In addition, the female superior position may be recommended during intercourse so that the woman can control the depth of penile penetration. Testosterone cream is not used for the treatment of vaginal atrophy.
A 34-year-old G1P1 comes to see you 6 weeks after an uncomplicated vaginal delivery for a routine postpartum examination. She reports no problems, and has been breastfeeding her newborn without any difficulties since leaving the hospital. During the bimanual examination, you note that her uterus is irregular, firm, nontender, and about a 15-week size.
Which of the following is the most likely etiology for this enlarged uterus?
The uterus achieves its previous nonpregnant size by about 4 weeks’ postpartum. Subinvolution (cessation of the normal involution) of the uterus can occur in cases of retained placenta or uterine infection. In such cases, the uterus is larger and softer than it should be on bimanual examination. In addition, the patient usually experiences prolonged discharge and excessive uterine bleeding. With endometritis, the patient will also have a tender uterus on examination, and will complain of fever and chills. In adenomyosis, portions of the endometrial lining grow into the myometrium, causing menorrhagia and dysmenorrhea. On physical examination, the uterus is usually tender to palpation, boggy, and symmetrically enlarged. The patient described here has a physical examination most consistent with fibroids. Uterine leiomyomas would cause the uterus to be firm, irregular, and enlarged.
A 39-year-old G3P3 comes to see you on day 5 after a repeat cesarean delivery. During the surgery she received two units of packed red blood cells for a hemorrhage related to uterine atony. Her past medical history is significant for type 2 diabetes mellitus and chronic hypertension. She weighs 110 kg. She is concerned because her incision has become very red and tender, and pus started draining from a small opening in the incision this morning. She has been experiencing general malaise and reports a fever of 38.8°C (102°F). Her vital signs are: temperature 37.8°C (100.1°F), pulse 69 beats per minute, respiratory rate 18 breaths per minute, and blood pressure is 143/92 mm Hg. Physical examination shows erythema around the incision, and a 1-cm defect at the left corner of the skin incision, which is draining a small amount of purulent liquid. There is tenderness along the wound edges.
Which of the following is the best next step in the management of this patient?
The incidence of incisional wound infection following cesarean delivery is approximately 6%. Risk factors that predispose to wound infections include obesity, diabetes, corticosteroid therapy, anemia, poor hemostasis, and immunosuppression. Obesity confers the highest risk. The use of preoperative prophylactic antibiotics decreases the incidence of wound infection to about 2%. Usually, incisional abscesses will cause a fever around POD 4, and erythema, induration, and drainage from the incision are also frequently noted. Opening of the incision and surgical drainage are key to curing the infection. Broad-spectrum antimicrobial agents are also administered. In all cases of wound infection, the incision must be probed to rule out a wound dehiscence (separation of the wound involving the fascial layer). As long as the fascial layer is intact, the open wound is kept clean and allowed to heal by secondary intention.
Which of the following is her greatest risk factor for her complication?
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