This is an area where an OB consult can be especially helpful to balance the needs of mother and baby. If a particular drug is not the best choice for a fetus, an OB can help find the next best option. The specialist’s familiarity with the use of medications in pregnancy may also shed light on a drug labeled “unsafe”: it may be problematic only during certain gestational ages or in concert with a particular drug.
Dr. McCue
“Sometimes right medication use is not obvious,” says Brigid McCue, MD, chief of the department of OB/GYN at Jordan Hospital in Plymouth, Mass. “Most people would not assume a pregnant woman could undergo chemotherapy for breast cancer or leukemia, but there are options out there. Many patients have been treated for cancer during their pregnancy and have perfectly healthy babies.
“It is a challenge, and every decision is weighed carefully. There is usually some consequence to the baby—maybe it is delivered early or is smaller. But it’s so much nicer for the mom to survive her cancer and be there for the baby.”
8 You can determine gestational age by the position of the uterus relative to the umbilicus.
To make a correct judgment about which medications to use, as well as other treatment decisions, it is vital to ascertain the gestational age of the fetus, but in an acute emergency, there may not be time to do an ultrasound to determine gestational age.
A good way to determine gestational age is to use the umbilicus as a landmark during the physical exam. The rule of thumb is that the uterus touches the umbilicus at 20 weeks and travels one centimeter above it every week thereafter until week 36 or so. As with left lateral uterine displacement after 20 weeks, this rule applies to singleton pregnancies. Multiple fetuses cause a larger uterus earlier in the pregnancy.
click for larger image.Figure 2. Causes of pregnancy-related deaths in the U.S., 2006-2009Source: Centers for Disease Control and Prevention. Division of Reproductive Health. Maternal and Infant Health. Pregnancy Mortality Surveillance System.
9 Do not use lower extremities for vascular access in a pregnant woman.
Dr. Zelop
Dr. Zelop points out that the weight of a pregnant uterus can “significantly compromise intravascular blood flow in the lower extremities.”
“Going below the waist for access can be problematic,” she adds. “Although there may be cases of trauma that make access in the upper limbs difficult or impossible, the lower extremities are not a viable choice.”
Some resuscitation protocols recommend intraosseous access; however, the lower extremities are still not recommended for access in a pregnant woman.
10 The pregnant airway must be treated with respect.
The pregnant airway differs from that of a nonpregnant woman in many important ways, so if intubation becomes necessary, make sure you are familiar with what you are facing. The airway is edematous, which varies the usual landmarks. Increased progesterone causes relaxation of the sphincters between the esophagus and the stomach, and this change predisposes pregnant women to aspiration and loss of consciousness.
In some studies, a failure rate as high as one in 250 is reported. If the patient’s airway needs to be secured, find the most experienced person available to do the intubation. Also, use a smaller tube than would be used for a nonpregnant intubation, usually one size down.
Always ask a woman in labor if she has had any complications during her pregnancy before doing a vaginal exam.