What is the treatment for a 28-year-old gravida 2 (G2), para 1 (P1), woman with painful swollen fingers due to an unknown poison?

Treatment for Poison-Induced Swollen Fingers in a Pregnant Woman

The treatment for a 28-year-old pregnant woman (G2P1) with painful swollen fingers due to poison should focus on supportive care, including gentle cleansing with antimicrobial solution, pain management, and close monitoring, while avoiding potentially teratogenic treatments.

Initial Assessment and Management

Immediate Actions

• Ensure airway, breathing, and circulation are stable
• Position patient in left lateral tilt to avoid supine hypotension syndrome 1
• Administer supplemental oxygen to maintain maternal oxygen saturation >95% to ensure adequate fetal oxygenation 1
• Establish IV access with two large-bore (14-16 gauge) lines for fluid resuscitation if needed 1

Blister and Skin Care

• Gently cleanse affected fingers with antimicrobial solution, taking care not to rupture any blisters 2
• Pierce blisters at the base with a sterile needle (bevel facing up) to facilitate drainage 2
• Apply gentle pressure with sterile gauze to absorb fluid 2
• Do not remove the roof of the blister 2
• Consider nonadherent dressings after drainage 2
• Provide adequate analgesia prior to any procedure 2

Specific Poison Management

Identification of Poison

• Contact regional poison center for expert guidance (US: 1-800-222-1222) 3
• Obtain detailed history about potential exposure
• Consider toxicology screening if intentional poisoning is suspected 2

Antidote Administration

• If organophosphate poisoning is suspected:
  • Administer atropine: 1-2 mg IV, doubled every 5 minutes until secretions are controlled 2, 3, 4
  • Consider pralidoxime: 1-2 g IV for adults 2, 3
• If opioid toxicity is suspected:
  • Administer naloxone: 0.2-2 mg IV/IM, titrated to respiratory effort 2, 3
• If benzodiazepine toxicity is suspected (with caution):
  • Flumazenil 0.2 mg, titrated up to 1 mg, only if no contraindications 2, 3

Special Considerations in Pregnancy

Maternal-Fetal Monitoring

• Continuous fetal monitoring for at least 4 hours if ≥23 weeks gestation 1
• Obstetrical ultrasound prior to discharge 1
• Consider extended monitoring (24 hours) if any concerning signs present 1

Medication Safety

• Antidotes should be used when there is a clear maternal indication despite limited evidence of teratogenic risk 5
• Avoid penicillamine due to known teratogenic effects 5
• Administer anti-D immunoglobulin to all Rh-negative pregnant women after poison exposure 1

Hyperbaric Oxygen Consideration

• If carbon monoxide poisoning is suspected, hyperbaric oxygen therapy should be considered despite pregnancy 2, 6
• The benefits of hyperbaric oxygen for the mother and fetus in CO poisoning outweigh potential risks 6

Ongoing Care

Monitoring and Follow-up

• Monitor for signs of infection, which is a significant risk and major cause of mortality 2
• Watch for electrolyte imbalances and correct as needed 3
• Observe for at least 24 hours after exposure 3
• Arrange follow-up with both obstetrics and toxicology

Potential Complications

• Be vigilant for signs of placental abruption, which may not be detected by ultrasound 1
• Monitor for preterm labor, which can be triggered by poisoning 4
• Watch for delayed neurological sequelae if neurotoxic poison is involved 2

Pitfalls to Avoid

• Do not delay treatment while waiting for identification of the specific poison 3
• Avoid inappropriate use of flumazenil in patients with risk factors for seizures 3
• Do not underestimate the severity of poisoning in pregnancy, as it can affect both mother and fetus 7
• Never withhold necessary treatment due to pregnancy concerns; the mother should be treated as effectively as possible 7

Remember that prompt diagnosis and treatment are necessary to avoid adverse outcomes for both mother and fetus. The general principles of poisoning management apply to pregnant women, with special consideration for the pregnancy status.