Am Fam Physician. 2007;75(1):112-114
Author disclosure: Nothing to disclose
Case Scenario
I am 20 weeks pregnant and an attending physician for a residency program. A patient presented to the emergency department with a chronic cough and shortness of breath. A resident took the patient's history, which revealed that the patient has acquired immunodeficiency syndrome (AIDS) and that his last CD4+ cell count was 30 per mm3. He recently was hospitalized for active tuberculosis (TB) and left the hospital against medical advice. He had sporadically gone to a nearby community clinic but was not compliant with antiretroviral or anti-TB therapy. Our infectious diseases consultant is concerned about the possibility of multidrug-resistant TB in this patient. The patient's cytomegalovirus (CMV) antibody status is unknown.
As I discussed the case with the resident and contemplated examining the patient myself, I began worrying about the potential harm that exposure to this patient could have on my pregnancy. What is the risk of him transmitting active TB or CMV to me and my baby, and how much is this risk reduced with standard precautions? Are there limits to my professional obligation to care for this patient if I feel that the risk to my pregnancy is unacceptable? Would it be appropriate for me to ask a colleague to care for this patient in my place?
Commentary
This scenario represents a familiar situation: a conscientious physician torn between pressing responsibilities to her patient and colleagues and her responsibility to her baby. She does not want special treatment or to jeopardize the patient's care, yet her concern about contracting an infectious disease is understandably heightened by her pregnancy. The physician's concerns can partially be assuaged by knowledge of the actual risks of specific infectious diseases to her and her fetus, but the “right” answer to her dilemma is a personal one.
The risk of health care workers contracting Mycobacterium tuberculosis infection from patients is dramatically decreased when isolation and airborne infection precautions are implemented. Transmission can occur when these precautions are not implemented correctly. In several reported outbreaks of multidrug-resistant TB among health care workers, delayed isolation or noncompliance with environmental precautions (e.g., insufficient negative airflow pressure in airborne infection isolation rooms) had occurred.1
Exposure to TB during pregnancy presents a special dilemma because of the need for antimycobacterial drugs and the vulnerability of newborns to this pathogen. A physician whose tuberculin skin test converts to positive during pregnancy should be treated for latent TB, although many pregnant women are reluctant to take medications, even those thought to be safe during pregnancy. In addition, presumed drug-resistant latent TB requires multiple antimycobacterial drugs, not all of which have been deemed safe during pregnancy.2 Finally, persons with a recently converted tuberculin skin test who develop signs of active tuberculosis (e.g., changes on chest radiography or cough and fever) need treatment. If this occurs in the peripartum period, the mother must be isolated from her baby for up to two weeks while the diagnosis is determined and therapy is initiated.3 This drastic measure is needed because tuberculosis can be life threatening in newborns.
CMV transmission occurs through close contact with bodily fluids, including saliva and urine. It is understandable why a pregnant physician would want to minimize her risk of CMV exposure because primary CMV infection is associated with serious fetal neurologic and ocular abnormalities.4 However, it is not recommended that pregnant physicians be excluded from caring for persons with known CMV infection because health care workers have the same overall rate of new infection as the general population.5 Transmission rates are high among close household contacts. In fact, approximately 50 percent of women of childbearing age have CMV antibodies.5 Although antibodies do not completely prevent reinfection, they decrease the risk of fetal infection and severe disease when infection occurs.5 Serologic screening for CMV antibodies in pregnant women is not universally recommended, but a positive result can provide some degree of reassurance.
Standard precautions offer sufficient protection against CMV infection.6 These precautions include handwashing, body fluid isolation, and use of gloves and standard non-N95 mask and gown when needed because of special risk of contact. Health care workers are more likely to contract CMV from casual contacts and patients with unidentified infection because standard precautions may be perceived as less important when treating these persons.5,6
Pregnant health care workers should be cautious about exposure to persons with a vesicular rash or maculopapular rash with fever. Vigilant implementation of standard and transmission-based measures can ensure protection before and during the critical period of infectivity. Transmission-based measures are contact, droplet, and airborne precautions, including the use of N95 respirators and patient isolation.6
Transmission of human immunodeficiency virus can occur through percutaneous, mucous membrane, or severe nonintact skin contact with infectious fluid and rarely occurs when standard precautions and procedures are followed. Pregnant physicians who are exposed to the virus can be treated with postexposure prophylactic drugs.5,6
Physicians have a responsibility to provide the best possible patient care—even to patients who pose infection risk. This responsibility does not dictate that a physician must always care for these patients personally. Each physician must find his or her own level of comfort with the inherent risks of the job. In circumstances that increase the risk of pregnancy-related complications, pregnant physicians should feel comfortable asking nonpregnant colleagues for assistance. Such requests should be made after careful and accurate assessment of the actual risks involved.