Postpartum

A woman has postpartum hemorrhage from placenta previa after a spontaneous vaginal delivery. Despite adequate resuscitation, she has persistent hypotension and spends several nights in the ICU. Eventually, she is discharged home, though her blood pressures remain quite low. She has some symptoms of orthostasis but really wants to go home. On her first postpartum visit, she notes that she hasn't been lactating. A few weeks later, she also complains of fatigue and anorexia. A year later, she has persistent oligomenhorrhea.

Challenge: What syndrome do you suspect?

DDX

A rapid response alert is called in labor and delivery. You rush in to find a woman who has just delivered who appears in acute respiratory distress. The obstetrician says, "she had postpartum bleeding from uterine atony, but I don't think she's lost more than a liter of blood." You can't get a history because the patient can barely speak. On exam, her breath sounds are very tight; she's not moving much air, and you hear expiratory wheezes. Her blood pressure and heart rate are fine. She's maintaining a sat of 90% with oxygen by face mask. Fluids are wide open along with oxytocin.

Challenge: She received one other medication which is causing her clinical presentation. What is it?

Image is in the public domain.

Postpartum

This contrast-enhanced CT is from a young G2P2 woman who just had a vaginal delivery. She had a previous C-section but elected for a vaginal birth after Cesarean (also called trial of labor after Cesarean). After a long labor, she delivered a healthy baby successfully, but subsequently had persistent bleeding and abdominal pain.

Challenge: What's the diagnosis?

Image shown under Fair Use.

Name That Object II

Challenge: What do you see here?

Image shown under Creative Commons Attribution Share-Alike License.

Aging

A 55 year old woman presents with complaints of pain with sex. She's noticed vaginal dryness, burning, and irritation as well as yellow discharge. In addition, she has dysuria and increased urinary frequency. On exam, you note scarce pubic hair, diminished elasticity and turgor of the skin, and fusion of the labia minora. Vaginal pH is 6.

Challenge: What's your diagnosis?

Refresher III

A 35 year old G1P0 woman who has not received prenatal care presents at 34 weeks of gestation. She has no prior medical history, but she is obese. She presents because of leg swelling, back pain, right upper quadrant abdominal pain, headache, gastroesophageal reflux, and fatigue. Her blood pressure is 150/100. Her labs show a hemoglobin of 10, platelets of 150,000, a normal creatinine, and normal liver function tests.

Challenge: What parts of her presentation makes this disease "severe"?

But Why?

A 30 year old previously healthy woman who is 11 weeks pregnant complains of heat intolerance, sweating, and anxiety. On examination, you note tachycardia and hand tremor. Her pregnancy has been notable for morning sickness and a slower weight gain than expected. A brilliant diagnostician, you send off thyroid function tests. Serum free T4 and T3 are slightly elevated. TSH is reduced.

The next time you see the patient, before you start any therapy, she is 15 weeks gestation. She says her symptoms have completely disappeared.

Challenge: How do you explain this?

Image is shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Hold It Up

This ultrasound is from a G4P2 woman presenting with transverse lie. The infant is 32 weeks gestation with low birth weight. The patient had spontaneous rupture of membranes just half an hour ago. You are called emergently by the obstetrical nurse because of a sudden, severe, prolonged fetal bradycardia. On manual examination, you make the diagnosis.

Challenge: What are you most worried about?

Squiggles

Challenge: What category is this tracing?

Image shown under Fair Use.

Avogadro

This 40 year old woman presented with severe nausea and vomiting. She also notes pelvic discomfort and vaginal bleeding the color of "prune juice." Her heart rate is 104, blood pressure is 152/91. She has a mild tremor. Her urine dipstick shows 1+ protein. Her hCG is quite elevated. Her TSH is low.

Challenge: What is this disease, first described by Hippocrates in 400BC?

Names

This rash begins in the second or third trimester. The erythematous excoriated nodules or papules are seen on the extensor surfaces of limbs and the trunk. It should resolve in the immediate postpartum period. Labs are unrevealing.

Challenge: What is one of the many names for this disease?

Image shown under Fair Use.

Encapsulated

This woman worries because she feels a painless discrete lump in her left breast. The mammogram is shown above.

Challenge: Luckily, the disease is benign. What is the most likely etiology?

Image shown under Fair Use.

Too Young

A newborn infant is brought to your attention within 24 hours post delivery because of failure to thrive. The mother notes excessive sweating, sneezing, fever, nasal stuffiness, and yawning. He has a high pitched cry, irritability, sleep and wake disturbances, hyperactive primitive reflexes, hypertonicity, and tremors. His feeding is poor. He has some vomiting and loose stools.

His labs including glucose are normal. His sepsis workup is negative. Thyroid studies are unremarkable.

Challenge: What can you tell me abut the mother's social history?

Rhapsody, Rhetoric, Rhythm

A 35 year old G4P1 woman at 32 weeks gestation is referred to your obstetric practice because of an unusual ultrasound. She has not had prenatal care because she immigrated from Mexico just several weeks ago. She established care with an obstetrician who obtained an ultrasound showing ascites, pericardial effusions, and pleural effusions. She then referred the patient to you for further workup and management.

The patient does not regularly see a doctor and doesn't know about any medical problems. Her family history includes diabetes, cataracts, and dementia. Her husband is healthy but has a family history of hypertension, kidney disease, and alcoholism. The patient's other children are healthy. Her past surgical history only includes several orthopedic surgeries and exploratory laparotomies when she had a severe car accident in her early twenties. She spent time in an ICU but does not recall the details. Although she has used IV drugs in the past, she has been clean for five years. She does not drink or smoke.

Challenge: You perform the test shown above. What are you looking for?

Image shown under Creative Commons Attribution Share-Alike License.

Rare Flower

A 25 year old G1P0 woman is followed by maternal-fetal-medicine because her fetus has severe intrauterine growth restriction. The patient is otherwise healthy but her family history is unknown because she was adopted. A healthy baby is born vaginally with no peripartum medical problems. The baby has very little adipose tissue giving her a wasted look.

Over the first year of life, the baby comes to the pediatrician's attention because of small stature and microcephaly. She otherwise has preserved body proportions. Growth hormone is normal. The child has malar hypoplasia, nasal prominence, a small mandible, protuberant ears, and no upper lateral incisors. She has several admissions to the hospital for recurrent vomiting and diarrhea leading to dehydration.

Over the second year of life, the family notices that she is quite sun-sensitive. In fact, she develops the characteristic rash of lupus, but a pediatric rhematologist rules that diagnosis out. She gets rashes on sun-exposed areas like the dorsum of the hands. She develops well-demarcated patches of hypopigmentation as well as cafe-au-lait spots, mostly on the trunk.

Her childhood years are characterized by gastroesophageal reflux disease, recurrent sinus infections, recurrent otitis media, and pneumonia. She has normal antibody responses to vaccines.

By age 10, she has a diagnosis of non-Hodgkin's lymphoma. By age 15, she has a second cancer diagnosis of leukemia. Her intelligence is slightly below average, but not remarkably so. She has impaired glucose tolerance. Later in life, she develops colon cancer, diabetes, and premature menopause.

Challenge: What is this autosomal recessive disorder?

Inside-Out

A G1P1 woman immediately postpartum presents with severe vaginal bleeding. Her labor was remarkably quick for being primiparous, and her pregnancy was only complicated by fetal macrosomia. She has a history of leiomyoma. Along with severe bleeding, she has lower abdominal pain. The first one to arrive is a medical student who does a pelvic exam and says she feels a smooth, round mass protruding from the cervix. Her abdomen is flat. The patient quickly develops hemorrhagic shock.

Challenge: What's the diagnosis?

Thyme, Lavender, Parsley, Basil

Challenge: What's the finding here?

Image shown under Fair Use.

Lethal

Along with the finding above, the ultrasound of the fetus shows a massive midline thoracoabdominal wall defect. There is a large wide-based amnioperitoneal sac inserting onto the placental chorionic plate; there's no umbilical cord. There is severe scoliosis, malrotation of the limbs, and club feet. The maternal AFP is markedly elevated.

Challenge: Unfortunately, this disease is lethal; what is it?

Image shown under Fair Use.

Terms of Agreement

A 20 year old G3P0 woman presents with left lower abdominal pain and vaginal discharge. She says she sometimes feels warm at night but hasn't had a marked fever. "I've had PID in the past, and this just isn't the same," she says. You are unable to do a complete pelvic exam because of significant adnexal tenderness. Because of this, you order pelvic imaging which is shown above. A CBC shows leukocytosis, and pregnancy test is negative. She undergoes surgery and cultures grow out a polymicrobial mix of E.coli, aerobic streptococci, Bacteroides, and Prevotella.

Challenge: What is the diagnosis?

Image shown under Fair Use.

Reverse Engineering II

A 51 year old woman taking the compound shown above is cautioned not to take it long term because of risks for stroke, venous thromboembolism, breast cancer, and cholecystitis.

Challenge: What is the drug and what is she taking it for?

Image is in the public domain.