A 32-year-old woman, gravida 5 para 1 aborta 3, at 37 weeks gestation comes to the hospital due to rupture of membranes and contractions over the past hour. The patient is tolerating her contractions well. She has had 3 prior miscarriages, and her most recent pregnancy ended at 29 weeks gestation due to preeclampsia with severe features. The current pregnancy has been complicated by diet-controlled gestational diabetes mellitus and asymptomatic group B Streptococcus bacteriuria. Blood pressure is 134/86 mm Hg, and pulse is 98/min. The uterus is nontender and has palpable contractions. Fetal heart rate tracing is category 1. The cervix is 5 cm dilated and 80% effaced, with the fetal vertex at −1 station. Blood glucose is 110 mg/dL. Which of the following additional therapy is indicated at this time?

Question

A 32-year-old woman, gravida 5 para 1 aborta 3, at 37 weeks gestation comes to the hospital due to rupture of membranes and contractions over the past hour.  The patient is tolerating her contractions well.  She has had 3 prior miscarriages, and her most recent pregnancy ended at 29 weeks gestation due to preeclampsia with severe features.  The current pregnancy has been complicated by diet-controlled gestational diabetes mellitus and asymptomatic group B Streptococcus bacteriuria.  Blood pressure is 134/86 mm Hg, and pulse is 98/min.  The uterus is nontender and has palpable contractions.  Fetal heart rate tracing is category 1.  The cervix is 5 cm dilated and 80% effaced, with the fetal vertex at −1 station.  Blood glucose is 110 mg/dL.  Which of the following additional therapy is indicated at this time?

Quizplus · Accepted Answer

11ec25c8_da3a_3f2a_bc81_1d2a0a5b3f92_MD0003_00 Group B Streptococcus (GBS) is a common colonizer of the gastrointestinal and genital tracts. GBS is typically asymptomatic in pregnant patients, but it can be vertically transmitted to the neonate during vaginal delivery or with rupture of membranes, resulting in early-onset neonatal infection (eg, sepsis, pneumonia). To decrease the risk of vertical transmission, most women are screened at 36-38 weeks gestation by rectovaginal culture and administered intrapartum antibiotic prophylaxis if they are GBS-positive. However, some women do not undergo GBS screening because they are considered to have persistent, heavy GBS colonization (ie, a high bacterial load) and therefore they are at increased risk for vertical transmission. Markers of heavy maternal colonization include GBS asymptomatic bacteriuria (as in this patient) or GBS urinary tract infection during the current pregnancy (regardless of treatment). Another marker of heavy maternal GBS colonization is prior delivery of an infant with early-onset neonatal infection (which is typically due to GBS). These women with heavy GBS colonization require intrapartum antibiotic prophylaxis (eg, penicillin) regardless of screening status or rectovaginal culture results (Choice D). (Choice A) Betamethasone is administered to patients at risk for preterm delivery (<37 weeks gestation) to promote fetal lung maturity and decrease the risk of neonatal respiratory distress syndrome. (Choice B) Women with either insulin-dependent gestational or prepregnancy diabetes mellitus require frequent glucose monitoring during labor and possible insulin administration for maternal blood glucose control. In contrast, patients with diet-controlled gestational diabetes mellitus do not have severe blood glucose fluctuations (as seen in this patient's normal glucose level); therefore, these patients do not require intrapartum glucose monitoring or insulin. (Choice C) Patients who have preeclampsia with severe features (eg, severe hypertension, headaches, scotomata) are at risk for eclampsia and require magnesium sulfate for seizure prophylaxis. This patient's blood pressure is normal. Educational objective: Patients with group B Streptococcus (GBS) asymptomatic bacteriuria or urinary tract infection in their current pregnancy (regardless of treatment) are heavily colonized with GBS and at high risk for vertical transmission to the neonate (ie, early-onset neonatal infection). These patients require intrapartum GBS prophylaxis (eg, penicillin) and do not require GBS screening. References: Practice bulletins no. 139: premature rupture of membranes. (http://www.ncbi.nlm.nih.gov/pubmed/24084566) Prevention of perinatal group B streptococcal disease-revised guidelines from CDC, 2010. (http://www.ncbi.nlm.nih.gov/pubmed/21088663)

A 32-Year-Old Woman, Gravida 5 Para 1 Aborta 3, at 37