By P. Hamil. Wheaton College, Wheaton Illinois.
With no other information to go on generic super p-force 160mg with amex erectile dysfunction doctors kansas city, the student would note that this patient has postpartum hemorrhage (blood loss of > 500 mL with a vaginal delivery) buy generic super p-force line impotence treatment vacuum devices. Using the “most common cause”information buy super p-force online erectile dysfunction medication causes, the student would make an educated guess that the patient has uterine atony. Now the most likely diagnosis is a genital tract laceration, usually involving the cer vix. Th u s, the f i r s t s t e p i n p a t i e n t a s s e s s m e n t a n d m a n a g e m e n t i s u t e r i n e massage to check if the uterus is boggy. This question is difficult because the next step has many possibilities; the answer may be to obt ain more diagnostic information, st age the illness, or introduce ther- apy. It is often a more challenging quest ion than “W hat is the most likeyly diag- nosis? Another possibility is that there is enough information for a probable diagnosis, and the next step is to st age t he disease. Hence,from clinicaldata,a judgment needs to be rendered regardinghow far along one is on the road of: Make a diagnosis → St age t he disease → Treat based on stage → Follow response Frequent ly, the st udent is t aught t o “regurgit at e” the informat ion that someone has written about a particular disease, but is not skilled at giving the next step. Make a diagnosis: “Based on the in for m at ion I h ave, I b elieve that this patient has a pelvic inflammatory disease because she is not pregnant and has lower abdominal t enderness, cervical mot ion t enderness, and adnexal t enderness. Stage the disease:“ I d o n o t b e l i e ve t h a t t h i s i s a s e ve r e d i s e a s e b e c a u s e s h e d o e s not have high fever, evidence of sepsis, or peritoneal signs. An ultrasound has already been done showing no abscess (tubo-ovarian abscess would put her in a severe category). Treat based on stage:“ T h e r e f o r e, m y n e x t s t e p i s t o t r e a the r w i t h i n t r a m u s c u l a r ceft r iaxon e an d or al d oxycyclin e. Fo l lo w res po ns e : “ I w a n t t o f o l l o w the t r e a t m e n t b y a s s e s s i n g h e r p a i n ( I w i l l a s k her to rate the pain on a scale of 1-10 every day), her temperature, and abdomi- nal examination, and reassess her in 48 hours. This information is sometimes tested by the dictum, “the gold standard for the diagnosis of acute salpingitis is laparoscopy to visualize the tubes, and particularly seeing purulent material drain from t he tubes. This question goes further than making the diagnosis, but also requires the student to understand the underlying mechanism for the process. For example, a clinical scenario may describe an 18-year-old adolescent female at 24 weeks’gest at ion, who develops dyspnea 2 days after being treated for pyelonephritis. The student must fir st d iagn ose the acu t e r esp ir at or y d ist r ess syn d r om e, wh ich oft en occu r s 1 t o 2 days after antibiotics are instituted. Then, the student must understand that the endot oxins t hat arise from Gram-negat ive organisms cause pulmonary injury, lead- ing t o capillary leakage of fluid int o t he pulmonary int erst it ial space. The student is advised to learn the mechanisms for each disease process, and not merely memorize a constellation of symptoms. From the bladder, the bacteria would ascend further to the kidneys and cau se an in fect ion in the r en al par en ch yma. T h e involvement of the kid n ey n ow cau ses fever ( vs an in fect ion of on ly the blad d er, wh ich u su ally d oes n ot in du ce a fever) an d flan k t en dern ess— a syst emic respon se n ot seen wit h lower urinar y t ract infect ion (ie, bact eriuria or cyst it is). Furt h ermore, t he body’s react ion t o t he bact e- ria brings about leukocytes in the urine (pyuria). Understanding the risk factors helps the practitioner to establish a diagnosis and to determine how to interpret tests. For example, understanding the risk factor analysis may help to manage a 55-year-old woman with post menopausal bleeding aft er an endomet rial biopsy shows no pat hologic changes. If the woman does not have any risk factors for endometrial cancer, the patient may be observed because the likelihood for uterine malignancy is not so great. On the other hand, if the same 55-year-old woman were diabet ic, had a long history of anovulat ion (irregu- lar menses), was nulliparous, and was hypert en sive, a pract it ioner sh ould pursue the postmenopausal bleeding further, even after a normal endomet rial biopsy. The physician may want to perform a hysteroscopy to visualize the endometrial cavity directly and biopsy the abnormal-appearing areas. Thus, the presence of risk fac- tors helps to categorize the likelihood of a disease process. Clinicians must be cognizant of the complications of a disease, so that they will understand how to follow and monitor the patient. Sometimes, the student will have to make the diagnosis from clinical clues, and then apply his or her knowledge of the consequences of the pathologic process. For example, a woman who presents wit h lower abdominal pain, vaginal discharge, and dyspareunia is first diagnosed as having pelvic inflammatory disease or salpingit is (infection of the fallopian tubes). Long-t erm complicat ions of t his process would include ect opic pregnancy or infer- tility from tubal damage. Understanding the types of consequences also helps the clin ician t o be awar e of the dan ger s t o a pat ient. O n e life-t h r eat en in g complicat ion of a tubo-ovarian abscess (which is the end-st age of a tubal infection leading to a collect ion of p u s in the r egion of the t ubes an d ovar y) is r upt u r e of the abscess. The clinical presentation is shock with hypotension, and the appropriate therapy is immediat e surgery. The student applies this information when she or he sees a woman wit h a t ubo-ovarian abscess on daily rounds, and monit ors for hypot ension, con fu sion, ap pr eh en sion, an d t ach ycar dia. T h e clin ician advises the t eam t o be vigi- lant for any sign s of abscess rupt ure, and t o be prepared t o undert ake immediat e surgery should the need arise. To answer this quest ion, the clinician needs t o reach the correct diagnosis, and assess the severit y of the condit ion, and t hen he or she must weigh t he situat ion to reach the appropriate intervention. For the student, knowing exact dosages is not as import ant as underst anding t he best medicat ion, t he route of delivery, mecha- nism of action, and possible complications. It is important for the student to be able to verbalize the diagnosis and the rationale for the therapy. A common error is for the student to “jump to a treatment,”like a random guess, and, therefore, he or she is given “right or wrong” feedback. In fact, t he student’s guess may be correct, but for the wrong reason ; conversely, the an swer may be a ver y reason able on e, wit h only one small error in thinking. Instead, the student should verbalize the steps so that feedback may be given at every reasoning point. For example, if the quest ion is, “W h at is the best t h erapy for a 19-year-old woman wit h a nont ender ulcer of the vulva and painless adenopat hy wh o is preg- nant at 12 weeks’gestation? In pregnancy, penicillin is t he only effective therapy to prevent congenit al syphilis. T herefore, the best treat ment for this woman wit h probable syph ilis is int ramu scu lar pen icillin (aft er con firming the diagnosis). The best prevent ive measure would be a barrier contraception such as condom use. In the previous scenario, the woman with a nontender vulvar ulcer is likely to have syphilis. The student should strive to know the limit ations of various diagnos- tic tests, and the manifestations of disease. Ap p r o a c h t o Su r g e r y The student should be generally aware of the various approaches to surgical man- agement of t he gynecologic pat ient. Ways to access the int raabdominal cavit y include (a) laparotomy (incision of t he abdomen), ( b) laparoscopy (using t hin, long inst rument s t h rough small incisions t o perform surgery), and (c) robot ic surgery (use of the console to direct instruments that have been docked).
The primary episode is usually a syst emic as well as local disease safe 160 mg super p-force erectile dysfunction in young, wit h t he woman oft en complaining of fever or general malaise buy 160 mg super p-force overnight delivery erectile dysfunction drug coupons. Local infect ion t ypically induces paresthesias before vesicles erupt on a red base 160mg super p-force otc erectile dysfunction stress. After the primary episode, the recurrent disease is local, with less severe symptoms. The gold standard diagnostic test is viral culture, but polymerase ch ain r eact ion t est s are in cr easin gly u sed becau se they are m or e sen sit ive. Infec- tions occur rarely in the United States and tend to be concentrated in southern regions. The organism is extremely tightly wound, and too thin to be seen on light microscopy. T h e u lcer u sually ar ises 3 weeks aft er exposure and disappears spont aneously aft er 2 t o 6 weeks wit hout t herapy. Darkfield m icr oscopy is an accept ed diagn ost ic t ool, but is limited in availability. Secondary syphilis is usually syst emic, occurring about 9 weeks after the primary chancre. The classic macular papular rash may occur any- wh ere on the body, but usually on the palms and soles of the feet. Flat moist lesions called con dylomat alat a m ay be seen on the vu lva ( Figu r e 39– 1), an d h ave a h igh con cen t r at ion of spir och et es. T r ep on em al an d n on t r ep on em al ser ologic t est s are positive at this stage. Because nontreponemal tests can be falsely positive, a positive treponemal test is required to make a serologic diagnosis. Latency of var yin g d u r at ion occu r s aft er secon d ar y d isease; lat en cy is su b d ivid ed int o early latent (< 1 year in duration), or late latent (> 1 year). If untreated, about one-third of women may progress to tertiary syphilis, which may affect the cardio- vascu lar syst em o r cen t r al n er vo u s syst em. O p t ic at r o p h y, t ab es d o r salis, an d ao r t ic aneurysms are some of t he manifest at ions. Pat ient s wit h lat e-lat ent syph ilis (> 1 year) sh ould be treated with a tot al of 7. In pregnancy, penicillin is t he only known effect ive t reat ment t o prevent or t reat congenit al syph ilis. T h e effect iveness of alt ernat ives t o penicillin in the t reat ment of early and lat ent syph i- lis h as not been well document ed. Treat ment of nonpregnant pen icillin-allergic women wit h doxycycline or t et racycline may be considered. After t herapy, clinical and serologic assessment should be performed at 6 and 12 months after treatment for early syphilis and additionally at 24 months after treating late latent or syphilis of unknown duration. An appropriate response is a four-fold fall in t it ers in 6 t o 12 mont h s, 12 t o 24 mont h s for lat e-lat ent syph ilis. When the titer does not fall appropriately, one possible etiology is neurosyphilis, wh ich may be diagnosed by lumbar punct ure. The organism is now called Klebsiellagran- ulomatis, a Gram-negative pleomorphic bacillus. Large painless ulcerative lesions of the mucus membranes is the typical present ation, usually without lymphade- nopathy. Penicillin G is the recommended treatment for all stages of syphilis in nonpregnant women. The pat ient st ates that she is allergic t o penicillin, wit h hives and swelling of t he t ongue and t hroat in t he past. On examination, she is noted to have atender fluctuant mass which appears above and below the right inguinal ligament. Penicillin G is the recommended treatment for all stages of syphilis and dat a regarding effect iveness of alternat ives to t reat ment for penicillin- allergic pat ient s are limited. It is ver y t h in an d t igh t ly wo u n d an d t h er efo r e n o t visib le o n ligh t m icr o s co p y. Transplacental infection during pregnancy is an important cause of congenit al syphilis. W h en a pr egn ant woman wit h syph ilis is allergic t o penicillin, sh e sh ould undergo desensit iza- tion and receive penicillin. Penicillin is the only known effective treatment for prevent ing congen it al syph ilis. D oxycyclin e u se may lead t o discolorat ion of the child’s teeth, and erythromycin has not been shown to be an effective treatment in treating an infected fetus. T h e classic examinat ion of neurosyphilis is unsteady balance and Argyll Robertson pupils. The primary stage is a painless lesion (papule) which usually only appears for a few days, followed by unilateral painful inguinal adenopa- thy (secondary stage) usually occurring 30 to 60 days after infection. Becau se they gr ow ceph a- lad an d caudad t o the inguinal ligament, t h ere is the so called “groove sign” in wh ich t he inguinal ligament forms a groove in the lymphat ic mass. H erpes is treated with acyclovir; gonorrhea is treated with ceftriaxone; and granuloma inguinale is treated with doxycycline or trimethroprim/ sulfa. Vulvovaginitis, sexually transmitted infections, and pelvic inflammatory disease sepsis. Sh e d e n ie s the u se o f m e d ica t io n s a n d h a s n o sig n ifica n t p a st m e d ica l history. Co n s i d e r a t i o n s This 29-year-old woman has a 2-day history of urinary urgency, frequency, and dysuria, all of which are very typical symptoms of a lower urinary tract infec- tion. Because she does not have fever or flank tenderness, she most likely has a bladder infect ion or simple cyst it is. O t her sympt oms of cyst it is may include hesitancy or hematuria (hemorrhagic cystitis). Urinalysis and/ or urine culture and sensit ivit y (if ant imicrobial resist ance/ complicated infect ion is suspected) would be the most appropriat e t est t o confirm the diagnosis. Current evidence suggests a 3-day course of trimethoprim/ sulfa (Bactrim) as the best agent for uncomplicated cystitis, un less bact er iology pat t er n s in the communit y point t o resist ance; in t hat case, a quinolone such as ciprofloxa- cin t wice daily for 3 days is effect ive. If the ur in e cu lt ur e demon st rat es n o growt h of organisms and the patient still has symptoms, urethritis is a possibility (often cau sed by Chlamydia trachomatis). Finally, some women wit h symptoms of bladder discomfort wit h persistently negat ive urine and uret hral culture may have a chronic condit ion of uret hral syndrome. The most commonly stated reason for the increased incidence of U T Is in women is the shorter length of the female urethra and its increased proximity to the rectum. The most common symptoms of lower tract infection (cystitis) are dysuria, urgency, and urinary frequency. Occasionally, the infection may induce a hem- orrhagic cystitis and the patient will have gross hematuria.
Dermatologic Effects Between 2% and 5% of patients develop a morbilliform (measles-like) rash order super p-force with american express kidney disease erectile dysfunction treatment. For this reason discount 160mg super p-force overnight delivery erectile dysfunction statistics nih, phenytoin should not be prescribed for patients known to have this mutation purchase discount super p-force on-line erectile dysfunction protocol hoax. It can cause cleft palate, heart malformations, and fetal hydantoin syndrome, characterized by growth deficiency, motor or mental deficiency, microcephaly, craniofacial distortion, positional deformities of the limbs, hypoplasia of the nails and fingers, and impaired neurodevelopment. Phenytoin can decrease synthesis of vitamin K–dependent clotting factors and can thereby cause bleeding tendencies in newborns. The risk for neonatal bleeding can be decreased by giving prophylactic vitamin K to the mother for 1 month before and during delivery and to the infant immediately after delivery. These dangerous responses can be minimized by injecting phenytoin no faster than 50 mg/min. B l a c k B o x Wa r n i n g : P h e n y t o i n [ D i l a n t i n, P h e n y t e k ] a n d F o s p h e n y t o i n [ C e re b y x ] When administered intravenously at rates exceeding 50 mg/min in adults, or at the slower rate of either 1 to 3 mg/kg/min or 50 mg/min in children, phenytoin can cause severe hypotension and cardiac dysrhythmias. Other Adverse Effects Hirsutism (overgrowth of hair in unusual places) can be a disturbing response, especially in young women. Interference with vitamin D metabolism may cause rickets and osteomalacia (softening of the bones). Interference with vitamin K metabolism can lower prothrombin levels, thereby causing bleeding tendencies in newborns. Interactions Resulting From Induction of Hepatic Drug-Metabolizing Enzymes Phenytoin stimulates synthesis of hepatic drug-metabolizing enzymes. As a result, phenytoin can decrease the effects of other drugs, including oral contraceptives, warfarin (an anticoagulant), and glucocorticoids (antiinflammatory and immunosuppressive drugs). Because avoiding pregnancy is desirable while taking antiseizure medications, and because phenytoin can decrease the effectiveness of oral contraceptives, the provider may need to increase the contraceptive dosage, or a switch to an alternative form of contraception may need to be made. Drugs That Increase Plasma Levels of Phenytoin Because the therapeutic range of phenytoin is narrow, slight increases in phenytoin levels can cause toxicity. Consequently, caution must be exercised when phenytoin is used with drugs that can increase its level. These agents increase phenytoin levels by reducing the rate at which phenytoin is metabolized. Drugs That Decrease Plasma Levels of Phenytoin Carbamazepine, phenobarbital, and alcohol (when used chronically) can accelerate the metabolism of phenytoin, thereby decreasing its level. Preparations, Dosage, and Administration Preparations There are a large number of phenytoin products on the market. Phenytoin products made by different manufacturers have equivalent bioavailability. Therefore, although switching between products from different manufacturers was a concern in the past, it is not a concern today. Levels below 10 mcg/mL are too low to control seizures; levels above 20 mcg/mL produce toxicity. Because phenytoin has a relatively narrow therapeutic range (between 10 and 20 mcg/mL), and because of the nonlinear relationship between phenytoin dosage and phenytoin plasma levels, after a safe and effective dosage has been established, the patient should adhere to it rigidly. Patients should be informed that gastric upset can be reduced by administering phenytoin with or immediately after a meal. Patients using the oral suspension should shake it well before dispensing because failure to do so can result in uneven dosing. Fosphenytoin Fosphenytoin [Cerebyx] is a prodrug that is converted to phenytoin when metabolized. It is recommended as a substitute for oral phenytoin when the oral route is contraindicated. Because it is converted to phenytoin, the mechanism of action, therapeutic and adverse effects, and drug interactions are the same as those of phenytoin. Pharmacokinetics Pharmacokinetic properties are essentially the same as phenytoin after conversion. There are a few differences that are attributable to the prodrug in its nonhydrolyzed state. Because it is more highly protein bound than phenytoin, protein binding with fosphenytoin may displace phenytoin from protein binding sites, resulting in a transient increase in free (unbound, active) phenytoin. Adverse Effects Adverse effects of fosphenytoin are the same as those of phenytoin, with one notable exception. This infusion-related reaction will resolve when the infusion rate is decreased or within 10 minutes after completion of the infusion. The drug is active against partial seizures and tonic-clonic seizures but not absence seizures. Mechanism of Action Carbamazepine suppresses high-frequency neuronal discharge in and around seizure foci. The mechanism appears to be the same as that of phenytoin: delayed recovery of sodium channels from their inactivated state. With continued treatment, the half-life decreases to about 15 hours because carbamazepine, like phenytoin and phenobarbital, induces hepatic drug-metabolizing enzymes. By increasing its own metabolism, carbamazepine causes its own half-life to decline. Therapeutic Uses Epilepsy Carbamazepine is effective against tonic-clonic, simple partial, and complex partial seizures. Because the drug causes fewer adverse effects than phenytoin and phenobarbital, it is often preferred to these agents. Many prescribers consider carbamazepine the drug of first choice for partial seizures. Bipolar Disorder Carbamazepine can provide symptomatic control in patients with bipolar disorder (manic-depressive illness) and is often effective in patients who are refractory to lithium. Trigeminal and Glossopharyngeal Neuralgias A neuralgia is a severe, stabbing pain that occurs along the course of a nerve. Carbamazepine can reduce neuralgia associated with the trigeminal and glossopharyngeal nerves. It should be noted that, although carbamazepine can reduce pain in these specific neuralgias, it is not generally effective as an analgesic and is not indicated for other kinds of pain. This is a primary reason for selecting carbamazepine over other antiseizure drugs. Carbamazepine can cause a variety of neurologic effects, including visual disturbances (nystagmus, blurred vision, diplopia), ataxia, vertigo, unsteadiness, and headache. These reactions are common during the first weeks of treatment, affecting 35% to 50% of patients. These effects can be minimized by initiating therapy at low doses and giving the largest portion of the daily dose at bedtime.
Exposure to an infected household member carries a 50% risk of infec- tion discount super p-force 160 mg amex erectile dysfunction over 65, and the risk is 20% to 50% in child care settings buy super p-force with paypal erectile dysfunction pump walgreens. Because the virus may cause an aplastic anemia by destroying erythroid precursors in the bone marrow buy super p-force australia erectile dysfunction causes pdf, Doppler assessment is used to assess for severe fetal anemia. If evidence of hydrops or severe anemia is present, fet al blood sh ou ld be sampled t o obt ain a h emat ocrit for fet al t ran sfu sion. Approximat ely h alf of pregnant women will h ave h ad par vovirus infect ion and be immune. Less than 5% of those susceptible pregnant women who are infected after 20 weeks’gestation will have fetuses complicated by anemia, but pregnancies at < 20 weeks have a higher risk of fetal loss. Hydrops fetalis is defined as excess fluid located in two or more fetal body cavi- ties, and many times is associated with hydramnios (see Table 19– 2 for causes of hydramnios); pregnancies < 20 weeks’ gestation are at particular risk. Parvovirus is the most common infectious cause of nonimmune hydrops (fetal cardiac arrhyth- mias are the most common cause of nonimmune hydrops overall). If hydrops does not develop within 8 weeks of maternal infection, it is unlikely to occur. For severely affect ed fet u ses, int raut erin e t ran sfu sion is on e opt ion, wh ile mild cases may sometimes be observed. O ther causes of fetal anemia are isoimmuniza- tion, such as an Rh-negative woman who is sensitized to develop anti-D antibodies, a large fet al-to-maternal hemorrhage, or t halassemia. An unusual fet al heart rat e pattern, called a sinusoidal pattern, is associat ed wit h sever e fet al an em ia or asph yxia. The possibility of exposure to parvovirus B19 may be a source of anxiety for preg- nant women. Exclusion from the workplace (eg, school or daycare) during endemic periods is not recommended, however, pregnant women may be advised to avoid people exposed to fifth disease. Routine serologic screening is not recommended, and such screening should be reserved for pregnant women with symptoms of parvovirus B19 infection, recent exposure to people with confirmed or suspected fifth disease. Affected infant s can have microcephaly, perivent ricular calcificat ions, deafness, chorioret ini- tis (blindness), seizures, and interstitial pneumonia. Exposure is from blood, urine, or saliva and especially from school-aged children. Transmission is highest in the third trimester, but neonatal effects are worse in the first trimester. Since there is no treatment, prevention remains the mainstay: careful handwashing, avoid sharing utensils especially with children (see also Table 1 9 – 3 ). Toxoplasmosis i s ca u s e d b y the i n t r a ce l lu l a r p a r a s i t e Toxoplasma gondii. Exp osu r e can be from u n d er cooked meat or oocyst s from the feces of in fect ed cat s. Ver t ical transmission increases with gestational age, but severity is worse in early pregnancy. Most neonates are asymptomatic at birth, but can later develop chorioretinitis (85% by an age of 20 years) and hearing loss. The classic triad is hydrocephalus, intracranial calcifications, and chorioretinitis. The keys in prevention are pet care precautions (avoid changing cat litter), handwashing, and meat preparation. Maternal infection in the fir st 8 weeks of pr egn an cy con fer s an 80% r isk of major con gen it al d efect s, bet ween 9 and 12 weeks’ gestation of 50%, and virtually no risk at 20+ weeks. The clas- sic t riad of congenit al rubella is cataracts, sensorineural deafness (60 %), and car- diac defects (pulmonary artery stenosis and patent ductus arteriosus). A diagnosis of hydramnios is made on the basis of an amniotic fluid volume of 32 cm (normal 5 to 25 cm). Serology is obt ained for parvovirus B19 revealing t hat t he IgM is negative, and the IgG is negative. This patient is n o t in fect ed wit h p ar vovir u s B1 9, an d is su scep t ib le. There is insufficient information to draw a conclusion about whether this patient is infected. T h e u lt r asou n d sh ows fet al ascit es, in cr eased am n iot ic flu id, h yd r oceph alu s, an d in t r acr an ial calcificat ion s. The obst et rician explains t hat t his part icular infect ion has a very high transmission rate and fetal effects in the first trimester. Rh isoimmunization can lead to significant fetal anemia if the baby is Rh positive. Middle cerebral artery Doppler studies indicating increased velocity of flow are consistent with significant fetal anemia. Fetal cardiac arrhythmias, especially supraventricular tachycardia, are associated with non- immune hydrops, but this would not affect the bone marrow and cause anemia. H ydramnios is associated with problems with fet al swallowing or intest i- nal atresias, or associated with hydrops. Fetal duodenal atresia, diagnosed by the“double bubble”on ultrasound, is associated with hydramnios. Fetal renal disease or placental insufficiency is associated with oligohydramnios. IgM an d IgG ser ology is the m ost com m on m et h od t o d iagn ose acu t e fift h disease. Typically, in the acute sett ing, if the IgG is positive and IgM is nega- tive, it indicates that the patient has been exposed to parvovirus previously and is immune. W hen t he IgG is negat ive and IgM is posit ive, then it usually means acute parvovirus infection; sometimes a false-positive IgM can occur, so the IgG and IgM are repeated in 1 to 2 weeks at which t ime t he IgG should be positive with a true infection. When the IgG and IgM are both negative, then the patient typically will not be infected and susceptible, provided suf- ficien t t im e h as elap sed p ast in cubat ion p er iod. In this case, the patient h as some symptoms of parvovirus infect ion in a high-risk sett ing, so although both IgG and IgM are negative, it would be wise to repeat it in 4 weeks to ensure t hat t he incubat ion period (up t o 20 days) has elapsed and ant ibodies have formed. C M V affect ed in fant s can h ave microceph aly, per ivent r icu lar calcificat ion s, deafness, chorioretinitis (blindness), seizures, and interstitial pneumonia. T h e classic t r iad of congen it al r ubella is con gen it al cat aract s, cardiac defects, and deafness. T h e classic t r iad of con gen it al t oxoplasmosis is cer ebral vent r icu lomegaly, ch or ior et in it is, an d int r acr an ial calcificat ion s. Rubella h as a ver y h igh t ran smission rat e in the first t r imest er (50%) an d high rate of fetal anomalies. Th e r a t e o f v e r t i c a l t r a n s m i s s i o n i n the f i r s t t r i m e s t e r i s 5 0 %. On examination, her blood pressure is 110/70 mm Hg, heart rate is 70 beats per minute (bpm), and she is afebrile. Understand that Chlamydia trachomatis is a common cause of cervicitis, and options of treatment in pregnancy. Know that chlamydial infections may lead to neonatal pneumonia or con- jun ct ivit is if unt reat ed.