Gastroenterology Consultations in Pregnancy
Sumona Saha, M.D.,1Joseph Manlolo, M.D.,2Christopher E. McGowan, M.D.,3
Steven Reinert, M.S.,4and Silvia Degli Esposti, M.D.5
Background: Training in gastrointestinal (GI) disorders in pregnancy is required for all gastroenterology fellows.
Nevertheless, the actual role of the gastroenterologist in the management of pregnant patients is unknown.
Establishing the characteristics of GI consultations in pregnancy can help focus trainee education and prepare
gastroenterologists for future practice. The purpose of this study was to determine the indications for consul-
tations in pregnancy and the gastroenterologist’s role in the evaluation and management of the pregnant patient.
Methods: A chart review was performed of all consecutive outpatient GI consultations for pregnant women at a
high-volume obstetrics hospital over a 3-year period. Referring source, patient characteristics, indication(s) for
consultation, diagnosis(es), change in management after consultation, and need for follow-up were recorded.
Results: We reviewed 370 charts. The mean age (?standard deviation [SD]) at referral was 28.7 years?6.5, and
mean weeks of gestation (?SD) was 21.3?8.8. Obstetrician=gynecologists requested most consultations (70.1%).
New GI symptoms arising in pregnancy comprised 35.4% of consultations, and worsening of a preexisting GI
disorder comprised 24.4%. The most common indications for consultation were viral hepatitis (20.2%), nausea
and vomiting (18.9%), and nonspecific abdominal pain (13.5%). The most common diagnoses were acute or
chronic viral hepatitis (17.8%), hyperemesis gravidarum (15.1%), gastroesophageal reflux disease (14.3%), and
constipation (13.0%). Consultation changed the diagnosis in 25.1% of patients and changed management in
78.6%. Follow-up was required in 77.3% of cases during pregnancy and 37.8% postpartum.
Conclusions: GI consultation in pregnancy is sought more frequently for the evaluation and management of GI
disorders not unique to pregnancy than for pregnancy-unique disorders. Although GI consultation changed the
diagnosis in a minority of cases, it changed management in the majority. Gastroenterologists should be familiar
with the most common indications for consultation in pregnancy and be prepared to evaluate and manage
pregnant women with GI disorders.
many medical conditions arising in pregnancy can be man-
aged by obstetricians alone, some problems are beyond their
scope of training and experience. Furthermore, with national
statistics showing a trend toward delayed childbearing1and
improvements in medical and surgical management allowing
women with chronic medical illness to conceive, the need
for medical consultants in the care of pregnant women is
Maternal=fetal medicine specialists and obstetric medicine
internists, where available, often take on the responsibility of
bstetricians are traditionally viewed as the main
providers of medical care to pregnant women. Although
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
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,3,4GI motility,5gallbladder
contractility,5and intrahepatic bile salt transport. In addition,
1University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
2Stony Brook University Medical Center, Stony Brook, New York.
3University of North Carolina, Chapel Hill, North Carolina.
4Lifespan Information Services, Providence, Rhode Island.
5The Warren Alpert Medical School of Brown University, Providence, Rhode Island.
JOURNAL OF WOMEN’S HEALTH
Volume 20, Number 3, 2011
ª Mary Ann Liebert, Inc.
immunological changes, such as maternal=fetal cell traffick-
ing7and maternal peripheral tolerance,8occur. 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 cur-
rently unknown. Establishing these indications, however, is
important for providing a focus for education for gastroen-
terologists and primary care providers who contribute to the
education with enhanced understanding of these conditions
will minimize the discomfort many nonobstetrician physi-
cians experience when confronted with a pregnant patient
with a GI or liver disorder and will improve maternal care.9
The purpose of this study was to determine the most
common indications for gastroenterology consultation in
pregnancy at a high-volume obstetrics hospital.
Materials and Methods
A retrospective chart review was conducted of all consec-
utive outpatient gastroenterology consultations for pregnant
women at the Center for Women’s Digestive Disorders at
Women and Infants Hospital, Providence, Rhode Island, over
a 3-year period. The study was conducted with the approval
of the Women and Infants institutional review board and in
compliance with the Health Insurance Portability and Ac-
of the nation’s leading specialty hospitals for women and
newborns. The primary teaching affiliate of the Alpert Med-
ical School of Brown University for obstetrics, gynecology,
and newborn pediatrics, Women and Infants Hospital is the
tenth largestobstetricalservice inthecountry. Morethan9700
deliveries take place in the hospital per year.
The Center for Women’s Gastrointestinal Services is a sec-
tion 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
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 con-
sultations for pregnant patients. Only outpatient consulta-
tions for new patients to the Center identified for the time
period specified were eligible for the study. Established pa-
tients of the Center who became pregnant during the study
period, women with multiple gestation pregnancies, and
women whose pregnancies ended in miscarriage were ex-
study period, only the first pregnancy was reviewed.
Medical charts were reviewed to ascertain patient demo-
graphics, obstetrical history, referring source, indication for
consultation, and final diagnoses (based on ICD-9 code).
Testing generated as a result of GI consultation, change in
management after consultation (defined as initiation or dis-
continuation of a medication, change in dosage or route of an
existing medication, recommendations for mode of delivery,
referral to another clinical service, or recommendations for
dietary changes), and need for GI follow-up during preg-
nancy or postpartum was also recorded. Patients with more
recorded. Patients with multiple final diagnoses had up to
four diagnoses included in the analysis.
Four hundred six outpatient GI consultations in pregnancy
were excluded as follows: (1) visit miscoding (patient not
pregnant at the time of consultation or patient previously
established at the Center at the time of pregnancy): 23, (2)
multiple gestation pregnancy: 6, (3) pregnancy ending in
miscarriage: 3, (4) second pregnancy during study period: 1,
and (5) patient chart missing or irretrievable: 14. The re-
maining 370 cases were included in this analysis.
Patients ranged in age from 14 to 51 years. The mean age
(?standard deviation [SD]) at referral was 28.7 years?6.5.
The median gravida per patient was 2.0 (range 0–9), and
median parity was 1.0 (range 0–8). Primigravidas comprised
36.7% of patients. The mean gestational age at the time of
referral was 21.3 weeks?8.8. Demographic data are sum-
marized in Table 1.
Obstetrician=gynecologists referred 70.1% of patients for a
consultation. Other referring providers included internal
Table 1. Characteristics of 370 Outpatient
CharacteristicTotal No. (%)
Mean age?SD (years)
Mean weeks gestation?SD (weeks)
Median gravida (range)
Median parity (range)
Midwife (family practice)
Emergency department physician
Maternalfetal medicine specialist
Main reason for referral
New GI symptoms in pregnancy
Worsening of preexisting GI
symptoms in pregnancy
Recurrent GI symptoms
in subsequent pregnancy
Advice on GI medication safety
in pregnancy or lactation
GI, gastrointestinal; SD, standard deviation.
360SAHA ET AL.
medicine providers (8.1%), family practice providers (5.4%),
and other gastroenterologists (4.1%) (Table 1).
Indications for consultation
Cases were categorized by main indication for consulta-
tion: 35.4% of consultations were for new GI symptoms aris-
ing in pregnancy, 24.4% for worsening of a preexisting GI
disorder or preexisting GI symptoms, 15.1% for GI symptoms
recurring in a subsequent pregnancy, and 3.0% for GI medi-
cation safety recommendations during pregnancy, lactation,
or both (Table 1).
The presenting symptoms=initial diagnoses of the consul-
tations are summarized in Table 2. The most common indi-
cations for consultation were viral hepatitis (20.2%), nausea
and vomiting (18.9%), and abdominal pain (13.5%).
The most common final diagnoses as a result of consulta-
tion were viral hepatitis (17.8%), hyperemesis gravidarum
(15.1%), and gastroesophageal reflux (14.3%) (Table 3). Con-
stipation was the fourth most common diagnosis, comprising
13.0% of consultations. The majority of patients diagnosed
with viral hepatitis had hepatitis B (n¼40), followed by
hepatitis C (n¼23) and acute hepatitis A (n¼3). Diagnosis of
viral hepatitis was based on serological testing or hepatitis B
DNA or hepatitis C RNA testing. Patients with hyperemesis
gravidarum were diagnosed based on the following findings:
intractable nausea and vomiting beginning at ?12 weeks of
gestation, ketonuria, and >5% loss of prepregnancy body
weight. A diagnosis of gastroesophageal reflux disease
(GERD) was made clinically based on symptoms of heartburn
(or pyrosis) or water brash. Lastly, constipation was diag-
nosed when patients reported having a bowel movement
fewer than three times per week or stools were described as
being hard, dry, small in size, and difficult to eliminate.
The pregnancy-unique liver diseases of intrahepatic cho-
lestasis of pregnancy, acute fatty liver of pregnancy, and he-
molysis elevated liver enzymes and low platelets (HELLP)
Table 2. Presenting Symptoms=Initial Diagnosis
No. of cases (%)
Viral hepatitis (chronic and acute)
Nausea and vomiting
Abdominal pain, not otherwise specified
Abnormal liver function tests
Inflammatory bowel disease (includes
ulcerative colitis, Crohn’s disease,
Perianal disease (includes anal fissure,
hemorrhoids, rectal pain)
Insufficient weight gain
Irritable bowel syndrome
Nonviral hepatitis (acute and chronic)
Gallstone disease (includes biliary colic,
and gallstone pancreatitis)
Peptic ulcer disease
Nutritional deficiency, fatigue after
aUp to four symptoms=initial diagnoses were recorded for each
Table 3. Final Diagnosis
No. of cases (%)
Viral hepatitis (acute and chronic)
Nausea and vomiting of pregnancy
Diarrhea (includes infectious
Abdominal pain, not otherwise specified
Inflammatory bowel disease (includes
Crohn’s disease, ulcerative colitis,
indeterminate colitis, and microscopic
Abnormal liver function tests
of unknown etiology
Helicobacter pylori gastritis
Gallstone and bile duct disease
(includes biliary colic,
Pregnancy-unique liver diseases (includes
intrahepatic cholestasis of pregnancy,
acute fatty liver of pregnancy, HELLP
Nonviral hepatitis (acute and chronic)
Hematemesis (includes Mallory Weiss
tear, esophageal varices)
Infectious colitis (includes Clostridium
Esophagitis (includes reflux
False positive viral hepatitis serology
Benign colon polyps
Peptic ulcer disease
Insufficient weight gain in pregnancy
aUp to four diagnoses were recorded for each case.
HELLP syndrome, hemolysis elevated liver enzymes and low
GI CONSULTATIONS IN PREGNANCY 361
syndrome, which are often the most feared indications for GI
consultation, accounted for only 2.4% of consultations. Con-
sultation led to a change in diagnosis in 25.1% of patients.
Management and follow-up
As a result of consultation, 84.5% of patients underwent
diagnostictesting. Laboratorytesting wasconducted in83.5%
of patients, diagnostic imaging in 25.4%, and endoscopy in
6.5%. Consultation led to a change in management in 78.6%
of patients. GI follow-up during pregnancy was scheduled
for 77.3% of patients and for 37.8% during pregnancy and
Mostphysicians agree thatinternists whospecialize should
know how to manage pregnant patients with medical prob-
lems specific to their specialty.10For gastroenterologists, this
is challenging, given that the many physiological, biochemi-
cal, and anatomic changes to the GI tract in pregnancy can
produce a spectrum of disorders. Knowing which conditions
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
for referral. Over 50% of consultations received were for viral
hepatitis (20.2%), nausea and vomiting (18.9%), and nonspe-
cific abdominal pain (13.5%). Most patients with viral hepa-
titis 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 symp-
toms extending beyond the first trimester or had signs and
symptoms suggestive of more aggressive disease (e.g., hy-
peremesis gravidarum) or another GI disorder. Finally, most
patients with abdominal pain were referred after pregnancy-
associated gynecological disorders (such as ectopic preg-
nancy, 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 encoun-
tered 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
laboratorystudies andpotentialrisks tothefetusinthecaseof
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 recommen-
dations, referral to another clinical service, and recommen-
dations for dietary changes. Therefore, similar to prior studies
examining consultation practices in obstetrics,11GI consulta-
tion 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
The Gastroenterology Leadership Council (GLC), com-
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 child-
bearing issues about which trainees should be knowledge-
able.12Although comprehensive teaching on allthese 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
Asaresult,gastroenterologists intraining lackself-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 inter-
ventions 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 Gy-
necology has stated that consultation should be sought when
the patient’s needs go beyond the primary caregiver’s edu-
cation, training, experience, or available resources.14Al-
though the frequency of GI consultation in pregnancy is not
known, given the rising rates of delayed maternal childbear-
ing and pregnancies complicated by chronic illness, it is
probable that as obstetricians are stretched farther, they will
request consultative services with greater frequency. At Wo-
men 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 preg-
nant 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. Al-
though 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 preg-
nancy. Based on trends at our center, we predict that pro-
viding 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 hos-
pital; therefore, patientsseen atour institution maynot 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 gastro-
enterology 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.
362SAHA ET AL.
GI tract physiology, which in turn can precipitate the onset of
new GI symptoms or exacerbate preexisting GI conditions,
very few data on the actual indications for GI consultation in
pregnancy exist. Our study highlights the most common in-
dications for outpatient GI consultation at a high-volume,
tertiary care obstetrics hospital. This lends focus to the issues
that gastroenterologists must be prepared to manage during
not unique to pregnancy are the most common indications for
to evaluate and manage these disorders in pregnancy so we
may serve as a valuable resource to our colleagues and im-
prove the quality of healthcare delivered to pregnant women.
We thank Steven Moss, M.D., and Colleen Kelly, M.D., at
Brown University for their careful review of the manuscript.
The project described was supported by Award Number
K12HD055894 (S.S.) from the Eunice Kennedy Shriver Na-
tional Institute of Child Health and Human Development.
The contentissolelytheresponsibility oftheauthorsand does
not necessarily represent the official views of the Eunice
Kennedy Shriver National Institute of Child Health and Hu-
man Development or the National Institutes of Health.
The authors have no conflicts of interest to report.
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Address correspondence to:
Sumona Saha, M.D.
Department of Medicine
Division of Gastroenterology and Hepatology
University of Wisconsin School of Medicine and Public Health
UW Medical Foundation Centennial Building, Room 4224
1685 Highland Avenue
Madison, WI 53705-2281
GI CONSULTATIONS IN PREGNANCY363