Select the ONE best lettered option that is the most likely diagnosis of vaginal bleeding in pregnancy. Each lettered option may be selected once, more than once, or not at all. A 31-year-old woman has an uncomplicated labor and vaginal delivery of a healthy 3400-g male infant. However, her placenta has not yet delivered 2 hours after the delivery of her child. Under appropriate anesthesia manual extraction of the placenta is attempted, but the placenta is removed in fragments. She continues to have excessive vaginal bleeding after manual removal of her placenta. Her first child was delivered by a low transverse cesarean section because of fetal distress.
Answer(s): G
Placenta accreta is suggested by the difficulty with manual removal of the placenta in a woman with a prior cesarean section. Placenta accrete is also more common over any previous uterine incision, such as a myomectomy. Placenta accrete is also more common in women with placenta previa and there is greater than an eightfold increase in women with an AFP higher than 2.5 MOM. The safest and most appropriate treatment is a hysterectomy.
Select the ONE best lettered option that is the most likely diagnosis of vaginal bleeding in pregnancy. Each lettered option may be selected once, more than once, or not at all.A34-year-old woman, gravida 5, has a 17-hour first stage, a 3.5-hour second stage ending with a spontaneous vaginal delivery of a 4400-g infant, and a 15-minute third stage of labor. Immediately after the placenta delivers, she has profuse vaginal bleeding. On examination, her perineum is intact and there are no vaginal or cervical lacerations. Her uterus is soft and the uterine fundus is 45 cm above her umbilicus.
Answer(s): I
Prolonged labor with delivery of a macrosomic fetus (greater than 4000 g) in a highly parous woman are the risk factors for uterine atony. The diagnosis is confirmed by a boggy, noncontracted uterus that is larger than expected after a normal delivery. Treatment is a combination of manual massage of the uterus, oxytocin, blood transfusion to maintain hemodynamic stability, and careful inspection of the vagina, cervix, and uterus to exclude a vaginal or cervical laceration or retained placental fragments. Ergot derivatives or prostaglandins should be administered if the above measures fail to cause the myometrium to contract.Uterine artery embolization is an unproven therapy. Ahysterectomy is necessary if all measures fail to stop the postpartum hemorrhage
A 2-year-old child was recently adopted from India. She appears to be healthy, and there are no abnormal symptoms. Her weight and height are at 25th percentile for age. Her examination is normal. On screening, you find a positive TB skin test using purified protein derivative (PPD) with 20 mm induration. She has a history of receiving a BCG vaccination at birth. Your management plan is to do which of the following?
Answer(s): B
Generally, the interpretation of tuberculin skin test (TST) is the same regardless of BCG status. Induration >5 mm is considered positive in children in close contact with known or suspected cases of tuberculosis disease or children suspected to have tuberculosis disease. Induration >10 mm is considered positive in children at greater risk of disseminated disease (age <4 years; other medical conditions such as lymphoma, diabetes, chronic renal failure, or malnutrition) or children at greater risk of exposure to tuberculosis disease (born in, or parents born in high-prevalence regions, travel to these regions, exposure to adults at high risk, such as HIV infected, homeless, or drug abusers). Induration >15 mm is positive in children >4 years without any risk factors. Radiographic evaluation of all children with positive TST is recommended. Latent tuberculosis infection is defined as an infection in a person with a positive TST, no physical findings of the disease, and a chest radiograph that is either normal or reveals only granulomas or calcifications in the lungs or regional lymph nodes. Children with latent tuberculosis infection should receive prophylaxis, usually 9 months of INH. Those with symptoms, signs, and/or radiographic manifestations are said to have tuberculosis dsease. There is no benefit to repeating the test in 36 months, and it will delay treatment. Sputum cultures are difficult to obtain in younger children. Gastric aspirate specimens obtained with a nasogastric tube are preferred. Culture material should be obtained in children with evidence of the disease in order to obtain information on drug susceptibility and resistance patterns.
A baby is born to a mother who is positive for hepatitis B surface antigen (HBsAg). Your plan is to do which of the following?
Answer(s): C
Transmission of perinatal hepatitis B virus (HBV) infection can be prevented in 95% of infants born to HBsAg-positive mothers by early active (immunization) and passive immunoprophylaxis (HBIG), preferably within 12 hours of life. The immunization series should be completed by 6 months of life. The child should have serology testing 13 months after completion of the series. Testing for anti-HBs will establish if additional vaccine doses are needed; testing for HBsAg will identify infants who are chronically infected.Mothers whose HBsAg status is unknown should be tested as soon as possible; the first vaccine dose should be given within 12 hours of birth. If the woman is found to be positive, HBIG should be given as soon as possible, not later than 7 days of age.
In an adolescent presenting with pityriasis rosea, which of the following would be an appropriate blood test to order?
Answer(s): A
Pityriasis rosea is a papulosquamous eruption consisting of multiple oval-shaped scaling lesions which are truncal in distribution. This eruption resembles the papulosquamous eruption of secondary syphilis, although the rash of secondary syphilis often involves the palms and soles. The etiology of pityriasis rosea is unknown, but is felt to be viral. It is a self-limiting illness lasting several weeks to a few months, and there is no adequate treatment other than symptomatic treatment of pruritus, when necessary.
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