Pulmonary Problems in Pregnancy (eBook)

Preface 6
Contents 7
Acknowledgments 9
Contributors 10
Part I: Normal Pregnancy 13
Physiological Transition from Fetal to Neonatal Life in Pregnancy 14
Evolution of Air-Breathing Respiration 14
Fetal Respiration 15
Lung Growth and Development 19
Importance of Surfactant 21
Surface Tension 21
Cellular Morphology and Morphogenesis 25
Cells Derived from Entoderm 25
Cells Derived from Mesoderm 26
Summary of Lung Development In Utero and Beyond 27
References 29
Respiratory Physiology in Pregnancy 30
Introduction 30
Chest Wall and Lung Mechanics in Pregnancy 30
Airflow Mechanics 31
Ventilation and Gas Exchange 31
Physiologic Dyspnea of Pregnancy 33
Summary and Conclusions 34
Abbreviations 35
References 35
High Altitude, Chronic Hypoxia, and Pregnancy 38
Respiratory Physiology at High Altitude 38
Pregnancy Outcomes Associated with High Altitude 40
Uteroplacental Circulation and Oxygen Transport 42
Chronic Hypoxia and Effect on the Placenta 43
References 44
Sleep Physiology in Pregnancy 47
Sleep Physiology in Pregnancy 47
Overview of Sleep Stages 47
The Sleep-Wakefulness Cycle 48
Overview of Sleep in Pregnancy 48
Mechanical and Somatic Factors Affecting Sleep Initiation and Sleep Maintenance 49
Gastroesophageal Factors 49
Urinary Factors 49
Musculoskeletal Factors 49
Obstetric Factors 49
Anatomic Changes Predisposing to Sleep-Disordered Breathing 50
Upper airway Changes 50
Hormonal Factors Affecting Sleep in Pregnancy 50
Progesterone 50
Estrogen 53
Corticotropin Releasing Hormone (CRH) and Cortisol 53
Growth Hormone (GH) 54
Melatonin 54
Prolactin 54
Oxytocin 55
Human Gonadotropic Hormone (HCG) 55
Cytokines 55
Nitric oxide 56
Oxygenation During Sleep in Pregnancy 57
Control of Breathing During Sleep in Pregnancy 58
Sleep Measures in Normal Pregnancy 59
Summary 60
References 60
Part II: General Management Principles in Pregnancy 66
Diagnostic Imaging in Pregnancy 67
Ionizing Radiation 67
Teratogenicity 68
Radiation Dose 68
Timing of Radiation Exposure 68
Method of Administration 72
Intrauterine Fetal Death 72
Oncogenicity 72
Use of Contrast Agents 73
Ultrasound 74
Magnetic Resonance Imaging (MRI) 74
Nuclear Medicine 75
Informed Consent 75
Summary 75
References 76
Prescribing in Pregnancy and Lactation 78
The Myth of the Placental Barrier 78
The Myth of the ‘‘Safe’’ Period 78
Drug Safety Data in Pregnancy 79
Animal Studies 79
Case Reports and Case Series 79
Pregnancy Registries 80
Case Control Studies 80
Physiologic Changes of Pregnancy Affecting Pharmacokinetics 82
Choosing Medication in Pregnancy 82
Breast Feeding and Medications 83
Conclusion 94
Abbreviations 95
References 95
Monitoring Fetal Well-Being in the Critical Care Setting 96
Introduction to Electronic Fetal Monitoring 96
EFM Descriptions 97
Ancillary Methods to Assess Fetal Status 109
Timing of Monitoring 109
Interventions for a Non-Reassuring FHR 110
Perimortem Cesarean Section 110
References 111
Anesthetic Considerations in Pregnant Patients with Pulmonary Disorders 113
Introduction 113
Airway Management 115
Neuraxial Blockade and Pulmonary Function 119
General Anesthesia and Pulmonary Function 121
Anesthesia for Specific Pulmonary Disorders 122
References 123
Part III: Pulmonary Disorders in Pregnancy 127
Obstructive Sleep Apnea in Pregnancy 128
Definitions of Obstructive Sleep Apnea Syndrome (OSAS) 128
Alterations of Pregnancy and OSAS 128
Anatomic and Physiologic Sleep Changes During Pregnancy 128
Changes Protective Against Sleep Disorder Breathing 129
Adverse Changes During Pregnancy Contributing to Sleep-Disordered Breathing 129
Hypoxemia During Sleep and Pregnancy 129
Incidence of Snoring and Sleep-Disordered Breathing During Pregnancy 130
Complications from OSAS in Pregnancy 131
Risks to the Mother 131
Risks to the Fetus 133
Screening for OSAS in Pregnancy 134
Treatment of OSAS in Pregnancy 134
Benefits of Treatment 134
Conclusions 135
References 135
Restless Legs Syndrome and Periodic Limb Movement Disorder in Pregnancy 139
Introduction 139
RLS Definition 139
RLS Epidemiology and Diagnosis 140
Pathophysiology 141
Clinical and Polysomnographic Evaluation 143
Treatment 143
Periodic Limb Movement Disorder 145
References 145
Asthma in Pregnancy 147
Introduction 147
Epidemiology: The Prevalence of Asthma During Pregnancy 147
Clinical Description: What Happens to Asthma During Pregnancy 148
Changes in Asthma Symptoms During Pregnancy 148
Changes in Lung Function During Pregnancy 148
Changes in Asthma During Labor 149
Mechanisms for the Effect of Pregnancy on Maternal Asthma 149
Hormonal Influences 149
Maternal Inflammation and Immune Function 149
The Influence of Fetal Sex 150
Complications of Asthma During Pregnancy: Exacerbations 150
Prevalence of Exacerbations 151
Risk Factors for Exacerbations 151
Severe Asthma 152
Viral Infection 152
Inadequate Prenatal Care 152
Obesity 152
Inadequate Medication Use 152
Timing of Exacerbations 153
Association of Asthma with Adverse Pregnancy Outcomes 153
The Effect of Exacerbations on Low Birth Weight 154
The Effect of Exacerbations on Preterm Delivery 154
The Effect of Exacerbations on Pre-eclampsia and Pregnancy-Induced Hypertension 155
The Effect of Exacerbations on Perinatal Mortality 155
Management and Treatment of Asthma During Pregnancy 156
Safety of Drug Treatments for Asthma 156
Risk of Congenital Malformations 156
beta2-Agonists 157
Inhaled Corticosteroids 157
Oral Corticosteroids 158
Leukotriene Receptor Antagonists 158
Treatment of Exacerbations During Pregnancy 159
Health Behavior 160
Cessation of Inhaled Steroid Use During Pregnancy 160
Education and Self-Management of Asthma During Pregnancy 161
Smoking During Pregnancy 162
Anxiety and Depression During Pregnancy 163
Conclusions 163
References 164
Tuberculosis and Pregnancy 169
Introduction 169
Evaluation 170
Skin Testing 170
Methods and Special Circumstances 170
Interpretation and Guidelines 170
Serum Quantiferon Testing 170
Roentgenography 171
Sputum Analysis 171
Specific Treatment Situations 172
Preventive Therapy 172
Latent Tuberculosis 172
Active Tuberculosis 172
Current Guidelines 172
Agents Used for the Treatment of Tuberculosis 173
First-Line Agents 173
Isoniazid 173
Rifampin 173
Ethambutol 174
Pyrazinamide 174
Streptomycin 174
Second-Line Agents 175
Amikacin 175
Capreomycin 175
Clofazimine 175
Cycloserine 175
Dapsone 175
Ethionamide 176
Para-Aminosalicylic Acid 176
Fluoroquinolones 176
Rifabutin 176
Thalidomide 176
Other Agents 177
Pyridoxine 177
Dexamethasone 177
Breast Feeding 177
Tuberculosis Transmission 178
Pulmonary Tuberculosis 178
Extra-Pulmonary Tuberculosis 178
References 178
Pneumonia in the Pregnant Patient 181
Epidemiology 181
Risk Factors 182
Pathogenesis of Pneumonia and its Complications in Pregnancy 183
Bacteriology 186
Clinical Features and Management of Specific Respiratory Infections 188
Bacterial Pneumonia 188
Viral Pneumonias 191
Influenza Virus 191
Varicella Pneumonia 193
Fetal and Neonatal Effects 194
Other Viruses 194
Fungal Pneumonia 195
Aspiration Pneumonia 195
Prevention of Pneumonia 196
Pneumonia Complicating Human Immunodeficiency Virus (HIV) Infection 196
Summary 197
References 197
Chronic Pulmonary Disease and Pregnancy 201
Respiratory Physiology of Normal Pregnancy 201
Introduction to Chronic Lung Disease in Pregnancy 202
Lymphangioleiomyomatosis and Pregnancy 202
Pulmonary Langerhans Cell Histiocytosis and Pregnancy 204
Sarcoidosis 204
Overview of Disease 204
Outcomes in Pregnancy and Sarcoidosis 204
Management of Sarcoidosis During Pregnancy 205
Idiopathic Pulmonary Fibrosis in Pregnancy 205
Kyphoscoliosis 206
Overview of Disease 206
Kyphoscoliosis and Effects on Pulmonary Function 207
Kyphoscoliosis and Pregnancy 207
Lung Transplantation and Pregnancy 207
Smoking Cessation and Pregnancy 208
Anti-Smoking Interventions 209
Counseling 209
Pharmacologic Therapy 210
Lung Cancer in Pregnancy 210
Diagnosis 211
Treatment 211
Summary 212
References 212
Neuromuscular and Chest Wall Diseases in Pregnancy 216
Introduction 216
Neuromuscular Diseases 216
Chest Wall Diseases 217
Complications in Neuromuscular and Chest Wall Diseases During Pregnancy 217
Pregnancy 218
Labor 219
Postpartum 219
Management of Pregnancy in Neuromuscular and Chest Wall Diseases 219
Monitoring During Pregnancy 220
Respiratory Muscles Aids 221
Inspiratory Muscle Aids: Non-invasive Ventilation 221
IPPV Mouthpiece 222
IPPV Nasal 222
Expiratory Muscle Aids and Assisted Coughing 223
Manually Assisted Coughing 223
Mechanically Assisted Coughing 224
Glossopharyngeal Breathing 225
Pregnancy in Bulbar Neuromuscular Patients 225
Complications During Pregnancy that Can Affect Respiratory Function 225
Abbreviations 226
References 226
Pregnancy and the Cystic Fibrosis Patient 230
Introduction-Cystic Fibrosis 230
Sexual Health 231
Fertility 231
Bioethics and Pregnancy in the CF Patient 232
How Cystic Fibrosis Exerts Changes on Pregnancy 232
Perinatal Mortality 232
Maternal Morbidity and Mortality 233
How Pregnancy Exerts Changes on CF 234
Lung Function 234
Nutritional and Metabolic Changes 234
Cardiopulmonary Changes 235
Immunity 236
Factors in the Care of the Pregnant CF Patient 236
Nutritional and Metabolic Aspects 236
Labor and Delivery 236
Breastfeeding and Postpartum Care 237
Pharmacological Aspects and the Pregnant CF Patient 237
Lung Transplant and the Pregnant CF Patient 238
Summary 238
References 239
Pulmonary Complications of Collagen Vascular Disease in Pregnancy 241
Immunity and Pregnancy 241
Respiratory Physiology During Pregnancy 242
Systemic Sclerosis 243
The Effect of Pregnancy on Systemic Sclerosis 243
The Effect of Systemic Sclerosis on Pregnancy and Fetal Outcome 244
Systemic Lupus Erythematosus 245
The Effect of Pregnancy on SLE 245
The Effect of SLE on Pregnancy and Fetal Outcome 245
Antiphospholipid Antibody Syndrome 246
Obstetric Complications 247
Thrombosis 247
The Catastrophic aPL Syndrome 248
Treatment of Pregnant Women with Antiphospholipid Syndrome 248
Rheumatoid Arthritis 248
The Effect of Pregnancy on RA 249
The Effect of RA on Pregnancy and Fetal Outcome 249
Spondyloarthropathies (SA): 249
Sjögren’s Syndrome 249
The Effect of Pregnancy on Sjögren’s Syndrome 249
The Effect of Sjögren’s Syndrome on Pregnancy and Fetal Outcome 249
Polymyositis and Dermatomyositis 250
The Effect of Pregnancy on Myositis 250
The Effect of Myositis on Pregnancy and Fetal Outcome 250
Conclusion 250
References 251
Venous Thromboembolism in Pregnancy 255
Introduction 255
Epidemiology 255
Preconception Counseling 257
Risk Factors 257
Activated Protein C Resistance and Factor V Leiden 258
Prothrombin Gene Variant 258
Protein C, Protein S, and Antithrombin Deficiencies 259
Antiphospholipid Antibodies 259
Hyperhomocysteinemia 259
Elevated Factor VIII 260
Compound Heterozygotes 260
Diagnosis 260
Clinical Predictors 261
Diagnostic Procedures 261
Arterial Blood Gases 261
Electrocardiography 262
Imaging Procedures 262
Radiation Exposure and Fetal Safety 262
Chest Radiography 262
Ventilation-Perfusion Scans 262
CT Pulmonary Angiograms 263
CTPA and Pregnancy 263
Fetal Radiation Exposure 264
Breast Radiation Exposure 264
Isolated Subsegmental Emboli 264
Pulmonary Angiography 265
Magnetic Resonance Imaging 265
Imaging of the Lower Extremities 265
Impedence Plethysmography 265
Compression Ultrasonography 266
Lower Extremity Venograms 267
Conventional Venograms 267
CT Venograms 268
MR Venograms 268
2-D Echocardiography 268
Laboratory Tests 268
D-Dimers 268
Prognostic Biomarkers 269
Other Thromboses 269
Management 270
Treatment 270
Pharmacologic Therapy 270
Pharmacokinetics, Dosing, and Monitoring 270
Complications 272
Fetal Safety 273
Duration of Therapy 273
Management of Anticoagulation Around Labor and Delivery 273
Non-pharmacologic Therapy 274
Thrombolytic Therapy 274
Prophylaxis for Thromboembolic Disease 274
Normal Pregnant Women 274
Thrombophilic Women with No Prior History of VTE or Prior Obstetric Complication 275
Ante-Partum Period 275
Post-Partum Period 275
Women with Previous VTE 275
Patients with Previous History of VTE 275
Patients with Current or Recent VTE, Currently on Treatment 276
Conclusion 277
References 277
Pulmonary Arterial Hypertension in Pregnancy 287
Introduction 287
The Pulmonary Circulation in Healthy Adults 288
Pulmonary Hypertension 289
The Pulmonary Circulation in Pregnancy 293
Association of Pulmonary Hypertension with Pregnancy 293
Evaluation of Pulmonary Hypertension in the Pregnant Patient 295
Treatment of Pulmonary Hypertension 298
Management of Pulmonary Hypertension in the Pregnant Patient 301
Management of Labor and Delivery in the Pulmonary Hypertensive Patient 303
Management of Pulmonary Hypertension in the Post-partum Patient 306
Summary and Conclusions 308
References 308
Pulmonary Procedures During Pregnancy 315
Introduction 315
Interventional Pulmonology 316
Multidisciplinary Approach 317
Pre-procedure Considerations 317
Positioning of the Patient 318
Topical Anesthesia and Conscious Sedation 319
Topical Anesthesia 319
Conscious Sedation 319
Patient and Fetal Monitoring 321
Bronchoscopy 322
Fluoroscopy 324
Pleural Procedures 325
Pleural Effusion 325
Thoracentesis 325
Pleural Space Drainage 327
Pleural Biopsy 328
References 328
Critical Illness in Pregnancy 332
Introduction 332
The Physiology of Pregnancy 333
General ICU Assessment 334
Circulatory Disorders in the Gravid Patient 335
Hypovolemic Shock 335
Causes of Hypovolemic Shock Unique to Pregnancy 337
Placental Abruption 337
Placenta Previa 337
Uterine Rupture 337
Uterine Atony 337
Septic Shock 338
Introduction 338
Management 338
General Principles 338
Early Goal Directed Therapy 339
Insulin Therapy for ‘‘Tight’’ Glucose Control 341
Drotrecogin Alpha (Activated Protein C) 341
Corticosteroids 342
Chorioamnionitis 342
Cardiogenic Shock 342
Introduction 342
General Management 343
Cardiac Dysfunction Acquired During Pregnancy 344
Peripartum Cardiomyopathy 344
Aortic Dissection 344
Critical Care Syndromes Specific to Pregnancy 344
Preeclampsia 344
Eclampsia 345
HELLP Syndrome 346
Pulmonary Embolism 346
Amniotic Fluid Embolism 348
Cardiopulmonary Arrest 348
Trauma 349
Summary 349
Clinical Pearls 349
Example Cases 350
Case One 350
Case Two 351
Case Three 351
References 352
Acute Lung Injury in Pregnancy 356
Introduction 356
Definition 356
Epidemiology 357
Clinical Features 357
Etiology 358
Pathogenesis 359
Hypoxemia During Pregnancy: Risks and Protections 360
Differential Diagnosis 362
Variants of Pulmonary Edema 362
Preeclampsia 362
Tocolytic-Induced Pulmonary Edema 362
Cardiogenic Pulmonary Edema 364
Rare in Pregnancy: Mimics of ARDS 366
Management 367
Monitoring 367
Ventilator Strategy 368
Non-invasive Positive Pressure Ventilation 370
Positive End-Expiratory Pressure (PEEP) 371
Oxygen Therapy 371
Circulatory Management 372
Experimental Therapy 373
Timing of Delivery 374
Outcomes 375
References 375
Airway Management and Mechanical Ventilation in Pregnancy 385
Introduction 385
Anatomic and Physiological Changes During Pregnancy 386
Airway Assessment 387
Preeclampsia and Airway-Related Changes 387
Morbid Obesity in Pregnancy and Airway 387
Aspiration of Gastric Contents 388
Obstetricians’ Role in Management of Airway 389
Incidence of Failed Intubation 389
Anesthesia and Maternal Mortality 389
Cesarean Section: Recognized Difficult Airway 389
Regional Anesthesia 389
Awake Intubation 390
Acute Fetal Distress 390
Cesarean Section: Unrecognized Difficult Airway 391
Airway Devices 391
Laryngeal Mask Airway 391
Proseal-LMA (PLMA) 392
Intubating Laryngeal Mask Airway (ILMA) 393
Combitube 393
Mechanical Ventilation in Pregnancy 394
Volume Control Type 394
Pressure Control Type 395
Dual Control Ventilators 395
Modes of Mechanical Ventilation 395
Controlled Mechanical Ventilation 395
Assist Control Mode (A/C) 395
Synchronized Intermittent Mandatory Ventilation (SIMV) 396
Pressure Support Ventilation 396
Continuous Positive Airway Pressure (CPAP) 396
PEEP 396
Oxygenation Goal 396
Ventilation Goal 397
Respiratory Physiology Issues in Pregnancy 397
Ventilator Setup: Choose 398
Calculations Important for Respiratory Monitoring 398
Weaning 399
Weaning Parameters 399
Conclusion 400
References 400
Index 404