Voiceover: Welcome to NP certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer.
So, if you're ready, let's jump right in.
Margaret Fitzgerald: A 22-year-old woman who's 20 weeks pregnant was treated for C. trachomatis 4 weeks ago with an appropriate anti-microbial. She presents today for a follow-up visit and reports that she's currently without symptoms, and that her partner was also treated: “We both took the medication just like we were advised.” Which of the following represents the next two steps in this patient's care? Choose two that apply.
A: Testing for C. trachomatis should be obtained at today's visit.
B: A repeat of C. trachomatis testing should be conducted at 1-month postpartum.
C: Given she is without symptoms and her partner has also been treated, no further C. trachomatis testing is advised.
D: In the absence of new clinical findings, follow-up test is advised around 28-32 weeks gestation.
And the correct answer here is A and D. Let's take a look at what kind of a question this is. Given that we're told that she was diagnosed with chlamydia 4 weeks ago and treated, then what we're doing here is evaluation or looking at follow-up post-diagnosis and post-treatment. Let's take a look at a bit of background information.
Chlamydia trachomatis infection is the most commonly reported bacterial STI, affecting primarily adolescents and adults younger than age 25 years. The organism is an obligate intracellular parasite closely related to gram negative bacteria. This is a bug that has an incubation period of around 7 to 14 days. And often it takes another week beyond the 7 or 14 days before the person is symptomatic. While this organism can cause symptoms such as dysuria and purulent vaginal or penile discharge, many individuals, regardless of birth sex, will be without symptoms.
Cervicitis leading to report of post-coital bleeding as well as a finding of adherent mucopurulent cervical discharge will often be noted. Even in the absence of PID findings, about one-third will have some endometrial involvement. For this infection during pregnancy, there’s also a concern that if left untreated, the newborn can be exposed to the organism during the birth process with resulting conjunctivitis and risk for pneumonia.
As a result, screening for Chlamydia trachomatis periodically during pregnancy is advised with the frequency based on risk assessment results. The currently recommended medications for the treatment of chlamydia during pregnancy include azithromycin as the first-line product. You will note that this is in contrast with the recommendations for non-pregnant individuals, where doxycycline is recommended. Why the difference?
I suspect you know this already. Doxycycline is a known teratogenic. Fetal exposure can result in permanent teeth staining. Azithromycin has a long safety profile for use in pregnancy and it is not used first-line these days when doxy is more appropriate because of the risk of treatment failure. Typically with the treatment of chlamydia with a first-line drug like doxy and a non-pregnant individual, there actually is no recommendation for test of cure.
But there is recommendation to retest at 3 months due to the risk of reinfection. Often we treat conditions during pregnancy very much like we would in the non-pregnant individual. Things like iron deficiency anemia, pregnant, not pregnant. Same treatment. But sometimes there are differences during pregnancy and this is one example where there is. There is aa universal recommendation for testing 3 to 4 weeks out from treatment in Chlamydia trachomatis during pregnancy.
This is because of the aforementioned risk to both the pregnant individual and also the risk to the newborn. With this is background information, let's take a look at the question and possible answers. A 22-year-old woman who was 20 weeks pregnant, who was treated for Chlamydia trachomatis just 4 weeks ago with an appropriate anti-microbial.
She presents today for a follow-up visit and reports that she is without symptoms and that her partner was also treated. She also mentions, “We both took the medication just like we were advised.” Which of the following represents the next steps in the patient's care? We're going to choose two that apply. And just as a reminder, before we can take a look at the answers, if it says the patient was treated with an appropriate antimicrobial and if the patient reports that she and partner took it just advised, and then that's what you have to go by.
You can't get into guessing. ‘Yeah, but I want to ask a few more questions.’ You've got enough information here to answer the question. Move on. A: Testing for Chlamydia trachomatis should be obtained during today's visit. This is one of the correct answers.
And this is one of the few times when a test of cure is recommended with the treatment of chlamydia. This recommendation holds even if the patient reports taking the meds as directed, even if now asymptomatic, even with the partner being treated, you still do this test of cure for chlamydia when we see it during pregnancy.
B: A repeat of C. trachomatis testing should be conducted at 1-month postpartum. This is clearly incorrect. Waiting until after the baby is born could be really quite dangerous for both mom and child, particularly if there was persistent C. trachomatis tests or possible reinfection. C: Given she's without symptoms and her partner was also treated no further C. trachomatis testing is advised.
As I said before, the CDC recommends that everyone with chlamydia infection be retested at 3 months to see if there has been re-acquisition of the organism, and this response is inconsistent with standard of care. D: A follow-up test is advised at around 20 to 32 weeks gestation. This is the other appropriate response.
As anyone who has acquired C. trachomatis infection should have retesting at about 3 months out from the original time of treatment is advised to see if the organism's been reacquired. The other part is that quite often we do in higher risk situations like this repeat STI testing in the third trimester. Key takeaway: there are recommendations for testing and treatment that are specific to pregnancy.
Knowing the reason why is key to safe practice and board success.
Voiceover: Thank you for listening to NP certification Q&A presented by Fitzgerald Health Education Associates.
Please rate, review, and subscribe to this podcast, and for more NP resources, visit FHEA.com.