Endometrial cancer is a gynecologic malignancy that has easily identifiable risk factors and typically presents with symptoms that lead to an early diagnosis. Risk factors include nulliparity, obesity, late menopause, hypertension and exposure to unopposed estrogens. Of these risk factors, obesity confers the greatest risk of developing endometrial carcinoma, especially when the patient is more than 50 pounds over ideal body weight (10-fold increase). However, in this case, the patient's greatest risk for developing an endometrial cancer is the presence of complex atypical hyperplasia (CAH) on endometrial biopsy. If left untreated, this process has approximately a 28% chance of progressing to an invasive cancer. More importantly, approximately 30% of women with a diagnosis of CAH will be found to have an invasive endometrial cancer on final pathology. Most women who develop endometrial cancer are postmenopausal, but this is less of an issue because of the finding of CAH. Less than 5% of women diagnosed with endometrial cancer are asymptomatic. Approximately 80-90% of women with endometrial carcinoma present with vaginal bleeding or discharge as their only presenting symptom. Since this patient does not have any symptoms or risk factors for endometrial cancer, she does not need to have any diagnostic testing. Risk factors for endometrial cancer include late menopause, unopposed estrogen therapy, nulliparity, obesity, Tamoxifen therapy and diabetes mellitus. Although sometimes associated with Hereditary Non-polyposis Colorectal Cancer Syndrome (HNPCC, or Lynch II), endometrial cancer is typically not a genetically-inherited malignancy, and so genetic counseling for risk assessment would not be recommended unless a more significant family history existed. Endometrial cancer ranks as the fourth most common cancer detected in women in the US. In 2010, according to the American Cancer Society, there will be an estimated 43,470 new endometrial cancer cases. It is the most common gynecologic malignancy.
Top Five Cancers Detected in Women:
• Breast 28%
• Lung 14%
• Colon 10%
• Uterine 6%
• Ovary 3%
• Uterine 52%
• Ovary 26%
• Cervix 14%
• Vulva 5%
• Vagina 3%
The recommended components of the surgical approach to an early endometrial cancer are the extrafascial total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic and para-aortic lymphadenectomy. Alternative surgical approaches to early endometrial cancer include a total vaginal hysterectomy with or without a bilateral salpingo-oophorectomy in women who are medically unstable or have contraindications to major abdominal surgery. Ideally, this approach would only be utilized in patients with well-differentiated endometrioid adenocarcinomas and avoided in patients with high-grade lesions or aggressive cell types, such as clear cell or papillary serous carcinomas. A total laparoscopic hysterectomy, BSO, with or without staging is being utilized more and more in lieu of the traditional open approach for select patients in many centers, and is a reasonable alternative. Although chemotherapy, radiation, and hormonal therapy may be utilized, it is usually in an adjuvant setting. Postmenopausal bleeding or discharge accounts for the presenting symptom in 80-90% of women with endometrial cancer. However, the most common causes of postmenopausal bleeding are atrophy of the endometrium (60-80%), hormone replacement therapy (15-25%), endometrial cancer (10-15%), polyps (2-12%), and hyperplasia (5-10%). Any history of vaginal bleeding requires a thorough history, physical/pelvic examination, and assessment of the endometrium. This is ideally done via office endometrial sampling as part of the initial work-up. The use of pelvic transvaginal ultrasound can provide useful information as to the presence of any structural changes (polyps, myomas, endometrial thickening), and for which a diagnosis of endometrial cancer would be less likely if the endometrial thickness is < 5 mm. Although this patient is likely to have atrophy as the cause of her spotting, a thin endometrial stripe does not exclude the possibility of a non-estrogen dependent carcinoma of the atrophic endometrium. Vaginal estrogen or clindamycin are not indicated. Based on this patient's initial evaluation, it seems highly likely that she has an advanced stage ovarian carcinoma. Given her lack of significant medical co-morbidities, and a gynecologic examination suggestive that the tumor would be potentially resectable, it would be appropriate to offer her a surgical intervention. The surgical staging of an apparent ovarian cancer should include a vertical skin incision, sampling ascites for cytology, inspection of the entire peritoneal cavity, total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, cytoreduction to microscopic disease or to residual disease <1 cm in maximum diameter, and pelvic and para-aortic lymph node dissection if omental disease is <2 cm or if bulky, lymph node disease is present. Thoracentesis to rule out malignant pleural effusion is part of the staging criteria, but may not be justified if the effusion is too small, and would not impact the need to perform surgery. Neoadjuvant chemotherapy is generally considered when a patient has unresectable disease or is a poor surgical candidate, at which point paracentesis for cytologic confirmation would be needed The patient is most likely infected with herpes. Herpes simplex virus is a highly contagious DNA virus. Initial infection is characterized by viral like symptoms preceding the appearance of vesicular genital lesions. A prodrome of burning or irritation may occur before the lesions appear. With primary infection, dysuria due to vulvar lesions can cause significant urinary retention requiring catheter drainage. Pain can be a very significant finding as well. Treatment is centered on care of the local lesions and the symptoms. Sitz baths, perineal care and topical Xylocaine jellies or creams may be helpful. Anti-viral medications, such as Acyclovir, can decrease viral shedding and shorten the course of the outbreak somewhat. These medications can be administered topically or orally. Syphilis is a chronic infection caused by the Treponema pallidum bacterium. Transmission is usually by direct contact with an infectious lesion. Early syphilis includes the primary, secondary, and early latent stages during the first year after infection, while latent syphilis occurs after that and the patient usually has a normal physical exam with positive serology. In primary syphilis, a painless papule usually appears at the site of inoculation. This then ulcerates and forms the chancre, which is a classic sign of the disease. Left untreated, 25% of patients will develop the systemic symptoms of secondary syphilis, which include low-grade fever, malaise, headache, generalized lymphadenopathy, rash, anorexia, weight loss, and myalgias. This patient's symptoms are less consistent with syphilis, but she should still be tested for it. Human immunodeficiency virus is an RNA retrovirus transmitted via sexual contact or sharing intravenous needles. Vulvar burning, irritation or lesions are not typically noted with this disease, although generalized malaise can be. HIV can present with many different signs and symptoms, therefore risk factors should be considered, and testing offered. Trichomonas is a protozoan and is transmitted via sexual contact. It typically presents with a non-specific vaginal discharge. It does not have a systemic manifestation. The patient is most likely has candida vaginalis. Clinically women have itching and thick white cottage cheese like discharge. They may also have burning with urination and pain during intercourse. Herpes simplex viral infections are characterized by viral like symptoms preceding the appearance of vesicular genital lesions. A prodrome of burning or irritation may occur before the lesions appear. With primary infection, dysuria due to vulvar lesions can cause significant urinary retention requiring catheter drainage. Pain can be a very significant finding as well. Treatment is centered on care of the local lesions and the symptoms. Sitz baths, perineal care and topical Xylocaine jellies or creams may be helpful. Anti-viral medications, such as acyclovir, can decrease viral shedding and shorten the course of the outbreak somewhat. These medications can be administered topically or orally. Syphilis is a chronic infection caused by the Treponema pallidum bacterium. Transmission is usually by direct contact with an infectious lesion. Early syphilis includes the primary, secondary, and early latent stages during the first year after infection, while latent syphilis occurs after that and the patient usually has a normal physical exam with positive serology. In primary syphilis, a painless papule usually appears at the site of inoculation. This then ulcerates and forms the chancre, which is a classic sign of the disease. Left untreated, 25% of patients will develop the systemic symptoms of secondary syphilis, which include low-grade fever, malaise, headache, generalized lymphadenopathy, rash, anorexia, weight loss, and myalgias. Bacterial vaginosis is due to an overgrowth of anaerobic bacteria and characterized by a grayish / opaque foul smelling discharge. Trichomonas is a protozoan and is transmitted via sexual contact. It typically presents with a non-specific vaginal discharge. It does not have a systemic manifestation. True precocious puberty is a diagnosis of exclusion where the sex steroids are increased by the hypothalamic-pituitary-gonadal axis, with increased pulsatile GnRH secretion. CNS abnormalities associated with precocious puberty include the following: tumors (e.g., astrocytomas, gliomas, germ cell tumors secreting human chorionic gonadotropin [hCG]); hypothalamic hamartomas; acquired CNS injury caused by inflammation, surgery, trauma, radiation therapy, or abscess; or congenital anomalies (e.g. hydrocephalus, arachnoid cysts, suprasellar cysts). These conditions are not likely in the presence of a normal work-up in this patient. McCune Albright Syndrome is characterized by premature menses before breast and pubic hair development. An ovarian neoplasm is unlikely with a normal pelvic ultrasound. The World Health Organization (WHO) defines osteopenia (low bone mass) as -1 to -2.5. The American College of Ob-Gyn (ACOG)) Committee Opinion recommends that physicians interpret T scores between −1.5 and −2.0 in combination with the patient's risk factors for fracture. The authors state: "Clinicians must be careful because the diagnosis of osteopenia often is interpreted as indicating a pathologic skeletal condition or significant bone loss, neither of which is necessarily true. Until better models of absolute fracture risk exist, postmenopausal women in their 50s with T scores in the osteopenia range and without risk factors may well benefit from counseling on calcium and vitamin D intake and risk factor reduction to delay initiation of pharmacologic intervention." Some of the risk factors for fracture include prior fracture, family history of osteoporosis, race, dementia, history of falls, poor nutrition, smoking, low body mass index, estrogen deficiency, alcoholism, and insufficient physical activity. The likely cause of this patient's sudden onset of symptom is an increase in androgens due to a tumor. Hirsutism is often the result of a benign condition, however, may be a sign of significant disease if sudden in onset and coupled with virilization. Virilization in the female may be manifested by frontal hair thinning, oily skin or acne, deepening of the voice, clitoral enlargement, menstrual irregularities, and increased muscle strength. Possible causes of virilization include PCOS, hypothyroidism, androgen producing tumors (ovarian, adrenal, or pituitary), and anabolic steroid use. A rare cause may be late onset congenital adrenal hyperplasia. This patient is having difficulty conceiving after trying for one year. Based on her history, the most likely underlying factor is tubal disease, as she has a history of being hospitalized for a pelvic infection, most likely pelvic inflammatory disease. This can cause adhesions and blockage of the tubes, which is best assessed with a hysterosalpingogram to evaluate the uterine cavity and tubes. After a single episode of salpingitis, 15% of patients experience infertility. Hysteroscopy will assess the uterine cavity and while sometimes used during a work up for infertility, it does not provide sufficient information about tubal patency. Progesterone levels, a Clomiphene challenge test or cervical mucous monitoring are used at times with infertility workups, but, in a young patient of normal BMI and with normal cycles, it is unlikely to find major ovulatory dysfunction. Lichen sclerosus is a chronic inflammatory skin condition that most commonly affects Caucasian premenarchal girls and postmenopausal women. The exact etiology is unknown, but is most likely multifactorial. Patients typically present with extreme vulvar pruritus and may also present with vulvar burning, pain and introital dyspareunia. Early skin changes include polygonal ivory papules involving the vulva and perianal areas, waxy sheen on the labia minora and clitoris, and hypopigmentation. The vagina is not involved. More advanced skin changes may include fissures and erosions due to a chronic itch-scratch-itch cycle, mucosal edema and surface vascular changes, and, ultimately, scarring with loss of normal architecture, such as introital stenosis, and resorption of the clitoris (phimosis) and labia minora. Treatment involves use of high-potency topical steroids. There is less than a 5% risk of developing squamous cell cancer within a field of lichen sclerosus. Lichen planus is a chronic dermatologic disorder involving the hair-bearing skin and scalp, nails, oral mucous membranes and vulva. This disease manifests as inflammatory mucocutaneous eruptions characterized by remissions and flares. The exact etiology is unknown, but is thought to be multifactorial. Vulvar symptoms include irritation, burning, pruritus, contact bleeding, pain and dyspareunia. Clinical findings vary with a lacy, reticulated pattern of the labia and perineum, with or without scarring and erosions as well. With progressive adhesion formation and loss of normal architecture, the vagina can become obliterated. Patients may also experience oral lesions, alopecia and extragenital rashes. Treatment is challenging, since no single agent is universally effective and consists of multiple supportive therapies and topical superpotent corticosteroids. Lichen simplex chronicus, a common vulvar non-neoplastic disorder, results from chronic scratching and rubbing, which damages the skin and leads to loss of its protective barrier. Over time, a perpetual itch-scratch-itch cycle develops, and the result is susceptibility to infection, ease of irritation and more itching. Symptoms consist of severe vulvar pruritus, which can be worse at night. Clinical findings include thick, lichenified, enlarged and rugose labia, with or without edema. The skin changes can be localized or generalized. Diagnosis is based on clinical history and findings, as well as vulvar biopsy. Treatment involves a short-course of high-potency topical corticosteroids and antihistamines to control pruritus. Two serotypes of HSV have been identified: HSV-1 and HSV-2. Most cases of recurrent genital herpes are caused by HSV-2. Up to 30% of first-episode cases of genital herpes are caused by HSV-1, but recurrences are much less frequent for genital HSV-1 infection than genital HSV-2 infection. Genital HSV infections are classified as initial primary, initial nonprimary, recurrent and asymptomatic. Initial, or first-episode primary genital herpes is a true primary infection (i.e. no history of previous genital herpetic lesions, and seronegative for HSV antibodies). Systemic symptoms of a primary infection include fever, headache, malaise and myalgias, and usually precede the onset of genital lesions. Vulvar lesions begin as tender grouped vesicles that progress into exquisitely tender, superficial, small ulcerations on an erythematous base. Initial, nonprimary genital herpes is the first recognized episode of genital herpes in individuals who are seropositive for HSV antibodies. Prior HSV-1 infection confers partial immunity to HSV-2 infection and thereby lessens the severity of type 2 infection. The severity and duration of symptoms are intermediate between primary and recurrent disease, with individuals experiencing less pain, fewer lesions, more rapid resolution of clinical lesions and shorter duration of viral shedding. Systemic symptoms are rare. Recurrent episodes involve reactivation of latent genital infection, most commonly with HSV-2, and are marked by episodic prodromal symptoms and outbreaks of lesions at varying intervals and of variable severity. Clinical diagnosis of genital herpes should be confirmed by viral culture, antigen detection or serologic tests. Treatment consists of antiviral therapy with acyclovir, famciclovir or valacyclovir. Uterine fibroids are the most common solid pelvic tumors in women. On postmortem examination, fibroids can be detected in as high as 80% of women. Most uterine fibroids are asymptomatic and do not require any treatment. Pregnant patients with fibroids usually are asymptomatic and do not have any complications related to the fibroids. Fibroids may grow or become symptomatic in pregnancy due to hemorrhagic changes associated with rapid growth, known as red or carneous degeneration. However, this is uncommon for smaller fibroids. Uncommonly, fibroids can be located below the fetus, in the lower uterine segment, or cervix, causing a soft tissue dystocia, necessitating delivery by Cesarean section. Myomectomy (removal of the fibroid) during pregnancy is contraindicated. Myomectomy at the time of Cesarean section should be avoided, if possible, secondary to the risk for increased blood loss. It is not necessary to follow the growth of fibroids during pregnancy, except for the rare cases when the fibroid is causing symptoms (primarily pain) or appear to be located in a position likely to cause dystocia. Nerve entrapment syndrome is a commonly misdiagnosed neuropathy that can complicate pelvic surgical procedures performed through a low transverse incision. The nerves at risk are the iliohypogastric nerve (T-12, L-1) and the ilioinguinal (T-12, L-1) nerve. These two nerves exit the spinal column at the 12th vertebral body and pass laterally through the psoas muscle before piercing the transversus abdominus muscle to the anterior abdominal wall. Once at the anterior superior iliac spine, the iliohypogastric nerve courses medially between the internal and external oblique muscles, becoming cutaneous 1 cm superior to the superficial inguinal ring. The iliohypogastric nerve provides cutaneous sensation to the groin and the skin overlying the pubis. The ilioinguinal nerve follows a similar, although slightly lower, course as the iliohypogastric nerve where it provides cutaneous sensation to the groin, symphysis, labium and upper inner thigh. These nerves may become susceptible to injury when a low transverse incision is extended beyond the lateral border of the rectus abdominus muscle, into the internal oblique muscle. Symptoms are attributed to suture incorporation of the nerve during fascial closure, direct nerve trauma with subsequent neuroma formation, or neural constriction due to normal scarring and healing. Damage to the obturator nerve, which can occur during lymph node dissection would result in the inability of the patient to adduct the thigh. The most recent consensus guidelines (2006) state that management of LSIL is initial colposcopic examination (unless the woman is pregnant, postmenopausal or an adolescent). An excisional procedure, such as cold knife biopsy or LEEP, is not warranted without a tissue diagnosis of dysplasia. The Pap smear is merely a screening tool and, as such, cannot formulate a definitive diagnosis. In fact, up to 20% of patients with LSIL on Pap smear have high-grade squamous intraepithelial lesion (HSIL) on colposcopically-directed biopsy. In contrast, up to 50% of patients with LSIL on Pap smear have a negative colposcopy. Antibiotic treatment is not warranted unless there is an infection. If a Pap smear is repeated prior to six to eight weeks following the last one, reparative changes may still be happening to the cervix. This reduces the ability of the test to be a good screening tool. (The false positive and/or false negative rates can be affected). In some instances, LSIL may be followed with serial Pap smears; however, a tissue diagnosis or a colposcopy without evidence of HSIL changes must be done initially. Endometrial biopsy is typically an office procedure which does not cause extreme discomfort for the patient. It results in information necessary to tailor the patient's care, such as presence of endometritis, endometrial polyps or endometrial carcinoma. In a patient with significant risk factors for endometrial carcinoma, this should be done prior to a hysterectomy or ablation, if at all possible. A hysterectomy or endometrial ablation would be incorrect, as further workup is needed prior to taking the patient for one of these procedures. In addition, this patient potentially has a treatable condition, such as endometritis, an endometrial polyp, endometrial hyperplasia or an enlarging submucosal fibroid, which could all be treated with either medical therapy or a less radical procedure. With stable vital signs and a hematocrit of 29, erythropoietin and a blood transfusion would not be indicated for this patient. Her anemia could be corrected using ferrous sulfate over a period of a few months, along with targeted therapy to decrease her vaginal bleeding (therapy would be based on the endometrial biopsy result). A hysterectomy with bilateral salpingo-oophorectomy is the definitive treatment for a patient with pelvic pain due to endometriosis. In 60% of cases, when a patient with endometriosis undergoes a simple hysterectomy without bilateral salpingo-oophorectomy for pelvic pain, re-operation for continued pain will be necessary. Even if the patient requires hormone replacement therapy postoperatively, her pain is unlikely to return. A laparoscopy is indicated in the workup of pelvic pain in order to determine the etiology of the pain. If endometriosis is noted, it may be excised, fulgurated or burned by laser. This may offer some relief of the patient's pain; however, relief is usually temporary in a pre-menopausal female. In addition, this patient had a previous laparoscopy with only temporary relief. A radical hysterectomy, usually used to treat cervical cancer, is too invasive for the treatment of endometriosis. It is very unlikely in this scenario to decrease the patient's pain simply by changing her oral contraceptive pill. An endometrial ablation is an acceptable treatment for menorrhagia and will likely not be helpful in this patient. Although Levonorgestrel IUD may effectively relieve endometriosis, it is unlikely to do so in this patient who has been on progestins and oral contraceptives without relief. A 38-year-old G1P1 comes to the office for a health maintenance examination. She has noticed some urinary frequency over the past month. She has no dysuria, hematuria, urgency or incontinence. She has normal cycles, no history of abnormal Pap smears or sexually transmitted infections and is sexually active, with one partner. She smokes a quarter of a pack of cigarettes daily, and drinks one glass of wine per day. Her mother had breast cancer at age 30. Her general examination is normal. On pelvic exam, she has normal external genitalia; vagina and cervix are without lesions. Her uterus is normal size, anteverted and nontender. Her left adnexa is normal, right adnexa has a mobile, slightly tender 4 cm mass. Laboratory results show a normal urinalysis, a negative urine pregnancy test and a normal Pap smear. What is the most appropriate next step in the management of this patient?
A. Perform a transvaginal ultrasound
B. Perform a diagnostic laparoscopy
C. Recommend a CT-guided drainage of the mass
D. Order a KUB plain film
E. Perform an exploratory laparotomy
A transvaginal ultrasound would be the best way to begin a workup for an incidental finding of an adnexal mass. Using this modality, one can distinguish an adnexal mass from other structures, as well as note the characteristics of the mass (simple vs. complex, solid vs. cystic, thin or thick walled, size, and ancillary structures involved). Using this information, a management plan may be constructed. In a stable, asymptomatic patient, laparoscopy or laparotomy would not be indicated for diagnosis until further imaging studies had been done. A CT-guided drainage would not be a good choice until one has a better understanding of the characteristics of the mass. If the mass was malignant, draining it in this manner could not only seed the needle tract, but it could also spill intra-abdominally, causing the malignancy to spread. A plain film would not be helpful unless the mass contains calcium and thus would not give additional data. The external genitalia, specifically the clitoris, are essential organs involved in the arousal component of the sexual response cycle, which consists of desire, arousal, orgasm, and resolution. Hormones such as androgen and estrogen (produced by the ovaries) are key to desire, while genital mechanisms such as clitoral, labial, and vaginal engorgement are key to arousal. With arousal and adequate sensory stimulation, orgasm ultimately may occur consisting of repeated motor contractions of the pelvic floor including uterine and vaginal smooth muscle contractions. Female sexual dysfunction can be classified as disorders in sexual desire, arousal, orgasm, or sexual pain, and can include any combination of these. In this case, because she states a desire to initiate in sexual activity and has been enjoying masturbation, it is unlikely that she will experience any problems related to desire, arousal, or orgasm. However, in the presence of severe atrophy and lack of estrogen, she may in fact experience pain related to dyspareunia. She should be encouraged to use some form of water-based lubricant to diminish the effects of the vaginal dryness since estrogen is likely contraindicated with her breast cancer diagnosis. Although body image may play a role, it would be classified under the category of sexual desire. A flattened nasal bridge, small size and small rotated, cup-shaped ears may be associated with Down syndrome and should prompt a survey looking specifically for other features seen with Down syndrome that include sandal gap toes, hypotonia, a protruding tongue, short broad hands, Simian creases, epicanthic folds, and oblique palpebral fissures. The initial physical findings may be a variant of normal, therefore, you should not share any concerns with the mother until you perform a detailed physical examination. Wide-spaced nipples and lymphedema are associated with Turner syndrome. It is not standard of care to offer amniocentesis to a 19-year-old, unless she has specific risk factors. Progesterone, estrogen, and placental lactogen, as well as prolactin, cortisol, and insulin, appear to act in concert to stimulate the growth and development of the milk-secreting apparatus of the mammary gland. Prolactin is responsible for the synthesis of milk, but although present in large quantities during gestation, its action is inhibited by the hormones of pregnancy, particularly estrogen and progesterone. After delivery, large amounts of prolactin continue to be secreted, milk is produced after the inhibitory action of estrogen and progesterone is lifted. A 41-year-old G3P2 woman presents with cramping, vaginal bleeding and right lower quadrant pain for five days which has progressively worsened. Her last normal menstrual period occurred seven weeks ago. Her surgical history is notable for a bilateral tubal ligation following her last delivery. On physical exam, vital signs are: blood pressure 110/74; pulse 82; respirations 18; temperature 98.6°F (37.0°C). On abdominal exam, she has right lower quadrant tenderness, with rebound and bilateral guarding in the lower quadrants. On pelvic exam, she has scant old blood in the vagina and a normal appearing cervix. Her uterus is normal size and slightly tender. She has cervical motion tenderness on bimanual examination, and marked tenderness on rectal examination. Her quantitative Beta-hCG is 4000 mIU/ml; progesterone 6.2 ng/ml; hematocrit 34%; and WBC 15,400/mcL, with 88% segmented neutrophils and no bands. The transvaginal ultrasound shows an empty uterus with endometrial thickening, a mass in right ovary measuring 3.8 x 2 cm, and a small amount of free fluid in the pelvis. What is the most likely diagnosis in this patient?
A. Pelvic inflammatory disease
B. Ectopic pregnancy
C. Heterotopic pregnancy
D. Missed abortion
E. Ruptured corpus luteum cyst
Lupus is notoriously variable in its presentation, course, and outcome. Clinical manifestations include malaise, fever, arthritis, rash, pleuropericarditis, photosensitivity, anemia, and cognitive dysfunction. A significant number of patients have renal involvement. There is no cure, and complete remissions are rare. Mild disease may be disabling because of pain and fatigue. Nonsteroidal anti-inflammatory drugs are used to treat arthralgia and serositis. Severe disease is managed with corticosteroids. Hydroxychloroquine is used to help control skin manifestations and may be associated with lupus flares if discontinued. HELLP syndrome is a disease process in the spectrum of severe preeclampsia. The acronym stands for "hemolysis, elevated liver enzymes, low platelets" and can lead to swelling of the liver capsule and possibly, liver rupture. It may or may not be accompanied by right upper quadrant pain. It is possible to only have thrombocytopenia and elevated transaminases, without clear hemolysis (elevated bilirubin and anemia), especially if a diagnosis is made early. This patient does not have seizures and, therefore, does not have eclampsia. The clinical scenario is not consistent with hepatitis or cholecystitis. Acute fatty liver almost always manifests late in pregnancy. Symptoms develop over several days to weeks and include malaise, anorexia, nausea and vomiting, epigastric pain, and progressive jaundice. In many women, persistent vomiting in late pregnancy is the major symptom. About half of all women have hypertension, proteinuria, and edema signs suggestive of preeclampsia. There is usually severe liver dysfunction with hypofibrinogenemia, hypoalbuminemia, hypocholesterolemia, and prolonged clotting times. As acute fatty liver worsens there is marked hypoglycemia. This patient was sensitized during her first pregnancy that was complicated by abruption and required Cesarean delivery. Transplacental hemorrhage of fetal Rh-positive red blood cells into the circulation of the Rh-negative mother may occur following a number of obstetric procedures and complications, such as amniocentesis, chorionic villus sampling, spontaneous/threatened abortion, ectopic pregnancy, dilation and evacuation, placental abruption, antepartum hemorrhage, preeclampsia, cesarean section, manual removal of the placenta and external version. Preterm delivery increases the risk of morbidity and mortality, increasing with higher orders of multiples. Preterm birth occurs in over 50% of twin pregnancies, 90% of triplet pregnancies, and almost all quadruplet pregnancies. While all the choices may occur with a multiple gestation, prematurity has the most significant consequences as it is associated with an increased risk of respiratory distress syndrome (RDS), intracranial hemorrhage, cerebral palsy, blindness, and low birth weight. Intrauterine growth restriction, intrauterine death of one or more fetuses, miscarriage and congenital anomalies are all more common with multiple gestations, as are the complications of preeclampsia, diabetes and placental abnormalities. This patient is undergoing a placental abruption, with a deteriorating fetal condition. An emergent Cesarean delivery is necessary. The mother risks excessive blood loss, DIC and possible hysterectomy. The fetus risks neurological injury from anoxia or death. Risk factors for abruption include smoking, cocaine use, abdominal trauma, chronic hypertension, multiparity and prolonged premature rupture of membranes. Since immediate delivery is needed, amniotomy, induction, or tocolysis are not appropriate. A double set-up examination (performed in the operating room with a Cesarean section team scrubbed and ready) is not indicated, since the ultrasound determined the location of the placenta to be fundal.qq Variable decelerations show an acute fall in the FHR, with a rapid down slope and a variable recovery phase. They are characteristically variable in duration, intensity, and timing, and may not bear a constant relationship to uterine contractions. They are typically associated with cord compression, especially in the setting of low amniotic fluid volume. Early decelerations are physiologic caused by fetal head compression during uterine contraction, resulting in vagal stimulation and slowing of the heart rate. This type of deceleration has a uniform shape, with a slow onset that coincides with the start of the contraction and a slow return to the baseline that coincides with the end of the contraction. Thus, it has the characteristic mirror image of the contraction. A late deceleration is a symmetric fallin the fetal heart rate, beginning at or after the peak of the uterine contraction and returning to baseline only after the contraction has ended. Late decelerations are associated with uteroplacental insufficiency. The true sinusoidal pattern is a regular,smooth, undulating form typical of a sine wave that occurs with a frequency of two to five cycles/minute and an amplitude range of five to 15 beats/minute. It is also characterized by a stable baseline heart rate of 120 to 160 beats/minute and absentbeat-to-beat variability. Uterine atony is the most common cause of postpartum hemorrhage. Risk factors for uterine atony include precipitous labor, multiparity, general anesthesia, oxytocin use in labor, prolonged labor, macrosomia, hydramnios, twins and chorioamnionitis. Patients at risk for genital tract lacerations are those who have a precipitous labor, macrosomia or who have an instrument-assisted delivery or manipulative delivery i.e. breech extraction. Factors that lead to an over-distended uterus are risk factors for uterine inversion. Grand multiparity, multiple gestation, polyhydramnios and macrosomia are all risk factors. The most common etiology of uterine inversion, however, is excessive (iatrogenic) traction on the umbilical cord during the third stage of delivery. Although the patient is at risk for uterine dehiscence and uterine rupture because of her history of a prior Cesarean section, these are infrequent occurrences so the most likely cause of postpartum hemorrhage in this patient is uterine atony. Sertraline is a Category C drug. Depression is more common in women than men. Appropriate treatment, including during the antepartum period, is a component of good medical care. As in all cases, when considering treatments, the benefits should outweigh the risks. With Category A drugs, there are adequate, well-controlled studies in pregnant women that have not shown an increased risk of fetal abnormalities to the fetus in any trimester of pregnancy. With Category B, animal studies have revealed no evidence of harm to the fetus; however, there are no adequate and well-controlled studies in pregnant women or animal studies that have shown an adverse effect, but adequate and well-controlled studies in pregnant women have failed to demonstrate a risk to the fetus in any trimester. Category C drugs have animal studies that show an adverse effect and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks. Category D drugs have adequate well-controlled or observational studies in pregnant women and are known risks to the fetus. Category X drugs should not be used in pregnancy, because adequate well-controlled or observational studies in animals or pregnant women have demonstrated positive evidence of fetal abnormalities or risks. Correct answer is C. This fetus had intrauterine growth restriction and, with the exception of polyhydramnios, all of the morbidities listed above may complicate intrauterine growth restriction. In general, the causes of polyhydramnios relate to amniotic fluid production (abnormalities of the fetal urinary tract) and removal (abnormalities of fetal swallowing and intestinal reabsorption of fluid). Some investigators report an increase in fetal urinary output when there is hyperglycemia and increased renal osmotic load, thus resulting in polyhydramnios. Abnormal fetal swallowing may be a result of a CNS or gastrointestinal tract abnormalities, such as anencephaly, esophageal or duodenal atresia, diaphragmatic hernia or primary muscular disease. Typically, polyhydramnios is not associated with asymmetric growth restriction (the most common form of IUGR), since an asymmetric growth pattern reflects poor uterine blood flow and limited substrate availability. In fact, oligohydramnios is frequently identified in pregnancies complicated by fetal growth restriction. Necrotizing fascitis, a dangerous infection caused by gas forming organisms, such as Clostridium, can quickly cause sepsis and death. Classic clinical manifestations include fever, pain and induration of the wound. Treatment involves early recognition, antibiotics and debridement of the necrotic tissue. Classic clinical findings for endomyometritis include fever and maternal tachycardia, uterine tenderness and no other localizing signs of infection. Cellulitis presents as swollen, erythematous, tender and warm area, but without grey necrotic edges. Hematoma findings include a swollen, tender and painful area that may be expanding.