#305 OB for the Internist: What to Expect

November 15, 2021 | By Beth Garbitelli

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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Credits

• Producer: Beth Garbitelli
• Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP; Beth Garbitelli 
• Show Notes by: Shelagh Browne
• Cover Art and Infographic: Edison Jyang 
• Reviewer:   Molly Heublein MD
• Editor: Matthew Watto MD (written materials); Clair Morgan of nodderly.com
• Guest:  Xiaolei Chen MD

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Show Segments

• Intro
• Picks of the week 
• Preconception counseling
• Lifestyle: caffeine, alcohol, exercise 
• Preconception medications 
• Management of acute complaints during pregnancy 
• Go-to medications for acute complaints during pregnancy
• Chronic diseases during pregnancy
• Postpartum management
• Breastfeeding recommendations
• Take-home points
• Outro 

Obstetrics for Internist Pearls 

1. Focus on individualizing the care for each pregnant patient. Emphasize risk/benefit analysis for each medical condition and medication. 
2. Ask about the patient’s pregnancy history. A history of gestational diabetes increases the risk of developing type 2 diabetes later in life. History of preeclampsia increases the likelihood of future cardiovascular disease. It is important to know this so that the patient can be monitored accordingly.
3. Start folic acid anytime a patient is contemplating pregnancy.
4. Most SSRIs are safe in pregnancy. The American College of Obstetricians and Gynecologists recommends against use of paroxetine, however. 
5. Most antibiotics are safe in pregnancy, however it is recommended to avoid fluoroquinolones and tetracyclines. 
6. For pregnant patients with headache: extra strength tylenol, metoclopramide, caffeine, and hydration. 
7. For pregnant patients with nausea, doxylamine and pyridoxine, and can also consider metoclopramide or an anti-histamine. 
8.  There is a risk of postpartum depression up to one year after delivery. PHQ-9 or Edinburgh Postnatal Depression can be used at each visit to monitor.

Preconception Counseling 

Taking a History

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. 

Lifestyle Counseling

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). 

Labs, Medications, and Vaccinations

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:

• Dr. Chen advises patients to start folic acid anytime they are thinking about pregnancy (Goetzl, 2021). 

• Taper down benzodiazepines before pregnancy as able (Shyken et al, 2019).

• For patients with opioid dependence, buprenorphine and methadone are approved during pregnancy (NIDA, 2017)

• SSRIs are safe in pregnancy. However, the American College of Obstetricians and Gynecologists recommends against paroxetine as first line treatment  (Malm et. al, 2011). 

Management of Acute Complaints during Pregnancy

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: 

• Headache: Extra strength acetaminophen, metoclopramide, small caffeinated beverages, and increase overall oral hydration.  Many patients have persistent headaches that start in pregnancy, says Dr. Chen.  If they are taking acetaminophen and metoclopramide every day or a few times a week, start daily 400 mg magnesium oxide.  If trouble with sleep is causing headache, Dr. Chen will start low-dose amitriptyline.  For patients with chronic headaches or migraines prepregnancy, adjustment of their chronic medications might be necessary. 

• Nausea: Pyridoxine (vitamin b6) and doxylamine are generally considered first line treatments for nausea/vomiting in pregnancy (Herrell 2014).  Since constipation can exacerbate nausea symptoms, Dr. Chen also recommends considering low-dose or limited course of metoclopramide as extra pyramidal symptoms are rare (Pasternak 2013), or an antihistamine, which is considered safe in pregnancy (Gilboa, 2014). Ondansetron can be used but should be saved as a second-line drug.

• Constipation: Docusate, metamucil, milk of magnesia are safe during pregnancy. Stimulant laxatives such as bisacodyl or senna as second-line and with caution during pregnancy (Cullen, 2007). Dr. Chen advises that patients stay on top of their bowel regimen, and make sure they are eating a fiber-rich diet, hydrating adequately, and exercising. 

Common Chronic Diseases During Pregnancy

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. 

Postpartum Management

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. 

Breastfeeding
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. 

Links*

1. You’re Next (IMDB) 
2. Such a Fun Age by Kiley Reid 
3. Uprooted by Naomi Novik
4. ACOG Prepregnancy Counseling  
5. ACOG Practice Bulletin No. 201: Pregestational Diabetes Mellitus. (2018). Obstetrics and Gynecology. https://doi.org/10.1097/AOG.0000000000002960
6. ACOG Practice Bulletin No. 190: Gestational Diabetes Mellitus. (2018). Obstetrics and Gynecology. https://doi.org/10.1097/AOG.0000000000002501
7. ACOG Practice Bulletin No. 203: Chronic Hypertension in Pregnancy. Obstet Gynecol. 2019 Jan;133(1):e26-e50. https://doi.org/10.1097/AOG.0000000000003020
8. Ogunwole SM, Chen X, Mitta S, Minhas A, Sharma G, Zakaria S, Vaught AJ, Toth-Manikowski SM, Smith G. Interconception Care for Primary Care Providers: Consensus Recommendations on Preconception and Postpartum Management of Reproductive-Age Patients With Medical Comorbidities. Mayo Clin Proc Innov Qual Outcomes. 2021 Sep 16;5(5):872-890. doi: 10.1016/j.mayocpiqo.2021.08.004. PMID: 34585084; PMCID: PMC8452893.
9. Magee LA, von Dadelszen P, Rey E, Ross S, Asztalos E, Murphy KE, Menzies J, Sanchez J, Singer J, Gafni A, Gruslin A, Helewa M, Hutton E, Lee SK, Lee T, Logan AG, Ganzevoort W, Welch R, Thornton JG, Moutquin JM. Less-tight versus tight control of hypertension in pregnancy. N Engl J Med. 2015 Jan 29;372(5):407-17. doi: 10.1056/NEJMoa1404595. 
10. PHQ-9 
11. Edinburgh Postnatal Depression Scale
12. Hale’s Medications & Mothers’ Milk 
13. InfantRisk Center Resource guide (and apps!) h/t to listener Dr. Ashley Parks of York Hospital FM Residency

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on our Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.

Goal

Listeners will appreciate how to manage primary care concerns for pregnant and postpartum patients. 

Learning objectives

By the end of this podcast listeners will:

1. Review basic screening, nutritional, and referral tools for patients seeking pregnancy.
2. Advise patients on pre-conception relevant topics such as nutrition, vaccination, genetic screening, and more.
3. Manage basic primary care and acute concerns in the pregnant or breastfeeding patient.
4. Counsel patients effectively about pharmaceuticals that may impact breastfeeding. 
5. Evaluate for sequelae of pregnancy and breastfeeding including postpartum depression and mastitis. 

Disclosures

Dr.  Chen reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

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.