Dr. Wes: "I wonder if I could treat a pregnant woman, 36 weeks gestation, who wants to breast feed, is hemodynamically stable but has atrial fibrillation with rapid ventricular response unresponsive to digoxin/beta blockers, with short-acting Ibutilide?"Guess which drug I used?
Dr. Google: "Several case reports exist treating pregnant patients with atrial fibrillation and atrial flutter without injury to mother or fetus and with no adverse effects."
The Obstetrician: "What's ibutilide?"
The Neonatologist: "Ibutilide? Has teratogenic potential at high dose in animals, including cleft lip and scoliosis, but at 36 weeks?...Maybe... Let me check with a pediatric electrophysiologist..."
Pediatric electrophysiologist: "We've used it in kids, but very cautiously... Never in pregnancy."
Pharmacist: "We have some concern, given the lack of human data."
ACC Guidelines 2006-Atrial fibrillation in Pregnancy(pdf): (Level of evidence: II-b or not II-b): "Ancient ineffective antiarrhyhmic drugs like quinidine sulfate or procainamide are generally thought to be safe in pregnancy."
Although I'm not proud of this, I caved to the paranoia. She stayed in the hospital another 18 hours because of it. A small price to pay, I suppose, but I am convinced I did not render the best care, just the safest care... for me.
It never ceases to amaze me how the threat of litigation constantly influences the medical care we deliver.