Jessica Cabral: The Case

HPI:

Ms. Jessica Cabral is a 41-year-old female, gravida 3 para 2, who seeks prenatal care at the University of Louisville Ob/Gyn clinic. Her past obstetric history includes the spontaneous vaginal delivery of an 8 pound, 7 oz. female infant 12 years ago. Her second pregnancy was complicated by the fetal diagnosis of Down’s Syndrome at 18 weeks gestation. She delivered that child via C-section at 37 weeks gestation at University Hospital 4 years ago.

Today Ms. Cabral presents for a routine prenatal visit at 16 weeks. Her pregnancy thus far has been uncomplicated. She complains of fatigue, knee pain and swelling, and thinks she may have “caught a virus or something going around at her child’s school.” She has had a low-grade fever for the last 3 days, and reports that her eyes are more red, watery and itchy than normal. She recently returned from a two-week visit back to Florida for her mother’s funeral, and reports that she has been feeling more stressed than usual lately due to her mother’s death and the recent travel. She associates her symptoms with this stress, her pregnancy, as well as “seasonal illnesses.” She reports no history of neck stiffness, seizures, or weight loss. She had a headache a few days ago that resolved with Tylenol.

Social History:

Ms. Cabral is recently divorced, and cares for her children as a single parent. Her children’s father just moved out of state, and has no contact with Ms. Cabral or her children. Her current pregnancy was unplanned, and her husband is not involved. She and her two children live in New Albany, where she works as a manager at a local Kroger. Her 12-year-old daughter attends a public middle school, and her 4-year-old son with Down’s Syndrome is in a full-time public daycare program. Ms. Cabral feels constantly stressed about work and financial obligations, and worries she isn’t spending enough time with her children. She receives some support from her church group with transporting her son to his occupational and physical therapy appointments during the week, but outside of that, she has no other help with her children or around the house.

Physical Exam:

Vitals

Test	Value
T	100.3
HR	85
BP	138/85
RR	17
Weight	75.75 kg
Gen	Patient in no apparent distress, but does appear stressed and fatigued.

HEENT:

Eyes: pupils equal, round, reactive to light. Positive for injected conjunctivae bilaterally. Negative for purulent discharge, pain, loss of visual acuity, photophobia. Oropharynx clear, TM’s clear.

Neck: no lymphadenopathy, thyromegaly or JVD.

Lungs: clear to auscultation and percussion.

Heart: Regular rate and rhythm without murmur, rub, or gallop.

Abd: soft, gravid, non-tender

Fundal Height: 2 finger-breadths below umbilicus

Fetal Heart Tones: 150s

Urine: negative protein, negative glucose

Patient was informed that labs would be drawn given her symptoms. She is counseled about the potential risk of Zika exposure following her recent trip to Florida and advised to return to the clinic in 3 weeks to discuss the results.

Diagnostic studies from initial OB/GYN visit:

Test	Value
WBC	11,000
Hgb	12.2
Platelets	200,000
Comprehensive Metabolic Panel	Normal
RPR	Non-reactive
HIV	Non-reactive
Hepatitis BS Ag	Non-reactive
Hepatitis C Ab	Negative
Gonorrhea	Negative
Chlamydia	Negative
Varicella	Immune
Rubella	Immune
Pap Smear	NIL, negative high-risk HPV testing
Urine culture	Negative
Blood Type and Rh	B+
Antibody screen	Negative
Hemoglobin electrophoresis	Normal Phenotype
TSH	1.13

Three days later, Ms. Cabral’s prenatal care provider calls her with the following results:

Prenatal Results

Test	Value
CMV IgM	Negative
CMV IgG	Positive
Parvovirus IgM	Negative
Parvovirus IgG	Positive
Toxoplasmosis IgM	Negative
Toxoplasmosis IgG	Negative
Monospot test	Negative
Quad screen	Negative for Down Syndrome, negative for Trisomy 18, negative ONTD

Three weeks later Ms. Cabral returns to the clinic to discuss her results. Her diagnostic workup reveals that she is positive for Zika virus.

Zika Results

Test	Value
ZIKV rRTPCR of serum	Positive
ZIKV rRTPCR of urine	Negative
ZIKV IgM antibodies	Positive
Dengue rRTPCR of serum	Negative
Chikungunya rRTPCR of serum	Negative

She has an ultrasound performed that shows the following (Image 1 on the left).  There has been a decrease in fetal head circumference and the intracranial anatomy is abnormal (see Image 1 on the right) for normal intracranial anatomy at 19 weeks).

Ms. Cabral is concerned about what a Zika diagnosis means for her at this stage of her pregnancy. She has heard on the news that Zika is associated with birth defects and is worried about the potential outcomes for her fetus. When you explain the results of the ultrasound to her, she wants to know what a diagnosis of microcephaly will mean for her baby’s health, and how this diagnosis will affect the rest of her pregnancy. She wants to know if Zika can have any other effects on her pregnancy.

She asks about her options for pregnancy termination at this stage in her pregnancy. She is overwhelmed at the prospect of caring for and financing another special-needs child. She has never previously considered an abortion, and describes that she “grew up in a conservative family, and never gave much thought to the issue.” She is worried about the stigma she would face in her community if she was to have an abortion. Ms. Cabral expresses that she doesn’t know “where she would go to get a procedure like this,” what the procedure would entail, and if her insurance would cover an abortion. She wants to know what you think she should do.