A45-year-old woman has bilateral breast pain that is most severe premenstrually. On palpation, there is excessive nodularity, tenderness, and cystic areas that diminish in size after menses. Which of the following is the most likely diagnosis?
Answer(s): A
The classic symptom of fibrocystic breast disease is cyclic bilateral breast pain. The pain and associated diffuse breast engorgement is most severe premenstrually. Cystic changes palpated premenstrually typically are smaller postmenstrually. Fibroadenomas are firm, rubbery, freely mobile, solid, and usually solitary masses. Intraductal papilloma does not cause diffuse breast symptoms. Spontaneous and intermittent nipple discharge is the classic sign of an intraductal papilloma. Intraductal carcinoma is more likely if there is a discharge from multiple ducts. Breast cancer should be suspected when a solitary firm nodule does not change throughout the menstrual cycle. A mammogram is helpful, but any suspicious mass should be biopsied. Hyperprolactinemia can cause breast engorgement, but the pain is usually mild, and cystic areas tend not to vary in size
A 35-year-old woman at 30 weeks' gestation discovers a lump in her left breast. Examination reveals a 23 cm, firm nodule in the upper outer quadrant. Which of the following is the most appropriate next step in the management of this patient?
Answer(s): E
Breast cancer is rare in women younger than 35 years, and the approximate incidence of breast cancer in pregnancy is 1 in 3000 deliveries. Survival rates from breast cancer in pregnancy are less than in nonpregnant women of comparable age. This is due to delayed diagnosis, not a biological effect of pregnancy. Pregnant women, when matched for disease stage, have identical survival rates as nonpregnant women. Despite the pregnancy, the presence of a dominant mass requires histologic evaluation. Temporizing measures (choices A through D) are inappropriate in the presence of a dominant mass. Imaging studies of the breast during pregnancy are difficult to interpret because of the ductular and glandular hypertrophy of pregnancy.
A1-cm carcinoma of the breast is diagnosed by an excisional biopsy in a 36-year-old woman at 14 weeks' gestation. The axillary nodes are negative.Which of the following is the best management of this patient?
Breast cancers in young women tend to be aggressive tumors and estrogen receptor negative, both of which worsen the prognosis. For his reason, the cancer should be treated surgically, usually a modified radical mastectomy to minimize the need for adjuvant radiation or chemotherapy with wide local excision or a lumpectomy. There is little convincing evidence that termination of pregnancy improves the prognosis.
A woman at 31 weeks' gestation complains of feeling dizzy and lightheaded when she lies on her back. She is Rh negative but denies vaginal bleeding, abdominal trauma, or abdominal pain. The diagnosis is probably the supine hypotensive syndrome.This results in which of the following?
In late pregnancy, the large uterus commonly compresses the inferior vena cava and impedes return of blood from the lower extremities to the heart. This may be sufficient to reduce cardiac output. In approximately 10% of women, arterial hypotension occurs, which can result in diminished uteroplacental blood flow and a decreased fetal heart rate. None of the other options occur as a result of this syndrome.Management is to have the woman roll on to her side or lean forward if she is sitting. Both these maneuvers cause the uterus to fall away from the inferior vena cava.
A woman at 31 weeks' gestation complains of feeling dizzy and lightheaded when she lies on her back. She is Rh negative but denies vaginal bleeding, abdominal trauma, or abdominal pain. The diagnosis is probably the supine hypotensive syndrome.In which of the following circumstances is the administration of anti-D immune globulin not necessary?
Answer(s): D
Anti-D immune globulin should be given at the time of any vaginal bleeding, trauma, or invasive procedure (e.g., amniocentesis) during pregnancy. Although maternal isoimmunization usually occurs as a result of fetomaternal transfusion at the time of delivery, a small percentage of women become isoimmunized during pregnancy. Anti-D immune globulin is routinely given to unsensitized Rh- negative women at 28 weeks' gestation to reduce this risk. Anti-D immune globulin must also be administered within 72 hours after the birth of an Rh-positive infant. Administration at 40 weeks' gestation before the onset of labor is unnecessary if the infant is Rh negative and may be ineffective if the infant is Rh positive and there is a significant fetomaternal transfusion.
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