Respiratory Flashcards
Discuss asthma in pregnancy
-Incidence
-Effect of pregnancy on asthma (5)
-Effect of asthma on pregnancy (5)
- Incidence
-Asthma impacts 7% of pregnancies - Effect of pregnancy on asthma
-33% have deterioration, 33% no change 33% improved
-Effect of pregnancy on asthma depends on severity
-Deterioration often due to cessation of treatment due to safety risks
-Severe episodes from 24-36 weeks
-90% labour without asthma sx. occurring - Effect of asthma on pregnancy
-Mostly if well controlled asthma doesn’t impact pregnancy
-If poorly controlled: HTN, PET, reduced glucose tolerance,
-PPROM, PTB, LBW (Inhaled corticosteriods protective against this)
-TTN/NICU/Hypoglycemia
-Atopic disease in neonate (10% if mother affected 33% if both parents affected)
Discuss asthma treatment in pregnancy
-Types of medications (4)
-Safety
-Association with malformations
- B2 agonists - ventolin - safe in pregnancy
- Inhaled corticosteroids - Flixotide
-Minimal absorption by fetus
-May improve birthweight
-No poor fetal outcomes
-Safe in pregnancy - Systemic steroids
-Do not impact fetal hypothalamic, pituitary, adrenal axis
-High doses in first trimester linked to cleft palate but has been refuted
-No evidence of increased MC, SB, NND
-Safe to use in pregnancy - Leukotriene receptor antagonists - Montelukast
-Minimal evidence on safety
-Don’t start in pregnancy
-If asthma well controlled on motelukast then continue in pregnancy
Discuss antenatal management of asthma in pregnancy (7)
- MDT input
- Advise poorly controlled asthma has worse outcomes than well controlled asthma.
- Advise to stop smoking and avoid triggers
- Caution with aspirin for PET prophylaxis
- Counsel regarding risk of atopic disease in child (10% only mother 30% both parents)
- Optimise treatment as would for non-pregnant women
- Monitor BP and glucose levels if on PO steroids
Discuss management of asthma in pregnancy
-Intrapartum
-Postpartum
- Intrapartum care
-Continue medications in labour
-Aim vaginal delivery
-If been on PO steroids >7.5mg prednisolone for >2 weeks then cover with hydrocortisone
-OK for miso/prostaglandin/synto induction
-Caution with carboprost and ergometrine
-Caution with morphine - Postpartum
-Encourage breastfeeding - reduces risk of atopy
-Continue asthma meds
-Caution with NSAIDS
Discuss cystic fibrosis in pregnancy
-Incidence (2)
-Pathophysiology (6)
-Likelihood of fetus being affected (3)
- Incidence
-1:2000 live births
-1:25 are carriers - Pathophysiology
-Autosomal recessive condition with 1700 mutations identified to the CFTR gene on chromosome 7
-CFTR important for sodium and water transport. Results in thick mucous secretions
-In lungs results in mucous build up and increased resp infections
-In pancreas results in stagnant secretions in ducts and malabsorption
-In billary tract results in bile stasis and cirrhosis
-In women fertility not impacted but in men congenital absence of Vas - Likelihood of fetus being affected
-Mother will be homozygous
-If father is a carrier then risk to fetus is 50%
-If father is not a carrier of common mutations then risk is 1:250
Discuss cystic fibrosis in pregnancy
-Effect of pregnancy on cystic fibrosis (5)
-Effect of cystic fibrosis on pregnancy (4)
-What are the predictors of poor outcome in pregnancy (4)
- Effect of pregnancy on cystic fibrosis
-Increased maternal mortality compared to non-CF pregnant women. But NOT pregnancy related.
-Pregnancy well tolerated if CF is well controlled with FEV1 >70% predicted
-Poor maternal weight gain
-Deterioration in lung function (reversible)
-Diabetes or impaired glucose tolerance - Effect of cystic fibrosis on pregnancy
-No impact on miscarriage or congenital abnormalities
-PTB
-IUGR secondary to chronic hypoxia
-Still birth - Predictors of poor outcome in pregnancy
-Pulmonary HTN / Cor pulmonale (pregnancy contraindicated)
-Severe lung disease FEV1 <60% expected (<30-40% of expected. Pregnancy contra-indicated)
-Poor maternal nutrition (BMI <18)
-Hypoxemia
Discuss preconception management for women with cystic fibrosis (7)
- Counsel about risk to fetus, risk of pregnancy to woman
- Offer to assess risk to fetus
-Check partner
-Offer amnio/CVS - Optimise maternal nutrition
- Optimise lung function with PT and antibiotics
- Get baseline Lung function testing and echo
- 5mg folic acid and vit D supplementation
- Check for diabetes with OGTT
Discuss antenatal care for women with cystic fibrosis (7)
- MTD input with physician, PT, MW, Obs, nuritionist
- Support nutrition with increased calorie diet
- Screen for diabetes at 16 weeks and if negative at 28 weeks
- Aggressively control infection
- Avoid periods of hypoxia with admission for bed rest and O2 if necessary
- Serial growth scans
- Anaesthetic review (Best to avoid GA)
Discuss management of cystic fibrosis in pregnancy
-Intrapartum cares
-Postnatal cares
- Intrapartum cares
-Can aim for a spontaneous vaginal delivery at term
-CS rate higher cf normal population
-Consider instrumental to reduce length of second stage to avoid risk of pneumothoracies
-Monitor O2 sats
-Avoid GA - Postpartum cares
-Breastfeeding OK but high nutritional requirement and so exclusive breastfeeding might be too hard
-Monitor respiratory function
-Screen new born for CF
Discuss tuberculosis in pregnancy
-Effects of pregnancy on TB (4)
-Effects of TB on pregnancy (5)
- Effects of pregnancy on TB
-Pregnancy doesn’t alter the course of disease
-Pregnancy can lead to delayed diagnosis
-Increased mortality 30-40% when treatment is delayed
-Increase in incidence of extra-pulmonary TB - Effect of TB on pregnancy
-PTB
-IUGR (Esp extra-pulmonary TB)
-Congenital TB
-Neonatal TB
-PET
Discuss management of TB in pregnancy
-Antenatal care (7)
-Postnatal care (5)
- Antenatal care
-Treat latent TB with isoniazid
-Treat active TB with triple/quadruple therapy
-Monitor LFTs
-In those treated with isoniazid also give pyridoxine 25-50mg OD)
-In those treated with isoniazid or rifampicin give Vit K 10mg OD from 36 weeks to decreased PPH and HDN
-Serial growth scans
-MDT - Postnatal
-Screen neonate for TB
-Give BCG vaccination
-Consider isoniazid prophylaxis
-Encourage breastfeeding in sputum smear negative mothers.
-PO contraception has reduced efficacy with TB meds. Choose alternative
Discuss influenza in pregnancy
-Maternal complications (3)
-Fetal complications (7)
- Maternal complications
-Increased risk of severe infection and complications
-Higher rates of hospitalisation
-Increased risk of maternal death - Fetal complications
-Spontaneous miscarriage
-LBW
-PTB
-Still birth
-If infection during first trimester
->Hydrocephaly, cleft lip. NTD, congenital heart defects (Probably fever. Influenza doesn’t cross placenta)
Why do pregnant women have increased risk of influenza susceptibility (4)
- Change in respiratory physiology in pregnancy
-Reduced functional residual capacity
-Progesterone mediated hyperventilation
-Increased oxygen demand - Shift towards Th2 immunity and away from Th1 immunity which is targeted at intracellular microbes.
Discuss management of influenza in pregnancy (3)
- Oseltamivir - start within 48hrs of symptoms
-Cat B1 medication
-Give to pregnant women and up to 2/52 PP
-Increase ICU admission and maternal death rate given after 48hrs - Give steroids if concern for need to delivery / TPTL before 34+/40. Doesn’t cause maternal worsening of symptoms.
- Severe disease
-MDT supportive care
-Consider secondary bacterial sepsis
-Thromboprophylaxis
-Consider delivery if gravid uterus impacting ventilation
Discuss influenza vaccination RANZCOG guidelines (3)
- Recommended pre-pregnancy or during any trimester
- Recommended in each pregnancy
- Safe to receive during breastfeeding