21/01/2013
Answer to the Q-12 with Explanation:
The correct answer is A. This patient is presenting with Sheehan’s syndrome or postpartum pituitary necrosis, caused by hemorrhage during delivery. Risk factors include pregnancy with multiples (twins or triplets) and abnormal- ities of the placenta. Peripartum hemorrhage predisposes the already enlarged pituitary to ischemia, leading to necrosis of parts of the anterior and/or posterior pituitary. The most common clinical feature of Sheehan’s syndrome is an inability to lactate, caused by damage to the anterior pituitary and decreased prolactin production. Other symptoms include those associated with hypothyroidism (as seen by the pa- tient’s cold intolerance), along with central diabetes insipidus caused by decreased produc- tion of ADH. Diabetes insipidus presents with polyuria and dilute urine in the presence of el- evated serum sodium levels. Decreased FSH and LH levels often lead to amenorrhea and scant p***c and axillary hair growth. Treat- ment involves lifelong hormone replacement therapy of all deficient hormones, along with estrogen and progesterone supplementation.
Answer B is incorrect. Alcohol intake during pregnancy is not associated with any of the symptoms seen in this patient. Instead, it is as- sociated with growth and developmental de- fects in the offspring, such as microcephaly, fa- cial dysmorphism, and malformations of the brain, cardiovascular system, and genitourinary system. Fetal alcohol syndrome is the leading cause of mental retardation and is easily pre- ventable by maternal abstinence from alcohol during pregnancy.
Answer C is incorrect. Endometriosis is a common condition characterized by growth of ectopic endometrial tissue outside the uterus. It generally presents in women 20–40 years old, but its pathogenesis is poorly understood. Although its clinical presentation varies, endo- metriosis can present with pelvic pain associ- ated with the menstrual cycle, dysmenorrhea, and dyspareunia, or it can be asymptomatic. Endometriosis is a risk factor for ectopic preg- nancy and infertility, and many women who have endometriosis first present with problems getting pregnant. It is not associated with Shee- han’s syndrome.
Answer D is incorrect. Gestational diabetes is a form of diabetes that is present during preg- nancy and is often transient, although overt nongestational diabetes may later develop. Ges- tational diabetes is associated with increased fetal birth weight, increased fetal mortality, and increased incidence of neonatal respiratory dis- tress syndrome. In addition, increased fetal in- sulin levels created in response to maternal glu- cose levels can cause a hypoglycemic crisis after birth, when the maternal supply of glucose is no longer present. Gestational diabetes is not a known risk factor for Sheehan’s syndrome and would not cause this patient to present with the symptoms seen.
Answer E is incorrect. Incorrect use of tampons is associated with toxic shock syndrome (TSS), originally associated with the use of highly ab- sorbent tampons left in the va**na for long peri- ods of time. TSS is caused by an exotoxin pro- duced by Staphylococcus aureus, which grows on the tampon. This toxin is a superantigen that allows nonspecific binding of major histocom- patibility complex class II with T-lymphocyte re- ceptors, resulting in polyclonal T-lymphocyte activation and systemic symptoms. TSS gener- ally presents acutely with fever, hypotension, and desquamation of the palms and soles, nau- sea, vomiting, and diarrhea.
Answer F is incorrect. Having multiple sexual partners is associated with an increased risk of various sexually transmitted diseases (STDs), in- cluding HIV and HPV, the virus associated with cervical cancer. STDs present with various symptoms depending on the underlying infectious agent, but none would cause the symptoms seen in this patient.
Answer G is incorrect. PID is most commonly caused by infection with Chlamydia trachomatis or Neisseria gonorrhea, the latter presenting more acutely. Symptoms include fever, cervi- cal motion tenderness, lower abdominal pain, and painful in*******se, although PID is often asymptomatic. Treatment of the underlying cause is important because PID is a risk factor for ectopic pregnancy and infertility. It is not associated with Sheehan’s syndrome.
