A 25-year-old multiparous patient at 28 weeks’ gestation has condyloma lata. Six hours after receiving her first intramuscular dose of penicillin G benzathine, 2.4 mIU, she experiences fever, chills, malaise, headache, and myalgia. She also states that her lesions have become acutely painful. Her temperature is 38.3˚C (100.9˚F), pulse is 110 bpm, blood pressure in 90/60 mm Hg, and respirations are 24/min.
The most likely diagnosis is:
Correct Answer C:
The Jarisch-Herxheimer reaction resembles bacterial sepsis and can occur after initiation antibacterials such as penicillin or tetracycline, or treatment of tick-borne relapsing fever. This is the transient febrile reaction that occurs within the first few hours and peaks at 6-8 hours. The Jarisch-Herxheimer reaction follows a self-limited course. The Jarisch-Herxheimer reaction is often associated with fever, myalgia, headache, chills, tachycardia, increased respiratory rate, hemodynamic instability, exacerbation of skin lesions, and malaise. The circulating neutrophil count is elevated.
→ This is seen in meningococcemia.
→ Allergic reactions do not appear 6 hours after administration of the medication.
→ Secondary bacteremia will not make the lesions painful. Chills, malaise, and fever can be seen with bacteremia.
→ Condyloma lata is one of the lesions of secondary syphilis, not human papillomavirus.
If the embryonic disc divides 14 days after fertilization, the result is a:
Correct Answer D:
Division before day 4: diamniotic, dichorionic. Division during day 4-8: diamniotic monochorionic. Division during day 8-12: monoamniotic, monochorionic. Division after day 12: conjoined. Acardiac twins only occur in monochorionic with delayed cardiac function in one twin, with arterial anastomosis leading to reversed arterial perfusion and absence of development of the heart tube. (TRAP: twin reversed arterial perfusion syndrome).
→ Occurs before day 4.
→ Occurs between day 4 and 8.
→ This is where the cord inserts into the membrane away from the placental disc. It is more common in twin gestation that in singleton.
→ Acardiac twins are monochorionic twins, where the heart of one twin does not develop. This is a very rare condition.
A multipara has just delivered a 10-pound infant after a precipitous labor. When the placenta delivers a short while later, it appears to be attached to a large round firm mass that fills the vagina. A large amount of active bright red vaginal bleeding is noted. The patient becomes pale and her blood pressure is noted to be 70/30 mm Hg.
What is the most likely diagnosis?
Correct Answer B:
Complete uterine inversion after delivery is typically due to excessive cord traction with a fundal placenta. Accreta and the use of magnesium may increase the risk of this complication. Life threatening hemorrhage and profound hypotension may rapidly occur. Prompt treatment is necessary to prevent a possible fatal outcome. Immediate replacement of the uterus should be attempted. While attempting this maneuver, large bore intravenous lines must be placed and adequate fluid resuscitation started. If successful, then uterotonic agents should be given. If unsuccessful, then various agents to relax the uterus may be necessary.
→ Intraabdominal hemorrhage will not be visible from the vagina.
→ Retroperitoneal hemorrhage will not be visible from the vagina.
→ The uterus will be soft and boggy, not firm as in this case.
→ Uterine rupture can have significant bleeding, but a mass will not be seen.
In utero, the highest concentration of oxygen is found in which of the following fetal vessels?
The blood returning to the fetus from the placenta has the highest oxygen concentration. Blood in the umbilical vein travels through the ductus venosus into the inferior vena cava and into the right atrium. Most of this flow tends to go through foramen ovale into the left atrium and eventually out the ascending aorta. Blood returning from the heart via the superior vena cava tends to go through the tricuspid valve and out the pulmonary trunk, then through the ductus arteriosus into the aorta. Thus, higher oxygenated blood is found in the proximal aorta, which is supplying the head and neck.
→ Abdominal aorta is a mixture of blood from the placenta and blood returning from the body, since this artery is post-ductal.
→ This artery is taking blood to the placenta from the fetus.
→ The pulmonary artery is taking blood from the right ventricle. Due to the direction of flow, most of this blood is coming from the superior vena cava and is less oxygenated than the aortic arch.
→ This will have the same oxygen level as the abdominal aorta and the umbilical artery.
A 15-year-old patient request evaluation of masculinization and failure to begin menstruation. She was taller than her peers during childhood. Pubic hair growth began at 6 years, excessive facial hair growth began at 10. She now shaves 3 4 times a week. She is 150 cm (63 inches) tall, and her BP is 120/80 mmHg. She has prominent musculature, and her breasts are Tanner stage 2. Pelvic exam reveals an enlarged clitoris, moderate posterior labial-scrotal fusion, and a cervix in the vaginal vault. There are no pelvic masses on bimanual exam.
This patient’s sex chromosomes are most likely:
Correct Answer A:
This patient is demonstrating signs of increased androgen production. As her secondary sexual characteristics started appearing at age 6, she has, by definition, had a heterosexual precocious puberty. Since a cervix is present, the Mullerian system must have developed, meaning that the gonad is not testes, and that there is no Y component to her sex chromosomes. Her most likely sex chromosome pattern is XX.
The presence of a Y chromosome would lead the gonad to develop into testes. Anti-Mullerian hormone would be produced, and no cervix/uterus/fallopian tubes would develop.
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