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Pulmonary Diseases in Pregnancy

Ma. Asuncion A. Fernandez, MD, FPOGS, FPSREISt. Luke’s College of Medicine WHQuasha MemorialNovember 9, 2009

OUTLINE

P Physiological changes

U Unclear, usual, ubiquitous conditions

L Lay back, launch out or limit care ?

M Model case

O Outcome

Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 2


Physiologic conditions

PHYSIOLOGIC CHANGES

Increased DecreasedVital capacity Residual volume

Inspiratory capacity

Expiratory reserve volume

Tidal volume Functional residual capacity

Minute ventilation


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 ventilation

Grounds breathing is deeper NOT more frequent

Goal basal oxygen consumption increased

Gestational result

Plasma pH Arterial PO2

PCO2

HCO3



Unclear condition

UNCLEAR, USUAL, UBIQUITOUS

Dyspnea in Pregnancy

Common awareness need to breatheCommon complaint “shortness of breath”

at rest = midpregnancy

Clarity of mechanism ?But attributed to

Alveolar hyperventilationResponse to substantively decreased PCO2Consequence of anatomical changes in the thorax accompanying normal pregnancy



Usual conditions


Diseases in Pregnancy

PneumoniaAsthmaTuberculosisSarcoidosisCystic Fibrosis



Diseases in Pregnancy

Pneumonia Inflammation afffecting the lung parenchyma distal to the larger airwaysInvolving respiratory bronchioles, alveolar units

Broncho-pneumonia

Patchy and diffuse areas of involvementNo consolidation Less severe form of pneumonitis


Complication: Preterm labor 20 poorly tolerated fetal hypoxemia and acidosis


Diseases In Pregnancy

Bacterial Pneumoniacaught Inhalation nasopharyngeal

secretionsAspiration cause 2/3 Streptococcus

pneumoniae

Mycoplasma pneumoniaeInfluenza A

1/3 Indirect evidence ?Pneumococcal




Bacterial Pneumoniacommonsymptoms

Cough, feverChest pain, dyspneaMild upper respiratory symptomsMalaise

crucial for diagnosis

Chest x-rayCoughed-up sputum (gram stain)Serum, urine pneumococcal AgSerum mycoplasma-specific IgM


UNCLEAR, USUAL, UBIQUITOUSDiseases In Pregnancy

Bacterial Pneumoniacounsel Hospitalization !

choice Erythromycin 500-1000mg q 6 hrs(pneumococci, mycoplasma)

Cefotaxime, ceftizoxime, cefuroxime (staphylococcal, haemophilus pneumoniae)

consider Persistent fever : Repeat C-Xray ThoracentesisThoracostomy tube drainage

Pneumococcal vaccine: (HIV,DM, CP, renal patients)




Bacterial Pneumoniacomplications Tracheal intubation

Mechanical ventilationEmpyemaPneumothoraxPericardial tamponadePerinatal death


UNCLEAR, USUAL, UBIQUITOUSDiseases

In PregnancyInfluenza pneumonia

cause RNA virusescaught Aerosolized

dropletsCiliated columnar

epithelium, alveolar cells, mucus gland cells, macrophagesinfect

clinical course

2-5 days

complication Pneumonia Most commonPrimary pneumonitis

Most severe formMarks Sparse sputum

productionInterstitial infiltrates CXR


Viral Pneumonia


In PregnancyInfluenza pneumonia

check Swab culturesSerologic confirmationSeldom count: wbc >15000/ul

choice Amantadine (Category C) within 48 hours of symptoms

consider Influenza vaccineNot routineNonetheless, ok for DM, CVDNo evidence: teratogenicity


Viral Pneumonia


Varicella pneumonia cause Varicella-zoster virus (herpesvirus)caught Chickenpox exposure sero(-) women

constitutional symptoms

Fever, maculopapular, vesicular rash; tachypnea, cough, dyspnea

clinical course

3-5 days

complication Strep / staph skin infection

Most common

Varicella pneumonia

Most serious formMarks Chest pain,

that’s pleuritic

CXR

Nodular infiltratesInterstitial pneumonitis


Viral Pneumonia


In PregnancyVaricella pneumonia

choice Acyclovir 5-15 mg/kg intravenously q 8 hours

consider CDC (Centers for Disease Control)NOT included : Varicella-zoster immune globulin for exposed pregnant womanNonetheless: only given to immunocomprised


Viral Pneumonia


Asthma cause (precipitating factors)

AllergensStrenuous exerciseAspirin Respiratory infectionOB drugs: Fseries prostaglandins, ergonovine

characteristics(Hallmarks)

Bronchial smooth muscle contraction

Mucus hypersecretion

Mucosal edema

changes (biochemical effectors)

Primary mediators

Histamines

Secondary mediators

Prostaglandins, thromboxane, leukotrienes



in Pregnancy

Asthmacomplications fetal Preterm labor

Low birthweight infants AbortionNeonatal hypoxia

maternalLife-threatening

Status asthmaticusPneumo-thorax/mediastinum, Acute cor pulmonaleCardiac arrythmiasMuscle fatigue with respiratory arrest

correlation Maternal pulmonary funtion measurementsBirthweight



Asthma compromise (fetal)

Combination of factors

MA TER N A L

Decreased uterine blood flowDecreased maternal venous returnAlkaline leftward shift of the oxyhemoglobin dissociation curve

FETAL

Decreased umbilical blood flowIncreased systemic and pulmonary vascular resistanceDecreased cardiac output



Asthma clinical course Broad spectrum

Mild wheezing

Severe bronchoconstriction

Airway obstructionDecreased air flow

Chest tightness, wheezing, breathlessness

Respiratory failureSevere hypoxemia

Death



Asthma Clinical Stages of Bronchial Asthma

Stage PO2 PCO2 pH FEV1(% predicted)

Mild respiratory alkalosis

Normal 65-80

Respiratory alkalosis

50-64

Danger zone Normal Normal 35-49

Respiratory acidosis

<35

Pulmonary Diseases in Pregnancy Ma. Asuncion A. Fernandez, MD 23Barth & Harkins Modification 1991


Asthma Clinical evaluation

Subjective / severity inaccuratePatient’s impressionPhysician’s clinical exam

Signs that help predict severity

Labored breathingTachycardiaPulsus paradoxusProlonged expirationUse of accessory respiratory muscles

Signs of a potentially fatal attackCentral cyanosis

Altered level of consciousness



Asthma Clinical evaluation

Objective / severity accurateArterial blood gas analysis

Assessment

Maternal oxygenationVentilationAcid-base status

Pulmonary function testingAre MOST useful tests

Monitor airway obstruction

FEV1 (forced expiratory volume in 1 sec)

PEFR (peak expiratory flow rate)


An FEV1 <1 L, <20% of that predicted,= severe disease = hypoxia, poor response to therapy, high relapse rate.


Asthma Care Acute Asthma

Confinement: hospitalizationHydration : intravenous fluids * help clear pulmonary secretions

Hand over supplemental oxygen by mask


UNCLEAR, USUAL, UBIQUITOUSDiseases In pregnancy

Asthma Care Acute Asthma

Choice of pharmacological therapyFirst line: B-adrenergic agonist

Epinephrine, isoproterenol, terbutaline, albuterol, isoetharine, metaproterenol

Function:Bind to specific cell-surface receptors and activate adenyl cyclase, which increases intracellular cyclic AMP to modulate bronchial smooth muscle relaxation

Frequently combined with corticosteroidOnset of action several hours: whether IV or aerosol, should be given along with B-agonists


UNCLEAR, USUAL, UBIQUITOUSDiseases In pregnancy

Asthma Care Chronic Asthma

Choice of pharmacological therapyTheophylline

Aminophylline Cromolyn sodiumImmunotherapy

Status asthmaticus

Condition : severe asthma of any type NOT responding after 30-60 minutes of intensive therapy

Indications for intubation / mechanical ventilation

CO2 retention, hypoxemia, fatigue



Asthma Care Labor & Delivery

Steroids: been on it for the last 9 months? Corticosteroids: Give stress-dose Selection of analgesic for labor? Choice: Fentanyl (nonhistamine- releasing narcotic) preferred than morphine or meperidineSurgical delivery? Consider regional anesthesia than general anesthesia (intubation can trigger bronchospasm)Suppose: refractory postpartum hemorrhage ? Compounds: PGE2 better than PGF2a



Tuberculosis cause Mycobacterium tuberculosischaracteristics Granulomatous pulmonary

reactionclinical manifestations

Cough, minimal sputum productionLow grade fever, hemoptysis, weight loss

CXRay Infiltrative patterns, cavitation, mediastinal lymphadenopathy

culture (+) patients

Acid fast bacilli = sputum stained smears



Tuberculosis care


Nonpregnant Tuberculin +, <35, no active

disease

• Isoniazid 300mg daily x 1 year

Pregnantasymptom

atic

• Start after delivery• Withhold til after 12 weeks • Category C


Tuberculosis care


Nonpregnant active disease

• Isoniazid + rifampin +pyrazinamide

Pregnant active

disease

• Isoniazid 5mg/kg <300mg •Pyridoxine 50mg +•Rifampin 10mg/kg or ethambutol 15-25mg/kg

1st 2 mos

9 mos

Streptomycin : Category X in pregnancy: auditory, vestibular abnormalities, severe deafness


Sarcoidosis cause Chronic multisystem disease of

unknown etiology (penumonitis, uveitis, erythema nodosum, lymphadenopathy)

characteristics Accumulation of T lymphocytes and phagocytes within noncaseating granulomas pulmonary reaction

clinical manifestations

DyspneaDry cough

CXRay Interstitial pneumonitis (hallmark)

cure Prognosis good.Prednisone 1mg/kg OD x 4-6 weeks if still with inflammation



Cystic Fibrosiscause Serious genetic disorder;

Pseudomonas aeroginosa (90%), S. aureus, H. Influenzae

characteristics Exocrine gland dysfunction,with production of thick viscid secretions; bronchial gland hypertrophy with mucous plugging and airway obstruction

clinical manifestations

Chronic bronchitisbronchiectasis

Check “Sweat Test”; high Na, K, Cl



Cystic FibrosisComplication & cure

Pregnancy discouragedPre-pregnancy counselingPancreatic insufficiency: oral pancreatic enzyme replacementCor pulmonale: bronchodilators, oxygen, and diureticsChest physiotherapy, nutritional support



Ubiquitous condition

UNCLEAR, USUAL, UBIQUITOUSDanger In Pregnancy

Carbon monoxide poisoningcause CO: odorless, tasteless gas

with high affinity and binding to hemoglobinInadequately ventilated areas warmed by space heaters utilizing natural fuels

characteristics Nonsmoker: saturation=1-3%Smoker: 5-10%Symptomatic: 20-30%Severe-fatal: 50-60%

Cure Hyperbaric oxygen


Half life of CO

Rm temp=4-6 hrs100% O2=1 hour Hyperbaric O2=15- 30 mins


Lay back, Launch, Limit care

LAY BACK, LAUNCH OR LIMIT CARE?

Lay back Sarcoidosis treatment is the same for pregnant and nonpregnant. It has good prognosis and may heal spontaneously.

Launch Any pregnant woman suspected of having pneumonia should undergo anteroposterior and lateral chest radiography.

Management include: Prompt hospitalization, antimicrobial medications, and oxygen therapy when indicated.

Treatment of acute asthma during pregnancy is similar to that of the nonpregnant woman.

About one third of asthmatic women can expect worsening of disease at some time during pregnancy.Monitoring the fetal response is an indicator or maternal compromise. Aggressively manage all pregnant women with acute asthma.


LAY BACK, LAUNCH OR LIMIT CARE?

Limit care?

In over 95% of patients, tuberculosis is contained and lies dormant for long periods . In some, it becomes reactivated to cause clinical disease. Know if the disease is active or inactive.Carbon monoxide poisoning is almost everywhere. Both smokers and nonsmokers can be affected because of the high affinity of CO to hemoglobin.

Both the mother and fetus do not tolerate excessive CO inhalation. Treatment is supportive depending upon symptoms.



Model case

MODEL CASE


M.O.31 y/o G2P1

10 weeks AOG

No cough or hemoptysisAsymptomatic

Referred by pulmo:CXR: (+) PTB, activity ?

Outcome


OUTCOMEP Physiologic changes Vc Ic Tv Mv

RV+ ERV = FRC

U Unclear Dyspnea

Usual Diseases PATSCUbiquitous conditions Danger CMP

L Lay back Delay SLaunch Depart P, ALimit care Direct T, CMP

M Model case Deal or No deal?

Patient O


Pulmonary Diseases in Pregnancy
