Maternal/fetal medicine specialists and obstetric medicine internists, where available, often take on the responsibility of managing the medically complicated pregnancy. However, given the rapid advancements in diagnostic techniques and pharmacotherapeutics in each subfield of internal medicine, internal medicine subspecialists may be called upon to lend expertise in the care of the pregnant woman. To prepare for this role, they must know the indications for referral to their specialty during pregnancy and how to offer accurate and safe diagnostic and therapeutic recommendations.

In the gastrointestinal (GI) tract, normal physiological changes during pregnancy produce dramatic modifications. Visceral organs rearrange to accommodate uterine growth. Ovarian and placental hormone levels fluctuate, altering esophageal sphincter pressure,^3,4 GI motility,⁵ gallbladder contractility,⁵ and intrahepatic bile salt transport. In addition, immunological changes, such as maternal/fetal cell trafficking⁷ and maternal peripheral tolerance,⁸ occur. These may produce adverse, beneficial, or neutral effects in the pregnant mother with regard to autoimmune and infectious disease. Pregnancy, therefore, poses a unique medical stress to the GI tract, and for many women, is a period of vulnerability for the development of new or exacerbation of existing GI disorders.

The indications for GI consultation in pregnancy are currently unknown. Establishing these indications, however, is important for providing a focus for education for gastroenterologists and primary care providers who contribute to the care of the medically compromised pregnant woman. Focused education with enhanced understanding of these conditions will minimize the discomfort many nonobstetrician physicians experience when confronted with a pregnant patient with a GI or liver disorder and will improve maternal care.⁹

The Center for Women's Gastrointestinal Services is a section of the Department of Medicine at Women and Infants Hospital. Five thousand outpatient visits to the Center take place per year. In addition, the Center receives 400 inpatient consultations per year. A women's-only endoscopy unit is located within the Center wherein 2700 procedures take place per year.

A list of all completed outpatient visits for pregnant women between October 1, 2004, and October 17, 2007, at the Center for Women's Gastrointestinal Services was generated using the IDX Flowcast Application (GE Healthcare). These cases were identified using the scheduling search term “PCON” (Pregnancy Consultation), which is used to code new consultations for pregnant patients. Only outpatient consultations for new patients to the Center identified for the time period specified were eligible for the study. Established patients of the Center who became pregnant during the study period, women with multiple gestation pregnancies, and women whose pregnancies ended in miscarriage were excluded. For patients with more than one pregnancy during the study period, only the first pregnancy was reviewed.

We found that GI conditions that complicate but are not unique to pregnancy comprised the most common indications for referral. Over 50% of consultations received were for viral hepatitis (20.2%), nausea and vomiting (18.9%), and nonspecific abdominal pain (13.5%). Most patients with viral hepatitis were asymptomatic and diagnosed during routine prenatal care either during mandatory universal screening (hepatitis B) or after risk factor-based screening (hepatitis C). Most women referred for nausea and vomiting had symptoms extending beyond the first trimester or had signs and symptoms suggestive of more aggressive disease (e.g., hyperemesis gravidarum) or another GI disorder. Finally, most patients with abdominal pain were referred after pregnancy-associated gynecological disorders (such as ectopic pregnancy, miscarriage, or preterm labor) were ruled out.

It is notable that the most common indications for referral were for conditions or symptoms that are routinely encountered in gastroenterology practice. In the pregnant patient, however, their workup and management require special considerations. Differential diagnoses must include pregnancy-unique conditions. In addition, ordering and interpretation of diagnostic tests must account for the normal biochemical and physiological changes of pregnancy in the case of routine laboratory studies and potential risks to the fetus in the case of endoscopy and diagnostic imaging studies. Lastly, the safety of medications during pregnancy and lactation must be known, given the need to initiate, discontinue, or change the dose of a medication in 6.2% of cases and to render advice on medication safety in 3% of cases.

In the majority of cases, GI consultation confirmed the initial diagnosis of the referring provider. However, despite a change in diagnosis in 25.1% of cases, 78.1% of patients did undergo a change in management as a result of consultation. Changes in management included medication initiation, discontinuation or dose/route change, delivery recommendations, referral to another clinical service, and recommendations for dietary changes. Therefore, similar to prior studies examining consultation practices in obstetrics,¹¹ GI consultation served an important role in patient management, moreso than in diagnosis. Our study was not designed to measure the impact of the management changes on maternal and neonatal outcomes; however, this is an important area for future study.

The Gastroenterology Leadership Council (GLC), comprised of the four main U.S.- based professional gastroenterology societies, has recognized the importance of pregnancy-related GI disorders and has made training in this area a required component of gastroenterology fellowship. The GLC has published an extensive list of specific pregnancy and childbearing issues about which trainees should be knowledgeable.¹² Although comprehensive teaching on all these topics is ideal, multiple barriers, such as limited numbers of GI faculty with expertise in pregnancy issues and poor collaboration with obstetricians/gynecologists, limit the training process.¹³ As a result, gastroenterologists in training lack self-efficacy, or a sense of capability, in the evaluation and treatment of pregnant women, which may lead to delayed treatment or inappropriate care. Until the barriers to training are removed and comprehensive training is provided, educational interventions targeted toward the most common indications for consultation can fill the immediate need for expertise on pregnancy issues in gastroenterology.

Not unexpectedly, obstetrician/gynecologists comprised the largest referring source in our study, initiating 70.5% of consultations. The American College of Obstetrics and Gynecology has stated that consultation should be sought when the patient's needs go beyond the primary caregiver's education, training, experience, or available resources.¹⁴ Although the frequency of GI consultation in pregnancy is not known, given the rising rates of delayed maternal childbearing and pregnancies complicated by chronic illness, it is probable that as obstetricians are stretched farther, they will request consultative services with greater frequency. At Women and Infants Hospital, we have experienced a stable number of newborn deliveries from 2004 to 2009 (mean±SD, 9286±258). In comparison, the frequency with which pregnant women have been seen in our GI clinic over this period has steadily increased. In 2006, there were 206 outpatient encounters for a new consultation in pregnancy or follow-up of a GI disorder in pregnancy at the Center for Women's Gastrointestinal Services. In 2009, this number was 699. Although the appropriateness of these visits was not assessed in this study, the greater than 3-fold rise in the number of visits over 3 years suggests there is an increasing need or demand for gastroenterologists' oversight of women during pregnancy. Based on trends at our center, we predict that providing consultative support to the primary healthcare providers of pregnant women will become an increasingly important function for gastroenterologists in the future.