Pulmonary Diseases in Pregnancy

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Pulmonary Diseases in Pregnancy. Ma. Asuncion A. Fernandez, MD, FPOGS, FPSREI St. Luke’s College of Medicine WHQuasha Memorial November 9, 2009. Outline. - PowerPoint PPT Presentation

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Pulmonary Diseases in PregnancyMa. Asuncion A. Fernandez, MD, FPOGS, FPSREISt. Lukes College of Medicine WHQuasha MemorialNovember 9, 2009OutlinePPhysiological changes UUnclear, usual, ubiquitous conditions LLay back, launch out or limit care ?MModel caseOOutcome Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 2

Ma. Asuncion A. Fernandez, MD, FPOGS, FPSREISt. Lukes College of Medicine WHQuasha MemorialNovember 9, 2009Physiologic conditionsPhysiologic changesIncreasedDecreasedVital capacityResidual volumeInspiratory capacityExpiratory reserve volumeTidal volumeFunctional residual capacityMinute ventilation Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 4

RV + ERV = FRC Except for residual volume and lung capacities derived therefrom, the s can be measured using direct spirometric techniques.Physiologic changesSum of changes = Increased ventilationGroundsbreathing is deeper NOT more frequent Goalbasal oxygen consumption increasedGestational resultPlasma pHArterial PO2PCO2HCO3 Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 5

Substantially increased ventilation5

Ma. Asuncion A. Fernandez, MD, FPOGS, FPSREISt. Lukes College of Medicine WHQuasha MemorialNovember 9, 2009Unclear conditionunclear, usual, ubiquitousDyspnea in PregnancyCommon awarenessneed to breatheCommon complaintshortness of breath at rest = midpregnancyClarity of mechanism ?But attributed toAlveolar hyperventilationResponse to substantively decreased PCO2Consequence of anatomical changes in the thorax accompanying normal pregnancy Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 7

Ma. Asuncion A. Fernandez, MD, FPOGS, FPSREISt. Lukes College of Medicine WHQuasha MemorialNovember 9, 2009Usual conditionsunclear, usual, ubiquitousDiseases in PregnancyPneumoniaAsthmaTuberculosisSarcoidosisCystic Fibrosis Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 9unclear, usual, ubiquitousDiseases in PregnancyPneumoniaInflammation afffecting the lung parenchyma distal to the larger airwaysInvolving respiratory bronchioles, alveolar unitsBroncho-pneumoniaPatchy and diffuse areas of involvementNo consolidation Less severe form of pneumonitis Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 10Complication: Preterm labor 20 poorly tolerated fetal hypoxemia and acidosisunclear, usual, ubiquitousDiseases In PregnancyBacterial PneumoniacaughtInhalationnasopharyngeal secretionsAspiration cause2/3Streptococcus pneumoniaeMycoplasma pneumoniaeInfluenza A1/3Indirect evidence ?Pneumococcal Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 11unclear, usual, ubiquitousDiseases In PregnancyBacterial PneumoniacommonsymptomsCough, feverChest pain, dyspneaMild upper respiratory symptomsMalaise crucial for diagnosisChest x-rayCoughed-up sputum (gram stain)Serum, urine pneumococcal AgSerum mycoplasma-specific IgM Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 12unclear, usual, ubiquitousDiseases In PregnancyBacterial PneumoniacounselHospitalization !choiceErythromycin 500-1000mg q 6 hrs(pneumococci, mycoplasma)Cefotaxime, ceftizoxime, cefuroxime (staphylococcal, haemophilus pneumoniae) considerPersistent fever : Repeat C-Xray ThoracentesisThoracostomy tube drainagePneumococcal vaccine: (HIV,DM, CP, renal patients) Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 13logical13unclear, usual, ubiquitousDiseases In PregnancyBacterial Pneumoniacomplications

Tracheal intubationMechanical ventilationEmpyemaPneumothoraxPericardial tamponadePerinatal death Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 14logical14unclear, usual, ubiquitousDiseases In PregnancyInfluenza pneumonia causeRNA virusescaughtAerosolized dropletsCiliated columnar epithelium, alveolar cells, mucus gland cells, macrophagesinfectclinical course2-5 dayscomplicationPneumoniaMost commonPrimary pneumonitisMost severe formMarksSparse sputum productionInterstitial infiltrates CXR Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 15Viral Pneumonia

unclear, usual, ubiquitousDiseases In PregnancyInfluenza pneumonia checkSwab culturesSerologic confirmationSeldom count: wbc >15000/ulchoiceAmantadine (Category C) within 48 hours of symptomsconsiderInfluenza vaccineNot routineNonetheless, ok for DM, CVDNo evidence: teratogenicity Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 16Viral Pneumonia

unclear, usual, ubiquitousDiseases In PregnancyVaricella pneumonia causeVaricella-zoster virus (herpesvirus)caughtChickenpox exposure sero(-) womenconstitutional symptomsFever, maculopapular, vesicular rash; tachypnea, cough, dyspneaclinical course3-5 dayscomplicationStrep / staph skin infectionMost commonVaricella pneumoniaMost serious formMarksChest pain, thats pleuriticCXRNodular infiltratesInterstitial pneumonitis Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 17Viral Pneumonia

unclear, usual, ubiquitousDiseases In PregnancyVaricella pneumonia choiceAcyclovir 5-15 mg/kg intravenously q 8 hoursconsiderCDC (Centers for Disease Control)NOT included : Varicella-zoster immune globulin for exposed pregnant womanNonetheless: only given to immunocomprised Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 18Viral Pneumonia

unclear, usual, ubiquitousDiseases In PregnancyAsthma cause (precipitating factors)AllergensStrenuous exerciseAspirin Respiratory infectionOB drugs: Fseries prostaglandins, ergonovinecharacteristics(Hallmarks)Bronchial smooth muscle contractionMucus hypersecretionMucosal edemachanges (biochemical effectors) Primary mediatorsHistaminesSecondary mediatorsProstaglandins, thromboxane, leukotrienes Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 19unclear, usual, ubiquitousDiseases in PregnancyAsthmacomplicationsfetalPreterm laborLow birthweight infants AbortionNeonatal hypoxiamaternalLife-threatening

Status asthmaticusPneumo-thorax/mediastinum, Acute cor pulmonaleCardiac arrythmiasMuscle fatigue with respiratory arrestcorrelationMaternal pulmonary funtion measurementsBirthweight Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 20unclear, usual, ubiquitousDiseases In PregnancyAsthma compromise (fetal)Combination of factorsMA TER N A LDecreased uterine blood flowDecreased maternal venous returnAlkaline leftward shift of the oxyhemoglobin dissociation curveFETALDecreased umbilical blood flowIncreased systemic and pulmonary vascular resistanceDecreased cardiac output Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 21unclear, usual, ubiquitousDiseases In PregnancyAsthma clinical course Broad spectrumMild wheezingSevere bronchoconstrictionAirway obstructionDecreased air flowChest tightness, wheezing, breathlessnessRespiratory failureSevere hypoxemiaDeath Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 22unclear, usual, ubiquitousDiseases In PregnancyAsthma Clinical Stages of Bronchial AsthmaStage PO2PCO2pHFEV1(% predicted)Mild respiratory alkalosisNormal65-80Respiratory alkalosis50-64Danger zoneNormal

Normal

35-49Respiratory acidosis