A 33-year-old G3P2 at 38 weeks’ gestation develops flu-like illness and breaks out with a pruritic, vesicular lesions all over her body. Three days later she goes into spontaneous labor and delivers a healthy appearing male infant via vaginal delivery. Her lesions are beginning to heal and she feels well.
What is the most appropriate next step in the management of this patient and her baby?
Varicella, or chicken pox, is usually diagnosed based on the clinical findings of a classic pruritic, vesicular rash. Pregnant women should have varicella immunity documented in early pregnancy by a history of previous infection or varicella vaccination. Pregnant women who have no history of chicken pox or have serology demonstrating lack of immunity should avoid varicella infected individuals until their lesions have crusted over and they are no longer infectious. Neonatal mortality rates are close to 25% when maternal varicella develops around the time of delivery, due to the lack of protective maternal antibodies and the relative immaturity of the fetal immune system. Therefore, if a mother has clinical evidence of varicella infection 5 days before or up to 48 hours after delivery, the newborn should receive varicella-zoster immune globulin. Typically, varicella infection in the mother only requires supportive therapy, but pregnant women have a higher and mortality related to development of pneumonia. If pneumonia is diagnosed, intravenous acyclovir should be given. The newborn should be isolated from the mother if she is infective, and if the neonate develops signs or symptoms of varicella infection, then intravenous acyclovir would be administered. Pregnant women should not receive the live-attenuated varicella vaccine.
A 29-year-old G1 at 9 weeks’ gestation presents to your office for a new OB visit. She reports a history of well-controlled hypothyroidism. She takes 88 mcg of levothyroxine daily.
How do you expect her thyroid laboratory values to change during pregnancy?
There are considerable changes in maternal thyroid function during pregnancy. Maternal total or bound thyroid hormone levels increase with serum concentration of thyroid-binding globulin. TSH decreases in early pregnancy because of weak stimulation of its receptors by human chorionic gonadotropin (hCG) during the first trimester After the first trimester, TSH levels return to baseline values and progressively increase in the third trimester related to placental growth and production of placental deiodinase. Free T4 remains stable during pregnancy. A high TSH and low free T4 are characteristic of overt hypothyroidism. These physiologic changes should be considered when interpreting thyroid function test results during pregnancy.
A 19-year-old P0 presents for her first OB visit at 10 weeks’ gestation. You order routine OB laboratory tests, and it returns showing a positive nucleic acid probe for Neisseria gonorrhoeae. One year ago, she was treated with ampicillin for a simple urinary tract infection and developed a severe allergic reaction.
Which of the following is the best option for treatment at this time?
Patients with a severe allergic reaction to ampicillin should not receive penicillin. Patient with this type of reaction have up to a 20% incidence of reaction to cephalosporins, so ceftriaxone should be avoided as well unless desensitization is undertaken. Spectinomycin used to be the treatment of choice for pregnant women with Neisseria gonorrhoeae infections and who were allergic to penicillin; however, the production of this medication was discontinued in the United States in 2006. The use of doxycycline or tetracycline is generally contraindicated in pregnancy. Azithromycin 2 g orally as a single dose may be used as an alternative to treat both gonorrhea and chlamydia.
A 22-year-old pregnant woman has just been diagnosed with toxoplasmosis.
Which of the following risk factors is most likely to have contributed to her diagnosis?
Toxoplasmosis is caused by the intracellular parasite Toxoplasma gondii. This infection is usually asymptomatic and self limited, but can present with asymptomatic cervical lymphadenopathy, fever, malaise, night sweats, and myalgias. Symptoms occur in only 10% to 20% of immunocompetent adults. Human infection can result from ingestion of raw or under-cooked meat infected by the organism, or from contact with infected cat feces. The French, because their diet includes raw meat, have a higher incidence (but not the English). The incidence of vertical transmission through the placenta varies by trimester, with the highest risk of transmission in the third trimester. The earlier the fetus is infected, the more severe the disease.
A 17-year-old woman at 22 weeks’ gestation presents to the emergency department with a 3-day history of nausea, vomiting, and abdominal pain. The pain started in the middle of the abdomen, and is now located along her mid-to-upper right side. She is noted to have a temperature of 38.4°C (101.1°F). She reports no prior medical problems or surgeries.
How does pregnancy alter the diagnosis and treatment of the disease?
The incidence of appendicitis in pregnancy is 1 in 2000, the same as that in the nonpregnant population. The diagnosis can be difficult to make during pregnancy because leukocytosis, nausea, and vomiting are common in pregnancy. In addition, the upward displacement of the appendix by the uterus may cause appendicitis to have a nonclassic presentation. Surgery is necessary even if the diagnosis is not certain. Rupture of the appendix is more likely in pregnant women, likely due to the delay in diagnosis and reluctance to operate on pregnant women.
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