A 26-year-old primigravida at 12 weeks gestation comes to the office for a routine prenatal visit. She reports no concerns with her pregnancy but for the past month the patient has had episodes of dyspnea and wheezing twice a week. She has a 10-year history of asthma that had previously been well-controlled with a low-dose inhaled corticosteroid and an as-needed albuterol inhaler. She has no other medical conditions and takes a daily prenatal vitamin. Vital signs and pulse oximetry are normal. BMI is 32 kg/m². The patient has gained 4 kg (8.8 lb) during this pregnancy. Lung auscultation reveals normal breath sounds. The remainder of the physical examination shows no abnormalities. Which of the following is the most appropriate response by the physician?

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11ec25c8_da1e_a1a5_bc81_abb58f53adb2_MD0003_00 In pregnancy, worsening asthma can be due to several factors (eg, altered daily activities, increased stress/anxiety), including (in a third of cases) pregnancy itself. In addition, pregnant patients may discontinue medications due to limited knowledge regarding their safety and concerns about fetal harm. Although nonessential medications should be minimized in pregnancy, most asthma medications (including inhaled beta agonists and inhaled corticosteroids) are safe, and their discontinuation may lead to worsening asthma symptoms, which are associated with worse outcomes. Given this patient's pattern of worsening symptoms after years of good control, medication discontinuation (eg, out of fear of harming the fetus) should be considered. The discussion should begin with a nonjudgmental inquiry into the patient's use of her asthma medications. The review should focus on when, how, and how often the patient uses both the controller and rescue medication. In many cases, providing reassurance regarding the safety of most asthma medications and education regarding the benefits of good asthma control during pregnancy is helpful. Careful follow-up (eg, more frequent visits) has been found to improve adherence to asthma medications. (Choice A) Excessive maternal weight gain in pregnancy is associated with increased risk for exacerbation of asthma. However, attributing this patient's worsening asthma to weight and counseling about diet is premature when her medication adherence is unknown. (Choice B) Using judgmental language or scare tactics and starting with closed ended questions about medication adherence is not conducive to a productive discussion and may erode trust in the provider's care. (Choice C) Although asthma can worsen due to pregnancy itself, this patient's symptoms should not be attributed simply to pregnancy without an appropriate review of medication use. If medication discontinuation is identified as the cause of her worsening symptoms, it may be possible to gain better control by restarting these medications. Furthermore, even if the worsening asthma is due to pregnancy, medication adjustment (rather than close monitoring of symptoms) may be required. Educational objective: Most asthma medications are safe in pregnancy and should be continued. Worsening symptoms after years of good control suggests nonadherence to controller medication. When nonadherence is considered, the discussion should begin with a nonjudgmental inquiry into the patient's use of medication, focusing on when, how, and how often the patient uses both the controller and rescue medication.

A 26-Year-Old Primigravida at 12 Weeks Gestation Comes to the Office