Pulmonary

 Disorders    
in  Pregnancy  

Maria  Therese  Beriña-­‐Mallen,  MD    

Fellow,  Philippine  Obstetrical  and  Gynecological  Society  
Fellow,  InternaBonal  FederaBon  of  Pediatric  and  Adolescent  Gynecology  
 Review  of  Pulmonary  Physiology  in  Pregnancy  

§  Diaphragm  elevates  by  4cm    

§  Func6onal  residual  capacity  (FRC)  =  Expiratory  reserve  
volume  (ERV)  +  Residual  volume  (RV)  
§  ê  FRC,  EV  and  RV    
§  compensated  for  by  an  increase  in  both  the  AP  and  
transverse  diameters  of  the  chest  wall  
§  Tidal  volume  éby  40%  due  to  respiratory  s6mula6on  
by  progesterone  
§  Total  lung  capacity  (TLC)  is  unchanged  
§  RR  unchanged  
 Review  of  Pulmonary  Physiology  in  Pregnancy  

•  é  O2  consump6on  
§  increases  incrementally  from  20  to  40  mL/min  in  
the  second  half  of  pregnancy  
•  Physiologic  dyspnea  
§  increased  awareness  of  a  desire  to  breathe  
§  to  compensate  for  respiratory  alkalosis,  
plasma  HCO3  levels  ê  from  26  to  22  mmol/L  

 
 Review  of  Pulmonary  Physiology  in  Pregnancy  

 
The  end  result  of  these  pregnancy-­‐induced  
changes  is  substan6vely  increased  venBlaBon  
due  to  deeper  but  not  more  frequent  breathing.    
 
•  Prevalence  during  pregnancy:  4-­‐8%  
•  Chronic  inflammatory  airway  syndrome  
with  a  major  hereditary  component  
•  Hallmarks:  
§  reversible  airway  obstruc6on  
§ bronchial  smooth  muscle  contrac6on  
§ vascular  conges6on  
§ tenacious  mucus  
§ mucosal  edema  
 Implicated  SBmuli  
•  Allergens,  including  pollens,  house-­‐dust  mites,  
cockroach  an6gen,  animal  dander,  molds,  and  
Hymenoptera  s6ngs    
•  Irritants,  including  cigareZe  smoke,  wood  
smoke,  air  pollu6on,  strong  odors,  
occupa6onal  dust,  and  chemicals    
•  Medical  condi6ons,  including  viral  upper  
respiratory  tract  infec6ons,  sinusi6s,  
esophageal  reflux,  and  Ascaris  infesta6ons    
 Implicated  SBmuli  

•  Drugs  and  chemicals,  including  aspirin,  

nonsteroidal  an6-­‐inflammatory  drugs,  beta  
blockers,  radiocontrast  media,  and  sulfites    
•  Exercise    
•  Cold  air    
•  Emo6onal  stress  
 Clinical  Course  
•  findings  range  from  mild  wheezing  to  severe  
bronchoconstric6on    
•  ê  FEV1,/FVC,  PEFR  
•  even  early  asthma  stages  may  be  dangerous  
for  the  pregnant  woman  and  her  fetus  
§  smaller  FRC  and  increased  pulmonary  shun6ng  
render  the  woman  more  suscep6ble  to  hypoxia  
and  hypoxemia  
 Clinical  EvaluaBon  
•  clinical  signs  indica6ng  severity:  
§  labored  breathing,  tachycardia,  pulsus  paradoxus,  
prolonged  expira6on,  use  of  accessory  muscles  
•  signs  of  a  poten6ally  fatal  aZack:  
§  central  cyanosis  and  altered  consciousness  
§  objec6ve  measures  of  airway  func6on  are  
more  accurate  
 Clinical  EvaluaBon  
§  Pulmonary  funcBon  tesBng  should  be  rou6ne  
in  the  management  of  chronic  and  acute  
asthma  
§  sequen6al  measurement  of  the  FEV1  or  the  PEFR  
(peak  expiratory  flow  rate)  are  the  best  measures  
of  severity  
§  FEV1  less  than  1  L,  or  less  than  20%  of  predicted  
value,  correlates  with  severe  disease    
 Clinical  EvaluaBon  
•  ABG  
§  objec6ve  assessment  of  maternal  oxygena6on,  
ven6la6on,  and  acid-­‐base  status    
§  pH,  PO2,  PCO2,  HCO3  
§  results  should  be  interpreted  in  rela6on  to  normal  
values  for  pregnancy  
§  not  rouBnely  done  
 Effects  of  Pregnancy  on  Asthma  
•  no  evidence  that  pregnancy  has  a  predictable  
effect  on  underlying  asthma  
 Pregnancy  Outcome  
•  unless  disease  is  severe  or  is  poorly-­‐
controlled,  pregnancy  outcomes  are  generally  
excellent    

 
 Fetal  Effects  
•  perinatal  outcomes  are  generally  good  if  
control  is  adequate  
•  fetal  response  to  maternal  hypoxemia  is  
decreased  umbilical  blood  flow,  increased  
systemic  and  pulmonary  vascular  resistance,  
and  decreased  cardiac  output  
§  incidence  of  IUGR  increases  with  asthma  severity  
•  no  evidence  that  commonly  used  an6-­‐
asthma6c  drugs  are  harmful    
 Management  of  Chronic  Asthma  
Guidelines:  
•  Pa6ent  educa6on  -­‐  general  asthma  management  
and  its  effect  on  pregnancy    
•  Environmental  precipita6ng  factors  -­‐  avoidance  
or  control.  Viral  infec6ons,  including  the  common  
cold,  are  frequent  triggering  events    
•  Objec6ve  assessment  of  pulmonary  func6on  and  
fetal  well-­‐being  -­‐  monitor  with  PEFR  or  FEV1    
•  Pharmacological  therapy  -­‐  in  appropriate  
combina6ons  and  doses  to  provide  baseline  
control  and  treat  exacerba6ons  
 Management  of  Chronic  Asthma  
•  Treatment  depends  on  disease  severity    
§  β-­‐agonists  help  to  abate  bronchospasm    
§  cor6costeroids  treat  the  inflammatory  component  
§  Mild  asthma  
§  inhaled  β-­‐agonists  as  needed  are  usually  sufficient    
§  Persistent  asthma  
§  inhaled  cor6costeroids,  administered  q3  to  4  hrs    
 Severity  

                                                                             Persistent  

Component   IntermiZent   Mild   Moderate   Severe  

Symptoms   <  2  day/wk   >  2  day/wk,  not   Daily   Throughout  day  

daily  
Nocturnal   <  2x/mo   3-­‐4x/mo   >1/wk,  not   Oeen  7x/wk  
awakenings     nightly  
Short  acBng  β-­‐ <  2  day/wk   >  2  day/wk,  but   Daily   Several  6mes  
agonists  for  sxs     not  >1x/day   daily  
Interference   None   Minor  limita6on   Some  limita6on   Extremely  limited  
with  normal  
acBvity  
Lung  funcBon   Normal  between  
exacerba6ons  
FEV1   >80%  predicted   >80%  predicted   60-­‐80%  predicted   <60%  predicted  
FEV1/FVC   Normal   Normal   Reduced  5%   Reduced  >5%  
 Management  of  Chronic  Asthma  
•  women  with  moderate  to  severe  
asthma:    
§  measure  and  record  either  FEV1  or  PEFR  
2x/day  
§  FEV1  ideally  is  >  80%  of  predicted    
§  predicted  values  of  PEFR  =  380  to  550  L/min  
§  each  woman  has  her  own  baseline  value,  
and  therapeu6c  adjustments  can  be  made  
using  this    
 Management  of  Acute  Asthma  
•  treatment  is  similar  to  that  for  the  non-­‐
pregnant  asthmaBc,  although  the  threshold  
for  hospitaliza6on  is  lowered  
•  therapeu6c  aim  is  to  maintain  the  pO2  >  60  
mm  Hg,  and  preferably  normal,  along  with  
95%  O2  saturaBon  
•  baseline  pulmonary  func6on  tes6ng  includes  
FEV1  or  PEFR    
 Management  of  Acute  Asthma  
•  First-­‐line  therapy  for  acute  asthma:  β-­‐agonist,  
given  subcutaneously,  taken  orally,  or  inhaled  
§  3  doses  within  60-­‐90  mins.    
§  Ex.  terbutaline,  albuterol,  epinephrine    
 
§  For  maintenance:  β-­‐agonist  +  inhaled  
corBcosteroids  
 Management  of  Acute  Asthma  
§  For  severe  exacerba6ons:  β-­‐agonist  +  inhaled  
corBcosteroids  +  oral  or  parenteral  
corBcosteroids  (methylprednisolone,  40  to  60  
mg,  every  6  hours  for  four  doses  is  commonly  
used)    
 Management  of  Acute  Asthma  
•  advise  admission  if  pa6ent  is  in  respiratory  
distress,  or  if  the  FEV1  or  PEFR  is  <  70%  of  
predicted  aeer  three  doses  of  β-­‐agonist  
•  discharge  is  considered  if  there  is  
improvement  of  FEV1  or  PEFR  to  above  70%  
of  baseline    
 Management  of  Acute  Asthma  
Status  AsthmaBcus  and  Respiratory  Failure  
•  severe  asthma  of  any  type  not  responding  
aeer  30  to  60  mins  of  intensive  therapy    
•  consider  early  intuba6on  when  maternal  
respiratory  status  worsens  despite  aggressive  
treatment    
 Labor  and  Delivery  
•  maintenance  medica6ons  are  con6nued  
through  delivery    
•  stress-­‐dose  corBcosteroids  are  administered  
to  any  woman  given  systemic  cor6costeroid  
therapy  within  the  preceding  4  weeks    
§  100  mg  hydrocor6sone/IV  q8  during  labor  
and  for  24  hrs  aeer  delivery    
§  take  serial  measurements  of  FEV1  or  PEFR  
 Labor  and  Delivery  
•  for  surgical  delivery,  conducBon/regional  
analgesia  is  preferred  because  tracheal  
intuba6on  (like  in  general  anesthesia)  can  
trigger  severe  bronchospasm  
 Labor  and  Delivery  
•  Postpartum  hemorrhage  is  treated  with  
oxytocin  or  prostaglandin  E2  (dinoprostone)  
§  Prostaglandin  F2α  (carboprost)  or  ergotamine  
derivaBves  (ex.  methergin)  are  contraindicated  
because  they  may  cause  significant  bronchospasm  
50%  is  caused  by  bacterial  pathogens  
 
 Bacterial  Pneumonia  
•  pregnancy  itself  does  not  predispose  to  
pneumonia  
•  S.  pneumoniae  is  the  most  common  cause    
•  Sxs:    fever,  produc6ve  cough,  dyspnea  and  
pleuri6c  chest  pain    
•  CXR  is  essen6al  for  diagnosis    
•  sputum  cultures,  serological  tes6ng,  cold  
agglu6nin  iden6fica6on,  and  tests  for  
bacterial  an6gens  are  not  recommended    
 Management  
•  An6microbial  treatment  is  empirical    
§  Macrolide  (azithromycin,  clarithromycin,  or  
erythromycin)    
•  For  women  with  severe  disease:  
§  Fluoroquinolone  (levofloxacin)  or    
§  Macrolide  plus  a  β-­‐lactam  (high-­‐dose  amoxicillin  
or  amoxicillin-­‐clavulanate)  
§  β-­‐lactam  alterna6ves  include  ceeriaxone,  cefpodoxime,  
or  cefuroxime    
 Criteria  for  Severe  Pneumonia  
(requires  hospitaliza6on)  

•  RR  >  30/min  
•  PaO2/FiO2  ra6o  <  250  
•  Mul6lobular  infiltrates  
•  Confusion/disorienta6on  
•  Uremia  
•  Leukopenia  (WBC  <  4000/uL)  
•  Thrombocytopenia  (<  100,000/uL)  
•  Hypothermia  (core  temp  <36C)  
•  Hypotension  requiring  aggressive  fluid  
resuscita6on  
 Management  
•  clinical  improvement  is  usually  evident  in  48  
to  72  hours  with  resolu6on  of  fever  in  2  to  4  
days    
•  radiographic  abnormali6es  may  take  up  to  6  
weeks  to  completely  resolve    
•  pneumonia  treatment  is  recommended  for  a  
minimum  of  5  days    
Pregnancy  Outcome  with  Pneumonia  
•  premature  rupture  of  membranes  and  
preterm  delivery  are  frequent  complica6ons    
§  consequently,  LBW  infants  
 PrevenBon  
•  Pneumococcal  vaccine  is  60-­‐70%  protec6ve  
against  23  serotypes    
§  not  recommended  for  otherwise  healthy  
pregnant  women    
§  recommended  for:  
§  immunocompromised,  including  those  with  HIV  
infec6on  
§  significant  smoking  history  
§  diabetes  
§  cardiac,  pulmonary,  or  renal  disease  
§  asplenia,  such  as  with  sickle-­‐cell  disease    
 Influenza  Pneumonia  
•  agents:  Influenza  A  and  B  
•  difficult  to  dis6nguish  clinically  from  bacterial  
pneumonia  
•  Management:    
§  suppor6ve  (an6pyre6cs  and  bed  rest)  
§  early  an6viral  therapy  may  have  some  benefit  
(Oseltamivir  x  5  days)  
§  shortens  the  course  of  illness  by  1-­‐2  days  
§  PrevenBon:  vaccina6on  for  Influenza  A  is  
recommended  
•  Mycobacterium  tuberculosis  
•  characterized  by  a  granulomatous  pulmonary  
reac6on  
•  clinical  features:  
§  cough  with  minimal  sputum  produc6on  (may  be  
blood-­‐6nged)  
§  low-­‐grade  fever  
§  weight  loss  
§  CXR:  (+)  infiltrates,  cavita6on,  medias6nal  
lymphadenopathy  
 Diagnosis  
•  2  types  of  tests  which  detect  latent  or  ac6ve  
TB:  
§  TST  (Tuberculin  skin  test)  
§  IGRA  (interferon  gamma  release  assays)  
§  preferred  because  it  measures  interferon-­‐gamma  
release  in  response  to  an6gens  present  in  M  
tuberculosis,  but  not  BCG  vaccine    
§  it  is  recommended  that  either  skin  tes6ng  or  
IGRA  tes6ng  of  pregnant  women  who  are  in  
any  of  the  high-­‐risk  groups  be  done  
Groups  at  Risk  for  Latent  TB  InfecBon  
•  Healthcare  workers  
•  Contact  with  infec6ous  person/s  
•  HIV-­‐infected  
•  Alcoholics  
•  Drug  users  
 Tuberculin  Skin  Test  
•  preferred  an6gen  is  5  units  of  purified  protein  
deriva6ve  (PPD)  given  intracutaneously  

•  PosiBve  result:  
§  requires  evalua6on  for  ac6ve  disease,  
including  a  chest  radiograph    
 Tuberculin  Skin  Test  
•  For  very  high-­‐risk  pa6ents—that  is,  those  who  
are  HIV-­‐posi6ve,  those  with  abnormal  chest  
radiography,  or  those  who  have  a  recent  
contact  with  an  ac6ve  case—5  mm  or  greater  
is  considered  a  reason  to  treat.    
 Tuberculin  Skin  Test  
•  For  those  at  high  risk—  foreign-­‐born  
individuals,  intravenous  drug  users  who  are  
HIV-­‐nega6ve,  low-­‐income  popula6ons,  or  
those  with  medical  condi6ons  that  increase  
the  risk  for  tuberculosis—10  mm  or  greater  is  
considered  treatable.    
 Tuberculin  Skin  Test  
•  For  persons  with  none  of  these  risk  factors,  
15  mm  or  greater  is  defined  as  requiring  
treatment.    

 
 Pregnancy  Outcome  
•  ac6ve  pulmonary  tuberculosis  is  associated  
with  increased  incidences  of:  
§  preterm  delivery  
§  LBW  infants  
§  IUGR  
§  perinatal  mortality    
 Treatment  (AcBve  TB)  
•  First  line:  quadruple  an6-­‐Koch’s  (Isoniazid,  
Rifampicin,  Ethambutol,  Pyrazinamide)  
§  preferably  by  directly  observed  therapy  (high  cure  
rates)  
§  First  2  months  (Bactericidal  phase):  all  4  are  given  
§  Next  4  months  (Con6nua6on  phase):  only  
Isoniazid  and  Rifampicin  are  given  
 
 Treatment  (AcBve  TB)  
•  second-­‐line  regimens  which  are  ototoxic  to  
the  fetus  and  are  contraindicated:  
§  Aminoglycosides  (streptomycin,  kanamycin,  
amikacin,  and  capreomycin)  
 Treatment  (Latent  TB)  
•  Isoniazid  300  mg  OD  x  9  mos.  
•  most  recommend  that  isoniazid  therapy  be  
delayed  un6l  aeer  delivery    
§  Excep6ons:  (meaning  treatment  is  given  
antepartum)  
•  known  recent  skin-­‐test  convertors  
•  skin  test  posi6ve  women  exposed  to  ac6ve  
infec6on  
•  HIV-­‐posi6ve  women  
 Pulmonary  Disorders    
in  Pregnancy  

Maria  Therese  Beriña-­‐Mallen,  MD    

Fellow,  Philippine  Obstetrical  and  Gynecological  Society  
Fellow,  InternaBonal  FederaBon  of  Pediatric  and  Adolescent  Gynecology