A 25-year-old woman, gravida 1 para 1, comes to the office with her husband for an 8-week postpartum visit. The pregnancy and delivery were normal and without complications. The patient says, "I'm exhausted and sleep deprived but doing okay." Her husband is concerned about her extreme fatigue; he says she has gotten weaker and unsteady over the past week. He also says she has not been holding the baby as often and rarely goes upstairs to the nursery. The patient reports no depressed mood or appetite changes. Medical history is unremarkable. Blood pressure is 126/84 mm Hg, and pulse is 80/min. On physical examination, the patient appears tired. There is no scleral icterus, and the mucous membranes are pink and moist. The thyroid is not enlarged. Heart and lung sounds are normal, and the abdomen is soft and nontender. There is bilateral lower extremity weakness, left side more than right. Knee reflexes are increased bilaterally. Genital examination shows the episiotomy site has healed, and there is no vaginal discharge. Which of the following is the most appropriate next step in management?

Question

A 25-year-old woman, gravida 1 para 1, comes to the office with her husband for an 8-week postpartum visit.  The pregnancy and delivery were normal and without complications.  The patient says, "I'm exhausted and sleep deprived but doing okay."  Her husband is concerned about her extreme fatigue; he says she has gotten weaker and unsteady over the past week.  He also says she has not been holding the baby as often and rarely goes upstairs to the nursery.  The patient reports no depressed mood or appetite changes.  Medical history is unremarkable.  Blood pressure is 126/84 mm Hg, and pulse is 80/min.  On physical examination, the patient appears tired.  There is no scleral icterus, and the mucous membranes are pink and moist.  The thyroid is not enlarged.  Heart and lung sounds are normal, and the abdomen is soft and nontender.  There is bilateral lower extremity weakness, left side more than right.  Knee reflexes are increased bilaterally.  Genital examination shows the episiotomy site has healed, and there is no vaginal discharge.  Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

This patient's increasing fatigue, weakness, and imbalance with examination findings of asymmetric lower extremity weakness and increased knee reflexes are concerning for a neurologic disorder. Multiple sclerosis (MS) is a common immune-mediated inflammatory demyelinating disease of the CNS that typically presents in young adults, especially women of child-bearing age. Although pregnancy is protective for MS, there is an increased risk in the early postpartum period. MS symptoms may be focal or multifocal and develop over hours to days with partial resolution over weeks to months. Common symptoms include motor weakness, diplopia, gait disturbance and balance problems, sensory symptoms in limbs or face, unilateral vision loss, vertigo, and bladder dysfunction. The next step in evaluating a patient with suspected MS is MRI of the brain, with extension to the spinal cord if examination warrants. MRI findings of characteristic demyelinating plaques disseminated in space and time can be used to confirm the clinical diagnosis. Additional tests such as lumbar puncture for oligoclonal bands and visual evoked potentials can also help make the diagnosis if the clinical picture or MRI findings are equivocal. (Choices A and D) All postpartum patients should be evaluated for depression; cognitive-behavioral therapy and/or selective serotonin reuptake inhibitors are appropriate first-line treatments. However, this patient's fatigue and probable reluctance to climb stairs to the nursery are more likely due to her muscle weakness and imbalance. Any patient who demonstrates neurological deficits must undergo additional evaluation to rule out medical causes before a primary psychiatric illness is considered. (Choice C) Fatigue due to sleep deprivation is common in new parents. However, reassurance is inappropriate when it is accompanied by new-onset neurologic symptoms and functional deficits. (Choice E) Although fatigue and weakness can be seen in postpartum thyroid dysfunction, this patient lacks other characteristic symptoms of hypothyroidism (eg, cold intolerance, constipation, dry skin). In addition, hypothyroidism typically presents with bilateral proximal weakness as opposed to asymmetrical weakness, as well as delayed rather than increased reflexes. Educational objective: Multiple sclerosis (MS) is an immune-mediated inflammatory demyelinating disease that typically presents in young women with episodes of CNS dysfunction. When MS is suspected, brain MRI showing demyelinating plaques disseminated in time and space can help confirm the diagnosis. References: Effective utilization of MRI in the diagnosis and management of multiple sclerosis. (http://www.ncbi.nlm.nih.gov/pubmed/29157402) Optimizing treatment success in multiple sclerosis. (http://www.ncbi.nlm.nih.gov/pubmed/26705122)

A 25-Year-Old Woman, Gravida 1 Para 1, Comes to the Office