A 27-year-old primigravid woman at 16 weeks gestation comes to the office for an initial prenatal visit. She has had no pelvic pain, vaginal bleeding, or abnormal discharge. The patient immigrated to the United States 6 years ago. She has no medical issues or previous surgeries. She had regular menses prior to pregnancy and has no history of sexually transmitted infections. Family history is noncontributory. The patient takes a daily prenatal vitamin and does not use tobacco, alcohol, or illicit drugs. Blood pressure is 110/70 mm Hg. BMI is 23 kg/m². Fetal heart rate is 155/min. The patient's blood type is O, Rh negative. Rubella and varicella titers both show no immunity. Hemoglobin is 11.2 g/dL, and mean corpuscular volume is 84 fL. All other routine prenatal laboratory studies are normal. Which of the following is the best recommendation for this patient?

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11ec25c8_d993_2a96_bc81_8347fcb7f809_MD0003_00 Rubella infection is typically mild and self-limiting, presenting with fever, conjunctivitis, nasal congestion, and a characteristic exanthema of pink maculopapules. However, rubella infection during pregnancy can cause spontaneous abortion, intrauterine fetal demise, or congenital rubella syndrome (CRS) (eg, deafness, cardiac defects, hepatosplenomegaly, microcephaly, cataracts). Childhood vaccination for rubella via the measles-mumps-rubella (MMR) vaccine is associated with a high antibody response, but immunity can wane over time. exanthema of pink maculopapules To decrease the risk of CRS, all women are tested for rubella immunity at the initial prenatal visit by measuring antirubella IgG antibody concentration. The MMR vaccine, a live-attenuated vaccine, is contraindicated during pregnancy due to a theoretical risk of CRS; however, it is safe for breastfeeding mothers. All rubella-nonimmune patients should be vaccinated during the immediate postpartum period. (Choice A) Screening for hemoglobinopathies via hemoglobin electrophoresis during pregnancy is indicated for patients with anemia (hemoglobin <11 g/dL in pregnancy) and a mean corpuscular volume <80 fL. (Choice C) Repeating viral titers is indicated when the titers show an indeterminate result (eg, positive IgG antibodies but in a concentration lower than is known to confer immunity). This patient's rubella and varicella antibody titers showed no immunity, not an indeterminate result. (Choice D) Rho(D) immunoglobulin is indicated to prevent isoimmunization in Rh(D)-negative patients. Administration is recommended at 28 weeks gestation for prophylaxis and after delivery if the infant is Rh(D) positive. First-trimester administration is justified only in the setting of uterine bleeding, which is not seen in this patient. (Choice E) Universal screening for tuberculosis during pregnancy is not recommended. Screening is reserved for patients who would require treatment during pregnancy and who are at risk for active disease (eg, immunocompromised, contact with individuals with active disease). Asymptomatic patients who have recently immigrated (<5 years) are screened postpartum. This patient has no indication for the tuberculin skin test. (Choice F) This patient does not have varicella immunity and should receive the varicella vaccine postpartum. The varicella vaccine, a live-attenuated vaccine, is contraindicated during pregnancy due to a theoretical risk of congenital varicella. Educational objective: Immunity to rubella is routinely evaluated at the initial prenatal visit. Patients without immunity are vaccinated in the immediate postpartum period with the live-attenuated mumps-measles-rubella vaccine. Postpartum vaccination prevents future infection but avoids the theoretical risk of congenital rubella. References: Rubella susceptibility in pregnant women and results of a postpartum immunization strategy in Catalonia, Spain. (http://www.ncbi.nlm.nih.gov/pubmed/25731790) Pregnancy outcome following rubella vaccination: a prospective controlled study. (http://www.ncbi.nlm.nih.gov/pubmed/15368496) Rubella infection in pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/16580940)

A 27-Year-Old Primigravid Woman at 16 Weeks Gestation Comes to the Office