When a pregnant woman requires hospitalization for a medical issue, the management of her care may fall into a bit of “a gray zone” as Lisa Bernstein, MD, FACP, describes it.
Hospitalists are accustomed to treating hypertension, diabetes, or deep venous thrombosis, but “as soon as you throw pregnancy in the mix, they get nervous,” said Dr. Bernstein, an associate professor of medicine at Emory University School of Medicine in Atlanta.
On the other side, obstetricians/gynecologists are well attuned to pregnancy-related complications, such as preeclampsia. “But again when you throw in medical issues on top of pregnancy, it becomes this area that nobody is exactly comfortable with,” Dr. Bernstein said. “So it's really about trying to bridge that gap.”
Hospitalizations are not that uncommon during pregnancy, with 5.7% of pregnant women hospitalized and discharged while still pregnant, according to an analysis published by Obstetrics & Gynecology in 2002. (An additional 2.1% of the women experienced a pregnancy loss.)
With their medical expertise, hospitalists can play a vital role in treating these women, Dr. Bernstein and other experts said. The guiding principle is to start by developing the treatment plan as though the patient were not pregnant. Then read up on any medication or other concerns relevant in pregnancy, and consult with specialists to hammer out the safest course.
“It's a matter of what's reasonable and indicated—not a matter of safe versus not,” said ACP Member Michael Carson, MD, an associate professor of medicine and obstetrics/gynecology at Hackensack Meridian School of Medicine at Seton Hall University in New Jersey. “The bottom line is the best thing for a healthy baby is a healthy mother.”
When weighing diagnostic or treatment steps for a pregnant patient, Dr. Carson considers the downside of not getting a specific test or drug. “The downside is often, ‘I don't know what the patient has, or the mom can get sicker without the treatment,’” he said. “That real tangible benefit, which you can quantitate, is typically going to outweigh the theoretical and rare downsides of the test or the medication.”
Weighing safety risks
In evaluating the safety of a medication for a pregnant patient, there are several factors for physicians to consider, including the stage of fetal development and how long the medication will be needed, Dr. Carson said. “One dose of any drug has never been shown to be harmful to any fetus,” he said, with the exception of radioactive iodine.
Some medications, such as warfarin, can be teratogenic with longer use but that list is short, Dr. Carson said. Physicians can check online medical and drug databases for the relative safety and mechanism of any drugs that they're considering prescribing, he said. For instance, enoxaparin and unfractionated heparin are preferred as anticoagulants during pregnancy because they don't cross the placenta.
Medications should be particularly avoided in the first trimester if at all feasible, since that's when the fetus's organs are developing, Dr. Bernstein said. “But if you need it, you use it,” she said. “If she has uncontrolled diabetes or uncontrolled hypertension, that is far more dangerous to a pregnancy outcome than worrying about the medication.”
Such worries are common in practice, the experts said. In some cases, “internists or nonobstetricians are very skittish to even give any medication to a patient. So instead of providing the best care of the patient, you are withholding the treatment, because you don't think that it can be given to the patient,” said Diana Ramos, MD, MPH, an associate clinical professor in obstetrics and gynecology at the Keck School of Medicine of the University of Southern California, Los Angeles.
Similarly, don't delay in ordering an imaging test if it's needed for diagnosis, Drs. Bernstein and Ramos said. A study published July 24 by JAMA Network Open evaluated recent trends in CT imaging in pregnant women and found that overall scans increased nearly fourfold in the U.S. from 1996 to 2016, but leveled off starting in 2007 and have been declining since 2010.
Dr. Ramos called the findings interesting and indicative of broader trends in imaging tests in all patients regardless of pregnancy. “You do have to realize the risk of the radiation,” she said, while not losing sight of the bigger picture. “Again you're going to go back to making the diagnosis that's going to help diagnose and treat and maybe even save the mom's life versus not.”
In some circumstances, a noninvasive image or one without radiation, such as an ultrasound, might be an alternative, Dr. Bernstein said. For instance, since the treatment for a deep venous thrombosis and a pulmonary embolism are the same, if a pregnant woman has swelling in one leg and a clot is suspected, an ultrasound would be the preferred test. But if there's no leg swelling and the physician suspects a possible pulmonary embolism, a chest CT scan should be ordered, along with protective measures, such as shielding the woman's abdomen, she said.
“If, diagnostically, you would do this for a patient who wasn't pregnant and there is no other way to get the information, then you do it,” Dr. Bernstein said.
With few exceptions, radiation exposure through CT scans and nuclear medicine imaging is “at a dose much lower than the exposure associated with fetal harm,” according to the most recent committee opinion on diagnostic imaging from the American College of Obstetricians and Gynecologists (ACOG), published in 2017. (The opinion also notes that the use of gadolinium contrast with MRI should be limited and that it should only be used as the contrast agent “if it significantly improves diagnostic performance and is expected to improve fetal or maternal outcome.”)
To date, no fetal abnormalities, growth restriction, or spontaneous abortion have been seen at radiation exposure levels of less than 50 mGys (5 Rads), according to the 2017 ACOG committee opinion. Using an accompanying ACOG table that delineated fetal exposure of various imaging tests, Dr. Carson showed in a talk at Internal Medicine Meeting 2019 in Philadelphia in April that many imaging tests could be ordered before reaching that threshold. That would include 75 to 5,000 chest CT scans and 5,000 to 100,000 chest X-rays, he said.
If a chest CT scan is needed to diagnose a pulmonary embolism, that's well below the threshold, Dr. Carson said. Plus, he said, ordering the test is preferable to prescribing an anticoagulant for a pregnant patient without knowing what's being treated.
Hyperemesis gravidarum is one of the leading reasons pregnant women are hospitalized. It was cited in 9.3% of cases, second behind only preterm labor (24.4%), in the 2002 analysis in Obstetrics & Gynecology. The other most common reasons were hypertension (9.1%), kidney disorders (6.2%), and premature rupture of membranes (6.1%).
At large hospitals with an obstetrics service, these patients would likely be treated by an obstetrician, but at a smaller community hospital without on-site obstetrics, a hospitalist would likely assume that role, said Karyn Kolman, MD, a practicing hospitalist and an assistant professor in the department of family and community medicine at the University of Arizona College of Medicine-Tucson. “Patients don't always understand that all hospitals don't do all things, so they go to their nearest emergency department,” she said.
Between 0.3% and 3% of pregnant women will develop hyperemesis gravidarum. The pregnancy complication doesn't have a single accepted definition, but rather is diagnosed when other clinical causes of the symptoms are ruled out, according to the most recent ACOG practice bulletin on nausea and vomiting, published in 2018. An outpatient doctor might refer the woman to the hospital if she's dehydrated, has tachycardia, or has lost weight, Dr. Kolman said. “Any weight loss is significant because you shouldn't be losing weight while you're pregnant,” she said.
By the time these women reach the hospital, they often are “in this horrible cycle of nausea and vomiting and no matter what they do, they can't keep anything down,” Dr. Kolman said. “And a lot of times dehydration is feeding that cycle.” While other causes of the symptoms are being ruled out, she said, IV fluids can be started.
Thyroid disease, whether existing or new (including transient gestational hyperthyroidism), is associated with hyperemesis, so it's a good idea to run a thyroid test if the woman has other symptoms that might point to thyroid problems, Dr. Kolman said.
But because thyroid results can be tricky to interpret during pregnancy, she recommends consulting with an obstetrician, an endocrinologist, or other subspecialist. Other bloodwork, including a complete blood count, can be done to check for any underlying sign of infection, as well as electrolytes and kidney function, she said.
There also is the rare possibility that any of several nutritional deficiencies can result from hyperemesis, including deficiencies of thiamine or folate, said Dr. Kolman, adding that she hasn't seen these deficiencies herself, only issues with dehydration or electrolyte imbalances.
To treat vomiting, the ACOG practice bulletin recommends four possible medications that can be administered intravenously in dehydrated patients, including dimenhydrinate and metoclopramide. Once the woman's symptoms improve, she can be switched to an oral version of the selected drug and then sent home with vitamin B6 and doxylamine to hopefully keep her nausea sufficiently at bay to get adequate nutrition, Dr. Kolman said.
When the woman is discharged, be sure to line up close follow-up with an outpatient physician, as readmission is not uncommon, Dr. Kolman said. “This [hyperemesis] is usually limited to the first trimester, but it can extend into the second trimester.”
For a hospitalist evaluating a pregnant woman, one of the biggest challenges is differentiating the normal symptoms of pregnancy from a potential medical condition, Dr. Bernstein said. “A lot of what would make us nervous in a nonpregnant patient can be quote unquote ‘normal’ in a pregnant patient,” she said, ticking off several examples, including shortness of breath, swelling in the legs, and a systolic heart murmur.
Still, other potential causes need to be pursued, Dr. Bernstein said. She described a scenario in which a pregnant woman comes to the hospital, reports being unable to breathe comfortably while lying down, perhaps gasping for breath at night, and also has swelling in her legs. In that case, physicians should consider the possibility of peripartum cardiomyopathy, which can develop toward the end of pregnancy or postpartum, and perform a physical exam along with ordering an echocardiogram, she said.
Other conditions can flare for the first time or be unmasked during pregnancy, such as a thyroid problem, Dr. Bernstein said. Pregnant women also are more vulnerable to developing gallstones, she said. Both she and Dr. Kolman stressed that doctors should stay savvy to other hidden issues, such as intimate partner violence, that might be causing a pregnant woman to keep returning to the hospital. It's important that patients are screened without their partners present, they stressed.
Or something else might explain frequent hospital visits, Dr. Kolman said. “Maybe it's depression or some sort of mental health issue that she is grappling with and she doesn't really know how to say it.”
Above all, hospitalists should embrace the value of their internal medicine knowledge to quarterback care, Dr. Carson said. Don't get intimidated, and consult and comanage with other specialists along the way.
“What you need is for the OB and medicine attendings to talk possibly every day to reassure one another, and maybe it's more the medicine people getting reassured,” Dr. Carson said. “Get support on, ‘Are we doing the right thing for both the mom and the baby?’”