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Medical Principles in Obstetrical Consults

  • Jonathan S. Zipursky
    Affiliations
    Department of Medicine University of Toronto, Ontario, Canada
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  • Donald A. Redelmeier
    Correspondence
    Requests for reprints should be address to Donald A. Redelmeier, MD, FRCPC, Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre, G-151, 2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M5.
    Affiliations
    Department of Medicine University of Toronto, Ontario, Canada

    Evaluative Clinical Sciences Program Sunnybrook Research Institute Toronto, Ontario, Canada

    Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada

    Division of General Internal Medicine Sunnybrook Health Sciences Centre Toronto, Ontario, Canada

    Center for Leading Injury Prevention Practice Education & Research Toronto, Ontario, Canada
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      Introduction

      The ideal pregnancy should be medically uncomplicated. In contrast, maternal mortality in the United States equates to approximately 3 deaths per day and averages approximately 1 in 4000 live births (a total of 1063 deaths in 2015).
      GBD 2015 Maternal Mortality Collaborators
      Global, regional, and national levels of maternal mortality, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015.
      Moreover, the annual number of maternal deaths has nearly doubled in the last 25 years for the United States, unlike most other causes of mortality in young adults.
      GBD 2015 Maternal Mortality Collaborators
      Global, regional, and national levels of maternal mortality, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015.
      Of course, the majority of women survive, yet 1 in 10 will suffer from some illness during pregnancy, amounting to approximately 800,000 total cases in 2015 for the United States.
      • Admon LK
      • Winkelman TNA
      • Moniz MH
      • Davis MM
      • Heisler M
      • Dalton VK
      Disparities in chronic conditions among women hospitalized for delivery in the United States, 2005-2014.
      In total, pregnancy accounts for approximately 30 million patient-days in the hospital annually.

      Weiss AJ, Elixhauser A. Overview of hospital stays in the United States, 2012: statistical brief #180. Available at: http://www.ncbi.nlm.nih.gov/pubmed/25506966. Accessed April 3, 2018.

      Most maternal deaths can be prevented and most perinatal illnesses are treatable, thereby underscoring the importance of an internist in the care of pregnant patients (hereafter referred to as obstetric medicine). The classic approach in obstetric medicine tends to divide illnesses into 3 categories: 1) chronic conditions that predate pregnancy (eg, asthma); 2) new conditions that occur because of pregnancy (eg, hyperemesis); and 3) acute conditions that are unrelated to pregnancy (eg, pneumonia). Context matters too because the surrounding social contributors may be complex, including social isolation and financial deprivation. A further nuance is that many illnesses in pregnancy resolve spontaneously with no intervention.
      Consultation in obstetric medicine requires a different expertise than that for older adults with multiple comorbidities. Even so, standard textbooks, formal medical training, and evidence-based medicine provide little guidance for internists involved in the care of pregnant women. This commentary identifies selected principles for the medical care of pregnant women based on our experience. These distinctions may sometimes make managing pregnant patients entirely special and distinctive, comparatively more straightforward, or comparatively more complex compared with managing other patients in internal medicine (Table).
      TableDistinctions of Medical Consults for Pregnant Patients
      Entirely Special and Distinctive
      1. Consider the trimester to gauge changes in anatomy and physiology.
      2. Distinction is pregnancy with fertility medications and pregnancy without fertility medications.
      3. Realize that some diseases only occur in pregnancy.
      4. Remember that decisions are made in collaboration with the obstetrical service.
      5. Be aware that a poor outcome can have a negative impact on the child for a lifetime.
      6. Stay sensitive to heart-wrenching emotional overtones.
      Comparatively More Straightforward
      1. Keep in mind that the Occam's razor principle generally holds true.
      2. Recognize that a core priority is to gauge disease severity.
      3. Be grateful that there is no long list of comorbidities.
      4. Appreciate that there is no long list of chronic medications.
      5. Notice that there are no complicated advanced care directives.
      6. Realize that patients are often highly motivated in managing illness.
      Comparatively More Complex
      1. Don't forget that some medications are contraindicated in pregnancy.
      2. Resist the temptation of an exuberant cascade of diagnostic testing.
      3. Be mindful that there is no easy availability to return to clinic repeatedly.
      4. Be prepared to communicate recommendations to multiple stakeholders.
      5. Understand that evidence-based medicine has gaps in obstetric medicine.
      6. Appreciate that patient counseling is done under substantial degrees of uncertainty.

      Entirely Special and Distinctive

      A consultant must distinguish normal physiological changes that occur during pregnancy from those related to serious underlying pathology. For example, a subjective feeling of dyspnea is common in the third trimester, partially because of diaphragmatic elevation. Hypoxia, in contrast, is abnormal and should prompt investigation for a pulmonary embolism, pneumonia, or other important causes. Similarly, symptoms such as constipation, gastroesophageal reflux, insomnia, fatigue, pruritus, and nausea are often expected but sometimes can reflect serious disease in pregnancy. These distinctions inform all considerations including the choice of whether to address individuals as ‘patients’ or as ‘women.’
      Pregnancies that follow fertility therapy are another universal distinction and a growing trend, with nearly 1 in 50 infants born in the United States now conceived using fertility therapy.

      Centers for Disease Control and Prevention. ART success rates. Available at: https://www.cdc.gov/art/artdata/index.html. Accessed January 7, 2018.

      Women who undergo fertility therapy are at higher risk of gestational diabetes, preeclampsia, placenta previa, placental abruption, and venous thrombosis.
      • Jackson RA
      • Gibson KA
      • Wu YW
      • Croughan MS
      Perinatal outcomes in singletons following in vitro fertilization: a meta-analysis.
      • Henriksson P
      • Westerlund E
      • Wallén H
      • Brandt L
      • Hovatta O
      • Ekbom A
      Incidence of pulmonary and venous thromboembolism in pregnancies after in vitro fertilisation: cross sectional study.
      Fertility therapy medications also have unique side effects, such as clomiphene-induced hepatitis or large-volume ascites from ovarian hyperstimulation syndrome. Furthermore, fertility therapy is used disproportionately for older women who have less physiological reserve.
      Another special distinction is that the medical illness is never the only priority. Because of this, medical decisions must usually be made in collaboration with the obstetric service. Importantly, achieving a good outcome for a pregnant mother can have a positive impact on the child for a lifetime. In addition, some unique disorders require specialized training (eg, intrahepatic cholestasis of pregnancy). Together, all these special distinctions demand a slightly different skillset for the consultant than they do for treating older patients. Pregnancy, moreover, can be an emotional time for all those involved, including the consulting physician.

      Comparatively More Straightforward

      One basic reason that consults are sometimes comparatively more straightforward in obstetric medicine is that the Occam's razor principle generally holds true. A pregnant patient who presents with dysuria, frequency, and urgency probably has bacterial cystitis and not schistosomiasis. When making a diagnosis in a pregnant patient, the simplest explanation is likely the correct one (Occam's razor). This simplicity is one reason why exhaustive testing is not usually appropriate or necessary in obstetric medicine.
      All internists must gauge disease severity and not just make a diagnosis. A classic example is hypertension because consultation with the obstetric medicine consultant may inform peripartum care. The timing of disease during pregnancy may also be a relevant indicator of severity. Blood pressure, for example, typically reaches a nadir around the 20th week of gestation, which means hypertension that develops in mid-pregnancy indicates more serious disease that will likely further intensify. And, of course, disease severity will fluctuate over time and require repeated assessments for diligent care.
      Young, healthy pregnant women do not often have the same burden of comorbidities and polypharmacy as older adults. As a consequence, the consultant rarely needs to review a long list of chronic medications or complicated past medical history. Similarly, there are seldom difficult advance care directives to ponder. Pregnant patients are also highly motivated and may be especially willing to adopt a healthy lifestyle, quit smoking, and follow treatment recommendations. Together, the simplicity of their disease and the energy of motivated patients can make an obstetrical medicine consultant's work efficient and gratifying.

      Comparatively More Complex

      One reason that obstetric medicine consults are sometimes a challenge is that several medications are unsafe in pregnancy. For example, isotretinoin (Accutane) is contraindicated in pregnancy because of the risk of fetal craniofacial, cardiac, and neurologic abnormalities. The safety of other medications varies by trimester; for example, methimazole should not be used in the first trimester but can be started in the second trimester when the risk of aplasia cutis is low. Other drugs such as nonsteroidal anti-inflammatory drugs are safe in early but not late pregnancy. These nuances are impossible to memorize and require checking authoritative sources.

      Garey J, Lavigne S, Lione A, Lusskin SI, Nichols G, Scialli AR. Reprotox. Available at: https://reprotox.org/. Accessed March 14, 2018.

      Obstetric medicine consultants need to be judicious when ordering diagnostic tests in pregnant patients. Patients may be reluctant to undergo complicated procedures because of potential adverse effects on the child (ultrasound being the major exception). In particular, tests that may expose the mother and child to radiation should only be done when necessary (and the abdomen should be shielded with a protective covering). Consequently, the clinical diagnosis must rely heavily on history, examination, and clinical judgment.
      Many other practicalities need to be remembered in obstetric medicine. Pregnant women often have busy schedules and may have difficulty attending multiple follow-up visits. Partners, parents, and friends may accompany pregnant women and bring their own questions, so the consultant must be prepared to communicate to multiple stakeholders. Counseling in obstetric medicine is done with a particularly large degree of uncertainty because much of the available evidence is not as robust as in other specialties. For these reasons, the obstetric medicine consultant must have savvy bedside manner.

      Conclusions

      Medical conditions are becoming the leading cause of maternal morbidity and mortality.
      • Admon LK
      • Winkelman TNA
      • Moniz MH
      • Davis MM
      • Heisler M
      • Dalton VK
      Disparities in chronic conditions among women hospitalized for delivery in the United States, 2005-2014.
      Ironically, modern advances allowing women to become pregnant despite chronic medical conditions has led to increases in high-risk pregnancies. There will undoubtedly be an increased role for the obstetric medicine consultant to support women when managing such medical illnesses during pregnancy. We hope a shortlist of principles offers insight into aspects of obstetric medicine and helps foster better care for pregnant women. The ‘high-risk’ pregnancy is no longer the exception but a new norm.

      Acknowledgments

      We thank the following individuals for thoughtful comments on earlier drafts of this work: Allan Detsky, Robert Zipursky, David Juurlink, Steven Shumak, Shital Gandhi, and Sheharyar Raza.

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        • Winkelman TNA
        • Moniz MH
        • Davis MM
        • Heisler M
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        Disparities in chronic conditions among women hospitalized for delivery in the United States, 2005-2014.
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      1. Weiss AJ, Elixhauser A. Overview of hospital stays in the United States, 2012: statistical brief #180. Available at: http://www.ncbi.nlm.nih.gov/pubmed/25506966. Accessed April 3, 2018.

      2. Centers for Disease Control and Prevention. ART success rates. Available at: https://www.cdc.gov/art/artdata/index.html. Accessed January 7, 2018.

        • Jackson RA
        • Gibson KA
        • Wu YW
        • Croughan MS
        Perinatal outcomes in singletons following in vitro fertilization: a meta-analysis.
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        • Henriksson P
        • Westerlund E
        • Wallén H
        • Brandt L
        • Hovatta O
        • Ekbom A
        Incidence of pulmonary and venous thromboembolism in pregnancies after in vitro fertilisation: cross sectional study.
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