Here’s a young woman in my office, the third appointment of the day for me. She’s in her second trimester of pregnancy; maybe she hasn’t seen a doctor since she graduated from her own pediatrician a few years ago. She thinks of herself as healthy, and she is, except that when we start talking, it turns out she’s had asthma since childhood. Her initial prenatal care provider figured out that this patient’s asthma is a bigger problem, and sent her over to my high-risk obstetrical clinic at Montefiore Medical Center.
Five more minutes into this appointment, I discover that this patient needs medications at least four to five times a week to breathe comfortably; she’s been borrowing medications from her cousin. But when she found out she was pregnant, she stopped all of them, because she worried: “Are they safe for the baby?”
I take a deep breath. I try not to sigh. Because we see this all the time in our high-risk prenatal clinic. And of course, she needs her medications. Because here’s what I have to teach, what I teach our patients, our residents and our Albert Einstein College of Medicine students who rotate with me in clinic: This baby needs oxygen and we need to deliver it better, and the right medicines will help us do that.
But that’s only part of the far more important rule I have to teach, and it’s arguably the first commandment of my specialty, maternal-fetal medicine: If mama ain’t happy, nobody’s happy. So if we’re not keeping this woman breathing effectively, nothing else is going to matter to this pregnancy.
If you value your pregnancy, please value yourself; that’s what I have to say to her, and it’s what I hope she can hear.
Managing Asthma During Pregnancy
We see a lot of asthma in pregnancy here in the Bronx, commensurate with environmental factors and with the high rate of poverty in the population we serve. There are lots of things I try to do for these women. First, we try to figure out how to prevent their asthma flares—can we figure out what’s causing them? We talk about smoking and other common triggers.
Doctor and patient both have limited power over these environmental factors, especially for young women with difficult lives and irregular housing. I try very, very hard to get all my patients to accept the flu shot to try to avoid what can be a dangerous spiral of upper respiratory viral infection plus reactive airway disease.
When I see patients with asthma, I try to make sure they all have peak-flow meters so they can better assess their disease progress at home. I’m a huge fan of getting patients tools that give them a little more knowledge about what is happening in their bodies. I talk a lot about how pregnancy changes their bodies, explaining that their lungs are not entirely their own; because of the physiologic changes of pregnancy they have a decreased amount of oxygen remaining in their lungs after each breath. This means that once their lungs are starting to work too hard, we have less time to get ahead of their disease. I remind them that they can come in to see us in our emergency room (before 20 weeks’ gestation) or our obstetric triage any time—day or night, whatever the weather.
I make sure each of them has a current albuterol inhaler, and the opportunity to hang out with our talented nurses to make sure she knows how to use it properly.
Escalating Asthma Care for Mothers
For some patients, none of this is enough. For these patients, we start working our way up the ladder of escalating medications. Each medicine causes a discussion with patient and provider of its risks and monitoring in pregnancy. If the patient’s asthma is particularly concerning, I set her up with a pulmonologist; even if I think I’m doing everything right, even if the patient is as healthy as I think she can be, she will eventually have her baby, and she’ll still need asthma care. If her asthma is severe enough, this is an opportunity to connect her with the specialty care she will need for the rest of her life.
* * *
In the end, all of this care comes from that first commandment: If mama ain’t happy, nobody is happy. And for this patient, today, what I mean by that commandment is this: Your health is important to me; if that’s not enough, it’s important to your pregnancy, and it’s important to your child, now and forever. Your health is worth a lot, actually—and I hope you know that.