A 28-year-old G1 presents at 25 weeks’ gestation complaining of severe left calf pain and swelling. On physical examination, the area of concern is slightly edematous, and the patient demonstrates a positive Homans sign, but no erythema is apparent.
Which of the following diagnostic modalities should you order to confirm your suspected diagnosis?
The patient’s presentation is concerning for deep vein thrombosis (DVT). Noninvasive modalities are the preferred tests for diagnosing venous thromboemboli. Historically, venography has been considered the gold standard for diagnosis; however, it is not commonly used, because it is cumbersome to perform, expensive, and has potentially serious complications. Compression ultrasonography is the procedure of choice to detect proximal DVT. MRI may be used in cases when ultrasound findings are equivocal.
A 20-year-old G1 patient delivers a live-born infant with cutaneous lesions, limb defects, cerebral cortical atrophy, and chorioretinitis. Her pregnancy was complicated by pneumonia at 18 weeks.
For the clinical scenario presented, select the most likely causative agent.
Maternal infection with viruses and bacteria during pregnancy can cause an array of fetal effects from none to congenital malformations and death. Maternal infection with varicella zoster during the first half of pregnancy can cause malformations such as cutaneous and bony defects, chorioretinitis, cerebral cortical atrophy, and hydronephrosis. Adults with varicella infection fare much worse than children; about 10% will develop a pneumonitis, and some of these will require ventilatory support.
A 34-year-old G2 at 36 weeks delivers a growth-restricted infant with cataracts, anemia, patent ductus arteriosus, and sensorineural deafness. She has a history of chronic hypertension, which was well controlled with methyldopa during pregnancy. She had a viral syndrome with rash in early pregnancy.
Rubella is one of the most teratogenic agents known. Fetal manifestations of infection correlate with time of maternal infection and fetal organ development. If infection occurs in the first 12 weeks, 80% of fetuses manifest congenital rubella syndrome, while only 25% develop this syndrome if infection occurs at the end of the second trimester. Congenital rubella syndrome includes one or more of the following—eye lesions, cardiac disease, sensorineural deafness, CNS defects, growth restriction, thrombocytopenia, anemia, liver dysfunction, interstitial pneumonitis, and osseous changes.
A 25-year-old G3 at 39 weeks delivers a small-for-gestational-age infant with chorioretinitis, intracranial calcifications, jaundice, hepatosplenomegaly, and anemia. The infant displays poor feeding and tone in the nursery. The patient denies eating any raw or undercooked meat and does not have any cats living at home with her. She works as a nurse in the pediatric intensive care unit at the local hospital.
Cytomegalovirus in the mother is usually asymptomatic, but 15% of adults will have a mononucleosis-like syndrome. Maternal immunity does not prevent recurrence or congenital infection. Congenital infection includes low birth weight, microcephaly, intracranial calcifications, chorioretinitis, mental and motor retardation, sensorineural deficits, hepatosplenomegaly, jaundice, anemia, and thrombocytopenic purpura. The virus is shed in the secretions of affected individuals. Cytomegalovirus is common in day care centers and by age 2 or 3 children usually acquire the infection from one another and transmit it to their parents.
A 23-year-old G1 with a history of a flulike illness, fever, myalgias, and lymphadenopathy during her early third trimester delivers a growthrestricted infant with seizures, intracranial calcifications, hepatosplenomegaly, jaundice, and anemia.
T gondii is transmitted by eating infected raw or undercooked meat, and by contact with infected cat feces. Maternal immunity appears to protect against fetal infection, and up to one-third of American women are immune prior to pregnancy. Acute infection in the mother is often subclinical, but symptoms can include fatigue, lymphadenopathy, and myalgias. Fetal infection is more common when the disease is acquired later in pregnancy (60% in third trimester vs 10% in first trimester). Congenital disease consists of low birth weight, hepatosplenomegaly, jaundice, anemia, neurological disease with seizures, intracranial calcifications, and mental retardation.
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