USMLE

Sheehan's syndrome is the result of ischemic injury to the anterior pituitary gland
observed following severe postpartum hemorrhage. Patients commonly present with
oligomenorrhea, impaired lactation, cold intolerance, coarse hair, fatigue, and
weight loss. Symptoms and laboratory findings are consistent with
panhypopituitarism, specifically depressed levels of LH, FSH, GH, TSH, ACTH, and
prolactin. These abnormalities in turn lead to low T4, estradiol, and cortisol
concentrations. Replacement hormone therapy is required to alleviate symptoms
and offer patients the opportunity to conceive.

Polycystic ovarian syndrome, also known as Stein-Leventhal syndrome, is an

idiopathic disorder characterized by anovulatory menstrual cycles and infertility,
multiple ovarian cysts, as well as hirsutism, acne, alopecia, and hypertension. In
addition, patients are often mildly obese and demonstrate impaired insulin
sensitivity. The disorder is marked by excessive ovarian androgen production. These
androgens undergo aromatization into weak estrogens in peripheral fat, which in
turn exert a positive feedback loop on LH secretion as well as suppression of FSH
release. LH further stimulates the proliferation of ovarian cysts, leading to continued
androgen production.

This cycle of events explains the classic laboratory findings of the syndrome,
notably an LH:FSH ratio in excess of 2 in addition to elevated levels of
androstenedione and testosterone. When not desirous of fertility, patients often
experience symptomatic relief with oral contraceptive therapy. If fertility is desired,
clomiphene citrate is the most common therapy. This anti-estrogen, when given
appropriately, alters GnRH and support gonadotropic release in order to stimulate
induction of ovulation.

Kallmann syndrome is an X-linked disorder marked by GnRH deficiency and olfactory

defects leading to anosmia or hyposmia. The condition is thought to be the result of
impaired migration of GnRH-producing cells to the hypothalamus during
embryogenesis. In the absence of GnRH stimulation, low LH and FSH levels lead to
hypogonadism. The development of secondary sexual characteristics is delayed
because of low levels of peripheral estradiol in affected girls/women and
testosterone in the affected boys/men. If fertility is desired, the affected
girls/women may be treated with pulsatile GnRH therapy and gonadotropins.

Asherman's syndrome is a condition marked by uterine adhesions or synechiae that

form in response to excessive endometrial curettage or uterine surgery. However,

USMLE
less commonly, it can also occur because of severe pelvic infection. In response to
trauma, the normal endometrial lining is replaced by scar tissue, leading to the
development of amenorrhea and infertility. Treatment via hysteroscopic adhesiolysis
has been moderately successful for improving fertility.

Meigs' syndrome describes a triad of hydrothorax, peritoneal ascites, and the

presence of a benign ovarian fibroma. Patients most commonly present with
expanding abdominal girth caused by tumor growth and ascites formation. The
subsequent development of pleural effusions leads to dyspnea and pleurisy. CA-125
levels are characteristically elevated, and the diagnosis is confirmed with
exploratory laparotomy revealing non-malignant tumor. Unilateral or bilateral
salpingo-oophorectomy should be performed, depending on the patient's desire for
preservation of fertility. Upon resection, ascites and pleurisy disappear and CA-125
levels return to normal.

Explanation A parturient is a woman in labor. A nullipara has never completed a

pregnancy beyond an abortion. A gravida is or has been pregnant. The terms
primipara and multipara differ only by quantity.
Explanation Toxoplasmosis is a protozoal infection. Maternal immunity protects
against intrauterine infection. The infection complicates about one to five per 1000
pregnancies. The infection is most often subclinical, but fatigue, muscle pains, and
sometime lymphadenopathy may develop. The risk of fetal infection, with an acute
infection in the mother, is about 50 percent, and is associated with the duration of
the pregnancy.
Explanation
The described symptoms and labs are highly suggestive of urinary tract infection,
which occurs at a slightly higher rate during pregnancy than it does in non-pregnant
women. There is a higher risk of developing pyelonephritis in gravidity, and even if
it is asymptomatic, it needs to be treated. Of all the above-mentioned antibiotics,
Cephalexin is the only one safe to be given at the end of pregnancy.

Penicillin and cephalosporins are usually safe in pregnancy; however, antibiotics

with high protein binding capacity, like sulfasoxazole, which is a sulfonamide like
ceftriaxone are contraindicated shortly before delivery because they can cause
bilirubin displacement and result in kernicterus.

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Doxycycline is a tetracycline and therefore contraindicated in pregnancy due to
impairment of bone development and dentition.

Trimethoprim is a diaminopyrimidine; it should be avoided in pregnancy due to

inhibition of the folic acid synthesis.

Nitrofurantoin should be avoided in pregnancy with birth being imminent. It affects

the glutathione reductase activity; therefore, it can cause hemolytic anemia.