A 25-year-old woman, gravida 2 para 1, at 24 weeks gestation comes to the office in mid-November for a routine prenatal visit. She has felt normal fetal movement and no abdominal pain, vaginal bleeding, or leakage of fluid. Three days ago, the patient's 5-year-old son was diagnosed with varicella; however, she has not had fever, malaise, or a rash. The patient has no chronic medical issues or previous surgeries. She takes a prenatal vitamin and iron supplement. The patient does not use tobacco, alcohol, or illicit drugs. Blood pressure is 110/60 mm Hg and pulse is 64/min. BMI is 27 kg/m². Physical examination shows no rash or lymphadenopathy. Fundal height is appropriate for gestational age. The fetal heart rate by bedside Doppler is 145/min. The patient's prenatal laboratory results are as follows: Administration of which of the following is the best next step for this patient?

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11ec25c8_d2a0_9a2e_bc81_15649b4e2bae_MD0003_00 Maternal vaccination is beneficial to both mother and fetus, and the optimal time for administration is prior to conception. Vaccinations during pregnancy are indicated if the vaccine has minimal risk, if significant risk exists for infection exposure, and if increased morbidity and mortality are associated with infection. Vaccines that are safe during pregnancy include immunoglobulins (eg, Rho(D) immunoglobulin), toxoids (eg, tetanus toxoid), and inactivated vaccines (eg, tetanus toxoid-reduced diphtheria toxoid-acellular pertussis [Tdap], injectable influenza virus). Live-attenuated vaccines (eg, intranasal influenza) are contraindicated during pregnancy due to the theoretical risk of congenital infection. Pregnant women are at increased risk for morbidity (eg, pneumonia) and mortality from the seasonal influenza virus. All pregnant women without contraindications (eg, allergic response to prior vaccination) should receive the influenza vaccination as soon as it becomes available. The inactivated influenza vaccine is safe during every trimester of pregnancy and while breastfeeding. This vaccine prevents maternal influenza-related illness and provides passive neonatal immunity, thereby decreasing the risk of influenza-related illness in newborns. (Choice A) The Haemophilus influenzae type b vaccine, an inactivated vaccine, is safe in pregnancy. However, it is indicated only in unvaccinated or high-risk patients (eg, HIV, sickle cell disease, prior splenectomy). (Choice C) This patient is not immune to rubella as evidenced by negative IgG and IgM serologies. The measles-mumps-rubella (MMR) vaccine is a live-attenuated vaccine contraindicated during pregnancy. This patient should be vaccinated in the immediate postpartum period to prevent future infection. (Choices D and E) Varicella in pregnancy can be associated with maternal complications (eg, pneumonia, meningitis, encephalitis) and with congenital anomalies (eg, cicatricial lesions, cataracts, chorioretinitis). Patients who are exposed to varicella but lack evidence of varicella immunity (eg, negative IgG antibody serologic testing, no history of childhood infection) are treated with postexposure prophylaxis. In pregnancy, postexposure prophylaxis includes varicella-zoster immunoglobulin administration. The varicella-zoster vaccine, a live-attenuated vaccine, is contraindicated in pregnancy. This patient has had a recent varicella exposure, but her testing suggests immunity (serology with positive varicella IgG antibodies) and requires no further treatment. Educational objective: Vaccines that are safe during pregnancy include inactivated influenza, Tdap, and Rho(D) immunoglobulin. The inactivated seasonal influenza vaccine is safe during every trimester of pregnancy and should be administered to all pregnant patients as soon as it becomes available. References: Committee opinion no. 608: influenza vaccination during pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/25162283)

A 25-Year-Old Woman, Gravida 2 Para 1, at 24 Weeks