Pulmonary Disorders in Pregnancy

Dr. Coloma; 2/22/2012

Respiratory Physiology
Hormonal changes in pregnancy affect the upper
respiratory tract and airway mucosa
o Hyperemia, mucosal edema, hypersecretion and
increased mucosal friability
Estrogen is probably responsible for producing tissue
edema, capillary congestion and hyperplasia of mucus
glands

Anatomic changes in pregnancy
The diaphragm is displaced cephalad by as much as 4 cm
The A-P and transverse diameter of the thorax increases
chest wall circumference enlarges
Diaphragm excursion greater than in non-pregnant

Pulmonary Function in pregnancy
Decreased
o Functional residual capacity, 10-20% by term
o Residual volume
o Expiratory reserve volume
o Peak expiratory flow rate
o Total lung capacity
Unchanged
o RR
o Vital capacity
o Lung compliance
Increased
o Tidal volume
o Airway conductance
o Total pulmonary resistance
**No difference in pulmonary function between singleton
and twin pregnancies

Ventilation
Minute ventilation increases significantly reaching 20-40%
above baseline at term
Alveolar ventilation increases by 50-70%
Because of
o Enhanced respiratory drive due to high serum
progesterone level
o Compensated respiratory alkalosis
o Low expiratory reserve volume

Oxygen Delivery
Maternal arteriovenous oxygen difference is decreased
o Increased tidal volume delivers more oxygen
than required
o Increased total hemoglobin and oxygen carrying
capacity (Bohr effect) during normal pregnancy

Arterial Blood Gases
Physiological hyperventilation results in respiratory
alkalosis
Compensatory renal excretion of bicarbonate
Reduced pC02 from maternal hyperventilation aids CO2
(waste) transfer from the fetus to the mother while
facilitating oxygen release to the fetus

Physiologic Dyspnea
Increased awareness of desire to breathe
Can occur early in pregnancy
Does not interfere with daily activities
Actual exercise tolerance not greatly affected
Increase progesterone levels probably is the most
important mechanism
Mechanical impediment of the gravid uterus often blamed

It is important to distinguish the physiologic dyspnea from disorders
complicating pregnancy

The presence of other symptoms and signs of cardiopulmonary
disease indicates a possible pathologic nature of dyspnea and the
patient should further be evaluated

ASTHMA in pregnancy
Chronic inflammatory airway disorder with major
hereditary component
Environmental stimulant can trigger reversible airway
obstruction
Airway obstruction are due to bronchial smooth muscle
contraction, vascular congestion, mucosal edema and
tenacious mucus

Pregnancy outcome in Asthma
Clinical features of asthma during pregnancy are the same
as those in non-pregnant women
Unless there is severe disease, pregnancy outcomes are
generally excellent
According to a study by Gluck et al: 1/3 improved, 1/3
unchanged, 1/3 clearly worsened
Increased morbidity linked with progressively more severe
disease, poor control or both
o Preterm delivery, preeclampsia, abruptio
placenta, LBW, miscarriages, CS delivery

Status Asthmaticus
Life threatening complication
o Muscle fatigue, respiratory arrest
o Pneumothorax, pneumomediastinum
o Acute cor pulmonale
o Arrhythmias
Maternal and perinatal mortality significantly increased
when mechanical ventilation is required

Fetal Effects of Asthma
Response to maternal hypoxemia
o Decreased umbilical blood flow
o Increased systemic and pulmonary vascular
resistance
o Decreased CO fetal growth restriction
Fetal response is an indicator of maternal status

Fetal outcome
Physician and patients should not inappropriately avoid
the use of effective pharmacotherapy because of concerns
for fetal effects of drugs

Clinical Course
Mild wheezing to severe bronchoconstriction
Can be intermittent to persistent (mild, moderate, severe)
Symptoms
o Nocturnal awakening
o Interference with normal activity
Short acting beta-agonist for symptoms
Assess lung function

Clinical Evaluation
Subjective severity of asthma does not frequently
correlate with objective measures of airway function or
evaluation
PE is also an inaccurate predictor of severity

Useful clinical signs
Labored breathing
Tachycardia
Pulsus paradoxus
Prolonged expiration
Use of accessory muscle
Central cyanosis and altered consciousness are sign of
potentially fatal attack

Pulmonary function testing
Should be routine in management of acute and chronic
asthma
Best measure of severity
o FEV1 less than 1 L or <20% of predicted value
o Peak expiratory flow rate
Woman determines her own baseline when asymptomatic
(personal best), to compare with values when
symptomatic

Ideally
FEV1 >80% of predicted
PEFR predicted values 380-550 L/min
Therapeutic adjustments based on womans personal best

Therapy
1. Avoidance and control of asthma triggers
a. Including allergy, URTI, sinusitis, exercise,
aspirin, NSAIDs
b. Irritants (tobacco smoke , chemical fumes,
humidity, emotional upset)
c. F-series prostaglandins , ergonovine
d. GERD
i. Due to relaxation of LES
2. Medications during pregnancy
a. Poorly controlled asthma is potentially more
dangerous for the fetus than medication
i. Teratogenic period at 4-10 weeks after
LMP
b. Medications are added in a sequential fashion
with few differences from the non-pregnant
patient

Guidelines for Chronic Asthma
1. Patient education effect on pregnancy and general
management
2. Avoidance or control of environmental precipitating
factors
3. Objective assessment of pulmonary function and fetal well
being
4. Pharmacologic therapy to provide baseline control and
treat exacerbations

Step Therapy Medical Management of Asthma during Pregnancy
Mild Intermittent Asthma
o No daily medications, inhaled beta agonist as
needed
Mild Persistent Asthma
o Preferred: low dose inhaled CS
o Alternative: Cromolyn, leukotriene receptor
antagonist, or theophylline (serum level: 5-12
mcg/mL)
Moderate Persistent Asthma
o Preferred: low dose inhaled CS and long acting
beta agonist or medium dose inhaled CS or
medium dose inhaled CS and long acting beta
agonist
o Alternative: low dose or (if needed) medium
dose inhaled CS and either leukotriene receptor
antagonist or theophylline (serum level 5-12
mcg/mL)
Severe persistent asthma
o Preferred: High dose inhaled CS and long acting
beta agonist and (if needed) oral CS
o Alternative: High dose inhaled CS and
theophylline and oral CS if needed


Leukotriene receptor antagonists
Not effective for acute disease
Used with inhaled steroids to minimize dosing
No widespread experience with use in pregnant women

Theophylline
Might be used as a third line agent after beta agonist
therapy and inhaled steroids
Extensive experience
Does not appear to cause developmental risk
Has limited use in acute exacerbation

Acute Asthma Exacerbation
Beta agonist with or without ipratropium via a metered
dose inhaler with a spacer or in nebulized form
Systemic CS
Oxygen to maintain pO2 >60 mmHg and preferably
normal, the O2 saturation at or above 95% to ensure fetal
well being
IV hydration
FEV1 or PEFR
o Continuous pulse oximetry and EFM
Lowered threshold for hospitalization in pregnant
Aggressive management of asthma exacerbation is
recommended because of greater risk to the fetus from
untreated asthma

Non-responders
EARLY INTUBATION for worsening respiratory status
despite aggressive treatment
Indications for MECHANICAL VENTILATION
o Fatigue
o CO2 retention
o Hypoxemia

PNEUMONIA in Pregnancy
Infrequent, yet, serious complication
o Most frequent cause of non-obstetric infection
o 3
rd
most frequent cause of indirect obstetric
death
Can occur at any time during gestation
o In the 3
rd
trimester it is associated with preterm
labor
Causes significant fetal complications
o Hypoxia and acidosis poorly tolerated by fetus

Bacteriology
Virtually any infectious agent can cause pneumonia in a
pregnant patient
S. pneumonia is the most common
Other etiologic agents
o M. pneumonia
o H. influenzae
o Influenza and other viruses

Clinical features
Preceding URTI
Cough, fever, dyspnea and chills
Delay in recognition might lead to development of
complications such as respiratory failure or empyema

Diagnosis
CXR is essential for diagnosis
Tests to identify specific pathogen are optional

Management
Hospitalize pregnant women with radiologically proven
pneumonia
MONOTHERAPY with macrolide: azithromycin,
clarithromycin, erythromycin
Severe disease admit to ICU
o ARDS common
o Mechanical ventilation may be needed
o Respiratory fluoroquinolones: Levofloxacin
o Or Beta Lactam + Macrolide: Amoxicillin or Co-
amoxiclav, Cefuroxime or Ceftriaxone
Clinical improvement in 48-72 hours:
o Fever lyses
o Pleural effusion develops in 20%
Radiographic abnormalities may take 6 weeks to resolve
Persistent fever requires follow up radiograph

Criteria for severe CAP
RR >30/min
PaO/FiO 250 below
Confusion or disorientation
Uremia
Leukopenia 4,000 below
Thrombocytopenia 100,000 below
Hypothermia
Hypotension requiring aggressive fluid resuscitation

Pregnancy outcome
0.8% maternal mortality rate
7% required intubation and mechanical ventilation
1/3 of cases PROM, preterm delivery, LBW

Prevention
Pneumococcal vaccine recommended for:
o Immunocompromised
o Significant smoking history
o Diabetes, cardiac, pulmonary or renal disease
o Asplenia

Severe pneumonitis
Life threatening
o Influenza pneumonia
o Varicella pneumonia

TUBERCULOSIS in pregnancy
Mycobacterium tuberculosis granulomatous pulmonary
reaction
90% disease contained, dormant for lung
In immunocompromised or with other disease, reactivated
to clinical disease

Clinical features
Cough with minimal sputum production
Low grade fever
Hemoptysis
Weight loss
Extrapulmonary TB in immunocompromised
Infiltrative patterns on chest radiograph
AFB bacilli in sputum of 2/3 of culture positive patients

High risk TB
1. Healthcare workers
2. Contact with infectious patient
3. Working or living in homeless shelters
4. Alcoholics
5. Illicit drug users
6. Detainees and prisoners
7. HIV infected

Skin Testing A
5 tuberculin units of purified protein derivative P
No further evaluation if negative
Positive skin test of 5 mm or more requires CXR

Skin Testing B
Very high risk 5 mm
o HIV positive, abnormal CXR, recent contact with
active case
High risk 10 mm
o Foreign-born, drug users, HIV negative, low
income population, with medical conditions that
increase risk for TB
No risk factors 15 mm

Treatment
DOTS Quadruple regimen for active infection
o HRZE
o + pyridoxine 25 mg daily to reduce hepatic
toxicity
Monotherapy with INH for latent infection
Breastfeeding not prohibited during therapy

Neonatal TB
Transplacental
Aspiration of infected secretions at delivery
Congenital TB: hepatosplenomegaly, respiratory distress,
fever and lymphadenopathy
Unlikely if mother treated before delivery or sputum
negative
Newborn is susceptible (50%) so isolate from mother with
active disease