A 28-year-old woman, gravida 1 para 0, comes to the office in November for her first prenatal visit. The patient has mild nausea and vomiting every morning but can tolerate food during the rest of the day. She has had no vaginal bleeding, abnormal discharge, or cramping. Her last menstrual period was 8 weeks ago. The patient has no medical conditions and takes only prenatal vitamins. She does not use tobacco, alcohol, or illicit drugs. Family history is significant for a father with type 2 diabetes mellitus who had a heart attack at age 55. The patient has had 2 lifetime sexual partners and has never had a sexually transmitted infection. Blood pressure is 118/78 mm Hg and pulse is 84/min. BMI is 23 kg/m². Pelvic examination shows an 8-week anteverted uterus and a closed cervix. Transvaginal ultrasound reveals an 8-week intrauterine gestation with a normal fetal heartbeat. Which of the following is indicated at this visit?

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11ec25c8_da76_3728_bc81_4d7ea5c41451_MD0003_00 Pregnancy is associated with an increased risk for influenza-associated morbidity and mortality (eg, pneumonia, acute respiratory distress syndrome). Therefore, all pregnant women without contraindications should receive the inactivated influenza vaccination as soon as it becomes available. The inactivated influenza vaccine is safe during every trimester of pregnancy and while breastfeeding. The live attenuated intranasal vaccine is contraindicated during pregnancy due to the risk of congenital infection but is safe during breastfeeding. In addition to preventing influenza in the mother, vaccination also provides passive neonatal immunity and has been shown to decrease the frequency and severity of influenza in newborns. (Choice A) A baseline 24-hour urine collection for protein is performed at the initial prenatal visit in patients at risk for preeclampsia. In patients who develop increased blood pressure later in pregnancy, the test is repeated and compared to the baseline result to distinguish between chronic hypertension (urine protein level unchanged) and preeclampsia (increased proteinuria). This patient has a normal blood pressure and no other risk factors for preeclampsia (eg, pregestational diabetes mellitus, multiple gestation). (Choice B) All women are screened at 24-28 weeks gestation for gestational diabetes mellitus. High-risk patients (eg, morbid obesity, prior macrosomic infant) are screened early in pregnancy. Although this patient's family history includes type 2 diabetes mellitus, her BMI is <25 kg/m²; therefore, she is not considered high risk. In addition, screening for gestational diabetes mellitus is with the 50-g 1-hour glucose challenge test because it is more sensitive than a fasting blood glucose test. ² (Choice D) During pregnancy, routine screening for Trichomonas vaginalis is indicated in HIV-infected women due to high disease prevalence. In contrast, asymptomatic, HIV-negative pregnant women do not undergo routine T vaginalis screening. (Choice E) Wet mount microscopy is used in the evaluation of vaginitis (eg, abnormal vaginal discharge). It is not performed in asymptomatic patients. Educational objective: Influenza infection during pregnancy is associated with increased morbidity and mortality. During influenza season, all pregnant patients should be vaccinated with the inactivated influenza vaccine. Vaccination is safe in every trimester and during breastfeeding. References: Maternal immunization. Clinical experiences, challenges, and opportunities in vaccine acceptance. (http://www.ncbi.nlm.nih.gov/pubmed/25483490) Enhancing uptake of influenza maternal vaccine. (http://www.ncbi.nlm.nih.gov/pubmed/30587042)

A 28-Year-Old Woman, Gravida 1 Para 0, Comes to the Office