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Medical Principles in Obstetrical Consults

nurse showing an elderly woman something on a tablet in office

The ideal pregnancy should be medically uncomplicated. In contrast, maternal mortality in the United States equates to approximately 3 deaths per day and averages approximately 1 in 4000 live births (a total of 1063 deaths in 2015).1 Moreover, the annual number of maternal deaths has nearly doubled in the last 25 years for the United States, unlike most other causes of mortality in young adults.1 Of course, the majority of women survive, yet 1 in 10 will suffer from some illness during pregnancy, amounting to approximately 800,000 total cases in 2015 for the United States.2 In total, pregnancy accounts for approximately 30 million patient-days in the hospital annually.3

Most maternal deaths can be prevented and most perinatal illnesses are treatable, thereby underscoring the importance of an internist in the care of pregnant patients (hereafter referred to as obstetric medicine). The classic approach in obstetric medicine tends to divide illnesses into 3 categories: 1) chronic conditions that predate pregnancy (eg, asthma); 2) new conditions that occur because of pregnancy (eg, hyperemesis); and 3) acute conditions that are unrelated to pregnancy (eg, pneumonia). Context matters too because the surrounding social contributors may be complex, including social isolation and financial deprivation. A further nuance is that many illnesses in pregnancy resolve spontaneously with no intervention.

Consultation in obstetric medicine requires a different expertise than that for older adults with multiple comorbidities. Even so, standard textbooks, formal medical training, and evidence-based medicine provide little guidance for internists involved in the care of pregnant women. This commentary identifies selected principles for the medical care of pregnant women based on our experience. These distinctions may sometimes make managing pregnant patients entirely special and distinctive, comparatively more straightforward, or comparatively more complex compared with managing other patients in internal medicine (Table).

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-Jonathan S. Zipursky, MD, FRCPC, Donald A. Redelmeier, MD, FRCPC, MSHSR

This article originally appeared in the December issue of The American Journal of Medicine.

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