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 antiestrogen, 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, 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.

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.