Pulmonary Problems in Pregnancy

Preface

Contents

Acknowledgments

Contributors

Part I: Normal Pregnancy

Physiological Transition from Fetal to Neonatal Life in Pregnancy

Evolution of Air-Breathing Respiration

Fetal Respiration

Lung Growth and Development

Importance of Surfactant

Surface Tension

Cellular Morphology and Morphogenesis

Cells Derived from Entoderm

Cells Derived from Mesoderm

Summary of Lung Development In Utero and Beyond

References

Respiratory Physiology in Pregnancy

Introduction

Chest Wall and Lung Mechanics in Pregnancy

Airflow Mechanics

Ventilation and Gas Exchange

Physiologic Dyspnea of Pregnancy

Summary and Conclusions

Abbreviations

References

High Altitude, Chronic Hypoxia, and Pregnancy

Respiratory Physiology at High Altitude

Pregnancy Outcomes Associated with High Altitude

Uteroplacental Circulation and Oxygen Transport

Chronic Hypoxia and Effect on the Placenta

References

Sleep Physiology in Pregnancy

Sleep Physiology in Pregnancy

Overview of Sleep Stages

The Sleep-Wakefulness Cycle

Overview of Sleep in Pregnancy

Mechanical and Somatic Factors Affecting Sleep Initiation and Sleep Maintenance

Gastroesophageal Factors

Urinary Factors

Musculoskeletal Factors

Obstetric Factors

Anatomic Changes Predisposing to Sleep-Disordered Breathing

Upper airway Changes

Hormonal Factors Affecting Sleep in Pregnancy

Progesterone

Estrogen

Corticotropin Releasing Hormone (CRH) and Cortisol

Growth Hormone (GH)

Melatonin

Prolactin

Oxytocin

Human Gonadotropic Hormone (HCG)

Cytokines

Nitric oxide

Oxygenation During Sleep in Pregnancy

Control of Breathing During Sleep in Pregnancy

Sleep Measures in Normal Pregnancy

Summary

References

Part II: General Management Principles in Pregnancy

Diagnostic Imaging in Pregnancy

Ionizing Radiation

Teratogenicity

Radiation Dose

Timing of Radiation Exposure

Method of Administration

Intrauterine Fetal Death

Oncogenicity

Use of Contrast Agents

Ultrasound

Magnetic Resonance Imaging (MRI)

Nuclear Medicine

Informed Consent

Summary

References

Prescribing in Pregnancy and Lactation

The Myth of the Placental Barrier

The Myth of the ‘‘Safe’’ Period

Drug Safety Data in Pregnancy

Animal Studies

Case Reports and Case Series

Pregnancy Registries

Case Control Studies

Physiologic Changes of Pregnancy Affecting Pharmacokinetics

Choosing Medication in Pregnancy

Breast Feeding and Medications

Conclusion

Abbreviations

References

Monitoring Fetal Well-Being in the Critical Care Setting

Introduction to Electronic Fetal Monitoring

EFM Descriptions

Ancillary Methods to Assess Fetal Status

Timing of Monitoring

Interventions for a Non-Reassuring FHR

Perimortem Cesarean Section

References

Anesthetic Considerations in Pregnant Patients with Pulmonary Disorders

Introduction

Airway Management

Neuraxial Blockade and Pulmonary Function

General Anesthesia and Pulmonary Function

Anesthesia for Specific Pulmonary Disorders

References

Part III: Pulmonary Disorders in Pregnancy

Obstructive Sleep Apnea in Pregnancy

Definitions of Obstructive Sleep Apnea Syndrome (OSAS)

Alterations of Pregnancy and OSAS

Anatomic and Physiologic Sleep Changes During Pregnancy

Changes Protective Against Sleep Disorder Breathing

Adverse Changes During Pregnancy Contributing to Sleep-Disordered Breathing

Hypoxemia During Sleep and Pregnancy

Incidence of Snoring and Sleep-Disordered Breathing During Pregnancy

Complications from OSAS in Pregnancy

Risks to the Mother

Risks to the Fetus

Screening for OSAS in Pregnancy

Treatment of OSAS in Pregnancy

Benefits of Treatment

Conclusions

References

Restless Legs Syndrome and Periodic Limb Movement Disorder in Pregnancy

Introduction

RLS Definition

RLS Epidemiology and Diagnosis

Pathophysiology

Clinical and Polysomnographic Evaluation

Treatment

Periodic Limb Movement Disorder

References

Asthma in Pregnancy

Introduction

Epidemiology: The Prevalence of Asthma During Pregnancy

Clinical Description: What Happens to Asthma During Pregnancy

Changes in Asthma Symptoms During Pregnancy

Changes in Lung Function During Pregnancy

Changes in Asthma During Labor

Mechanisms for the Effect of Pregnancy on Maternal Asthma

Hormonal Influences

Maternal Inflammation and Immune Function

The Influence of Fetal Sex

Complications of Asthma During Pregnancy: Exacerbations

Prevalence of Exacerbations

Risk Factors for Exacerbations

Severe Asthma

Viral Infection

Inadequate Prenatal Care

Obesity

Inadequate Medication Use

Timing of Exacerbations

Association of Asthma with Adverse Pregnancy Outcomes

The Effect of Exacerbations on Low Birth Weight

The Effect of Exacerbations on Preterm Delivery

The Effect of Exacerbations on Pre-eclampsia and Pregnancy-Induced Hypertension

The Effect of Exacerbations on Perinatal Mortality

Management and Treatment of Asthma During Pregnancy

Safety of Drug Treatments for Asthma

Risk of Congenital Malformations

beta2-Agonists

Inhaled Corticosteroids

Oral Corticosteroids

Leukotriene Receptor Antagonists

Treatment of Exacerbations During Pregnancy

Health Behavior

Cessation of Inhaled Steroid Use During Pregnancy

Education and Self-Management of Asthma During Pregnancy

Smoking During Pregnancy

Anxiety and Depression During Pregnancy

Conclusions

References

Tuberculosis and Pregnancy

Introduction

Evaluation

Skin Testing

Methods and Special Circumstances

Interpretation and Guidelines

Serum Quantiferon Testing

Roentgenography

Sputum Analysis

Specific Treatment Situations

Preventive Therapy

Latent Tuberculosis

Active Tuberculosis

Current Guidelines

Agents Used for the Treatment of Tuberculosis

First-Line Agents

Isoniazid

Rifampin

Ethambutol

Pyrazinamide

Streptomycin

Second-Line Agents

Amikacin

Capreomycin

Clofazimine

Cycloserine

Dapsone

Ethionamide

Para-Aminosalicylic Acid

Fluoroquinolones

Rifabutin

Thalidomide

Other Agents

Pyridoxine

Dexamethasone

Breast Feeding

Tuberculosis Transmission

Pulmonary Tuberculosis

Extra-Pulmonary Tuberculosis

References

Pneumonia in the Pregnant Patient

Epidemiology

Risk Factors

Pathogenesis of Pneumonia and its Complications in Pregnancy

Bacteriology

Clinical Features and Management of Specific Respiratory Infections

Bacterial Pneumonia

Viral Pneumonias

Influenza Virus

Varicella Pneumonia

Fetal and Neonatal Effects

Other Viruses

Fungal Pneumonia

Aspiration Pneumonia

Prevention of Pneumonia

Pneumonia Complicating Human Immunodeficiency Virus (HIV) Infection

Summary

References

Chronic Pulmonary Disease and Pregnancy

Respiratory Physiology of Normal Pregnancy

Introduction to Chronic Lung Disease in Pregnancy

Lymphangioleiomyomatosis and Pregnancy

Pulmonary Langerhans Cell Histiocytosis and Pregnancy

Sarcoidosis

Overview of Disease

Outcomes in Pregnancy and Sarcoidosis

Management of Sarcoidosis During Pregnancy

Idiopathic Pulmonary Fibrosis in Pregnancy

Kyphoscoliosis

Overview of Disease

Kyphoscoliosis and Effects on Pulmonary Function

Kyphoscoliosis and Pregnancy

Lung Transplantation and Pregnancy

Smoking Cessation and Pregnancy

Anti-Smoking Interventions

Counseling

Pharmacologic Therapy

Lung Cancer in Pregnancy

Diagnosis

Treatment

Summary

References

Neuromuscular and Chest Wall Diseases in Pregnancy

Introduction

Neuromuscular Diseases

Chest Wall Diseases

Complications in Neuromuscular and Chest Wall Diseases During Pregnancy

Pregnancy

Labor

Postpartum

Management of Pregnancy in Neuromuscular and Chest Wall Diseases

Monitoring During Pregnancy

Respiratory Muscles Aids

Inspiratory Muscle Aids: Non-invasive Ventilation

IPPV Mouthpiece

IPPV Nasal

Expiratory Muscle Aids and Assisted Coughing

Manually Assisted Coughing

Mechanically Assisted Coughing

Glossopharyngeal Breathing

Pregnancy in Bulbar Neuromuscular Patients

Complications During Pregnancy that Can Affect Respiratory Function

Abbreviations

References

Pregnancy and the Cystic Fibrosis Patient

Introduction-Cystic Fibrosis

Sexual Health

Fertility

Bioethics and Pregnancy in the CF Patient

How Cystic Fibrosis Exerts Changes on Pregnancy

Perinatal Mortality

Maternal Morbidity and Mortality

How Pregnancy Exerts Changes on CF

Lung Function

Nutritional and Metabolic Changes

Cardiopulmonary Changes

Immunity

Factors in the Care of the Pregnant CF Patient

Nutritional and Metabolic Aspects

Labor and Delivery

Breastfeeding and Postpartum Care

Pharmacological Aspects and the Pregnant CF Patient

Lung Transplant and the Pregnant CF Patient

Summary

References

Pulmonary Complications of Collagen Vascular Disease in Pregnancy

Immunity and Pregnancy

Respiratory Physiology During Pregnancy

Systemic Sclerosis

The Effect of Pregnancy on Systemic Sclerosis

The Effect of Systemic Sclerosis on Pregnancy and Fetal Outcome

Systemic Lupus Erythematosus

The Effect of Pregnancy on SLE

The Effect of SLE on Pregnancy and Fetal Outcome

Antiphospholipid Antibody Syndrome

Obstetric Complications

Thrombosis

The Catastrophic aPL Syndrome

Treatment of Pregnant Women with Antiphospholipid Syndrome

Rheumatoid Arthritis

The Effect of Pregnancy on RA

The Effect of RA on Pregnancy and Fetal Outcome

Spondyloarthropathies (SA):

Sjögren’s Syndrome

The Effect of Pregnancy on Sjögren’s Syndrome

The Effect of Sjögren’s Syndrome on Pregnancy and Fetal Outcome

Polymyositis and Dermatomyositis

The Effect of Pregnancy on Myositis

The Effect of Myositis on Pregnancy and Fetal Outcome

Conclusion

References

Venous Thromboembolism in Pregnancy

Introduction

Epidemiology

Preconception Counseling

Risk Factors

Activated Protein C Resistance and Factor V Leiden

Prothrombin Gene Variant

Protein C, Protein S, and Antithrombin Deficiencies

Antiphospholipid Antibodies

Hyperhomocysteinemia

Elevated Factor VIII

Compound Heterozygotes

Diagnosis

Clinical Predictors

Diagnostic Procedures

Arterial Blood Gases

Electrocardiography

Imaging Procedures

Radiation Exposure and Fetal Safety

Chest Radiography

Ventilation-Perfusion Scans

CT Pulmonary Angiograms

CTPA and Pregnancy

Fetal Radiation Exposure

Breast Radiation Exposure

Isolated Subsegmental Emboli

Pulmonary Angiography

Magnetic Resonance Imaging

Imaging of the Lower Extremities

Impedence Plethysmography

Compression Ultrasonography

Lower Extremity Venograms

Conventional Venograms

CT Venograms

MR Venograms

2-D Echocardiography

Laboratory Tests

D-Dimers

Prognostic Biomarkers

Other Thromboses

Management

Treatment

Pharmacologic Therapy

Pharmacokinetics, Dosing, and Monitoring

Complications

Fetal Safety

Duration of Therapy

Management of Anticoagulation Around Labor and Delivery

Non-pharmacologic Therapy

Thrombolytic Therapy

Prophylaxis for Thromboembolic Disease

Normal Pregnant Women

Thrombophilic Women with No Prior History of VTE or Prior Obstetric Complication

Ante-Partum Period

Post-Partum Period

Women with Previous VTE

Patients with Previous History of VTE

Patients with Current or Recent VTE, Currently on Treatment

Conclusion

References

Pulmonary Arterial Hypertension in Pregnancy

Introduction

The Pulmonary Circulation in Healthy Adults

Pulmonary Hypertension

The Pulmonary Circulation in Pregnancy

Association of Pulmonary Hypertension with Pregnancy

Evaluation of Pulmonary Hypertension in the Pregnant Patient

Treatment of Pulmonary Hypertension

Management of Pulmonary Hypertension in the Pregnant Patient

Management of Labor and Delivery in the Pulmonary Hypertensive Patient

Management of Pulmonary Hypertension in the Post-partum Patient

Summary and Conclusions

References

Pulmonary Procedures During Pregnancy

Introduction

Interventional Pulmonology

Multidisciplinary Approach

Pre-procedure Considerations

Positioning of the Patient

Topical Anesthesia and Conscious Sedation

Topical Anesthesia

Conscious Sedation

Patient and Fetal Monitoring

Bronchoscopy

Fluoroscopy

Pleural Procedures

Pleural Effusion

Thoracentesis

Pleural Space Drainage

Pleural Biopsy

References

Critical Illness in Pregnancy

Introduction

The Physiology of Pregnancy

General ICU Assessment

Circulatory Disorders in the Gravid Patient

Hypovolemic Shock

Causes of Hypovolemic Shock Unique to Pregnancy

Placental Abruption

Placenta Previa

Uterine Rupture

Uterine Atony

Septic Shock

Introduction

Management

General Principles

Early Goal Directed Therapy

Insulin Therapy for ‘‘Tight’’ Glucose Control

Drotrecogin Alpha (Activated Protein C)

Corticosteroids

Chorioamnionitis

Cardiogenic Shock

Introduction

General Management

Cardiac Dysfunction Acquired During Pregnancy

Peripartum Cardiomyopathy

Aortic Dissection

Critical Care Syndromes Specific to Pregnancy

Preeclampsia

Eclampsia

HELLP Syndrome

Pulmonary Embolism

Amniotic Fluid Embolism

Cardiopulmonary Arrest

Trauma

Summary

Clinical Pearls

Example Cases

Case One

Case Two

Case Three

References

Acute Lung Injury in Pregnancy

Introduction

Definition

Epidemiology

Clinical Features

Etiology

Pathogenesis

Hypoxemia During Pregnancy: Risks and Protections

Differential Diagnosis

Variants of Pulmonary Edema

Preeclampsia

Tocolytic-Induced Pulmonary Edema

Cardiogenic Pulmonary Edema

Rare in Pregnancy: Mimics of ARDS

Management

Monitoring

Ventilator Strategy

Non-invasive Positive Pressure Ventilation

Positive End-Expiratory Pressure (PEEP)

Oxygen Therapy

Circulatory Management

Experimental Therapy

Timing of Delivery

Outcomes

References

Airway Management and Mechanical Ventilation in Pregnancy

Introduction

Anatomic and Physiological Changes During Pregnancy

Airway Assessment

Preeclampsia and Airway-Related Changes

Morbid Obesity in Pregnancy and Airway

Aspiration of Gastric Contents

Obstetricians’ Role in Management of Airway

Incidence of Failed Intubation

Anesthesia and Maternal Mortality

Cesarean Section: Recognized Difficult Airway

Regional Anesthesia

Awake Intubation

Acute Fetal Distress

Cesarean Section: Unrecognized Difficult Airway

Airway Devices

Laryngeal Mask Airway

Proseal-LMA (PLMA)

Intubating Laryngeal Mask Airway (ILMA)

Combitube

Mechanical Ventilation in Pregnancy

Volume Control Type

Pressure Control Type

Dual Control Ventilators

Modes of Mechanical Ventilation

Controlled Mechanical Ventilation

Assist Control Mode (A/C)

Synchronized Intermittent Mandatory Ventilation (SIMV)

Pressure Support Ventilation

Continuous Positive Airway Pressure (CPAP)

PEEP

Oxygenation Goal

Ventilation Goal

Respiratory Physiology Issues in Pregnancy

Ventilator Setup: Choose

Calculations Important for Respiratory Monitoring

Weaning

Weaning Parameters

Conclusion

References

Index