pulmonary diseases in pregnancy ma. asuncion a. fernandez, md, fpogs, fpsrei st. luke’s college of...

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 Decreased

Vital 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 CHANGES

Sum 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 breathe

Common complaint “shortness of breath” at rest = midpregnancy

Clarity of mechanism ?But attributed to

Alveolar hyperventilation

Response to substantively decreased PCO2

Consequence of anatomical changes in the thorax accompanying normal pregnancy



Usual conditions


Diseases in Pregnancy

Pneumonia

Asthma

Tuberculosis

Sarcoidosis

Cystic Fibrosis



Diseases in Pregnancy

Pneumonia Inflammation afffecting the lung parenchyma distal to the larger airways

Involving respiratory bronchioles, alveolar units

Broncho-pneumonia

Patchy and diffuse areas of involvement

No consolidation

Less severe form of pneumonitis


Complication: Preterm labor 20 poorly tolerated fetal hypoxemia and acidosis


Diseases In Pregnancy

Bacterial Pneumonia

caught Inhalation nasopharyngeal secretionsAspiration

cause 2/3 Streptococcus pneumoniae

Mycoplasma pneumoniae

Influenza A

1/3 Indirect evidence ?Pneumococcal




Bacterial Pneumonia

commonsymptoms

Cough, fever

Chest pain, dyspnea

Mild upper respiratory symptoms

Malaise

crucial for diagnosis

Chest x-ray

Coughed-up sputum (gram stain)

Serum, urine pneumococcal Ag

Serum mycoplasma-specific IgM




Bacterial Pneumonia

counsel Hospitalization !

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

Cefotaxime, ceftizoxime, cefuroxime (staphylococcal, haemophilus pneumoniae)

consider Persistent fever : Repeat C-Xray Thoracentesis

Thoracostomy tube drainage

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




Bacterial Pneumonia

complications Tracheal intubation

Mechanical ventilation

Empyema

Pneumothorax

Pericardial tamponade

Perinatal death




Influenza pneumonia cause RNA viruses

caught Aerosolized droplets

Ciliated columnar epithelium, alveolar cells, mucus gland cells, macrophagesinfect

clinical course

2-5 days

complication Pneumonia Most common

Primary pneumonitis

Most severe form

Marks Sparse sputum production

Interstitial infiltrates CXR


Viral Pneumonia



Influenza pneumonia check Swab cultures

Serologic confirmation

Seldom count: wbc >15000/ul

choice Amantadine (Category C) within 48 hours of symptoms

consider Influenza vaccine

Not routine

Nonetheless, ok for DM, CVD

No 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 form

Marks Chest pain, that’s pleuritic

CXR

Nodular infiltrates

Interstitial pneumonitis


Viral Pneumonia



Varicella 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 woman

Nonetheless: only given to immunocomprised


Viral Pneumonia



Asthma cause (precipitating factors)

Allergens

Strenuous exercise

Aspirin

Respiratory infection

OB 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



Diseases in

Pregnancy

Asthmacomplications fetal Preterm labor

Low birthweight infants

Abortion

Neonatal hypoxia

maternalLife-threatening

Status asthmaticus

Pneumo-thorax/mediastinum,

Acute cor pulmonale

Cardiac arrythmias

Muscle fatigue with respiratory arrest

correlation Maternal pulmonary funtion measurements

Birthweight




Asthma compromise (fetal)

Combination of factors

MA TER N A L

Decreased uterine blood flow

Decreased maternal venous return

Alkaline leftward shift of the oxyhemoglobin dissociation curve

FETAL

Decreased umbilical blood flow

Increased systemic and pulmonary vascular resistance

Decreased cardiac output




Asthma clinical course Broad spectrum

Mild wheezing

Severe bronchoconstriction

Airway obstruction

Decreased air flow

Chest tightness, wheezing, breathlessness

Respiratory failure

Severe 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


Barth & Harkins Modification 1991

UNCLEAR, USUAL, UBIQUITOUSDiseases In Pregnancy

Asthma Clinical evaluation

Subjective / severity inaccuratePatient’s impression

Physician’s clinical exam

Signs that help predict severity

Labored breathing

Tachycardia

Pulsus paradoxus

Prolonged expiration

Use of accessory respiratory muscles

Signs of a potentially fatal attack

Central cyanosis

Altered level of consciousness


UNCLEAR, USUAL, UBIQUITOUSDiseases In Pregnancy

Asthma Clinical evaluation

Objective / severity accurateArterial blood gas analysis

Assessment

Maternal oxygenation

Ventilation

Acid-base status

Pulmonary function testing

Are 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: hospitalization

Hydration : intravenous fluids * help clear pulmonary secretions

Hand over supplemental oxygen by mask



Diseases In pregnancy

Asthma Care Acute Asthma

Choice of pharmacological therapy

First 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 corticosteroid

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



Diseases In pregnancy

Asthma Care Chronic Asthma

Choice of pharmacological therapy

Theophylline

Aminophylline

Cromolyn sodium

Immunotherapy

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 meperidine

Surgical delivery? Consider regional anesthesia than general anesthesia (intubation can trigger bronchospasm)

Suppose: refractory postpartum hemorrhage ? Compounds: PGE2 better than PGF2a




Tuberculosis

cause Mycobacterium tuberculosis

characteristics Granulomatous pulmonary reaction

clinical manifestations

Cough, minimal sputum production

Low 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

Pregnantasympto

matic

• 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


Dyspnea

Dry cough

CXRay Interstitial pneumonitis (hallmark)

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




Cystic Fibrosis

cause 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


Chronic bronchitis

bronchiectasis

Check “Sweat Test”; high Na, K, Cl




Cystic Fibrosis

Complication & cure

Pregnancy discouraged

Pre-pregnancy counseling

Pancreatic insufficiency: oral pancreatic enzyme replacement

Cor pulmonale: bronchodilators, oxygen, and diuretics

Chest physiotherapy, nutritional support



Ubiquitous

condition


Danger In Pregnancy

Carbon monoxide poisoning

cause CO: odorless, tasteless gas with high affinity and binding to hemoglobin

Inadequately 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


OUTCOME

P Physiologic changes Vc Ic Tv Mv

RV+ ERV = FRC

U Unclear Dyspnea

Usual Diseases PATSC

Ubiquitous conditions Danger CMP

L Lay back Delay S

Launch Depart P, A

Limit care Direct T, CMP

M Model case Deal or No deal?

Patient O


Pulmonary Diseases in Pregnancy


pulmonary diseases in pregnancy ma. asuncion a. fernandez, md, fpogs, fpsrei st. luke’s college of...

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