PULMONARY DISORDERS

Dr. Añover

Physiological Alterations Induced by Pregnancy  Mucosal inflammation

(Wise and Associates 2006): o Characterized by infiltration of eosinophils,
1. Vital capacity and inspiratory capacity increase by mast cells and T lymphocytes causes airway
approximately 20% by late pregnancy. inflammation and increased responsiveness to
2. Expiratory reserve volume decreases from 1300ml numerous stimuli
to approximately 1100ml.  F series prostaglandins and ergonovine exacerbate
3. Tidal volume increases approximately 40% as a asthma and should be avoided if possible
result of respiratory stimulation by progesterone.
4. Minute ventilation increases 30% to 40% due to Clinical Course
increased tidal volume. As a result, arterial PO2  Asthma manifestation ranges from mild wheezing to
increases from 100 to 105 mmHG. severe bronchoconstriction which obstructs airway
5. Increasing metabolic demands causes a 30% rise and decreases airflow
in CO2 production. But, becauses of its  Lowers the FEV1/FVC and PEF
concomintantly increased diffusion capacity and
hypervenmtilation, the arterial PCO2 decreases
from 40 to 32 mmHG.
6. Residual volume decreases approximately 20%
from 1500ml to approximately 1200ml.
7. Chest wall compliance is reduced by a third by the
expanding uterus and increased intaabdominal
pressure. This causes 10% to 20% decreases in
functional residual capacity (the sum of of expiratory
reserve and residual volume).

ASTHMA
 Reactive airway disease frequently seen in young
women
 Estimated prevalence during pregnancy between 4
and 8 percent, appears to be rising
 Evidence is accruing that fetal and neonatal
environmental exposure may contribute to the
origins or mitigation of asthma

Pathophysiology
 Chronic inflammatory syndrome with a major
hereditary component
 Increased airway responsiveness and persistent
subacute inflammation are associated with
polymorphism genes chromosomes 5q that include
cytokine gene clusters, beta adrenergic and
glucocorticoid receptor genes and the T-cell antigen
receptor gene.
 Etiologically and clinically heterogeneous
 Environmental stimulants – serves as promoter for
susceptible individuals
 Hallmarks of asthma
o Reversible airway obstruction from bronchial
smooth muscle contraction
o Vascular congestion
o Tenacious mucus
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o Mucosal edema
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ZALGIATROZ 2021 S.Y. 2019-2020 AGUSTIN, AMAGO, BAJO, GERALE, IGANO, ROMPAL, POSION
 Subsequent alterations in oxygenation primarily
reflect ventilation-perfusion mismatching
because the distribution of airway narrowing is
uneven.
 Hypoxia initially mitigated by hyperventilation which
maintains PO2 within normal range but lowers
PCO2 leading to respiratory alkalosis
 With severe obstruction, ventilation becomes
impaired as fatigue causes early CO2 retention
 Because of hyperventilation, this may only be seen
initially as an arterial PCO2 returning to normal
range
 With continuing obstruction, respiratory failure
follows from fatigue
 Early asthma stages may be dangerous to pregnant
woman and her fetus because smaller functional
capacity and increased pulmonary shunting render
the woman more susceptible to hypoxia and
hypoxemia.

Clinical Evaluation  Arterial blood gases analysis provides objective

 Subjective severity of asthma frequently does not assessment of:
correlate with objective measures of airway function o Maternal oxygenation
or ventilation o Ventialation
 Useful signs o Acid-base status
o Labored breathing  Pulmonary function test should be a routine
o Tachycardia management
o Pulsus paradoxus o Peak expiratory flow rate – best measure of
o Prolonged expirations severity
o Use of accessory muscles
 Signs of potentially fatal attack
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o Central cyanosis
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o Altered consciousness

ZALGIATROZ 2021 S.Y. 2019-2020 AGUSTIN, AMAGO, BAJO, GERALE, IGANO, ROMPAL, POSION
Management of Chronic Asthma
 Management guidelines includes:
o Patient education
o Environmental precipitating factors
o Objective assessment of pulmonary function
and fetal status
o Pharmacological therapy
ACUTE BRONCHITIS
 Infection of the large airways is manifest by cough
without pneumonitis
 Common in adults, especially winter months
 Caused by Influenza A and B, parainfluenza,
respiratory syncytial virus, corona virus, and
rhinovirus
 Cough persist for 10-20 days and occasionally lasts
a month or longer
 Routine antibiotic treatment is not indicated

PNEUMONIA
 Frequent indication for postpartum readmission

Bacterial Pneumonia
 Caused by Streptococcus pneumonia,
Haemophilus influenza and Legionella species
 Typical symptoms:
o Cough, dyspnea, sputum production and
pleuritic chest pain
o Mild respiratory, malaise and mild leukocyotsis
precede these symptoms
 Chest radiograph is essential for diagnosis
 Rapid serological testing for Influenza A and B is
Management of Acute Asthma
also recommended
 Similar to that for the nonpregnant asthmatic
 Management:
 First line therapy
o Can be safely treated as outpatient if not
o SABA
clinically severe
 Antibiotics not given unless there is concomitant
o Antimicrobial and antiviral treatment is
pneumonitis
empirical

Status Asthmaticus and Respiratory Failure

Empirical Antimicrobial Treatment for Community-
 Severe asthma of any type not responding after 30-
Acquired Pneumonia
60 mins of intensive therapy
Uncomplicated, otherwise healtha
 Early intubation should be done if maternal
Macrolidesb: clarithromycin or azithromycin
respiratory status worsens despite aggressive
PLUS
treatment
Oseltamivir for suspected influenza A infection
 Mechanical ventilations indication:
o Fatigue
Severe pneumoniac
o CO2 retention
Respiratory fluoroquinolones: moxifloxacin,
o Hypoxemia
gemifloxacin, or levofloxacin
 CS delivery is done with caution
or
β-lactams: amoxicillin/clavulanate, ceftriaxone,
Labor and Delivery
cefotaxime, or cefuroxime plus a macrolide
 Maintenance medications are continued
PLUS
 Stress dose corticosteroid are administered to any
Oseltamivir for suspected influenza A infection
woman given systemic corticosteroid therapy within
the preceding 4 weeks a
Use as inpatient or outpatient regimen
o 100 mg Hydrocortisone IV every 8 hours during b
Doxycycline may be given instead if postpartum
labor and for 24 hours after delivery c
See Table 51-3 for criteria
 Oxytocin or prostaglandin E1 or E2 for cervical
ripening and for postpartum hemorrhage
 Fentanyl for labor and epidural analgesia is ideal
 For surgical delivery, conduction analgesia is
preferred
 Ergotamine is contraindicated because it can cause
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bronchospasm
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ZALGIATROZ 2021 S.Y. 2019-2020 AGUSTIN, AMAGO, BAJO, GERALE, IGANO, ROMPAL, POSION

 Clinical improvement is usually evident in 48-72
hours with resolution of fever in 2-4 days
 Prematurely ruptured membranes and preterm
delivery are frequent complications
 Prevention
o Pneumococcal vaccines (23-serotype and 13-
serotype)
- 13-serotype is contraindicated in pregnant
woman but recommended for women who
are immunocompromised
Influenza Pneumonia
 Caused by influenza A and B, self-limited
 Onset is 1 to 4 days following exposure
 Common symptoms
o Fever, cough, myalgia and chills
 Management
o Supportive and antiviral treatment for
uncomplicated influenza
o Oseltamivir 75mg PO BID or Zanamivir 10mg
BID via inhalation for 5 days
 Prevention
o Vaccination for Influenza A is recommended by
ACOG and CDC
Varicella Pneumonia
 Infection with varicella-zoster virus
Fungal and Parasitic Pneumonia
 Pneumocystic Pneumonia
o Pneumocystis jeroveci
o Characterized by dry cough, tachypnea,
dyspnea, and diffuse radiographic infiltrates
o Can be identified by sputum culture,
bronchoscopy with lavage or biopsy
o Most frequent HIV-related disorder in pregnant
women
o Treatment: Trimethoprim-sulfamethoxazole for
14-21 days; alternative agent- Pentamidine
 Fungal Pneumonia
o Seen in women with HIV infection or
immunocmpromised
ZALGIATROZ 2021 S.Y. 2019-2020
o Mild and self-limited
o Characterized by fever and cough
o Treatment: Amphotericin B IV
Severe Acute Respiratory Syndrome (SARS)
 Coronaviral respiratory infection identified in China
in 2002
TUBERCULOSIS
 Infection is caused by inhalation of Mycobacterium
tuberculosis
 Symptoms include:
o Cough with minimal sputum production, low
grade fever, hemoptysis, and weight loss
 Various infiltrative patterns seen on chest
radiographs
 Acid-fast bacilli are seen on stained smears of
sputum
 Forms of extrapulmonary TB:
o Lymphadenitis, pleural, genitourinary, skeletal,
meningeal, gastrointestinal and military or
disseminated
 Treatment: Isoniazide, Rifampicin, Pyrazinamide
and Ethambutol for 6 months
 TB and Pregnancy
o Outcomes are dependent on the site of
infection and gestational age at diagnosis
o Active pulmonary TB was associated with
increased incidence of preterm delivery, low
birth weight and growth restricted newborns
and perinatal mortality
o Treated TB is associated with good outcomes
o Diagnoses:
 Tuberculin skin test (PPD)
 Interferon-gamma release assay (blood
tests that measure interferon-gamma
release in response to antigen present in M.
Tuberculosis
o Treatment:
 Latent Infection – Isoniazid 300 mg PO for
9 months
 Active Infection- Four drug regimen
(Rifampicin, Isoniazid, Ethambutol,
Pyrazinamide) along with Pyridoxine for 6
months (First 2 months- all 4 drugs are
given; then followed by 4 month phase-
isoniazid and rifampicin)
SARCOIDOSIS
 This is a chronic, multisystem inflammatory disease
of unknown etiology characterized by an
accumulation of T helper lymphocytes and
phagocytes within noncaseating granulomas.
 Genetically determined and characterized by an
exaggerated response of t helper lymphocytes to
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environmental factors
 More common for blacks than for whites; between
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20 and 40 years of age
AGUSTIN, AMAGO, BAJO, GERALE, IGANO, ROMPAL, POSION
 Clinical presentation  Lung transplantation during pregnancy is less
o Dyspnea, dry cough without constitutional favorable
symptoms that develop insidiously over months
o Onset is abrupt and sometimes asymptomatic
at discovery
 Interstitial pnemonitis (hallmark of pulmonmary
involvement)
 Biopsy- for confirmation of diagnosis
 Good prognosis; often resolves without treatment
 Glucocorticoids is usually given for symptomatic
individuals
 Pregnancy Outcome
o Usually uncommon and frequently benign
o Incidences of preterm delivery, preeclampsia
and thromboembolism
o Active sarcoidosis is treated using guidelines as
for nonpregnant women
o Symptomatic uveitis, constitutional symptoms
and pulmonary symptoms are treated with
prednisone 1mg/kg PO per day

CYSTIC FIBROSIS
 Autosomal recessive excrinopathy
 Usually diagnosed shortly after birth because of
meconium peritonitis
 Mutations in the chloride channel cause altered
epithelial cell membrane transport of electrolytes
and this affects all sites in which epithelium
expresses CFTR-secretory cells
 Preconceptional Counselling
o Women with clinical cystic fibrosis are subfertile
because of tenacious cervical mucus
o Males are infertile, have oligospermia or
aspermia from vas deferens obstruction
o Both intrauterine insemination and in vitro
fertilization can be successful to affected
women
o ACOG recommends carrier screening be
offered to all women currently pregnant or
considering conception
o Pregnancy outcome is inversely related to
severity of lung dysfunction
 Management
o Serial pulmonary function testimg assits
management and estimating prognosis
o FEV1 of 70% at least, women can tolerate
pregnancy
o Beta adrenergic bronchodilators help control
airway constriction
o Inhaled recombinant human
deoxyribonuclease – improves lung function
by reducing sputum viscosity
o Nutritional status is assessed
o Oral synthetic penicillins and
cephalosporins for staphylococcal infections
o For labor and delivery, epidural analgesia is
CARBON MONOXIDE POISONING
 The most frequent cause of poisoning worldwide
 Odourless and tasteless and has high affinity for
haemoglobin binding
 Pregnancy and CO Poisoning
o With chronic exposure, maternal symptoms
usually appear when the carbocyhemoglobin
concentration is 5 to 20 percent
o Symptoms include headache, weakness,
dizziness, physical and visual impairment,
palpitations and nausea and vomiting
o With acute exposure, concentrations of 30-50
percent produce symptoms of impending
cardiovascular collapse
o Levels >50 percent may be fatal for the mother
o The fetus does not tolerate excessive exposure
o Haemoglobin F has an even higher affinity for
CO (10-15%) due to diffusion
o Half life of carboxyhemoglobin is 2 hours in the
mother but 7 hours in the fetus
o Fetus may be hypoxic even before maternal CO
levels are appreciably elevated
o Anoxic encephalopathy is the primary sequel of
fetal exposure
 Treatment
o Supportive along with 100% inspired oxygen
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recommended
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