I get an hour to teach Albert Einstein College of Medicine third-year students a formal lecture in obstetrics during their six-week rotations, so I cram in a lot of information during that session. Of course, I spend more time with them informally; we see patients together on labor and delivery, or in clinic at Montefiore Medical Center, where I practice.
I also see these med students around, or I’ve had them scrub with me for a C-section. And the med students get another few lectures from other faculty about my specialty, maternal-fetal medicine (MFM, otherwise known as high-risk obstetrics).
Sixty minutes of MFM knowledge
But for one hour on a Tuesday during their rotation, they sit down in front of me for my lecture, “Medical Problems in Pregnancy.” It’s an important subject and I sort of feel I should teach them absolutely everything else about MFM, right then and there.
Of course, that’s impossible. It took me four years of residency plus three years of fellowship to get certified in MFM, and I’m still learning every day. But I want them to understand what it is that I do (since I remain convinced that I have the coolest, most interesting job in the world).
How would you do that in 60 minutes or less?
I inherited this lecture from a colleague, Dr. Peter Bernstein, and although I’ve significantly changed a lot of the slides and some of the subject matter, I haven’t changed the overall structure, because I think it’s a brilliant didactic strategy.
Three diseases, many possible complications
The lecture teaches about three diseases. The first, asthma, is a disease where the presence of pregnancy doesn’t really change management. We discuss pregnancy lung physiology, and why diagnosis or management can be trickier—but ultimately, the regimens and the concerns are the same as in the nonpregnant patient. Easy, right?
Then we get to the second disease, Graves’ disease, an example of a disease where pregnancy changes management a bit. For example, we can’t use one of the first-line therapies, radioactive iodine ablation, in pregnancy, since we’d knock out the fetal thyroid too. We have medications, but we have to think about their teratogenic risks—those that cause congenital abnormalities. We also have to consider how the underlying antibodies that cause this illness can cross the placenta and affect the fetus. What would that look like? How would we know? What could we do in that case?
And finally, we talk about the autoimmune disease systemic lupus erythematosus and a frequent comorbidity, antiphospholipid syndrome; these are examples of disease processes in which pregnancy changes almost everything about how we manage this disease process. These diseases can be scary outside pregnancy, but in pregnancy, they’re often terrifying: they predispose to preeclampsia, but they also mimic preeclampsia, making it very hard to know when you need to deliver your patient, or when that would, in fact, be a terrible idea. They can cause unanticipated clots, and the dreaded complication of stillbirth. The antibodies associated with these autoimmune diseases can travel through the placenta—and destroy the developing electrical system of a developing fetal heart. How do you manage this? How do you get your patients—both the mother and the baby—through it, with both as intact as possible?
MFM challenges and rewards
At the end, I review the two questions you always have to ask as an MFM practitioner: How does the disease (and its diagnostics, and its therapies) affect the pregnancy? And then: How does the pregnancy affect the disease (and its diagnostics and its therapies)? You have to ask these questions for maternal health, and for fetal health—and the answers may change several times throughout the pregnancy.
By the end of the hour, they’re not MFM specialists; they’ve got about eight more years to go. But I hope they have started to understand how MFM providers think when we are taking care of patients, and why it’s so intellectually satisfying, so challenging—and, in fact, is the coolest, most interesting job in the world.