A hospitalist unfamiliar with the correct parameters in pregnancy could make a significant and life-threatening misjudgment.5
4 Thromboembolism and pulmonary embolism are some of the most common causes of maternal death.6
According to Carolyn M. Zelop, MD, board certified maternal-fetal medicine specialist and director of perinatal ultrasound and research at Valley Hospital in Ridgewood, N.J., “Thromboembolism and pulmonary embolism should always remain part of your differential, even if they are not at the top of the list of possible diagnoses.
“Tests required to exclude these diagnoses, even though they involve very small amounts of radiation, are important to perform,” says Dr. Zelop, a clinical professor at NYU School of Medicine in New York City.
Approaching these diagnostic tests with caution is justified, but it is trumped by the necessity of excluding a life-threatening condition.
5 Prior to 20 weeks, admit the patient to the physician treating her chief complaint.
“Whatever medical condition brings a patient to the hospital prior to 20 weeks, that is the physician that should do the admission,” Dr. Olson says. “If she is suffering from asthma, the internal medicine hospitalist or pulmonologist should admit. If it is appendicitis, the surgeon should do the admission.
“We need to take care of pregnant patients just as well as if they weren’t pregnant.”
During the first half of the pregnancy, care should be directed to the mother. Up until 20 weeks, what is best for the mother is what is best for the baby because the fetus is not viable. It cannot survive outside the mother, so the mother must be saved in order to save the fetus. That means you must give the mother all necessary care to return her to health.
click for larger image.Figure 1. Pregnancy-related hospitalizations by diagnosisSource: Data from National Hospital Discharge Survey, 1999 – 2000
6 After 20 weeks, make sure a pregnant woman is always tilted toward her left side—never supine.
Once an expectant mother reaches 20 weeks, the weight of her expanding uterus can compress the aorta and inferior vena cava, resulting in inadequate blood flow to the baby and to the mother’s brain. A supine position is detrimental not only because it can cause a pregnant woman to feel faint, but also because the interruption in normal blood flow can throw off test results during assessment. Shifting a woman to her left, even with a small tilt from an IV bag under her right hip, can return hemodynamics to homeostasis.
“Left lateral uterine displacement is particularly critical during surgery and while trying to resuscitate a pregnant woman who has coded,” Dr. Zelop says. “The supine position dramatically alters cardiac output. It is nearly impossible to revive someone when the blood flow is compromised by the compression of the uterus in the latter half of pregnancy.”
Click here to listen to Dr. Carolyn Zelop discuss cardiovascular emergencies in pregnant patients.
Remember, however, that the 20-week rule applies to single pregnancies—multiples create a heavier uterus earlier in the pregnancy, so base the timing of lateral uterine displacement on size, not gestational age.
7 Almost all medications can be used in pregnancy.
Despite the stated pregnancy category you read on Hippocrates and warnings pharmaceutical companies place on drug labels, almost all medications can be used in an acute crisis, and even in a subacute situation. As with the choice to perform the necessary tests to correctly diagnose a pregnant woman, the correct drugs to treat the mother must be used. Although there are medications to which you would not chronically expose a fetus, in an emergency situation, they may be acceptable.