Medically managing your pregnant patient
From the November ACP Observer, copyright © 2005 by the American College of Physicians.
By Deborah Gesensway
After nearly 20 years, Rhode Island internist Raymond O. Powrie, FACP, is still haunted by two patients he encountered during his residency at the University of Alberta in Edmonton. Both were pregnant women with health problems—and both, he thought, were being let down by the medical community.
The first patient, who suffered from asthma, did fine. The real problem was Dr. Powrie's own fear and anxiety about caring for a pregnant patient, which was so paralyzing that it nearly kept him from treating her.
"I can remember sitting at a desk writing the orders for steroids and an inhaler and wondering if I was doing something morally reprehensible" by prescribing drugs for a pregnant woman, he said.
The other case was momentous, the kind that sticks with a doctor forever. A young woman died of a rare peripartum cardiomyopathy while being treated on the hospital's obstetric floor. As chief internal medicine resident at the time, Dr. Powrie had to review all deaths. Although the tragedy technically may have resulted from a series of errors, Dr. Powrie thought the real cause was more straightforward: The patient and her disease belonged to no one specialty.
"Is an obstetrician really qualified to treat a cardiomyopathy?" he recalled asking himself. "And how can I be a chief internal medicine resident and not even have heard of this diagnosis?"
The answers struck him like a lightening bolt. "There are women with serious medical problems who are orphaned by the health care system," he said. "They don't really belong to their obstetrician, who is scared about medical illnesses, but they don't really belong to the internist or medical subspecialist, because these doctors are scared of the pregnancy." (See also "Pregnancy as a bellwether of later disease: The case for taking a pregnancy history.")
A growing problem
Women with serious medical conditions—from diabetes, seizure disorders and cardiac disease to asthma and obesity—are conceiving and delivering babies in record numbers.
Women with medical problems who in the past were counseled against becoming mothers are now more willing and able to have babies. And the fact that more women are delaying childbirth until their late 30s and 40s means that more women begin pregnancy with a preexisting medical condition.
Moreover, given the dramatic improvements in obstetrical medicine and surgery, the top causes of maternal mortality during childbirth in industrialized nations are now medical, not obstetrical, in nature. A study of pregnancy-related mortality between 1991 and 1999 found that embolism tops the list (no specific kind was cited), causing nearly 20% of pregnancy-related deaths. Researchers found that pregnancy-induced hypertension accounts for nearly 16%, and cardiomyopathy, 9%, according to the surveillance summary published in the Feb. 21, 2003, issue of Morbidity and Mortality Weekly Report. (See also "Obesity and pregnancy.")
"What this means is that women are dying from things that internists ought to be paying more attention to," said Richard V. Lee, FACP, professor of medicine, pediatrics, obstetrics and anthropology at the State University of New York at Buffalo and one of the nation's leading experts in the growing field of obstetric medicine.
Myths and mistakes
According to Dr. Lee—who is a co-author and co-editor of the ACP book, "Medical Care of the Pregnant Patient," published in 2000—one of the most persistent myths among internists regarding pregnant patients is that women are the obstetrician's problem.
Dr. Lee and other obstetric medicine champions are working to convince other physicians that obstetrical issues are as much a part of their job as caring for geriatric patients—another group, he pointed out, that used to be undertreated.
Another myth influencing both pregnant patients and physicians is that it is better to err on the side of caution than to potentially harm the fetus.
"One of the biggest mistakes internists make is that they take away women's medications that are needed," explained Linda A. Barbour, FACP, associate professor of medicine and obstetrics and gynecology at the University of Colorado Health Sciences Center in Denver, as well as a co-editor of the ACP book on medical management of pregnant patients. An updated edition of the book will be published next spring.
Consider the common case of the asthmatic woman whose internist or family doctor tells her to stop taking all her medications now that she is pregnant.
"We know that almost all the asthma medications are fine in pregnancy, but an internist often doesn't know that and stops them all—and then the poor pregnant woman comes in to me with horrible, life-threatening asthma," Dr. Barbour said. "The baby's oxygenation is dependent on mom's oxygenation."
Similarly, women with seizure disorders are often counseled to stop taking anti-seizure medications during pregnancy. "What happens is that someone will have seizures that will cause acidosis and hypoxia in the baby," said Karen Rosene-Montella, FACP, chief of medicine at Women & Infants Hospital of Rhode Island in Providence, R.I., which offers the nation's only fellowship program in obstetric medicine. Dr. Rosene-Montella is a co-author of the ACP book on caring for pregnant patients. "That was not better for the baby."
Obstetric medicine experts say the list of drugs known or suspected to be teratogenic or fetotoxic is much shorter than most people think. (See "Drugs that pregnant women should avoid.")
'I think we have become so paranoid that we actually harm women regularly by withholding appropriate medication.'
—Raymond O. Powrie, FACP
"I think we have become so paranoid "that we actually harm women regularly by withholding appropriate medication," explained Dr. Powrie, who is professor of medicine and obstetrics and gynecology at Brown University in Providence, R.I., and director of the division of obstetric and consultative medicine at Women & Infants Hospital of Rhode Island.
A few years ago, Dr. Powrie and his colleague Rshmi Khurana, ACP Member (who is now with the University of Alberta in Edmonton), conducted a study, asking 200 internists what antibiotic they would prescribe for a specific urinary tract infection. The 100 internists who reviewed the case and were told the woman wasn't pregnant all chose the correct antibiotic. The 100 physicians given the same case but told the patient was pregnant, however, tended to choose penicillin.
"They chose a drug that wouldn't have worked for that infection, but it was safe to the fetus," Dr. Powrie said. "But an untreated urinary tract infection has a 50% chance of causing preterm labor and a premature delivery, which can be very serious." He commonly gives his internal medicine colleagues some simple advice: "Don't say no because you don't know."
The same paranoia drives decisions about X-rays, Dr. Powrie continued. "Patients are nervous about them. Doctors are nervous about them. But these same babies, if they are born prematurely or if they go to the neonatal ICU, may get several X-rays in a day," he said.
On the other hand, overtreatment can also be an issue.
Again, take the example of seizure disorders. All too often, said Denver's Dr. Barbour, women continue taking their epilepsy medication even though they haven't had a seizure in 10 years. While many antiepileptics are teratogenic, she explained, "no one ever asks whether the patient still needs the drug, can be tapered off or can be changed to another agent that hasn't been associated with major malformations."
Obstetric medicine practitioners also point to another area where internists can do right by female patients in their childbearing years: play a bigger role in preconception counseling.
Because pregnant women rarely see an obstetrician until they are six to eight weeks into their pregnancies—after most embryogenesis has occurred—medical counseling before the fact can make an enormous difference in improving the health of both women and babies.
"Unless you talk to all your patients of childbearing age about the possibility of becoming pregnant and the impact of their medical illness on that, they don't have any way to know," said Dr. Rosene-Montella. Statistics show that at least 15% of all women entering prenatal care have underlying medical problems.
With almost half of all pregnancies in the United States unplanned, Dr. Rosene-Montella urges internists to address the issue up front. To all her women patients with medical conditions—teenagers through 45-year-olds—she gives the following advice:
"Your medical condition means that we need to know the very second you are pregnant. You are a person who has to be very careful about contraception—and check off the date of your period every month on your calendar. If you are one day late, I need to know about it."
According to Dr. Rosene-Montella, physicians can advise diabetic patients about the need for optimizing glucose control and normalizing hemoglobin A1c levels. They can counsel obese patients about the importance of weight loss before pregnancy.
They can take hypertension patients off ACE inhibitor drugs, and see if asthma patients can do well on drugs other than leukotriene modifiers. They can also substitute heparin for warfarin in patients with thromboembolic disease.
Obstetric practitioners also say that getting more involved in preconception counseling can have big payoffs for internists as well as for their patients. Patients are never more motivated to comply with doctors' advice and change dangerous behaviors as when they are pregnant or considering getting pregnant.
At the same time, pregnancy is the only time that all women—including low-income patients—have medical insurance until they qualify for Medicare. "It's a huge opportunity," Dr. Rosene-Montella said, "in terms of identifying risks and problems early."
Deborah Gesensway is a freelance health care writer in Toronto.
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
A 52-year-old woman comes to an internist for the first time with new menopause symptoms and asks about hormone-replacement therapy.
To see if therapy would be appropriate, said Karen Chacko, MD, a general internist in Denver, the physician needs to start by asking about the patient's pregnancy history. While most internists were never taught this and many have given the question little if any thought, a raft of new evidence has convinced Dr. Chacko to lead that charge.
From the pregnancy history, Dr. Chacko said she wants to know if the new patient had trouble with weird preeclampsia while she was pregnant or whether she clotted. The answers can be clues that may lead her to suspect an underlying hypercoagulable state that would make estrogen dangerous.
"Pregnancy really is a glimpse into the future for a number of women and a guide for what to do," Dr. Chacko said. As the nation's top experts in obstetric medicine like to say, pregnancy is a stress test.
"It is a stress test for the development of diabetes," explained Linda A. Barbour, FACP, associate professor of medicine and obstetrics and gynecology at the University of Colorado Health Sciences Center in Denver, and a co-editor of ACP's book, "Medical Care of the Pregnant Patient." "It is a stress test for the likelihood of developing blood clots and for [a patient's] cardiac reserve."
Experts are urging internists to add a few questions about pregnancy and delivery to their standard histories for all women patients. For younger women—and that includes teenagers to 45-year-olds—this can lead to important preconception counseling, staving off avoidable future problems. It can also lead to more vigilant screening or unmask factors that should guide medical decisions.
Diabetes is a good example. Research has shown that as many as half of all women who develop gestational diabetes during pregnancy—which goes away after delivery—will go on to develop type 2 diabetes over the next decade. For Hispanic women, the risks are even greater.
Dr. Chacko changes her management plans when she finds out that patients had gestational diabetes. "Now, I check a yearly fasting glucose on them. I counsel them that this is the right time to start working on diet and exercise because they are at high risk for developing diabetes," she said. "Most women tell me they never heard that during their pregnancy."
'Pregnancy is not a biologically neutral event.'
—Richard V. Lee, FACP
Also ask patients about their experience with blood pressure during pregnancy. If they were among the 4% of women who experienced pregnancy-induced hypertension, now is a particularly good time to counsel them about diet, exercise and salt intake and to begin a regular schedule of blood pressure checks. And Dr. Chacko also asks about post-partum thyroiditis, ordering a thyroid stimulating hormone test every year for patients who report having had the condition.
"Pregnancy is not a biologically neutral event," explained Richard V. Lee, FACP, of the State University of New York at Buffalo. "The internist who tells a pregnant patient that he doesn't want to see her until the kid is age 3 may miss a whole lot of important clues to some future developments."
One area where internists could make an enormous contribution in improving the health and safety of both pregnant mothers and their babies concerns obesity.
"It is an epidemic, and it is an area where we have been failing our patients," said Raymond O. Powrie, FACP, professor of medicine and obstetrics and gynecology at Brown University and director of the division of obstetric and consultative medicine at Women & Infants Hospital of Rhode Island. Internists, even more than ob-gyn specialists who don't see women until they are already pregnant, should counsel women of childbearing age about things they can do to maximize their chance of having a healthy pregnancy.
Obesity puts both the mother and fetus at risk of developing serious health problems, from preeclampsia and gestational diabetes to neural tube defects and fetal death. One-third of women are obese, said Linda A. Barbour, FACP, an obstetric internist at the University of Colorado Health Sciences Center in Denver, and the problem is even worse among black and Hispanic women. In addition, the higher a woman's body mass index is, the greater the chance that she will need a C-section.
"Weight loss measures before pregnancy are critical," she said.
For the first time, the American College of Obstetricians and Gynecologists (ACOG) in August released recommendations for dealing with obesity during pregnancy. "Obesity in Pregnancy," which was published in the September issue of Obstetrics & Gynecology, urges physicians to counsel patients more about weight and its effect on pregnancy and delivery.
ACOG's recommendation for weight gain is 25 to 35 pounds for women of pre-pregnancy normal weight, and 15 pounds to 25 pounds for obese women. The guidance also urges ob-gyns to talk frankly with their patients about the medical risks of obesity.
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