A 16-year-old female, gravida 1, para 0, with a history of chlamydia and gonorrhea, presents with a missed period, positive urine pregnancy test, nausea, vomiting, and dysuria, what is the diagnosis and treatment plan?

Comprehensive Case Analysis: Pregnant Adolescent with Suspected STI and Complications

Primary Diagnoses

This 16-year-old patient presents with three concurrent diagnoses requiring immediate treatment: intrauterine pregnancy at approximately 8 weeks gestation, acute pelvic inflammatory disease (PID) with probable recurrent chlamydia and/or gonorrhea infection, and urinary tract infection (UTI). 1

Subjective Data Summary

• Chief complaint: Two missed menstrual periods with positive urine pregnancy test 1
• Pregnancy symptoms: Daily nausea and vomiting for 2 weeks, consistent with first-trimester pregnancy 2
• Genitourinary symptoms: Dysuria for 2 weeks indicating concurrent UTI 1
• Sexual history: Sexually active with inconsistent contraception (withdrawal method only), history of treated chlamydia and gonorrhea earlier this year, partner non-responsive and likely untreated 1
• Social risk factors: Active tobacco use (1 pack/day), lives with family, no substance abuse reported 1
• Vaccination status: Has not received HPV vaccine series 1

Objective Data Summary

• Vital signs: BP 110/68, P 80, RR 18, T 37.1°C - all within normal limits 1
• Weight: 110 lbs (reports usual weight 120 lbs) - 10 lb weight loss concerning for hyperemesis gravidarum 2
• Pelvic examination findings: Cloudy yellow mucoid cervical discharge, friable cervix with cervical motion tenderness - pathognomonic for PID 1
• Bimanual examination: 8-week size uterus consistent with last menstrual period approximately 2 months ago 1
• Urinalysis: 2+ ketones (indicating inadequate oral intake/dehydration), 2+ nitrates and 3+ leukocytes (confirming UTI) 1, 2

Differential Diagnoses

1. Pelvic Inflammatory Disease (PID) - Most Likely Primary Diagnosis

• Clinical evidence: Cervical motion tenderness, cervical friability, mucopurulent discharge, history of recent STI treatment with likely untreated partner 1
• Risk factors: Age <25 years, multiple sexual partners (partner's treatment status unknown), previous chlamydia/gonorrhea infection, inconsistent barrier contraception 1, 3
• Complications if untreated: Tubal factor infertility, ectopic pregnancy, chronic pelvic pain, increased risk of pregnancy complications 4, 5

2. Recurrent Chlamydia and/or Gonorrhea Infection

• Clinical evidence: Previous documented infection earlier this year, partner likely untreated (not answering calls), high-risk sexual behavior 1, 3
• Reinfection rates: Up to 39% in adolescent populations when partners are not treated 1, 6
• Pregnancy implications: Risk of vertical transmission to neonate, preterm labor, premature rupture of membranes 1

3. Hyperemesis Gravidarum with Dehydration

• Clinical evidence: Daily nausea and vomiting for 2 weeks, 10 lb weight loss, 2+ ketones in urine 2
• Severity assessment: Ketonuria indicates inadequate oral intake and metabolic stress 2
• Complications: Risk of Wernicke's encephalopathy if thiamine deficiency develops, electrolyte imbalances 2

Comprehensive Diagnostic Testing Plan

Immediate Laboratory Testing (Today)

• STI screening panel: Nucleic acid amplification test (NAAT) for chlamydia and gonorrhea from vaginal swab specimen (preferred over cervical swab to minimize trauma in pregnant adolescent) 1, 3, 4
• Pregnancy-specific STI screening: Serologic test for syphilis (RPR or VDRL), hepatitis B surface antigen (HBsAg), HIV antibody test 1
• Urine culture and sensitivity: To identify specific UTI pathogen and guide antibiotic therapy 1
• Complete metabolic panel: Assess electrolytes (sodium, potassium, chloride), renal function, and liver function given vomiting and ketonuria 2
• Complete blood count: Evaluate for anemia and infection 1
• Blood type and antibody screen: Standard first-trimester prenatal testing 1
• Thyroid-stimulating hormone (TSH) and free T4: Rule out gestational thyrotoxicosis associated with hyperemesis 2

First-Trimester Obstetric Ultrasound

• Confirm intrauterine pregnancy: Rule out ectopic pregnancy given PID risk factors 1
• Establish accurate gestational age: Confirm dating consistent with 8-week examination findings 1
• Assess fetal viability: Document fetal cardiac activity 1

Follow-Up Testing (3-4 Weeks Post-Treatment)

• Test of cure for chlamydia and gonorrhea: Mandatory in pregnancy due to use of alternative regimens and high reinfection risk 1, 6, 7
• Repeat testing at 3 months: Screen for reinfection regardless of partner treatment status 1, 6, 3, 7

Evidence-Based Treatment Plan

Immediate Pharmacological Interventions

1. Treatment of Gonorrhea and Chlamydia in Pregnancy

Administer ceftriaxone 500 mg intramuscular single dose immediately for presumptive gonorrhea treatment, followed by azithromycin 1 g orally as a single dose for chlamydia. 1, 6, 8, 3, 7, 4

• Rationale for dual therapy: High coinfection rates (20-40%) in populations with gonorrhea prevalence, and patient has documented history of both infections 6, 3
• Pregnancy safety: Ceftriaxone and azithromycin are both safe in pregnancy; doxycycline is absolutely contraindicated 1, 6, 9
• Alternative if azithromycin not tolerated: Amoxicillin 500 mg orally three times daily for 7 days 1, 6
• Medication dispensing: Provide directly observed therapy for first dose to ensure compliance 1, 6

2. Treatment of Urinary Tract Infection in Pregnancy

Initiate empiric antibiotic therapy with pregnancy-safe agent (nitrofurantoin 100 mg twice daily for 7 days or cephalexin 500 mg four times daily for 7 days) pending urine culture results. 1

• Adjust therapy: Modify based on culture and sensitivity results when available 1
• Avoid fluoroquinolones: Absolutely contraindicated in pregnancy 1, 6

3. Management of Hyperemesis Gravidarum

Prescribe ondansetron 4-8 mg orally every 8 hours as needed for nausea, with thiamine (vitamin B1) 100 mg daily supplementation. 2

• Hospitalization criteria: Consider admission if unable to tolerate oral fluids, persistent vomiting despite antiemetics, or worsening electrolyte abnormalities 2
• Intravenous fluid replacement: May be necessary if oral intake remains inadequate 2
• Nutritional support: Small frequent meals, avoid triggers, ginger supplementation 2

Critical Counseling and Education

Sexual Activity Restrictions

Patient must abstain from all sexual intercourse for minimum 7 days after treatment initiation and until all symptoms resolve. 1, 6, 3

Partner Management - Highest Priority

All sexual partners from the previous 60 days must be evaluated, tested, and empirically treated with chlamydia and gonorrhea-effective regimens, even if asymptomatic. 1, 6, 3, 7

• Expedited partner therapy: Provide prescription for partner's treatment if he will not seek medical care 7, 4
• Partner notification: Assist with contacting partner; consider health department assistance for contact tracing 1
• Reinfection prevention: Emphasize that failing to treat partners leads to reinfection in up to 20% of cases 6

Smoking Cessation

Provide intensive smoking cessation counseling given pregnancy and current 1 pack/day use. 1

• Pregnancy risks: Increased risk of preterm birth, low birth weight, placental complications 1
• Referral: Connect with smoking cessation program and consider nicotine replacement therapy if appropriate 1

HPV Vaccination

Initiate HPV vaccine series today (first dose) and schedule subsequent doses at 2 and 6 months. 1

• Age-appropriate: Recommended for all adolescents starting at age 9 years 1
• Pregnancy safety: HPV vaccine is not contraindicated in pregnancy but typically deferred; however, given her high-risk status and history of STIs, benefits may outweigh theoretical risks 1

Prenatal Care Establishment

First Prenatal Visit Components

• Comprehensive prenatal laboratory panel: As outlined above in diagnostic testing 1
• Prenatal vitamins with folic acid: Prescribe prenatal vitamin with 400-800 mcg folic acid daily 1
• Genetic counseling: Discuss carrier screening options based on ethnicity and family history 1
• Obstetric risk assessment: Identify high-risk factors including adolescent pregnancy, STI history, tobacco use 1

Ongoing Prenatal Monitoring Schedule

• Repeat STI screening in third trimester: Test again for chlamydia and gonorrhea at 28-32 weeks given high-risk status 1
• Monthly prenatal visits: Until 28 weeks, then increase frequency 1
• Growth ultrasounds: Monitor fetal growth given maternal tobacco use 1

Social Support and Resources

Adolescent-Specific Interventions

• School coordination: Provide documentation for missed school days, connect with school counselor 1
• Family involvement: With patient's permission, involve mother and siblings in prenatal care planning 1
• Financial assistance: Refer to Medicaid/CHIP enrollment, WIC program for nutritional support 1
• Mental health screening: Assess for depression, anxiety, and provide counseling referrals as needed 1

Child Protective Services Consideration

• Mandatory reporting: Assess whether sexual partner's age requires reporting based on state statutory rape laws 1
• Support services: Connect with adolescent pregnancy support programs 1

Critical Clinical Pitfalls to Avoid

1. Delaying Treatment While Awaiting Test Results

Never delay empiric treatment for gonorrhea and chlamydia in pregnant patients with clinical PID findings. 1, 6

• Rationale: Complications of untreated PID in pregnancy include preterm labor, premature rupture of membranes, and vertical transmission to neonate 1, 4

2. Using Doxycycline in Pregnancy

Doxycycline is absolutely contraindicated in pregnancy due to effects on fetal bone and tooth development. 1, 6, 9

• Alternative: Always use azithromycin or amoxicillin for chlamydia treatment in pregnancy 1, 6

3. Failing to Ensure Partner Treatment

Assuming partner was treated without verification leads to reinfection in up to 20% of cases. 6

• Solution: Provide expedited partner therapy prescription or directly verify partner received treatment 7, 4

4. Omitting Test of Cure in Pregnancy

Test of cure is mandatory in pregnancy 3-4 weeks after treatment completion, unlike non-pregnant patients. 1, 6, 7

• Rationale: Alternative regimens used in pregnancy have lower efficacy, and untreated infection poses significant fetal risks 1, 6

5. Inadequate Hyperemesis Management

Failure to supplement thiamine in patients with ketonuria and vomiting can lead to Wernicke's encephalopathy. 2

• Prevention: Always prescribe thiamine 100 mg daily for pregnant patients with persistent vomiting and ketones 2

6. Missing Third-Trimester Repeat STI Screening

High-risk pregnant patients require repeat chlamydia and gonorrhea testing in third trimester to prevent neonatal transmission. 1

• Timing: Perform at 28-32 weeks gestation 1

Documentation Requirements

Medical Record Documentation

• STI diagnosis and treatment: Document clinical findings of PID, empiric treatment provided, partner notification attempted 1
• Pregnancy confirmation: Gestational age by examination, positive urine pregnancy test, ultrasound findings 1
• Counseling provided: Sexual abstinence, partner treatment, smoking cessation, medication compliance 1, 6
• Follow-up plan: Test of cure in 3-4 weeks, repeat testing at 3 months, third-trimester STI screening 1, 6, 7

Public Health Reporting

Chlamydia and gonorrhea are reportable diseases in all states; ensure timely reporting to local health department. 1

• Health department assistance: Request contact tracing support for partner notification 1