A 36-year-old woman comes to the physician because of progressively worsening painful swelling of both breasts for the past 24 hours. Three days ago, she vaginally delivered a healthy 2690-g (5-lb 15-oz) girl. The patient says that breastfeeding her newborn daughter is very painful. She reports exhaustion and moodiness. She has no history of serious illness. Medications include folic acid and a multivitamin. Her temperature is 37.4°C (99.3°F). Examination shows tenderness, firmness, and fullness of both breasts. The nipples appear cracked and the areolas are swollen bilaterally. Which of the following is the most appropriate next step in management?
Q22
A 27-year-old woman, gravida 1, para 1, presents to the obstetrics and gynecology clinic because of galactorrhea, fatigue, cold intolerance, hair loss, and unintentional weight gain for the past year. She had placenta accreta during her first pregnancy with an estimated blood loss of 2,000 mL. Her past medical history is otherwise unremarkable. Her vital signs are all within normal limits. Which of the following is the most likely cause of her symptoms?
Q23
A 30-year-old woman, gravida 2, para 1, abortus 1, comes to the physician because of failure to conceive for 12 months. She is sexually active with her husband 2–3 times per week. Her first child was born at term after vaginal delivery 2 years ago. At that time, the postpartum course was complicated by hemorrhage from retained placental products, and the patient underwent dilation and curettage. Menses occur at regular 28-day intervals and previously lasted for 5 days with normal flow, but now last for 2 days with significantly reduced flow. She stopped taking oral contraceptives 1 year after the birth of her son. Her vital signs are within normal limits. Speculum examination shows a normal vagina and cervix. The uterus is normal in size, and no adnexal masses are palpated. Which of the following is the most appropriate next step in management?
Q24
A 27-year-old woman, gravida 2, para 1, at 38 weeks' gestation comes to the emergency department in active labor. She received all of her prenatal care for this pregnancy. Pregnancy and delivery of her first child were uncomplicated. The patient's blood type is Rh-negative. Four hours after arrival, a healthy 3650-g (8-lb) female newborn is delivered. Delivery of the fetus is followed by placental retention and heavy vaginal bleeding. One hour later, the placenta is manually removed and the bleeding ceases. The mother's temperature is 36.7°C (98.1°F), pulse is 90/min, and blood pressure is 110/60 mm Hg. Examination shows blood on the vulva, the introitus, and on the medial aspect of each thigh. The neonate's blood type is Rh-positive. A single dose of anti-D immune globulin is administered. Which of the following is the most appropriate next step in management?
Q25
A previously healthy 32-year-old woman comes to the physician because of a 1-week history of progressively worsening cough with blood-tinged sputum, shortness of breath at rest, and intermittent left-sided chest pain. She has some mild vaginal bleeding since she had a cesarean delivery 6 weeks ago due to premature rupture of membranes and fetal distress at 38 weeks' gestation. She has been exclusively breastfeeding her child. Her temperature is 37°C (98.6°F), pulse is 95/min, respirations are 22/min, and blood pressure is 110/80 mm Hg. Breath sounds are decreased in the left lung base. The fundal height is 20 cm. Pelvic examination shows scant vaginal bleeding. Chest x-ray is shown. Further evaluation is most likely to reveal which of the following?
Q26
A 27-year-old G1P1001 is recovering in the postpartum unit three days after a Caesarean section. Her surgery was indicated for breech presentation of the infant. She was at 40 weeks and 2 days gestation at the time of delivery. The patient is now complaining of purulent discharge and continued heavy bleeding. She also notes difficulty and discomfort with urination. The patient’s prenatal course was complicated by one episode of pyelonephritis, which was treated with intravenous ceftriaxone and suppression nitrofurantoin for the remainder of the pregnancy. The patient has a medical history of generalized anxiety disorder and atopic dermatitis. On the third postpartum day, her temperature is 101.2°F (38.4°C), pulse is 112/min, blood pressure is 118/71 mmHg, and respirations are 13/min. Exam reveals that she is uncomfortable and diaphoretic. Her lochia is purulent with several blood clots, and her uterus is slightly boggy and soft. There is mild tenderness with uterine manipulation. Which of the following is the best next step in management for this patient's condition?
Q27
A 37-year-old G1P1001 presents for her 6-week postpartum visit after delivering a male infant by spontaneous vaginal delivery at 41 weeks and 5 days gestation. She notes that five days ago, her right breast began to hurt, and the skin near her nipple turned red. She also states that she has felt feverish and generally achy for 2 days but thought she was just sleep deprived. The patient’s son has been having difficulty latching for the last 2 weeks and has begun receiving formula in addition to breast milk, though the patient wishes to continue breastfeeding. She is generally healthy with no past medical history but has smoked half a pack per day for the last 15 years. Her mother died from breast cancer at the age of 62, and her father has hypertension and coronary artery disease. At this visit, her temperature is 100.6° F (38.1° C), blood pressure is 116/73 mmHg, pulse is 80/min, and respirations are 14/min. She appears tired and has a slightly flat affect. Examination reveals a 4x4 cm area of erythema on the lateral aspect near the nipple on the right breast. In the center of this area, there is a fluctuant, tender mass that measures 2x2 cm. The overlying skin is intact. The remainder of her exam is unremarkable. Which of the following is the best next step in management?
Q28
A 27-year-old woman, gravida 3, para 2, at 41 weeks' gestation is admitted to the hospital in active labor. Her pregnancy has been uncomplicated. Both of her prior children were delivered by vaginal birth. She has a history of asthma. Current medications include iron and vitamin supplements. After a prolonged labor, she undergoes vaginal delivery. Shortly afterwards, she begins to have heavy vaginal bleeding with clots. Her temperature is 37.2°C (98.9°F), pulse is 90/min, respirations are 17/min, and blood pressure is 130/72 mm Hg. Examination shows a soft, enlarged, and boggy uterus on palpation. Laboratory studies show:
Hemoglobin 10.8 g/dL
Hematocrit 32.3%
Leukocyte Count 9,000/mm3
Platelet Count 140,000/mm3
Prothrombin time 14 seconds
Partial thromboplastin time 38 seconds
Her bleeding continues despite bimanual uterine massage and administration of oxytocin. Which of the following is the most appropriate next step in management?
Q29
A 26-year-old woman presents to her physician at the 3rd week postpartum with a fever and a swollen breast with redness and tenderness. She has been breastfeeding her infant since birth. The symptoms of the patient started 4 days ago. She has not taken any antibiotics for the past 12 months. She does not have any concurrent diseases. The vital signs include: blood pressure 110/80 mm Hg, heart rate 91/min, respiratory rate 15/min, and temperature 38.8℃ (101.8℉). Physical examination reveals redness and enlargement of the right breast. The breast is warm and is painful at palpation. There is purulent discharge from the nipple. No fluctuation is noted. Which of the following is a correct management strategy for this patient?
Q30
A 32-year-old woman presents to her primary care doctor complaining of increased fatigue and cold intolerance after her recent delivery. The patient delivered a healthy 39-week-old boy 3 weeks ago via spontaneous vaginal delivery. Delivery was complicated by postpartum hemorrhage requiring admission to the intensive care unit with blood transfusions. Pregnancy was otherwise uneventful, and the baby is healthy. The mother has had some difficulty with lactation, but is able to supplement her breast milk with formula feeds. On exam, her temperature is 97.7°F (36.5°C), blood pressure is 112/78 mmHg, pulse is 62/min, and respirations are 12/min. The patient does not have any neck masses or lymphadenopathy; however, her skin appears dry and rough. Which of the following serum lab abnormalities may be expected?
Postpartum hemorrhage US Medical PG Practice Questions and MCQs
Question 21: A 36-year-old woman comes to the physician because of progressively worsening painful swelling of both breasts for the past 24 hours. Three days ago, she vaginally delivered a healthy 2690-g (5-lb 15-oz) girl. The patient says that breastfeeding her newborn daughter is very painful. She reports exhaustion and moodiness. She has no history of serious illness. Medications include folic acid and a multivitamin. Her temperature is 37.4°C (99.3°F). Examination shows tenderness, firmness, and fullness of both breasts. The nipples appear cracked and the areolas are swollen bilaterally. Which of the following is the most appropriate next step in management?
A. Oral antibiotics
B. Cold compresses and analgesia (Correct Answer)
C. Oral contraceptives
D. Mammography
E. Incision and drainage
Explanation: **Cold compresses and analgesia**
- The patient presents with bilateral breast pain, swelling, and fullness, along with cracked nipples, 3 days postpartum. This clinical picture is highly consistent with **breast engorgement**, a common physiological process in the early postpartum period.
- Management of breast engorgement includes **symptomatic relief** with cold compresses to reduce swelling and pain, and analgesics like NSAIDs to manage discomfort. Continued breastfeeding or pumping is also important.
*Oral antibiotics*
- While breast pain can sometimes indicate **mastitis**, the bilateral nature of the symptoms and the absence of fever (temperature 37.4°C is normal) make an infection less likely as the primary diagnosis at this stage.
- Administering antibiotics unnecessarily can lead to **antibiotic resistance** and is not indicated for physiological breast engorgement.
*Oral contraceptives*
- Oral contraceptives are **not indicated** for the treatment of breast engorgement and could potentially interfere with lactation, depending on the type.
- They are typically used for **contraception** and other hormonal indications, not for acute postpartum breast symptoms.
*Mammography*
- Mammography is a radiological imaging technique primarily used for **breast cancer screening** or investigation of suspicious masses.
- It is not indicated for the initial evaluation or management of acute postpartum breast pain and engorgement, which is a clinical diagnosis.
*Incision and drainage*
- Incision and drainage is a procedure performed for a **breast abscess**, which is a localized collection of pus.
- This patient's symptoms are diffuse and bilateral, and there's no localized fluctuance or signs of a severe bacterial infection (e.g., high fever, redness with clear borders) to suggest an abscess requiring drainage.
Question 22: A 27-year-old woman, gravida 1, para 1, presents to the obstetrics and gynecology clinic because of galactorrhea, fatigue, cold intolerance, hair loss, and unintentional weight gain for the past year. She had placenta accreta during her first pregnancy with an estimated blood loss of 2,000 mL. Her past medical history is otherwise unremarkable. Her vital signs are all within normal limits. Which of the following is the most likely cause of her symptoms?
A. Addison’s disease
B. Sheehan’s syndrome (Correct Answer)
C. Pituitary adenoma
D. Hashimoto thyroiditis
E. Cushing syndrome
Explanation: ***Sheehan’s syndrome***
- The patient's history of **placenta accreta** with significant **hemorrhage (2,000 mL)**, followed by symptoms like **galactorrhea, fatigue, cold intolerance, hair loss, and weight gain**, are highly suggestive of Sheehan's syndrome.
- **Sheehan's syndrome** is **ischemic necrosis** of the **pituitary gland** due to massive postpartum hemorrhage, leading to **hypopituitarism** and deficiency of pituitary hormones including **prolactin** (leading to failure of lactation, though galactorrhea can occur if other pituitary hormones are affected), **thyroid-stimulating hormone (TSH)**, and **adrenocorticotropic hormone (ACTH)**.
*Addison’s disease*
- While **fatigue** and **weight loss** can occur, Addison's disease (primary adrenal insufficiency) typically causes **hyperpigmentation**, **hypotension**, and **salt craving**, none of which are mentioned.
- It is due to adrenal gland destruction and does not directly explain galactorrhea or a history linked to postpartum hemorrhage.
*Pituitary adenoma*
- A **prolactin-secreting pituitary adenoma** (prolactinoma) can cause galactorrhea, but the constellation of other symptoms like **cold intolerance** and **fatigue** points to widespread hypopituitarism rather than isolated pituitary dysfunction.
- Although some adenomas can cause hypopituitarism, the history of postpartum hemorrhage is a strong indicator for Sheehan's syndrome.
*Hashimoto thyroiditis*
- **Hashimoto thyroiditis** can explain **fatigue, cold intolerance, hair loss, and weight gain** due to **hypothyroidism**.
- However, it does not typically cause **galactorrhea** or have a direct etiological link to **postpartum hemorrhage**.
*Cushing syndrome*
- **Cushing syndrome** is characterized by symptoms like **central obesity, moon facies, buffalo hump, and striae**, which are not described in this patient.
- It is a state of **cortisol excess**, whereas many of the patient's symptoms (fatigue, cold intolerance, weight gain) are consistent with **hormone deficiencies**.
Question 23: A 30-year-old woman, gravida 2, para 1, abortus 1, comes to the physician because of failure to conceive for 12 months. She is sexually active with her husband 2–3 times per week. Her first child was born at term after vaginal delivery 2 years ago. At that time, the postpartum course was complicated by hemorrhage from retained placental products, and the patient underwent dilation and curettage. Menses occur at regular 28-day intervals and previously lasted for 5 days with normal flow, but now last for 2 days with significantly reduced flow. She stopped taking oral contraceptives 1 year after the birth of her son. Her vital signs are within normal limits. Speculum examination shows a normal vagina and cervix. The uterus is normal in size, and no adnexal masses are palpated. Which of the following is the most appropriate next step in management?
A. Hysteroscopy with potential adhesiolysis (Correct Answer)
B. Measurement of serum FSH and LH concentrations
C. Measurement of antisperm antibody concentration
D. Dilation and curettage
E. Estrogen/progestin withdrawal test
Explanation: ***Hysteroscopy with potential adhesiolysis***
- The patient's history of **postpartum hemorrhage** requiring D&C, followed by significantly **reduced menstrual flow**, strongly suggests **intrauterine adhesions (Asherman's syndrome)**.
- **Hysteroscopy** is the definitive diagnostic and therapeutic procedure for Asherman's syndrome, allowing direct visualization and surgical lysis of adhesions.
*Measurement of serum FSH and LH concentrations*
- This step is typically used to evaluate **ovarian reserve** or **hypothalamic-pituitary-ovarian axis dysfunction** in cases of anovulation or primary ovarian insufficiency.
- Given the patient's regular menstrual cycles, ovulatory dysfunction is less likely to be the primary cause of her infertility symptoms.
*Measurement of antisperm antibody concentration*
- **Antisperm antibodies** are a cause of infertility in a small percentage of couples, affecting sperm function or fertilization.
- This test is usually pursued after more common causes of infertility have been ruled out, as there are stronger indicators for Asherman's syndrome in this case.
*Dilation and curettage*
- A **D&C** was previously performed and is the likely iatrogenic cause of her current symptoms (Asherman's syndrome).
- Performing another D&C without addressing the adhesions would likely worsen her condition and lead to further scarring.
*Estrogen/progestin withdrawal test*
- This test assesses the integrity of the **endometrium** and the presence of sufficient endogenous estrogen if a patient has **amenorrhea**, as bleeding after withdrawal indicates a responsive endometrium.
- The patient has regular, albeit reduced, menstrual cycles, making this test less relevant for her specific symptoms.
Question 24: A 27-year-old woman, gravida 2, para 1, at 38 weeks' gestation comes to the emergency department in active labor. She received all of her prenatal care for this pregnancy. Pregnancy and delivery of her first child were uncomplicated. The patient's blood type is Rh-negative. Four hours after arrival, a healthy 3650-g (8-lb) female newborn is delivered. Delivery of the fetus is followed by placental retention and heavy vaginal bleeding. One hour later, the placenta is manually removed and the bleeding ceases. The mother's temperature is 36.7°C (98.1°F), pulse is 90/min, and blood pressure is 110/60 mm Hg. Examination shows blood on the vulva, the introitus, and on the medial aspect of each thigh. The neonate's blood type is Rh-positive. A single dose of anti-D immune globulin is administered. Which of the following is the most appropriate next step in management?
A. Perform Kleihauer-Betke test
B. Administer additional dose of anti-D immune globulin
C. Perform rosette test (Correct Answer)
D. Perform flow cytometry
E. Perform Coombs test
Explanation: ***Perform rosette test***
- The **rosette test** is a qualitative screening test used to detect the presence of **fetal Rh-positive red blood cells** in the maternal Rh-negative blood circulation.
- It helps determine if a significant fetomaternal hemorrhage (FMH) has occurred, which would necessitate further quantification with a Kleihauer-Betke test to guide additional anti-D immune globulin dosing.
*Perform Kleihauer-Betke test*
- The **Kleihauer-Betke test** is a quantitative test used to determine the exact volume of **fetal Rh-positive red blood cells** in the maternal circulation.
- While necessary for determining the precise dose of anti-D immune globulin if FMH is suspected, it is usually performed *after* a positive screening test like the rosette test.
*Administer additional dose of anti-D immune globulin*
- Administering an additional dose without quantifying the extent of **fetomaternal hemorrhage (FMH)** is not the most appropriate immediate next step.
- The initial standard dose of anti-D immune globulin is a prophylactic measure, and further doses depend on the amount of fetal blood that entered maternal circulation.
*Perform flow cytometry*
- Flow cytometry is a highly sensitive method for detecting **fetal red blood cells** in maternal blood, but it is typically reserved for cases where other screening methods are inconclusive or a very precise quantification is needed.
- The rosette test is a more common and readily available initial screening test for significantly sized fetomaternal hemorrhage.
*Perform Coombs test*
- The **Coombs test** (both direct and indirect) is used to detect antibodies on the surface of red blood cells or free in the serum.
- It is primarily used to diagnose **hemolytic disease of the newborn** or **autoimmune hemolytic anemia**, not to determine the volume of fetomaternal hemorrhage for anti-D immune globulin dosing.
Question 25: A previously healthy 32-year-old woman comes to the physician because of a 1-week history of progressively worsening cough with blood-tinged sputum, shortness of breath at rest, and intermittent left-sided chest pain. She has some mild vaginal bleeding since she had a cesarean delivery 6 weeks ago due to premature rupture of membranes and fetal distress at 38 weeks' gestation. She has been exclusively breastfeeding her child. Her temperature is 37°C (98.6°F), pulse is 95/min, respirations are 22/min, and blood pressure is 110/80 mm Hg. Breath sounds are decreased in the left lung base. The fundal height is 20 cm. Pelvic examination shows scant vaginal bleeding. Chest x-ray is shown. Further evaluation is most likely to reveal which of the following?
A. Increased brain natriuretic peptide levels
B. Increased serum β-HCG levels (Correct Answer)
C. Increased angiotensin converting enzyme levels
D. Acid fast bacilli in sputum
E. Increased carcinoembryonic antigen levels
Explanation: ***Increased serum β-HCG levels***
- The patient's symptoms (cough with **hemoptysis**, shortness of breath, chest pain, and recent pregnancy) combined with a **mass on chest X-ray** are highly suggestive of **choriocarcinoma**, a gestational trophoblastic neoplasia.
- **Choriocarcinoma** is characterized by the production of **human chorionic gonadotropin (β-HCG)**, which would be significantly elevated in her serum.
*Increased brain natriuretic peptide levels*
- **BNP** levels are increased in **heart failure**, which typically presents with dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea, often with bilateral lung findings, which are not the primary symptoms here.
- While dyspnea is present, the **hemoptysis and chest mass** are not typical for isolated heart failure.
*Increased angiotensin converting enzyme levels*
- Elevated **ACE levels** are characteristic of **sarcoidosis**, a granulomatous disorder that can cause pulmonary involvement and dyspnea.
- However, sarcoidosis is less likely to present with **hemoptysis** and an acute, rapidly progressive course with a discrete chest mass in a peripartum woman.
*Acid fast bacilli in sputum*
- The presence of **acid-fast bacilli (AFB)** in sputum indicates **tuberculosis**. While TB can cause cough, hemoptysis, and lung lesions, the acute onset following a recent pregnancy and the specific chest X-ray findings are more suggestive of choriocarcinoma.
- TB is typically a more chronic illness, and a rapidly growing, infiltrative mass in this context is less common.
*Increased carcinoembryonic antigen levels*
- **Carcinoembryonic antigen (CEA)** is a tumor marker primarily associated with **colorectal cancer** and some other adenocarcinomas, such as lung cancer.
- While it can be elevated in lung malignancies, it is not the primary marker for gestational trophoblastic disease, nor does it fit the patient's peripartum history.
Question 26: A 27-year-old G1P1001 is recovering in the postpartum unit three days after a Caesarean section. Her surgery was indicated for breech presentation of the infant. She was at 40 weeks and 2 days gestation at the time of delivery. The patient is now complaining of purulent discharge and continued heavy bleeding. She also notes difficulty and discomfort with urination. The patient’s prenatal course was complicated by one episode of pyelonephritis, which was treated with intravenous ceftriaxone and suppression nitrofurantoin for the remainder of the pregnancy. The patient has a medical history of generalized anxiety disorder and atopic dermatitis. On the third postpartum day, her temperature is 101.2°F (38.4°C), pulse is 112/min, blood pressure is 118/71 mmHg, and respirations are 13/min. Exam reveals that she is uncomfortable and diaphoretic. Her lochia is purulent with several blood clots, and her uterus is slightly boggy and soft. There is mild tenderness with uterine manipulation. Which of the following is the best next step in management for this patient's condition?
A. Endometrial culture
B. Ceftriaxone
C. Clindamycin
D. Urinalysis and urine culture
E. Clindamycin and gentamicin (Correct Answer)
Explanation: ***Clindamycin and gentamicin***
- This combination provides broad-spectrum coverage for **postpartum endometritis**, targeting common polymicrobial infections, including both **aerobic and anaerobic bacteria**.
- Given the patient's fever, purulent lochia, uterine tenderness, and history of C-section, **endometritis** is the most likely diagnosis, warranting immediate empiric antibiotic treatment.
*Endometrial culture*
- While an endometrial culture could identify specific pathogens, it is **not the best initial next step** as it delays initiating crucial treatment for a potentially severe infection.
- Empiric antibiotics should be started promptly based on clinical suspicion, and cultures can be obtained simultaneously, if needed, to guide future adjustments.
*Ceftriaxone*
- Ceftriaxone provides good coverage for many **gram-negative and some gram-positive aerobic bacteria**, but it lacks adequate coverage for the **anaerobic bacteria** often implicated in postpartum endometritis.
- Therefore, it would be insufficient as monotherapy for this condition.
*Clindamycin*
- Clindamycin offers excellent coverage against **anaerobic bacteria** and some gram-positive aerobes, but it has limited activity against **gram-negative aerobic bacteria**, which are also common in polymicrobial postpartum infections.
- It would be inadequate as a single agent for broad-spectrum empirical treatment.
*Urinalysis and urine culture*
- Although the patient reports dysuria, suggesting a possible **urinary tract infection (UTI)**, the more prominent symptoms of fever, purulent lochia, and uterine tenderness point strongly towards **endometritis** as the primary and more urgent concern.
- While a urinalysis and urine culture may be indicated, treating the suspected endometritis takes precedence due to its higher morbidity risk.
Question 27: A 37-year-old G1P1001 presents for her 6-week postpartum visit after delivering a male infant by spontaneous vaginal delivery at 41 weeks and 5 days gestation. She notes that five days ago, her right breast began to hurt, and the skin near her nipple turned red. She also states that she has felt feverish and generally achy for 2 days but thought she was just sleep deprived. The patient’s son has been having difficulty latching for the last 2 weeks and has begun receiving formula in addition to breast milk, though the patient wishes to continue breastfeeding. She is generally healthy with no past medical history but has smoked half a pack per day for the last 15 years. Her mother died from breast cancer at the age of 62, and her father has hypertension and coronary artery disease. At this visit, her temperature is 100.6° F (38.1° C), blood pressure is 116/73 mmHg, pulse is 80/min, and respirations are 14/min. She appears tired and has a slightly flat affect. Examination reveals a 4x4 cm area of erythema on the lateral aspect near the nipple on the right breast. In the center of this area, there is a fluctuant, tender mass that measures 2x2 cm. The overlying skin is intact. The remainder of her exam is unremarkable. Which of the following is the best next step in management?
A. Mammogram
B. Cessation of smoking
C. Cessation of breastfeeding
D. Incision and drainage
E. Needle aspiration and oral dicloxacillin (Correct Answer)
Explanation: ***Needle aspiration and oral dicloxacillin***
- The patient's symptoms (unilateral breast pain, erythema, fever, body aches, fluctuant mass) are highly suggestive of a **breast abscess**, which typically develops from untreated mastitis.
- **Needle aspiration** is the preferred initial management for a breast abscess, often combined with a course of **antibiotics** like dicloxacillin, which covers common causative organisms like *Staphylococcus aureus.*
*Mammogram*
- A mammogram is not the initial diagnostic or management step for a suspected breast abscess in the postpartum period, especially with classic signs of infection.
- While it may be used to evaluate **recurrent abscesses** or rule out malignancy if the abscess does not resolve with treatment, it is not primary management.
*Cessation of smoking*
- While smoking cessation is crucial for overall health and reducing cancer risk, it is not the most immediate or appropriate action to address an acute breast infection and abscess.
- This is a long-term health goal rather than an acute management step for the presenting complaint.
*Cessation of breastfeeding*
- It is generally recommended to **continue breastfeeding** from the affected breast, as it helps with milk drainage and can prevent progression or recurrence of mastitis or abscess.
- Cessation of breastfeeding would worsen the problem by increasing **milk stasis**, which can exacerbate the infection.
*Incision and drainage*
- **Incision and drainage** is typically reserved for larger breast abscesses (usually >5 cm) or those that do not resolve with needle aspiration and antibiotics.
- Needle aspiration is generally preferred as it is less invasive and has comparable success rates for smaller abscesses, with less scarring.
Question 28: A 27-year-old woman, gravida 3, para 2, at 41 weeks' gestation is admitted to the hospital in active labor. Her pregnancy has been uncomplicated. Both of her prior children were delivered by vaginal birth. She has a history of asthma. Current medications include iron and vitamin supplements. After a prolonged labor, she undergoes vaginal delivery. Shortly afterwards, she begins to have heavy vaginal bleeding with clots. Her temperature is 37.2°C (98.9°F), pulse is 90/min, respirations are 17/min, and blood pressure is 130/72 mm Hg. Examination shows a soft, enlarged, and boggy uterus on palpation. Laboratory studies show:
Hemoglobin 10.8 g/dL
Hematocrit 32.3%
Leukocyte Count 9,000/mm3
Platelet Count 140,000/mm3
Prothrombin time 14 seconds
Partial thromboplastin time 38 seconds
Her bleeding continues despite bimanual uterine massage and administration of oxytocin. Which of the following is the most appropriate next step in management?
A. Administer methylergonovine (Correct Answer)
B. Transfuse blood
C. Perform hysterectomy
D. Administer carboprost tromethamine
E. Perform curettage
Explanation: ***Administer methylergonovine***
- The patient is likely experiencing **postpartum hemorrhage (PPH)** due to **uterine atony**, characterized by a soft, enlarged, and boggy uterus after delivery, with continued bleeding despite initial measures (massage, oxytocin).
- Given her history of **asthma**, carboprost tromethamine (prostaglandin F2-alpha) is **contraindicated** due to its potential to cause severe bronchospasm, making methylergonovine (an ergot alkaloid) the appropriate next uterotonic agent.
*Transfuse blood*
- While blood transfusions may eventually be necessary if bleeding is severe and leads to significant hemodynamic instability or severe anemia, it is **not the immediate next step** in managing the underlying cause of the hemorrhage (uterine atony).
- **Uterotonic agents** should be tried first to contract the uterus and stop the bleeding, as indicated by the patient's current vital signs being relatively stable (pulse 90/min, BP 130/72 mm Hg).
*Perform hysterectomy*
- **Hysterectomy** is a drastic measure considered only after all less invasive medical and surgical interventions (e.g., uterotonic agents, uterine tamponade, suturing techniques) have failed to control severe PPH.
- It would be **premature** to proceed directly to hysterectomy without attempting additional medical management for uterine atony.
*Administer carboprost tromethamine*
- **Carboprost tromethamine** is a prostaglandin analog that is effective in treating uterine atony but is **contraindicated in patients with asthma** due to its known side effect of inducing bronchospasm.
- The patient's history of asthma makes this a **dangerous option**, and an alternative uterotonic like methylergonovine should be chosen.
*Perform curettage*
- **Curettage** (removing retained placental fragments) would be appropriate if the cause of PPH was **retained placental tissue**.
- However, the examination finding of a **soft, enlarged, and boggy uterus** is characteristic of uterine atony, not retained placenta, and the initial management of atony involves uterotonic agents.
Question 29: A 26-year-old woman presents to her physician at the 3rd week postpartum with a fever and a swollen breast with redness and tenderness. She has been breastfeeding her infant since birth. The symptoms of the patient started 4 days ago. She has not taken any antibiotics for the past 12 months. She does not have any concurrent diseases. The vital signs include: blood pressure 110/80 mm Hg, heart rate 91/min, respiratory rate 15/min, and temperature 38.8℃ (101.8℉). Physical examination reveals redness and enlargement of the right breast. The breast is warm and is painful at palpation. There is purulent discharge from the nipple. No fluctuation is noted. Which of the following is a correct management strategy for this patient?
A. Manage with clindamycin and recommend to interrupt breastfeeding until the resolution
B. Manage with trimethoprim-sulfamethoxazole and encourage continuing breastfeeding
C. Prescribe dicloxacillin and encourage continuing breastfeeding (Correct Answer)
D. Prescribe dicloxacillin and bromocriptine for halting lactation
E. Prescribe trimethoprim-sulfamethoxazole and recommend emptying affected breast without feeding
Explanation: **Prescribe dicloxacillin and encourage continuing breastfeeding**
- The patient's symptoms (fever, swollen, red, and tender breast with purulent discharge) are consistent with **puerperal mastitis**, most commonly caused by *Staphylococcus aureus*. **Dicloxacillin** is a penicillinase-resistant penicillin, making it an appropriate first-line antibiotic for this infection.
- **Continuing breastfeeding** or expressing milk from the affected breast is crucial to prevent milk stasis, which can worsen mastitis and lead to abscess formation. It also helps clear the infection.
*Manage with clindamycin and recommend to interrupt breastfeeding until the resolution*
- While **clindamycin** is an alternative for mastitis, especially in penicillin-allergic patients or for certain resistant strains, it is not the first-line choice when penicillin-resistant penicillins like dicloxacillin are available and effective.
- **Interrupting breastfeeding** can lead to milk stasis, exacerbating the mastitis and increasing the risk of abscess formation. Unless there is an absolute contraindication, breastfeeding should be continued.
*Manage with trimethoprim-sulfamethoxazole and encourage continuing breastfeeding*
- **Trimethoprim-sulfamethoxazole (TMP-SMX)** is typically reserved for MRSA mastitis or penicillin-allergic patients, and there is no indication of MRSA in this patient's history (no recent antibiotic use, no concurrent diseases).
- While encouraging continued breastfeeding is correct, the choice of antibiotic is not optimal as a first-line treatment for typical mastitis.
*Prescribe dicloxacillin and bromocriptine for halting lactation*
- While **dicloxacillin** is an appropriate antibiotic, **bromocriptine** is used to halt lactation, which is generally not recommended in mastitis.
- Halting lactation can lead to milk engorgement and stasis, potentially worsening the infection and increasing the risk of breast abscess.
*Prescribe trimethoprim-sulfamethoxazole and recommend emptying affected breast without feeding*
- As mentioned, **trimethoprim-sulfamethoxazole** is not the preferred first-line antibiotic for typical mastitis.
- **Emptying the affected breast without feeding** (e.g., via pumping) is a good practice if direct feeding is temporarily impossible, but the critical point is to continue removing milk to prevent stasis, and if possible, direct feeding is preferred. However, the antibiotic choice is less appropriate.
Question 30: A 32-year-old woman presents to her primary care doctor complaining of increased fatigue and cold intolerance after her recent delivery. The patient delivered a healthy 39-week-old boy 3 weeks ago via spontaneous vaginal delivery. Delivery was complicated by postpartum hemorrhage requiring admission to the intensive care unit with blood transfusions. Pregnancy was otherwise uneventful, and the baby is healthy. The mother has had some difficulty with lactation, but is able to supplement her breast milk with formula feeds. On exam, her temperature is 97.7°F (36.5°C), blood pressure is 112/78 mmHg, pulse is 62/min, and respirations are 12/min. The patient does not have any neck masses or lymphadenopathy; however, her skin appears dry and rough. Which of the following serum lab abnormalities may be expected?
A. Increased glucocorticoids
B. Decreased thyroid stimulating hormone (TSH) (Correct Answer)
C. Increased follicle stimulating hormone
D. Increased luteinizing hormone
E. Decreased prolactin
Explanation: **Decreased thyroid stimulating hormone (TSH)**
- This patient is likely experiencing **Sheehan's syndrome**, a form of **hypopituitarism** caused by ischemic necrosis of the pituitary gland following severe postpartum hemorrhage. The symptoms of fatigue, cold intolerance, dry skin, and bradycardia are consistent with **hypothyroidism**.
- In Sheehan's syndrome, the secondary hypothyroidism results in decreased production of **TSH** from the damaged pituitary, leading to decreased thyroid hormone production.
*Increased glucocorticoids*
- **Adrenal insufficiency**, a possible consequence of Sheehan's syndrome, would lead to **decreased** rather than increased glucocorticoids (cortisol).
- Symptoms of glucocorticoid excess (e.g., Cushing's syndrome) are not described in this patient.
*Increased follicle stimulating hormone*
- In Sheehan's syndrome, the damaged pituitary would likely produce **decreased FSH**, leading to **hypogonadism** and amenorrhea, reflecting impaired gonadal function.
- High FSH levels would typically be seen in primary ovarian failure, where the ovaries fail to respond to pituitary stimulation.
*Increased luteinizing hormone*
- Similar to FSH, LH production from the anterior pituitary would be **decreased** in Sheehan's syndrome, contributing to **hypogonadism** and lactation difficulties.
- Increased LH would also suggest primary gonadal failure.
*Decreased prolactin*
- While Sheehan's syndrome often causes **decreased prolactin** due to pituitary damage, which explains the patient's difficulty with lactation, the question asks for a lab abnormality related to the *main* presenting symptoms of fatigue, cold intolerance, and dry skin (i.e., hypothyroidism).
- The low prolactin contributes to lactation difficulties but is not the primary cause of the systemic hypothyroid symptoms.
