What to expect when you’re taking care of a patient who’s expecting! This fantastic episode will help you work through preconception counseling with ease, assess and treat non-obstetrical acute concerns in pregnant patients, and help you conceptualize best practices for postpartum care. We are joined by expert guest Dr. Xiaolei Chen.
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Pregnancy puts stress on the body, so a preconception visit should be an overall risk assessment for that particular patient. It is important to assess if there is anything about the patient’s chronic medical conditions, lifestyle, or family history that could pose risk for a deviation from a normal, healthy pregnancy. Check out these fantastic checklists on preconception care from a paper that Dr. Chen co-authored.
For all new patients with a uterus, regardless of if they are planning a pregnancy, it is important to review an obstetric history to get a sense of pregnancy conditions such as gestational diabetes and preeclampsia which may raise risk of future health challenges (Ogunwole et al, 2021).
It is reasonable to ask patients whether or not they are planning for pregnancy at their annual visit and include this information in their social history. If they are planning for pregnancy in the next 6 months to a year, this will prompt a more detailed preconception conversation.
When talking to the patient, assess their lifestyle and make appropriate recommendations to optimize the patient for a healthy pregnancy. Touch on exercise, smoking, alcohol, substance use, caffeine, and sleep.
Dr. Chen advises her patients to develop a stable exercise regimen before or early in pregnancy and try to maintain it. Studies have found exercise reduces risk of preeclampsia (Weissgerber, 2004). It is advised to avoid exercise that has a risk of falls, such as skiing or rock climbing and exercise with risk of severe dehydration like hot yoga and saunas (Artal, 2021)
Some caffeine (1-2 cups of coffee) is ok during pregnancy (Garner, 2021).
There are no specific labs Dr. Chen orders for a preconception visit. Rather, she recommends tailoring labs to the patient’s age and specific medical conditions.
There is no medical reason to avoid vaccination during pregnancy. There are no particular vaccinations to order during a preconception visit; rather, evaluate appropriate vaccines for the patients age and risk factors. Every pregnant patient is recommended a Tdap during their 3rd trimester. The influenza vaccine is recommended for pregnant patients (CDC, 2021).
Dr. Chen recommends reviewing each patient’s chronic medications and medical conditions one by one to determine how to proceed during pregnancy. In recent years, there has been a shift away from the five FDA letter risk categories – A, B, C, D, and X – and towards a more individualized assessment of risk and benefit of each medication. A patient on a high risk medication, such as warfarin, and cannot come off it, might require a multidisciplinary approach and discussion (Ogunwole et al, 2021).
You might consider reviewing each medication in the literature prior to the visit to simplify the information for the patient. Pregnant people are often left out of clinical trials, so studies that come out about medications in pregnancy are often retrospective and subject to biases.
Specific medication advice:
Infections: treat the same as in nonpregnant patients. Dr. Chen points out that during pregnancy there should be a lower threshold to treat infections and close monitoring because the immune system is suppressed. Antibiotics to avoid in pregnancy include fluoroquinolones (risks of renal toxicity, cardiac defects, and central nervous system toxicity in the fetus) and tetracyclines (risks of congenital defects, teeth/bone discoloration) (Bookstaver et al, 2015). Sulfonamides may be used in certain times of pregnancy, but is best avoided during the first trimester and during the last month of pregnancy (May, 2020). In general, beta lactam antibiotics are the preferred choice for pregnant patients (Bookstaver et al, 2015). Acetaminophen is safe in pregnancy. However, ibuprofen and other NSAIDs should be avoided especially during the third trimester (Bermas, 2021).
Dr. Chen’s go-to medications for common complaints:
Patients with fairly mild, well controlled essential hypertension often do not need medication during the first trimester as blood pressure falls during this time, reaching a nadir around 22-24 weeks (James & Nelson-Piercy, 2004). However, this should be monitored closely for development of worsening hypertension.
Pregnancy is associated with worsening insulin resistance, so patients with pre-existing diabetes should be monitored carefully. Often patients have to be switched to insulin during pregnancy (Zera and Brown, 2021). Patients with poorly controlled diabetes during pregnancy will often be referred to the maternal fetal medicine service, per Dr. Chen. Patients without diabetes pre-pregnancy may develop gestational diabetes, which can often be managed with diet (Durnwald, 2021).
Well-controlled asthma will not usually need medication changes, in Dr. Chen’s expert opinion.
Gestational hypertension is defined as new onset elevated blood pressure greater than 140/90 after 20 weeks but without organ damage or proteinuria. Preeclampsia is elevated blood pressure after 20 weeks accompanied by proteinuria or end organ damage. There is an increased risk of future cardiovascular disease in patients with a history of preeclampsia, but this is less clear in patients with gestational hypertension. Dr. Chen recommends checking blood pressure closely within the first 6-8 weeks postpartum, at the 6 month visit, and then annually after (Ogunwole et al, 2021). Preeclampsia labs can be repeated to ensure any abnormalities have resolved: AST/ALTs, creatinine, urine studies (for proteinuria).
Postpartum depression is a common condition after delivery (Howard et al, 2014). The PHQ-9 or the Edinburgh Postnatal Depression Scale can be used to monitor mood. Screening for Intimate Partner Violence (IPV) should be routinely done at every annual visit, and should also be a part of the postpartum visit which is usually done by an obstetrician (USPSTF 2018).
Gestational diabetes increases risk of lifetime type 2 diabetes (Lowe, 2018). Check HbA1c 3-6 months postpartum and then annually after (Ogunwole et al, 2021).
Dr. Chen recommends repeating a CBC at 6 months postpartum if there was significant anemia during pregnancy. It is helpful to ensure the anemia has resolved, particularly if the patient goes on to have another pregnancy within a short interval. Anemia has also been shown to increase the risk of postpartum depression. Review this excellent checklist from a paper Dr. Chen recently co-authored for more help on thinking about postpartum care.
Dr. Chen recommends patients stay on their prenatal vitamin at least 2-3 months postpartum, and then continue to take it for the whole duration that the patient breastfeeds. A well balanced, nutritious diet is helpful in maintaining electrolytes. In general, there are similar guidelines for medications during breastfeeding as during pregnancy, but it is slightly more permissive. Dr. Chen uses the Hale’s Medications & Mothers’ Milk Handbook to reference specific medications.
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Listeners will appreciate how to manage primary care concerns for pregnant and postpartum patients.
By the end of this podcast listeners will:
Dr. Chen reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
Chen, X, Williams PN, Watto MF, Garbitelli B. #305 Obstetrics for Internist. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list November 15, 2021.
The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.
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