Pulmonary Disorders In Pregnancy CH 27

Question 1

aspiration pneumonitis pathogenesis

Answer 1

risk of aspiration increased due to elevated intra abdominal pressure, decreased gastroesophageal sphincter tone, delayed gastric emptying, and diminished laryngeal reflexes, and vomiting. also called Mandelson syndrome

Question 2

prevention of aspiration pneumonitis

Answer 2

expert airway management during use of general anesthesia. No oral intake during labor. NPO 6 to 8 hours before elective c section. use clear nonparticulate system alkalizers (alka seltzer) instead of particulate oral antacids (maalox, riopan) 30 minutes before induction of anesthesia. H2 receptor blockers (cimetidine, ranitidine) and reglan can be used but antacids preferred

Question 3

clinical findings of aspiration pneumonitis

Answer 3

immediately after aspiration: dyspnea, bronchospasm, cyanosis, tachycardia, or resp arrest. pt will be hypoxic, hypercapnic, and acidotic. if infection occurs, fever and leukocytosis will occur in 48 to 72 hours.

Question 4

XRAY after aspiration pneumonitis

Answer 4

abnormalities in ling bases if she was upright; abnormalities in upper lobes or superior segment of lower lobes of she was supine. diffuse interstitial pulmonary edema (white out) seen if large amount of very acidic material.

Question 5

action and labs after aspiration

Answer 5

immediate intubation and suction followed by ventilation and adequate oxygenation if during anesthesia. Broncoscopic suction needed if solid aspirates. serial blood gas. put pt in icu

Question 6

tx of aspiration pneumonitis

Answer 6

if gastric fluid pH greater that 3.0 and pt is well oxygenated, follow closely with x Ray and serial blood gas. x Ray should resolve without antibiotics in 48 to 72 hours. only give antibiotics (pcn or clindamycin) if clinical evidence or culture indicate bacterial infection

Question 7

asthma pathogenesis during pregnancy

Answer 7

triggers: URI, use of beta blocker, aspirin or nsaids, sulfites, food preservative, allergens, smoking, gastric reflux, exercise; high level of cortisol and progesterone may improve asthma. non compliance with asthma medication

Question 8

Asthma symptoms

Answer 8

dyspnea, chest tightness, wheezing

Question 9

mild intermittent asthma

Answer 9

symptoms < twice a week, nocturnal symptoms 80% with less than 20% variablility

Question 10

mild persistent asthma

Answer 10

symptoms occur >twice a week but not daily. nocturnal symptoms occur more than twice a month. PEF of FEV >80% but 20-30% variability

Question 11

moderate persistent asthma

Answer 11

symptoms occur daily and nocturnal symptoms occur more than once per week. PEF and FEV is <80% but >60% of normal with >30% variability

Question 12

severe persistent asthma

Answer 12

daytime symptoms occur continually and nocturnal attacks occur frequently. PEF and FEV is <60% of normal and > 30% variability

Question 13

asthma differential diagnosis

Answer 13

acute left ventricular failure (cardiac asthma), PE, exacerbation of acute bronchitis, carcinoid tumors, upper airway obstruction, GERD, cough caused by medication

Question 14

maternal complications of asthma

Answer 14

hyperemesis gravidarum, pneumonia, preeclampsia, vaginal bleeding, complicated labor

Question 15

fetal complications of asthma

Answer 15

intrauterine growth restriction, preterm birth, low birth weight, neonatal hypoxia, increased overall perinatal mortality. little to no risk with effective tx and control

Question 16

immunotherapy during pregnancy with asthma

Answer 16

may continue therapy but don’t increase dose. Don’t start immunotherapy during pregnancy because if anaphylaxis occurs, uterine contractions are likely

Question 17

vaccines during pregnancy with asthma

Answer 17

influenza and pneumococcal

Question 18

pharmacologic therapy for mild intermittent asthma

Answer 18

no need for daily meds, use 2 puffs of short acting beta 2 agonist (albuterol) when symptoms occur. use systemic corticosteroids if needed

Question 19

pharmacologic therapy for mild persistent asthma

Answer 19

low dose inhaled corticosteroid (budesonide) . recommended at earlier stages of asthma. use spacer. benefits may not be seen for 2-4 weeks so don’t use for acute attacks.

Question 20

pharmacologic therapy for moderate persistent asthma

Answer 20

combination of low dose or medium dose inhaled corticosteroid and long acting beta 2 agonist

Question 21

pharmacologic therapy for severe persistent asthma

Answer 21

high dose inhaled corticosteroid and long acting inhaled beta 2 agonist (only use if asthma not controlled by other means) and tapered systemic corticosteroid (prednisone)

Question 22

potential maternal side effects of systemic corticosteroid use

Answer 22

impaired glucose tolerance, frank diabetes mellitus, preclampsia, intrauterine growth restriction, premature delivery, maternal adrenal insufficiency (during stress and labor). use during 1st trimester associated with facial clefts

Question 23

asthma medications to avoid in pregnancy

Answer 23

epinephrine (causes vasoconstriction and reduces fetal oxygenation), isoproterenol, iodine containing meds (causes goiter in fetus causing airway obstruction), atropine ( speeds fetal HR causing inadequate breathing)

Question 24

tx from acute asthma attack in pregnant women

Answer 24

inhaled beta 2 agonist given by metered dose inhaler, 2-4 puffs every 20 mnutes to a max of 3 doses or less if side effects appear. SubQ beta 2 agonist (terbutaline) can be given and repeated once 20 minutes later. systemic corticostertoids (methylprednisone) given IV

Question 25

asthma management during labor and delivery

Answer 25

continue meds administered prior to labor. labor can trigger an attack. monitor pulmonary status with peak expiratory flow measurements. maintain hydration and give fenatyl if needed. monitor 02.

Question 26

what to avoid in asthma management during labor and delivery

Answer 26

prostaglandin F, general anesthesia, ergot derivatives, aspirin, NSAIDs, be very careful with magnesium

Question 27

fetal monitoring in pts with moderate to severe asthma

Answer 27

serial ultrasounds to monitor fetal growth restriction. fetal surveillance starting at 32 weeks and anytime in 3rd trimester when there is a exacerbation. fetal monitoring during labor and delivery

Question 28

Breast feeding and asthma medications

Answer 28

beta 2 agonists, cromolyn sodium, and steroids safe for use. Steroids may enter breast milk but only in smal amounts if total daily is less than 40 mg

Question 29

Pneumonia pathogenesis

Answer 29

rare complication, associated with significant fetal and maternal morbidity.

Question 30

Pneumonia prevention

Answer 30

flu vaccine

Question 31

Pneumonia clinical findings

Answer 31

fever, chills, productive cough, pleuritic chest pain, SOB, tachycardia, tachypneic, rales or decreased breat sounds on auscultation, lobar consolidation or infiltrate on xray in bacterial, cxr may appear normal with viral. leukocytosis with left shit on CBC

Question 32

Pneumonia differential diagnosis

Answer 32

PE, bronchitis, uncomplicated influenza

Question 33

Complications of Pneumonia

Answer 33

increases risk of fetal and maternal problems such as pulmonary edema and preterm labor

Question 34

Tx for pneumonia

Answer 34

Community acquired tx with azithromycin/azithromycin plus ceftriaxone. Varicella pneumonia tx with acyclovir, treat influenza pneumonia with oseltamivir (if resistant give zanamir

Question 35

TB pathogenesis

Answer 35

disease of pulmonary parenchyma caused by Myobacterium tuberculosis, nonmotile , acid fast aerobic rod. droplet transmission. TB tests are reactive after 2-10 weeks. then no longer symptomatic or infectious

Question 36

TB clinical findings

Answer 36

hx of cough, weight loss, positive TB skin test, and CXR

Question 37

Signs and symptoms TB

Answer 37

usually asymptomatic, except when dissemination occurs. Cough sometimes with hemoptysis, low grade fever, weight loss, fatigue, night sweats, anorexia

Question 38

Lab findings TB

Answer 38

positive ID of bacilli by Ziehl Neelsen staining and positive sputum culture. culture results can take several weeks but are necessary.

Question 39

TB skin test

Answer 39

perform early in pregnancy especially in high risk population. induration of 5 mm or greater is positive in HIV pts or those in close contact with infected. 10 mm induration positive for other high risk pts

Question 40

CXR in TB

Answer 40

shield abdomen, do chest xray if skin test positive (for the 1st time), upper lobes or superior lower lobe segments nodular infiltrates that may become cavitary. Calcified hilar node (Ghon’s complex) constitute healed primary lesion

Question 41

TB complications

Answer 41

congenital TB (rare). if fetus swallows amniotic fluid or infection is bloodbourne through umbilical circulation. diagnosis includes positive bacteriologic studies in 1st few days of life with an exclusion to extrauterine infection source

Question 42

untreated tb in pregnancy is associated with

Answer 42

intrauterine growth restriction, low birth weight, lower apgar scores

Question 43

prophylatic tb treatment in pregnancy

Answer 43

isoniazid (INH) recommended for those with positive skin test but CXR negative for active disease. withhold for pregnancy, early postpartum and women over 35 due to risk for INH realted hepatitis. DO initiate for those with HIV or especially high risk

Question 44

active tb treatment

Answer 44

treat immediately after diagnosis made. 3 drug regimen: INH, ethambutol, and rifampin for 8 weeks then INH and rifampin for 9 months (DONT use any -mycin medications due to risk for ototoxicity). Pyrazinamide may be added

Question 45

Major side effects of INH

Answer 45

hepatitis, hypersensitivity reaction, peripheral neuropathy, GI distress. get baseline liver function tests and repeat periodically due to risk of hepatotoxicity; give pyridoxine to prevent INH induced neuritis

Question 46

Major side effects of Rifampin

Answer 46

rifampin rarely causes optic neuritis; Rifampin can cause hepatitis, hypersensitivity reaction, hematologic toxicity, flu like symptoms, abdomen pain, acute renal failure, and thrombocytopenia. may make oral contraceptive ineffective

Question 47

Postpartum management of tb (contact with baby)

Answer 47

Mothers who’ve received tx with inactive disease or those with active disease with adequate tx can have contact with baby. A mother with active disease should be treated for at least 3 weeks before contact with baby and baby should get prophylactic INH. Breastfeeding not contraindicated.