Most physicians agree that internists who specialize should know how to manage pregnant patients with medical problems specific to their specialty.10
For gastroenterologists, this is challenging, given that the many physiological, biochemical, and anatomic changes to the GI tract in pregnancy can produce a spectrum of disorders. Knowing which conditions are most likely to be encountered in practice is needed to focus educational efforts in pregnancy issues such that accurate diagnostic and therapeutic recommendations may be offered.
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
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.
Limitations of our study include that this is a single-center experience and may not reflect national trends in GI referral. Women and Infants Hospital is a tertiary care obstetrics hospital; therefore, patients seen at our institution may not mirror the general obstetrics population. In addition, Women and Infants is unique in that it is an obstetrics hospital with full-time gastroenterologists on staff. The integration of gastroenterology into the clinical services at Women and Infants has created a stronger collaboration between gastroenterology and obstetrics than at most centers. This likely has influenced the volume and nature of consultations received.