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Respiratory 3 > Pulmonary Issues in Pregnancy > Flashcards

Pulmonary Issues in Pregnancy Flashcards

1
Q

What are some changes in the upper respiratory tract during pregnancy? What are the consequences of this?

A

–Airway mucosal changes • Hyperemia, hypersecretions, mucosal edema

Consequences • Nasal obstruction • Epistaxis • Sneezing spells • Changes in voice • Polyposis of the nasal sinus mucosa

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2
Q

Changes in the thoracic cage and diaphgram during pregnancy?

A

–Enlarging uterus leads to • Increased elevation in level of the diaphragm • Increase in the AP and transverse diameter of chest

–Function of the diaphragm and chest wall musculature is unimpaired and because tidal breathing is larger, their excursions are increased

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3
Q

Explain the changes in lung function see in pregnancy?

A
  • FRC decreases by 18% (decreased ERV and RV) decreased lung volume due to elevation of the diaphragm only partially offset by increase in chest wall diameter
  • Increased respiratory drive and minute ventilation due to increased serum progesterone 1˚ respiratory alkalosis with renal bicarbonate wasting as compensation
  • 30-35% increase in tidal volume leads to increased minute ventilation (VE)
  • Respiratory rate changes minimally early and rises only about 10% late in pregnancy
  • Oxygen consumption (VO2) increases 20 to 33% owning to both maternal and fetal metabolic demands
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4
Q

What are the adaptations to the respiratory system in pregnancy?

A
  • VO 2 increase 25-35% (100% in labor)
  • Minute ventilation (VE) increase in excess of CO2 production
  • FRC decrease 10-25% in supine position with possible atelectasis
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5
Q

Cardiovascular changes in pregnancy?

A

–Increase in CO begin during 8th week and is 30-50% above normal near term (increased HR andSV, decreased PVR)

–Extracellular water increase by 1-2 liters

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6
Q

Explain the circulatory changes in pregnancy?

A
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7
Q

Briefly describe the maternal fetal circulation?

A

Fetal Blood Supply is Received Via Umbilical Vein
• PO 2 of 26-32 mmHg • Saturation 80-90% • PCO 2 of 28-42 mmHg • pH of 7.30 to 7.35

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8
Q

Explain maternal ABGs?

A
  • pH 7.40 to 7.45
  • HCO3 18-21 mEq/L
  • PCO 2 31 mmHg
  • PO 2 106-108 mmHg 1st trimester 101-104 mmHg 3rd trimester
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9
Q

What are some symptoms and signs of dyspnea during pregnancy that could be indicative of lung disease?

A

Symptoms: –Acute, severe or progressive dyspnea

–Cough

–Sputum

–Wheezes

–Acute, extreme anxiety

–Pleuritic chest pain

Signs: –Cyanosis –Clubbing –Prominent jugular venous distention –Wheezes, rhonchi or diffuse rales –Hyperventilation with splinting –Evidence of pulmonary hypertension

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10
Q

Asthma is characterized by?

A

A disease characterized by the following:

–Airway obstruction that is reversible (at least to a significant degree)

–Airway inflammation

–Increased airway responsiveness to a variety of stimuli

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11
Q

Asthma in pregnancy?

A

Asthma is the most common potentially serious medical condition to complicate pregnancy.

It is estimated that 8% of pregnant women have asthma.

Poorly controlled asthma increases maternal and fetal morbidity and mortality.

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12
Q

In pregnancy asthma may? Peak severity? Control is important why? Standard therapy safety?

A
  • With pregnancy: – 1/3 asthma improves – 1/3 asthma worsens – 1/3 asthma unchanged
  • These changes are variable from woman to woman and pregnancy to pregnancy
  • Peak severity 25-32 weeks, improvement 36-40 weeks
  • Control of asthma is essential to avoid fetal hypoxia
  • Standard therapy is relatively safe during pregnancy and lactation
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13
Q

Goals of asthma in pregnancy?

A
  • Prevent chronic day and night symptoms
  • Maintain optimal pulmonary function and normal activities
  • Prevent asthma exacerbations
  • Maintain fetal oxygenation by preventing maternal hypoxia
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14
Q

What things should be stressed to an asthmatic mother?

A

– Patient education around self-management

– Continue pre-pregnancy asthma medication

– Monitor medication adherence

– Assessment of control

– Revisit of symptoms every 4 weeks

– variation in control and lung function can occur throughout pregnancy

– Identify and control triggers such as: • Gastroesophageal reflux (GERD) • Rhinitis • Cigarette smoking • Environmental triggers

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15
Q

Pharmacologic agents in the management of asthma?

A
  • Anti-inflammatories – Corticosteroids – Inhaled – Budesonide has been recommended as the inhaled corticosteroid of choice – Systemic oral corticosteroids
  • Bronchodilators – Beta 2-agonists – Leukotriene receptor antagonist – Anticholinergics – Theophylline – Methylxanthine
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16
Q

Asthma exacerbations in pregnancy? When are they likely to occur? Risk factors?

A

Risk from uncontrolled asthma < asthma exacerbation- neither desirable

Asthma exacerbation appears to be more common in the late 2nd trimester

Asthma exacerbations are unlikely to occur during labor and delivery

• History of severe asthma • Inadequate prenatal care • Obesity • Lack of appropriate treatment with inhaled corticosteroids

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17
Q

Medications to be avoided during pregnancy?

A
  • Decongestants
  • Antibiotics: tetracycline, aminoglycosides, sulfonamides, quinolones
  • Vaccines: live virus
  • Immunotherapy: do not start, do not increase dose if continuing
  • Iodides: liquid or tablet expectorants
  • Alpha-adrenergic compounds, epinephrine, phenylpropanolamine, phenylephrine, brompheniramine – Potential for fetal harm - malformation
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18
Q

Venous thromboembolism in pregnancy is difficult why?

A
  • Diagnosis confounded by common dyspnea and leg swelling complaints
  • Noninvasive leg studies compromised by inferior vena caval obstruction
  • Normal pregnancy is in itself a hypercoaguable state
  • Effective thromboprophylaxis may require higher doses
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19
Q

Explain Virchow’s Triad and how it relates to pregnancy?

A
  • Venous Stasis – progesterone-induced vasodilation pelvic compression by a gravid uterus rt. Iliac artery causing pulsatile compression on lt. iliac vein
  • Vascular damage during vaginal delivery or caesarian section
  • Hypercoagulability of pregnancy
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20
Q

What are the normal alterations in coagulation in women who do not have VTE?

A

– Increase in factors V, VII, IX, X, XII, fibrinogen & Von Willebrand factor

– Decrease in coagulation inhibitors (decreased protein S, increased resistance to activated protein C)

– Impaired fibrinolysis (increase in plasminogen activator inhibitors)

– D-dimer levels increase with gestational age

– Protein C and antithrombin levels do not change

– Low protein S levels and activated protein C resistance develop during pregnancy

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21
Q

What is the most common cause of maternal death? DVT’s and when they happen?

A
  • PE – the most common cause of maternal deaths
  • High rates of venous thromboembolism (VTE) postpartum
  • DVT – preponderance left leg
  • DVT distribution during pregnancy: –1 st trimester 24% –2 nd trimester 47% –3 rd trimester 29%
22
Q

VTE non-imaging diagnostic modalities? imaging?

A

Non-imaging: –Risk factors –Symptoms –Signs –ECG –D-dimer increases in gestational age

Imaging: –CXR –Lung scanning (V/Q) –Leg ultrasonography –Pulmonary angiography –MRI of pelvic veins without gadolinium –Echocardiogram

23
Q

Left rule for DVT’s?

A

The “LEFT” Rule is used to assess three variables to predict the likelihood of a DVT
1. (L) Calf circumference (≥ 2 cm greater than rt.)

  1. (E) Edema
  2. (FT) First trimester presentation
24
Q

DVT’s in pregnancy?

A
  • DVT three to fourfold more common than PE in pregnancy
  • Increase incidence of isolated pelvic vein thrombosis
  • 64% DVT only at the level of the iliofemoral veins
  • Can present as whole leg swelling and buttock, groin, flank, or abdominal pain
  • 95% of iliofemoral DVT’s reported in the left leg
25
Q

Evaluation for a suspected DVT/PE?

A
  1. Baseline Chest x-ray
  2. Compression duplex ultrasonography
  3. If pulmonary imaging is required, V/Q can preferred initial test
26
Q

Define a PE?

A
  • Obstruction of blood flow to one or more pulmonary arteries
  • Usually precipitated by DVT originating in pelvis, legs, or upper extremities
  • Primary or secondary hypercoagulable states
  • Massive: decreased BP, increased RV afterload, increased PA systolic pressure
  • Submassive: normal BP, possible RV hypokinesis or dilatation
27
Q

PE difficulty of diagnosis in general and mortality rates?

A
  • Difficulty of diagnosis –Multiple clinical presentations –Nonspecific signs and symptoms
  • Mortality rates in the general population –With treatment: 5-8% –Without treatment: 25-30%
28
Q

Signs/Symptoms of PE?

A

Signs: – Tachypnea (RR > 16/min) – Tachycardia (HR > 100/min) – Accentuated 2nd heart sound – Cyanosis (massive PE) – Fever

Symptoms: – Dyspnea (unexplained) – Pleuritic chest pain – Apprehension, anxiety – Syncope (massive PE) – Hemoptysis (rare) – Diaphoresis (rare)

29
Q

PE in pregnancy?

A
  • The leading cause of maternal death
  • Rate 5 times greater than for non-pregnant women of the same age
  • About 1 in 1500 deliveries
  • Risk even greater in the puerperium
30
Q

Which blood thinning medications cross and do not cross the placenta? When to use thrombolytic therapy?

A
  • Heparin does not cross the placenta
  • Warfarin crosses the placenta and is to be avoided Warfarin embryopathy
  • Direct oral anticoagulant cross the placenta and can cause congenital malformation/embryopathy
  • Thrombolytic therapy is relatively contraindicated near term except in hemodynamically unstable patients
31
Q

How do we treat VTE in pregnancy? Side effect of this med?

A
  • Low-Molecular-Weight heparin preferred over unfractionated heparin
  • Heparin → bone mineral density loss osteoporosis
  • Bone loss of pregnancy accelerated with heparin (osteoporosis related fx may be as high as 23%)
  • HIT (Heparin Induced Thrombocytopenia)
  • Bleeding
  • All risks appear reduced with LMWH
32
Q

Pulmonary infections in pregnancy?

A
  • The most common cause of non-obstetric infection in pregnant patients
  • An infrequent occurrence but a serious complication of pregnancy – Increased maternal mortality – Premature labor – Fetal loss
33
Q

Explain the Pulmonary Physiologic Response to Normal Pregnancy

A
34
Q

What happens to different immune cells as pregnancy advances?

A
35
Q

Explain how pregnancy affects some of the common lung infections?

A
36
Q

Agents causing pneumonia in pregnancy?

A
  • Strep pneumoniae
  • Haemophilus influenza
  • “Atypical agents” –Mycoplasma pneumonia –Chlamydia pneumonia (TWAR agent)
  • Viral – assume greater virulence
  • Aspiration – anaerobic
  • No pathogen identified (common finding)
37
Q

Clinical features of pneumonia in pregnancy?

A
  • Tachypnea, tachycardia, fever, etc.
  • Finding similar to patients who are not pregnant
38
Q

Diagnosis of Pneumonia in pregnancy?

A
  • Clinical feature
  • Chest x-ray (shield abdomen)
  • Laboratory/microbiology studies as indicated
39
Q

Pneumonia problems in pregnancy are increased secondary to what?

A

– Hypoxia • Loss of normal ventilatory reserve in the pregnant patient • Fetal intolerance of hypoxia

– Respiratory alkalosis

– Immunologic changes associated with pregnancy starting in the 2nd trimester •  cell-mediated immunity •  CD4+ and CD8+ – helper induced lymphocytes decrease

40
Q

Treatment of Pneumonia in pregnancy?

A

• Important to keep in mind what antibiotic to avoid, e.g., tetracycline, aminoglycoside, sulfonamides, quinolones

41
Q

What is Mendelson’s Syndrome?

A
  • Aspiration pneumonia associated with delivery
  • Declining due to its awareness of the problem leading to improved obstetric care
42
Q

What are some factors that predispose aspiration during labor and delivery?

A
  • Raised intragastric pressure due to the gravid uterus
  • Relaxed gastroesophageal sphincter tone (progesterone effect)
  • Delayed gastric emptying that accompanies pregnancy
  • Vigorous abdominal palpation examination
  • Reduced consciousness due to anesthesia and analgesia
43
Q

Tb information?

A
  • Infection shown by positive skin test
  • 5% of infected individuals will develop disease in their first or second year
  • An additional 5% of infected individuals will develop disease in their lifetime
  • This varies with age and immunologic status
44
Q

TB and Pregnancy? Clinical manifestations?

A

Active TB is a leading cause of maternal mortality especially in HIV-infected women Cases of latent TB > than active TB

–Cough 74% –Weight loss 41% –Fever 30% –Malaise and fatigue 30% –Hemoptysis 19% –No significant symptoms 20%

45
Q

latent TB screening/management in pregnancy?

A
  • World Health Organization does not recommend routine LTB screening
  • CDC: Screening for only “high-risk” women recommend IGRA over TST
  • High risk – Known TB contacts – IV drug abuse – Immunosuppressed patients – Foreign born – Residence in congregate settings
  • Interferon gamma release assay (IGRA): Quantiferon – TB Gold or T spot TB
  • TST: Mantoux

CDC recommendations • Isoniazid treatment only in pregnant women with known recent TB contact • All others with a positive LTBI test should defer treatment until 2-3 months post partum

Treatment of active TB: Follow CDC guidelines Consultation recommended

46
Q

What is Acute Hypoxemic Respiratory Failure due to?

A
  • AFE (Amniotic fluid embolism)
  • Pulmonary edema 2 to – Tocolytic use – Preeclampsia – Cardiomyopathy
  • Venous air embolism
  • Respiratory infections
47
Q

Classic presentation of an amniotic fluid embolus?

A
  • Unpredictable and unpreventable
  • Process is more similar to anaphylaxis than embolism
  • Severe and sudden dyspnea
  • Frequent association with shock, massive hemorrhage
  • DIC in 50% of patients over ensuing hours
  • Accounts for 7-10% of all maternal death
48
Q

Complications of an Amniotic Fluid Embolism?

A
  • Shock
  • Pulmonary hypertension
  • Hypoxia
  • Left heart failure
  • ARDS
  • Bleeding diathesis – Massive hemorrhage with uterine atony – DI
49
Q

Mortality of AFE’s?

A
  • 61% in US National Registry
  • Gilbert and Danielsen, Obstet Gyn 1999; 93:973 – Surveyed reported cases in California over 2 year period – 1/20,000 deliveries – Mortality 26% – Prognosis improved with early recognition and prompt resuscitation
50
Q

What is Tocolytic-induced pulmonary edema/

A
  • Most common cause of pulmonary edema in pregnancy
  • Associated with beta-adrenergic agents primarily terbutaline
  • Nonspecific clinical findings
  • Occurs during or < 24 hours after exposure
  • Prompt response to cessation of meds, support, diuresis

Respiratory 3 (10 decks)

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