Why obstetrics history should be part of primary care

Historically, most physicians have cared about maternal health in the context of the baby. For example, take the warnings, “Don't smoke because it's bad for baby,” “Be careful because you could fall down,” “It's not good for the baby.” But I really think the rhetoric should be, “Don't smoke because it's bad for you, Mom. It's bad for your lungs.”

We're always trying to affect maternal care through the baby, instead of saying what is important for this mom: She's a human being and an individual outside of being a pregnant person. She doesn't have to be defined by her pregnancy or defined by the fact that she's creating life.

On the flip side, this moment of creating life and being pregnant brings a lot of women into medical care. A relatively young, healthy population now has to go to the doctor all the time because they are pregnant. This is an opportunity for education, patient counseling, and even diagnosing diseases or manifestation of disease.

Med-peds is a branch of medicine where we're just like any other internal medicine physician, but we're also pediatricians, just like any other pediatrician. I do med-peds because I've always loved maternal health and pregnancy. But the thing is, in internal medicine residency, we never see pregnant people. A lot of times internal medicine physicians are scared of pregnant women. They shy away from seeing pregnant women, and they tend not to want to see them because it is an area where we are not trained very well.

What we need to do first is shake off the fear of pregnancy. Pregnant people are going to get colds; they're going to get asthma flares. We can't just say, “Oh, you're pregnant, I can't help you. You're pregnant, go see your obstetrician.” That shouldn't be the default. We as internal medicine physicians have to care about a woman's health, whether she's pregnant or not pregnant, preconception or postpartum. It doesn't matter. She's a person.

As with any patient who is coming to you for help, we have to think about pregnancy physiology. What is the disease or the concern that she's coming in with? How does that get affected by the pregnancy, and how is the pregnancy affecting that? If we can go in open-minded, without fear, and say, “OK, I got this. I am a doctor. I can work through the physiology,” we can help this person who might be suffering.

A pearl I always teach to residents is that in internal medicine, we rely so heavily on our medical interview and history taking for all of our patients. We are the specialty that asks a lot of questions. We love to get history, so we've got to incorporate an obstetric history into our medical interview from the get-go and make it second nature. Just like we ask social history, just like we ask family history, we have to start asking about obstetric history, because there are a lot of medical disorders that occur in pregnancy that have implications for the long term or future health of that person.

For example, people with hypertensive disorders of pregnancy—whether it's gestational hypertension or preeclampsia—are at higher risk for cardiovascular disease and chronic hypertension later in life. People who have gestational diabetes are much more at risk and have higher prevalence of type 2 diabetes later in life. These are two huge medical conditions that we see in women in later life, in their 50s, 60s, and 70s, so why wouldn't we want to ask these women, “Did you have preeclampsia? Did you have gestational hypertension? Did you have gestational diabetes?”

It just has to become a habit that we get into. You can do it simply. “Tell me, have you ever been pregnant before?” And if they say yes, then, “How many times have you been pregnant?” And then ask whether any of those pregnancies were affected by preeclampsia or gestational hypertension. This opens up a huge door for you as a clinician to put people into categories of risk. It's just one extra piece of really important information added to your history taking.

I would encourage people to ask this not just in older people who already have high blood pressure and cardiovascular disease, but in their younger patients, because then we can tell them, “You're at higher risk. You're at higher risk for diabetes, you're at higher risk for cardiovascular disease. Your body has already shown that when it is stressed, when it is pushed to its limits during pregnancy, your body is saying that it is probably going to get chronic hypertension or cardiovascular disease.” And we can help counsel them, help them to make lifestyle changes, and dietary and exercise modifications, incorporate those good things back into their life early, before it's too late.