Case Scenario

I have a 26-year-old patient whose first child was born at 30 weeks and survived; she then lost a second child in a miscarriage at 18 weeks. Currently, she is 20 weeks pregnant, and she very much wants this pregnancy to progress successfully. So far, everything has gone well—she has had no contractions, and her cervix is closed. Given her risk of pregnancy loss, I discussed the possibility of cerclage with our local obstetric consultant. According to my research, chances of cerclage helping in this instance were only one in 10. That may be the reason the consultant adamantly opposed the procedure.

After discussing the consultant's opinion with my patient, we both still thought we wanted to do everything possible to ensure the safe continuation of her pregnancy, so I sought the advice of a specialist at the city's university hospital. This consultant enthusiastically supported my plan for cerclage. Now, however, I am having some concerns. Was I wrong to go over the head of our local consultant? As a family physician practicing obstetrics in an unsupported geographic area, I rely on the local obstetric consultant to be supportive of my decisions. Given the low likelihood for the success of cerclage, was it worthwhile to risk my relationship with the local consultant? In general, how does one negotiate conflicts with consultants?

Commentary

This scenario presents two main issues. The first issue involves the evidence for or against the use of cerclage to prevent second-trimester pregnancy loss. The second issue is the way family physicians should interact with consultants.

The use of cerclage has come under scrutiny in the past several years. A Cochrane Collaboration review completed in 2002¹ identified six relevant trials, four of which studied the effect of cerclage versus no cerclage in preventing preterm delivery. Three studies, all using different definitions of very preterm labor, failed to show a beneficial effect of cerclage; in this meta-analysis, there was no difference in delivery at 28, 32, and 34 weeks. However, in the single largest trial, there was a reduction in births at less than 33 weeks (relative risk, 0.75; 95 percent confidence interval, 0.58 to 0.98) in the cerclage arm. There were increased pyrexia and tocolytic use in the women who had cerclage, but there was no serious morbidity noted for mother or fetus.

The evidence that cerclage related to cervical incompetence reduces a risk of pregnancy remains inconclusive. However, there is some evidence to support cerclage in women who have had two or more second-trimester losses. The concern remains that many studies have lacked sufficient power to detect differences. Even if there is no advantage to cerclage, current evidence does not show a worse outcome for women who have the procedure.² Thus it does not seem unlikely or unreasonable that different opinions were obtained from the two specialists in this scenario.

The second issue in this case is the conflict between the recommendations of the local and the university consultants and the question of how the family physician should handle this kind of conflict. What principle can be brought to bear on this issue? First is the concept of shared decision-making, which was used when the family physician discussed the recommendations of the local consultant with the patient. Because the patient and family physician desired to do “everything possible,” a second opinion was sought. This action does not represent “going over the head” of the local consultant but rather follows the reasonable desire of the patient. The American Academy of Family Physicians, in the definition of the term “consultant,” recognizes patient request as a valid reason to obtain a second consultation.³

The issue not addressed in this scenario is management of the pregnancy if a cerclage is placed. The local consultant expressed an opinion against cerclage in this case, so it is inappropriate to expect that consultant to provide coverage for this patient after cerclage placement. This patient may need to receive her care during pregnancy from the physician who places the cerclage, or the family physician might continue her care with back-up from the university consultant. As long as the local consultant does not have to provide care for this patient, these alternatives seem unlikely to create problems.

The patient has expressed a desire to do everything possible, and seeing a maternal fetal medicine specialist at the university would fit the bill and provide her with the opportunity to feel that she had tried “everything,” regardless of the outcome of the pregnancy. Without an open discussion with the patient, her wishes could have been missed, and this omission could have placed both physicians at some significant liability risk. Thus, the local obstetric consultant may be relieved that this patient obtained a second opinion.

The best approach in this kind of situation is to have an open discussion with local consultants and learn how they want to handle this situation the next time it arises—and it surely will.

Because of easy access to information on the Internet, many patients may ask for a second opinion (or more) when they think the answer they receive from a physician is not the same information they found on the Internet.

In regions that are not supportive of family physicians providing maternity care, maintaining an open relationship with consultants is critical. After practicing in several different areas of the country in both rural and urban environments, the best advice I can offer is to have frequent open discussions with your consultants when issues like this arise.