Pulmonary Disorders in

Pregnancy
Reference
• Williams Obstetrics 26th ed., 2018; Cunningham FG,
Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman
BL, Casey BM, Sheffield JS. Chapter 51

• Chapter 54
 Outline

1. Physiologic pulmonary changes induced

by pregnancy
2. Pulmonary diseases in pregnancy:
• ASTHMA
• BACTERIAL PNEUMONIA
• INFLUENZA PNEUMONIA
• TUBERCULOSIS

 Diagnosis, treatment, effect of pregnancy,

pregnancy outcome
 Physiologic Pulmonary changes induced
by pregnancy
• 1. Vital capacity and inspiratory capacity increase by
approximately 20 percent by late pregnancy.

• 2. Expiratory reserve volume decreases from 1300 mL

to approximately 1100 mL.

• 3. Tidal volume increases approximately 40 percent as

a result of respiratory stimulation by progesterone.

• 4. Minute ventilation increases 30 to 40 percent due

to increased tidal volume. As a result, arterial Po2
increases from 100 to 105 mm Hg.

Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
 Physiologic Pulmonary changes induced
by pregnancy
• Increasing metabolic demands cause a 30-percent rise in
carbon dioxide (CO2) production. But, because of increased
diffusion capacity and hyperventilation, the arterial PCO2
decreases from 40 to 32 mm Hg.
• 6. Residual volume decreases approximately 20 percent from
1500 mL to approximately 1200 mL.
• 7. Chest wall compliance is reduced by a third by the
expanding uterus and increased abdominal pressure, which
causes a 10-to 25-percent decrease in functional residual
capacity—the sum of expiratory reserve and residual volumes.

Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
1. ASTHMA
 Asthma: Pathophysiology
• Asthma is a chronic inflammatory airway syndrome with
a major hereditary component.

• Increased airway responsiveness and persistent subacute

inflammation

• Asthma is heterogeneous, and there inevitably is an

environmental allergic stimulant such as influenza
or cigarette smoke in susceptible individuals

Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
 Asthma: Pathophysiology
• The hallmarks of asthma: reversible airway obstruction
from bronchial smooth muscle contraction, vascular
congestion, tenacious mucus, and mucosal edema.

• There is mucosal infiltration with eosinophils, mast cells, and T

lymphocytes that causes airway inflammation and increased
responsiveness to numerous stimuli

• inflammatory mediators include histamine, leukotrienes,

prostaglandins, cytokines, and many others.

• Because F-series prostaglandins and ergonovine exacerbate

asthma, these commonly used obstetrical drugs should be
avoided if possible.
Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
 Classification of
Asthma severity

Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
Clinical stages of ASTHMA

FIGURE 51-1 Clinical stages of asthma. FEV1 = forced expiratory volume in 1

second.
 Effect of Pregnancy on Asthma
• Pregnancy has an unpredictable effect on
underlying asthma:
• approximately 1/3 improves, 1/3 remains unchanged,
or 1/3 worsens
• Exacerbations are more common with severe disease
• Some women have asthma exacerbations during
labor and delivery.

Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
 Pregnancy
outcome
• unless disease is severe, pregnancy outcomes
are generally excellent.
• Increased morbidity appears to be significantly linked
to severe disease, poor control, or both
• The incidence of spontaneous abortion in women
with asthma may be slightly increased
• Fetal Effects: With reasonable asthma control, perinatal
outcomes are generally good.

Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
 Asthma: clinical evaluation
• useful clinical signs include labored breathing,
tachycardia, pulsus paradoxus, prolonged expiration, and
use of accessory muscles.

• Signs of a potentially fatal attack include central

cyanosis and altered consciousness.

• Arterial blood gas analysis provides objective

assessment of maternal oxygenation, ventilation, and
acid-base status.  results must be interpreted in
relation to normal values for pregnancy.
Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
 Asthma: clinical
evaluation
• Pulmonary function testing should be routine in the
management of chronic and acute asthma.

• Sequential measurement of the FEV1 or the peak expiratory flow

rate—PEFR—are the best measures of severity.
• The PEFR correlates well with the FEV1, and it can be measured
reliably with inexpensive portable meters.
• An FEV1 less than 1 L, or less than 20 % of predicted value,
correlates with severe disease defined by hypoxia, poor response
to therapy, and a high relapse rate.
• It is advisable for each woman to determine her own baseline
when asymptomatic to compare with values when symptomatic.

Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
 Chronic Asthma: principles of
management
• 1. Patient education—general asthma management and its
effect on pregnancy

• 2. Environmental precipitating factors—avoidance or control.

Viral infections—including the common cold—are frequent
triggering events

• 3. Objective assessment of pulmonary function and fetal

wellbeing—monitor with PEFR or FEV1

• 4. Pharmacological therapy—in appropriate combinations and

doses to provide baseline control and treat exacerbations.

Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
 Chronic Asthma: management
• In general, women with moderate to severe asthma
should measure and record either their FEV1 or
PEFR twice daily.

• The FEV1 ideally is > 80 percent of predicted. For

PEFR, predicted values range from 380 to 550 L/min.

• Therapeutic adjustments can be made using this

Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
 Chronic Asthma: management
• Treatment depends on disease severity.

Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
 Chronic Asthma: management

• β-agonists help to relieve bronchospasm

• Corticosteroids treat the inflammation (anti-
inflammatory)
• For mild asthma, inhaled b-agonists as needed
are usually sufficient.
• For persistent asthma, inhaled corticosteroids
are administered every 3 to 4 hours.
• The goal is to reduce the use of β-agonists
for symptomatic relief.

Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
 Chronic Asthma: management
• Theophylline is a methylxanthine; bronchodilators and
possibly antiinflammatory agents.
• used less frequently since inhaled corticosteroids became
available
• useful for oral maintenance therapy if the initial
response to inhaled corticosteroids and β-agonists is
not optimal

• Antileukotrienes inhibit leukotriene synthesis and include

zileuton, zafirlukast, and montelukast for prevention,
but they are not effective for acute disease.
For maintenance, they are used in conjunction with inhaled
corticosteroids to allow minimal dosing.
Williams Obstetrics 24 ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
th

Chapter 51
 Chronic Asthma: management
• Cromones include cromolyn and nedocromil,
which inhibit mast cell degranulation.
• ineffective for acute asthma and are taken chronically for
prevention.
• not as effective as inhaled corticosteroids and are used primarily to treat
childhood asthma

Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
 Management of Acute
Asthma
• Treatment of acute asthma during pregnancy is similar to that
for the nonpregnant asthmatic
• Intravenous hydration may help clear pulmonary secretions,
and supplemental oxygen is given by mask.
• The therapeutic aim is to maintain the PO2 > 60 mm Hg, and
preferably normal, along with 95-percent oxygen saturation.
• First-line therapy for acute asthma includes a -adrenergic
agonist (terbutaline, albuterol, isoetharine, epinephrine,
isoproterenol, or metaproterenol, which is given
subcutaneously, taken orally, or inhaled)
• These drugs bind to specific cell-surface receptors and
activate adenylyl cyclase to increase intracellular cyclic AMP
and modulate bronchial smooth muscle relaxation.

Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
 Management of Acute
Asthma
• If not previously given for maintenance, inhaled corticosteroids
are commenced.
• A nebulized anticholinergic drug may be added
• for severe exacerbations, IV magnesium sulfate or theophylline
may prove effective
• Corticosteroids should be given early to all patients with severe
acute asthma.
• Unless there is a timely response to bronchodilator + inhaled
corticosteroid therapy, then oral or parenteral corticosteroids are
given:
• oral prednisone or prednisolone or IV methylprednisolone in a
dose of 30 to 45 mg daily for 5 to 10 days without tapering
• Because their onset of action is several hours, corticosteroids
are given initially along with b-agonists for acute asthma.
Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
 Status Asthmaticus
• Severe asthma of any type not responding after 30 to
60 minutes of intensive therapy

• Consideration should be given to early intubation

when maternal respiratory status worsens despite
aggressive treatment

• Fatigue, carbon dioxide retention, and hypoxemia are

indications for mechanical ventilation.

Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
 Labor and Delivery
• For the laboring asthmatic, maintenance medications
are continued through delivery.

• Stress-dose corticosteroids are administered to any

woman given systemic corticosteroid therapy within
the preceding 4 weeks.

• The usual dose is 100 mg of hydrocortisone given

intravenously every 8 hours during labor and for 24
hours after delivery.

Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
 Labor and Delivery

• Epidural analgesia is ideal.

• For surgical delivery, conduction analgesia is preferred

because tracheal intubation can trigger severe
bronchospasm.

• Prostaglandin F2 (eg carbpprost) or ergotamine

derivatives (eg methergine) are contraindicated
because they may cause significant bronchospasm.

Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
2. BACTERIAL
PNEUMONIA
 Bacterial Pneumonia
• Any pregnant woman suspected of having pneumonia should
undergo chest radiography.

• Typical symptoms include cough, dyspnea, sputum

production, and pleuritic chest pain.

• Mild upper respiratory symptoms and malaise usually precede

these symptoms, and mild leukocytosis is usually present.

Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
 Risk factors to that should
prompt hospitalization:

Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
 Bacterial Pneumonia
• With severe disease, admission to an ICU or
intermediate care unit is advisable.
• Severe pneumonia is a common cause of acute
respiratory distress syndrome during pregnancy
• Antimicrobial treatment is empirical :
• Because most adult pneumonias are caused by
pneumococci, mycoplasma, or chlamydophila,
monotherapy initially is with a macrolide—azithromycin,
clarithromycin, or erythromycin.

Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
Bacterial Pneumonia
TABLE 51-4. Empirical Antimicrobial Treatment for Community-Acquired
Pneumonia
Uncomplicated, otherwise healthya
Macrolidesb: clarithromycin or azithromycin
PLUS
Oseltamivir for suspected influenza A
infection
Severe pneumoniac
Respiratory fluoroquinolones: moxifloxacin,
gemifloxacin, or levofloxacin
or
β-lactams: amoxicillin/clavulanate, ceftriaxone, cefotaxime, or cefuroxime plus a
macrolide
PLUS
Oseltamivir for suspected influenza A infection

aUse as inpatient or outpatient regimen.

bDoxycycline may be given instead if postpartum.
 Bacterial Pneumonia
• For women with severe pneumonia:
• (1) a respiratory fluoroquinolone— levofloxacin,
moxifloxacin, or gemifloxacin;
• (2) a macrolide plus a β-lactam—high-dose amoxicillin
or amoxicillin-clavulanate, which are preferred β-
lactams.

• β-lactam alternatives include ceftriaxone, cefpodoxime,

or cefuroxime (preferred for “high-level” resistance
of pneumococcal isolates to macrolides)
• For community-acquired methicillin-resistant S aureus
(MRSA) is suspected: Vancomycin or linezolid are
Williams Obstetrics 24 ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
th

Chapter 51added
 Bacterial Pneumonia
• Clinical improvement is usually evident in 48 to 72
hours with resolution of fever in 2 to 4 days.
Radiographic abnormalities may take up to 6 weeks to
completely resolve

• Pneumonia treatment is recommended for a minimum

of 5-7 days

Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
 Pregnancy outcome with Pneumonia
• Prematurely ruptured membranes and preterm
delivery are frequent complications

• twofold increase in low-birthweight infants

• increased incidences of preterm and growth-

restricted infants as well as preeclampsia and
cesarean delivery

Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
 Pneumococcal
vaccine
• Two pneumococcal vaccines: 23-serotype older preparation
and a newer 13- serotype vaccine:

• The 23-serotype vaccine is 60- to 70-percent protective, and

its use lowers emergence of drug-resistant pneumococci

• The 13-serotype vaccine is not recommended for otherwise

healthy pregnant women  recommended for women who
are
immunocompromised, including those with HIV infection;
significant smoking history; diabetes; cardiac, pulmonary, or renal
disease; and asplenia, such as with sickle-cell disease

Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
3. INFLUENZA
PNEUMONIA
Influenza Pneumonia
• Influenza A and B are RNA viruses that cause respiratory
infection, including pneumonitis
• virus is spread by aerosolized droplets and quickly infects
ciliated columnar epithelium, alveolar cells, mucus gland cells,
and macrophages.
• Disease onset is 1 to 4 days following exposure.
• Common symptoms include fever, cough, myalgia, and chills
• In most healthy adults, infection is self-limited.
Treatment of Influenza
• Supportive treatment is recommended for uncomplicated influenza
• Early antiviral treatment is effective
• Hospitalization is considered for severely ill women
• The CDC (2016b) recommends neuraminidase inhibitors given within
2 days of symptom onset for chemoprophylaxis and treatment of
influenza A and B:
• The drugs interfere with release of progeny virus from infected host cells and
thus prevent infection of new host cells
• Oseltamivir is given orally, 75 mg twice daily, or zanamivir is given by
inhalation, 10 mg twice daily.
• Recommended treatment duration with either is 5 days.
• The drugs shorten the course of illness by 1 to 2 days, and they probably
reduce the risk for pneumonitis
• the drugs are not teratogenic in animal studies and are considered low
• risk
Vaccination for influenza A is recommended by the American College
Obstetricians and Gynecologists (2016b) and the CDC
of
(2016b).
4. TUBERCULOSIS
 Tuberculosis
• Infection is via inhalation of Mycobacterium
tuberculosis, which incites a granulomatous pulmonary
reaction.

• Manifestations usually include cough with minimal

sputum production, low-grade fever, hemoptysis, and
weight loss.

• Various infiltrative patterns are seen on chest radiograph,

and there may be associated cavitation or mediastinal
lymphadenopathy.

• Acid-fast bacilli are seen on stained smears of sputum

Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
 Tuberculosis: Diagnosis
• There are two types of tests to detect latent or
active tuberculosis:

1. tuberculin skin test (TST) – PPD 5 tuberculin units

A positive skin test result measures ≥5 mm in diameter and
requires evaluation for active disease, including a chest radiograph.

2. interferon-gamma release assays (IGRAs)

- blood tests that measure interferon-gamma release in response to
antigens present in M tuberculosis, but not bacille Calmette-
Guérin (BCG) vaccine
- QuantiFERON-TB Gold and T-SPOT.TB tests
Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
 Tuberculosis: Treatment
• Recommended initial treatment for active
tuberculosis in pregnant patients is a four-
drug regimen: isoniazid, rifampin, ethambutol, and
pyrazinamide, along with pyridoxine.

• bactericidal phase = In the first 2-month phase, all four

drugs are given
• continuation phase = 4-month phase of isoniazid and
rifampin

Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
 Tuberculosis: Treatment
• Breast feeding is not prohibited during
antituberculous therapy.

• Of the second-line regimens, the

aminoglycosides— streptomycin, kanamycin,
amikacin, and capreomycin—are ototoxic to the
fetus and are contraindicated

• Latent infection: 9 months tx with isoniazid

only

Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
 Neonatal
tuberculosis
• Tubercular bacillemia can infect the placenta, but it is
uncommon that the fetus becomes infected (congenital
tuberculosis)
• also applies to newborns who are infected by aspiration of
infected secretions at delivery.
• Neonatal infection is unlikely if the mother with active disease
has been treated before delivery or if her sputum culture is
negative.
• If untreated, the risk of disease in the infant born to a woman
with active infection is 50 percent in the first year
• Neonatal tuberculosis simulates other congenital infections and
manifests with hepatosplenomegaly, respiratory distress, fever,
and lymphadenopathy
Williams Obstetrics 24th ed., 2014; Cunningham FG, Leveno KJ, Bloom SL, Spong KY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS.
Chapter 51
 Summary
1. Physiologic pulmonary changes induced
by pregnancy
increase or decrease?
vital capacity
expiratory reserve volume
tidal volume
minute ventilation
residual volume
 Outline

1. Pulmonary diseases in pregnancy:

• ASTHMA
• BACTERIAL PNEUMONIA
• IINFLUENZA PNEUMONIA
• TUBERCULOSIS

 Diagnosis, treatment, effect of pregnancy,

pregnancy outcome
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