Pregnant 23-Year-Old With Asthma

Introduction

A 23-year-old pregnant patient presents to the hospital with coughing and wheezing that has been persistent for about three weeks. Her last prenatal visit was a month ago. She reports having chickenpox as a child and asthma, which was diagnosed at eight years. She denies using an inhaler since she was 19. She reports that all immunizations are up to date except for the flu shot, which she is scheduled for in October. She has been taking the prenatal vitamins, and denies using any drugs.

Diagnosis

Upon reviewing the patient’s history, presenting symptoms, and physical examination findings, the most likely diagnosis for the 23-year-old pregnant female is exacerbation of asthma. The patient’s history of childhood asthma, the presence of wheezing in all lung fields, non-productive cough, and the significant drop in FEV1 to 70% indicate an acute exacerbation of asthma.

Rationale for Diagnosis

1. History of Childhood Asthma: The patient’s history of asthma as a child, diagnosed at age 8, suggests a predisposition to respiratory issues (National Heart, Lung, and Blood Institute (NHLBI)., (2020). Asthma is a chronic condition characterized by airway inflammation and hyperresponsiveness, leading to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing. In most cases, the development of asthma starts at a early age, and is persistent, thus recognizable at any different ages in life (National Heart, Lung, and Blood Institute (NHLBI), 2020).
2. Exacerbation Trigger: The patient’s recent relocation due to an abusive domestic situation may have triggered the exacerbation. Stress and environmental changes can exacerbate asthma symptoms. Environmental interactions play a big factor in the development and expression of asthma.
3. Respiratory Symptoms: The presence of wheezing audible from across the room, non-productive cough, and fatigue are consistent with asthma exacerbation. Additionally, the nocturnal symptoms disrupting her sleep indicate poorly controlled asthma. Upon conducting a physical exam, there is presence of wheezing in all lung fields, a big indicator for asthma. Presence of a stridor is an indicator of irregular airflow into the lungs due to a narrow airway. A FEV1 of 70% is an indicator of decreased lung function for the patient, which is a symptom of asthma.

Treatment Plan

Pharmacologic Treatment:

1. Short-Acting Beta-Agonist (SABA): Albuterol via metered-dose inhaler (MDI) with a spacer as needed for acute symptom relief. The patient should be educated on proper inhaler technique and the importance of using the spacer to optimize drug delivery to the lungs.
2. Inhaled Corticosteroid (ICS): Low-dose ICS such as budesonide via MDI with a spacer for maintenance therapy to reduce airway inflammation and prevent future exacerbations. It is safe to use during pregnancy and provides long-term asthma control.
3. Oral Corticosteroids: A short course of oral prednisone may be considered for moderate to severe exacerbations to rapidly improve lung function and relieve inflammation.

Non-Pharmacologic Treatment:

1. Environmental Control: Identify and minimize exposure to triggers such as dust, pet dander, smoke, and strong odors in her current living environment. This manages the triggers and keeps the patients’ asthma at bay (Global Initiative for Asthma (GINA)., (2021). Construct different ways of managing these environmental triggers, in case the patient is exposed to them.
2. Asthma Action Plan: Develop an individualized written asthma action plan in collaboration with the patient, including instructions on medication use, recognizing worsening symptoms, and when to seek medical care.
3. Patient Education: Provide comprehensive education on asthma management during pregnancy, including the importance of medication adherence, recognizing warning signs of exacerbations, and utilizing peak flow monitoring (Schatz, et al., 2016).

Community Resources in Your State/City

1. Medicaid and Pregnancy-related Assistance Programs: Assist the patient in applying for Medicaid or other pregnancy-related assistance programs to obtain medical coverage for prenatal care and asthma management (American College of Obstetricians and Gynecologists (ACOG)., 2020). This will help her to access medications for both her pregnancy and asthma symptoms considering her current financial situation.
2. Women’s Shelters and Support Groups: Connect the patient with local women’s shelters and support groups that provide resources for individuals escaping abusive domestic situations, including housing assistance and emotional support.
3. Free or Low-Cost Clinics: Identify free or low-cost clinics in the area that offer prenatal care, obstetric services, and access to healthcare providers who can manage asthma during pregnancy (U.S. Department of Health & Human Services, 2021).

Communication Plan

1. Active Listening: Utilize active listening techniques to understand the patient’s concerns, fears, and challenges related to her recent relocation and asthma exacerbation. With a history of domestic abuse, refer patient to a social worker who will advise them and help reduce their stress, as this can be harmful during pregnancy thus causing an exacerbation.
2. Empathetic Communication: Express empathy towards the patient’s situation, acknowledging the stress of her recent experiences and the impact on her health. As a patient, they should be allowed to be comfortable sharing their emotions, thus she should be referred to therapy. With this, the patient can be taught and develop new strategies for dealing with stress and other factors during pregnancy. For a patient with a recent history of domestic violence, they should be guided through counselling to develop a good healthcare habit.
3. Health Literacy: Use plain language and visual aids to ensure the patient understands her diagnosis, treatment options, and self-management strategies. Do a homecare visit and assess the ability of the patient to follow a pregnancy treatment plan. Assess the knowledge of the patient about asthma and how to manage it in extreme or normal conditions. Once the patients’ knowledge is assessed, develop a plan to teach and care for them in a way that they understand. Create a communications channel where they can confidently express themselves, while you teach them on asthma and its effects, especially during pregnancy.
4. Shared Decision-Making: Engage the patient in shared decision-making regarding her treatment plan, addressing her preferences, values, and goals for managing her asthma during pregnancy. Allow the patient to express their specific needs and how they can meet them before giving them a solution. This way, they feel heard, thus opening up about their problems and giving an opportunity to be helped.
5. Follow-Up: Schedule regular follow-up appointments to monitor the patient’s asthma control, adjust treatment as needed, and provide ongoing support during her pregnancy.

Conclusion

The patient has symptoms of an uncontrolled asthma exacerbation for about three weeks now. Patient is 25 weeks pregnant, and recently moved from her home due to domestic violence. To keep the asthma under control, the treatment plan involves SABA and an ICS treatment (Centers for Disease Control and Prevention (CDC)., (2021). Scheduled follow up after 2 weeks to check on the medications given and the treatment plan. Regarding her financial status, the patient should be given access to hospital and social programs that will be beneficial for her and her child.

References

National Heart, Lung, and Blood Institute (NHLBI). (2020). Expert Panel Report 4 (EPR-4): Guidelines for the Diagnosis and Management of Asthma.

Schatz, M., Dombrowski, M. P., & Wise, R. (2016). Asthma in pregnancy: What do we know and how can we find out more? European Respiratory Journal, 48(1), 105-106.

American College of Obstetricians and Gynecologists (ACOG). (2020). ACOG Practice Bulletin No. 221: Prenatal care.

Global Initiative for Asthma (GINA). (2021). Global Strategy for Asthma Management and Prevention.

Centers for Disease Control and Prevention (CDC). (2021). Asthma in Pregnancy.

U.S. Department of Health & Human Services. (2021). Find Free or Low-Cost Health Coverage.