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A 28-year-old woman presents to her physician with concerns that she is unable to produce breast milk, despite having given birth approximately 1 month ago. On further questioning she indicates she has been exceptionally thirsty lately, and describes feelings of fatigue and cold intolerance. Physical examination reveals no abnormalities except a scarcity of axillary hair. Laboratory tests reveal a serum sodium level of 150 mEq/L and urinalysis reveals a urine osmolality of 220 mOsm/kg. Which of the following most likely increased the patient’s risk of developing this condition?



A. Abnormalities of the placenta
B. Alcohol intake during pregnancy
C. Endometriosis
D. Gestational diabetes
E. Incorrect use of tampons
F. Multiple sexual partners
G. Pelvic inflammatory disease

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Asked by Olivia, Last updated: Feb 16, 2020

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John Smith

John Smith

Answered Sep 09, 2016

Abnormalities of the placenta-the correct answer is a. this patient is presenting with sheehans syndrome or postpartum pituitary necrosis, caused by hemorrhage during delivery. risk factors include pregnancy with multiples (twins or triplets) and abnormalities 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 sheehans 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 patients cold intolerance), along with central diabetes insipidus caused by decreased production of adh. diabetes insipidus presents with polyuria and dilute urine in the presence of elevated serum sodium levels. decreased fsh and lh levels often lead to amenorrhea and scant pubic and axillary hair growth. treatment 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 associated with growth and developmental defects in the offspring, such as microcephaly, facial dysmorphism, and malformations of the brain, cardiovascular system, and genitourinary system. fetal alcohol syndrome is the leading cause of mental retardation and is easily preventable 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 2040 years old, but its pathogenesis is poorly understood. although its clinical presentation varies, endometriosis can present with pelvic pain associated with the menstrual cycle, dysmenorrhea, and dyspareunia, or it can be asymptomatic. endometriosis is a risk factor for ectopic pregnancy and infertility, and many women who have endometriosis first present with problems getting pregnant. it is not associated with sheehans syndrome.answer d is incorrect. gestational diabetes is a form of diabetes that is present during pregnancy and is often transient, although overt nongestational diabetes may later develop. gestational diabetes is associated with increased fetal birth weight, increased fetal mortality, and increased incidence of neonatal respiratory distress syndrome. in addition, increased fetal insulin levels created in response to maternal glucose 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 sheehans 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 absorbent tampons left in the vagina for long periods of time. tss is caused by an exotoxin produced by staphylococcus aureus, which grows on the tampon. this toxin is a superantigen that allows nonspecific binding of major histocompatibility complex class ii with t-lymphocyte receptors, resulting in polyclonal t-lymphocyte activation and systemic symptoms. tss generally presents acutely with fever, hypotension, and desquamation of the palms and soles, nausea, vomiting, and diarrhea.answer f is incorrect. having multiple sexual partners is associated with an increased risk of various sexually transmitted diseases (stds), including 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, cervical motion tenderness, lower abdominal pain, and painful intercourse, 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 sheehans syndrome.
 

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