A 28-year-old primigravid woman comes to the office for her first prenatal visit. She is 9 weeks pregnant by date of her last menstrual period. The patient reports excessive tiredness, intermittent nausea, and anorexia. She has also had subjective fever, night sweats, and dry cough. The patient has no prior medical problems and takes a prenatal multivitamin daily. She does not use tobacco, alcohol, or illicit drugs. The patient's mother recently came to visit her from Southeast Asia but had to return back early after becoming sick. Temperature is 38 C (100.4 F), blood pressure is 120/80 mm Hg, and pulse is 76/min. Sclerae are anicteric and mucous membranes are pink and moist. Heart sounds are normal with no murmurs. Fine crackles are present over the right posterior thorax. The abdomen is soft and nontender with no hepatosplenomegaly. Pelvic examination reveals an appropriately enlarged uterus. Chest radiograph reveals a right upper lobe infiltrate with a small cavity. Two of three sputum samples are positive for acid-fast bacilli. Liver function studies are within normal limits and testing for HIV, hepatitis B virus, and hepatitis C virus are negative. Which of the following is the most appropriate next step in management of this patient's pulmonary infection?

Question

A 28-year-old primigravid woman comes to the office for her first prenatal visit.  She is 9 weeks pregnant by date of her last menstrual period.  The patient reports excessive tiredness, intermittent nausea, and anorexia.  She has also had subjective fever, night sweats, and dry cough.  The patient has no prior medical problems and takes a prenatal multivitamin daily.  She does not use tobacco, alcohol, or illicit drugs.  The patient's mother recently came to visit her from Southeast Asia but had to return back early after becoming sick.  Temperature is 38 C (100.4 F), blood pressure is 120/80 mm Hg, and pulse is 76/min.  Sclerae are anicteric and mucous membranes are pink and moist.  Heart sounds are normal with no murmurs.  Fine crackles are present over the right posterior thorax.  The abdomen is soft and nontender with no hepatosplenomegaly.  Pelvic examination reveals an appropriately enlarged uterus.  Chest radiograph reveals a right upper lobe infiltrate with a small cavity.  Two of three sputum samples are positive for acid-fast bacilli.  Liver function studies are within normal limits and testing for HIV, hepatitis B virus, and hepatitis C virus are negative.  Which of the following is the most appropriate next step in management of this patient's pulmonary infection?

Quizplus · Accepted Answer

Explanation: This pregnant patient has an upper lobe cavitary infiltrate and acid-fast bacilli in her sputum, suggesting active pulmonary tuberculosis (TB). Pregnant women with active TB require treatment as untreated infections carry significant risk for the mother, fetus, and close contacts. Treatment usually involves 3-drug therapy with isoniazid (INH), rifampin (RIF), and ethambutol for 2 months followed by INH and RIF for 7 additional months. All 3 of these medications cross the placenta but are not associated with significant fetal toxicity. Pyrazinamide, part of the 4-drug TB treatment given to most nonpregnant individuals, is generally not administered to pregnant patients due to uncertain teratogenic properties and little contribution to overall TB treatment efficacy. Pregnant women undergoing treatment for TB should also receive pyridoxine (vitamin B₆) supplementation to prevent INH-induced neurotoxicity. Counseling about medication side effects and monthly monitoring for disease response and drug-associated hepatitis are required. ₆ (Choice A) The benefits of treatment outweigh the risk in pregnant patients with active TB. Those with latent TB (positive tuberculin skin test with no symptoms or chest x-ray abnormalities) generally do not require treatment until after delivery. (Choice B) Active TB rarely causes a placental infection but may result in a low birth weight infant. Treatment is effective, and pregnancy termination is not indicated. (Choice C) Ethambutol is given in addition to INH, RIF, and pyridoxine for the first 2 months of therapy. (Choice D) INH monotherapy is often used to treat latent (not active) TB. This patient with active TB requires multidrug therapy. Educational objective: Pregnant women who develop active tuberculosis require treatment with multidrug therapy and pyridoxine. Treatment usually involves 3-drug therapy with isoniazid (INH), rifampin (RIF), and ethambutol for 2 months followed by INH and RIF for 7 additional months.

A 28-Year-Old Primigravid Woman Comes to the Office for Her