1. Ass. Professor Iman GalalAss. Professor Iman Galal
Pulmonary Medicine DepartmentPulmonary Medicine Department
Ain Shams UniversityAin Shams University
Lungs & PregnancyLungs & Pregnancy
In Health & DiseaseIn Health & Disease

2. Page  2
Introduction:Introduction:
● Pregnancy induces profound changes in the mother,Pregnancy induces profound changes in the mother,
resulting in significant alterations in normal physiology.resulting in significant alterations in normal physiology.
● The anatomical & functional changes affect the respiratory &The anatomical & functional changes affect the respiratory &
cardiovascular systems.cardiovascular systems.
● Management of respiratory diseases in pregnancy requiresManagement of respiratory diseases in pregnancy requires
an understanding of these changes for interpretation ofan understanding of these changes for interpretation of
clinical & laboratory manifestations of disease states.clinical & laboratory manifestations of disease states.

3. Respiratory PhysiologyRespiratory Physiology

4. Page  4
Anatomical ChangesAnatomical Changes::
● Hormonal changes in pregnancy affect the URT & airwayHormonal changes in pregnancy affect the URT & airway
mucosa, producingmucosa, producing hyperemiahyperemia,, mucosal edemamucosal edema,,
hypersecretionhypersecretion, &, & increased mucosal friability.increased mucosal friability.
● EstrogenEstrogen is responsible for producingis responsible for producing tissue edematissue edema,,
capillary congestioncapillary congestion, &, & hyperplasiahyperplasia ofof mucousmucous
glands.glands.
● The enlarging uterus & the hormonal effects produceThe enlarging uterus & the hormonal effects produce
anatomical changes to the thoracic cage. As the uterusanatomical changes to the thoracic cage. As the uterus
expands, theexpands, the diaphragmdiaphragm isis displaced cephaladdisplaced cephalad by asby as
much asmuch as 4 cm4 cm; the; the A/PA/P && transverse diametertransverse diameter of theof the
thoraxthorax increasesincreases, which enlarges chest wall circumference., which enlarges chest wall circumference.
● Diaphragm function remainsDiaphragm function remains normalnormal, & diaphragmatic, & diaphragmatic
excursion isexcursion is not reduced.not reduced.

5. Page  5
Pulmonary FunctionPulmonary Function::
● Anatomical changes to the thorax produce a progressiveAnatomical changes to the thorax produce a progressive
decreasedecrease inin FRCFRC, which is, which is reducedreduced 10-20%10-20% byby term.term.
● TheThe RVRV cancan decreasedecrease slightly during pregnancy, but thisslightly during pregnancy, but this
finding is not consistent; decreased expiratory reservefinding is not consistent; decreased expiratory reserve
volume definitely changes.volume definitely changes.
● The increased circumference of the thoracic cage allows theThe increased circumference of the thoracic cage allows the
VCVC to remain unchanged, & theto remain unchanged, & the TLC decreasesTLC decreases onlyonly
minimally by term.minimally by term.
● Hormonal changes do not significantly affect airway function.Hormonal changes do not significantly affect airway function.
● Pregnancy does not change lung compliance, butPregnancy does not change lung compliance, but chest wallchest wall
&& total respiratory compliancetotal respiratory compliance areare reducedreduced at term.at term.

6. Page  6
VentilationVentilation::
● TheThe MVMV increases significantly, beginning in the firstincreases significantly, beginning in the first
trimester & reachingtrimester & reaching 20-40%20-40% above baseline at term.above baseline at term.
● Alveolar ventilationAlveolar ventilation increasesincreases byby 50-70%.50-70%.
● TheThe increaseincrease inin ventilationventilation occurs because ofoccurs because of increasedincreased
metabolic CO2 productionmetabolic CO2 production & because of increased& because of increased
respiratory drive due to the high serumrespiratory drive due to the high serum progesteroneprogesterone
level.level.
● TheThe VTVT increasesincreases byby 30-35%.30-35%.
● TheThe respiratory raterespiratory rate remains relativelyremains relatively constantconstant oror

7. Page  7
Arterial Blood GasesArterial Blood Gases::
● Physiological hyperventilationPhysiological hyperventilation results in respiratoryresults in respiratory
alkalosis with compensatory renal excretion ofalkalosis with compensatory renal excretion of
bicarbonate.bicarbonate.
● TheThe arterial CO2 pressurearterial CO2 pressure reaches a plasma level ofreaches a plasma level of
28-32 mmHg28-32 mmHg && bicarbonatebicarbonate isis ↓↓ to 18-21 mmol/Lto 18-21 mmol/L,,
maintaining anmaintaining an arterial pHarterial pH in the range ofin the range of 7.40-7.47.7.40-7.47.
● Mild hypoxemiaMild hypoxemia might occur when the patient is in themight occur when the patient is in the
supinesupine position.position.

8. Page  8
Arterial Blood GasesArterial Blood Gases::
● Oxygen consumptionOxygen consumption ↑↑ at the beginning of the firstat the beginning of the first
trimester &trimester & ↑↑ by 20-33% by term because of fetal demands &by 20-33% by term because of fetal demands &
↑↑ maternal metabolic processes.maternal metabolic processes.
● In active labor,In active labor, hyperventilationhyperventilation ↑↑ && tachypneatachypnea causedcaused
by pain & anxiety might result in markedby pain & anxiety might result in marked hypocapniahypocapnia &&
respiratory alkalosisrespiratory alkalosis, adversely affecting fetal, adversely affecting fetal
oxygenation by reducing uterine blood flow. In some patients,oxygenation by reducing uterine blood flow. In some patients,
severe pain & anxiety can lead tosevere pain & anxiety can lead to rapid shallowrapid shallow
breathingbreathing withwith alveolar hypoventilationalveolar hypoventilation,, atelectasisatelectasis,,
&& mild hypoxemia.mild hypoxemia.

9. Alterations In NormalAlterations In Normal
Physiology During PregnancyPhysiology During Pregnancy

10. Page  10
Hemodynamic ChangesHemodynamic Changes::
● Changes begin in theChanges begin in the 11stst
trimestertrimester of pregnancy & continueof pregnancy & continue
into theinto the postpartumpostpartum period.period.
● Maternal blood volumeMaternal blood volume ↑↑ progressively, peaking at aprogressively, peaking at a
value of approximatelyvalue of approximately 40%40% above baseline by theabove baseline by the 33rdrd
trimester.trimester. Plasma volumePlasma volume ↑↑ byby 45-50%45-50%, &, & red cellred cell
massmass ↑↑ byby 20-30%20-30%, resulting in, resulting in anemiaanemia of pregnancy.of pregnancy.
● TheThe ↑↑ blood volumeblood volume is associated withis associated with ↑↑ cardiac outputcardiac output
byby 30-50%30-50% above baseline levels byabove baseline levels by 25 wks.25 wks.

11. Page  11
Hemodynamic ChangesHemodynamic Changes::
● TheThe heart rateheart rate ↑↑ & reaches a& reaches a maximalmaximal value ofvalue of 10-30%10-30%
above baseline values byabove baseline values by 32 wks.32 wks.
● Systemic blood pressureSystemic blood pressure ↓↓ slightly during pregnancy, withslightly during pregnancy, with
thethe diastolic pressure fallingdiastolic pressure falling approximatelyapproximately 10-20%10-20% &&
reaching a nadir atreaching a nadir at 28 wks.28 wks.
● Plasma colloid oncotic pressurePlasma colloid oncotic pressure ↓↓ because of the dilutionbecause of the dilution
of plasma proteins; theof plasma proteins; the critical pulmonary capillarycritical pulmonary capillary
pressurepressure at which pulmonary edema forms alsoat which pulmonary edema forms also ↓↓..
● SVRSVR && PVRPVR ↓↓ byby 20-30%.20-30%.

12. Page  12
Dyspnea During PregnancyDyspnea During Pregnancy::
● Dyspnea during pregnancy is quite common, occurring inDyspnea during pregnancy is quite common, occurring in
approximatelyapproximately 60%60% of womenof women with exertionwith exertion && < 20% at< 20% at
rest.rest.
● Physiologic dyspneaPhysiologic dyspnea can occurcan occur earlyearly in pregnancy &in pregnancy &
does notdoes not interfere with daily activities. Althoughinterfere with daily activities. Although
mechanical impediment by the gravid uterus is oftenmechanical impediment by the gravid uterus is often
blamed,blamed, hyperventilationhyperventilation due todue to ↑↑ progesteroneprogesterone levelslevels
is the most important mechanism.is the most important mechanism.

13. Page  13
Dyspnea During PregnancyDyspnea During Pregnancy::
● Distinguishing physiologic dyspnea from breathlessnessDistinguishing physiologic dyspnea from breathlessness
caused by disorders complicating pregnancy or diseases thatcaused by disorders complicating pregnancy or diseases that
might coexist with pregnancy is essential.might coexist with pregnancy is essential.
● Actual exercise toleranceActual exercise tolerance despite dyspnea isdespite dyspnea is notnot
greatly affected.greatly affected.
● The presence of other symptoms & signs ofThe presence of other symptoms & signs of
cardiopulmonary disease indicates a possible pathologiccardiopulmonary disease indicates a possible pathologic
nature of dyspnea, & the patient should be evaluated.nature of dyspnea, & the patient should be evaluated.

14. Pulmonary PharmacologyPulmonary Pharmacology
During PregnancyDuring Pregnancy

15. Page  15
Absorption During PregnancyAbsorption During Pregnancy::
● Both theBoth the rate of gastric emptyingrate of gastric emptying & the& the rate ofrate of
gastric motilitygastric motility areare decreaseddecreased in the gravid patient.in the gravid patient.
Thus,Thus, absorptionabsorption properties are usuallyproperties are usually altered.altered.
● TheThe decreased intestinal motilitydecreased intestinal motility can favorcan favor
increased absorption.increased absorption.
● First-pass metabolismFirst-pass metabolism by theby the portal circulationportal circulation isis
unchangedunchanged in pregnancy.in pregnancy.

16. Page  16
Distribution During PregnancyDistribution During Pregnancy::
● The distribution of a drug is affected byThe distribution of a drug is affected by the rate ofthe rate of
perfusion of blood to the individual organsperfusion of blood to the individual organs,, lipidlipid
solubilitysolubility, &, & the degree of binding to the proteinsthe degree of binding to the proteins oror
tissue receptors.tissue receptors.
● Because the physiologic volume of distribution is larger inBecause the physiologic volume of distribution is larger in
pregnancy,pregnancy, high loading doseshigh loading doses of the drug might beof the drug might be
needed.needed.

17. Page  17
Protein Binding During PregnancyProtein Binding During Pregnancy::
● During pregnancy,During pregnancy, plasma protein bindingplasma protein binding usuallyusually
decreases.decreases.
● This can causeThis can cause higher circulating levels of free drughigher circulating levels of free drug
when normally protein-bound medication is administered.when normally protein-bound medication is administered.

18. Page  18
Elimination During PregnancyElimination During Pregnancy::
● The clearance of drugs viaThe clearance of drugs via direct extraction by the liverdirect extraction by the liver
isis not alterednot altered; however, pregnancy can; however, pregnancy can increaseincrease thethe
hepatic metabolismhepatic metabolism of certain drugs, resulting in aof certain drugs, resulting in a
decrease in plasma concentration.decrease in plasma concentration.
● Because theBecause the glomerular filtration rateglomerular filtration rate increasesincreases
during gestation, drugs primarily eliminated by renalduring gestation, drugs primarily eliminated by renal
excretion areexcretion are cleared more rapidlycleared more rapidly during pregnancy.during pregnancy.

19. Pulmonary MedicationsPulmonary Medications
During PregnancyDuring Pregnancy

20. Page  20
Drugs & Pregnancy:Drugs & Pregnancy:
Category (A)Category (A) Drugs which have been taken by a large number of pregnant women & women ofDrugs which have been taken by a large number of pregnant women & women of
childbearing age without any proven increase in the frequency of malformations orchildbearing age without any proven increase in the frequency of malformations or
other direct or indirect harmful effects on the fetus having been observed.other direct or indirect harmful effects on the fetus having been observed.
Category (B)Category (B) Drugs that have been taken by only a limited number of pregnant women & womenDrugs that have been taken by only a limited number of pregnant women & women
of childbearing age, without an increase in the frequency of malformation or otherof childbearing age, without an increase in the frequency of malformation or other
direct or indirect harmful effects on the human fetus having been observed.direct or indirect harmful effects on the human fetus having been observed.
Category (C)Category (C) Drugs that, owing to their pharmacological effects, have caused, or may be suspectedDrugs that, owing to their pharmacological effects, have caused, or may be suspected
of causing harmful effects on the human fetus or neonate without causingof causing harmful effects on the human fetus or neonate without causing
malformations. These effects may be reversible.malformations. These effects may be reversible.
Category (D)Category (D) Drugs that have caused, are suspected to have caused, or may be expected to cause anDrugs that have caused, are suspected to have caused, or may be expected to cause an
increased incidence of human fetal malformations, or irreversible damage. Theseincreased incidence of human fetal malformations, or irreversible damage. These
drugs may also have adverse pharmacological effects.drugs may also have adverse pharmacological effects.

21. Page  21
Methylxanthines During PregnancyMethylxanthines During Pregnancy::
● Both theophylline & aminophylline readilyBoth theophylline & aminophylline readily cross thecross the
placentaplacenta, but, but no fetal ill effectsno fetal ill effects oror malformationsmalformations
have been reported.have been reported.
● Theophylline pharmacokineticsTheophylline pharmacokinetics areare unaffectedunaffected byby
pregnancy, and this drug is alsopregnancy, and this drug is also secretedsecreted inin breast milk.breast milk.

22. Page  22
Beta Agonists During PregnancyBeta Agonists During Pregnancy::
● ββ-agonists have-agonists have little systemic absorptionlittle systemic absorption & a& a moremore
potent bronchodilatorypotent bronchodilatory effect viaeffect via inhalation.inhalation.
● Data on the use ofData on the use of inhaledinhaled ββ -agonists showed-agonists showed nono
differencedifference inin perinatal mortalityperinatal mortality,, congenitalcongenital
malformationsmalformations,, birth weightbirth weight, or, or Apgar scores.Apgar scores.

23. Page  23
Anticholinergics during PregnancyAnticholinergics during Pregnancy::
● The use ofThe use of anticholinergicsanticholinergics proved to beproved to be safesafe duringduring
pregnancy & have been associated withpregnancy & have been associated with no adverse fetalno adverse fetal
outcomes.outcomes.

24. Page  24
Bronchodilators In PregnancyBronchodilators In Pregnancy::
Generic NameGeneric Name Safety CategorySafety Category
TheophyllinesTheophyllines CC
SalmeterolSalmeterol CC
IpratropiumIpratropium BB
TiotropiumTiotropium No data availableNo data available
TerbutalinTerbutalin BB
FormoterolFormoterol CC
MontelukastMontelukast BB

25. Page  25
Corticosteriods During PregnancyCorticosteriods During Pregnancy::
● The use of corticosteroids during pregnancy continues to beThe use of corticosteroids during pregnancy continues to be
controversial, although numerous reports confirm their usecontroversial, although numerous reports confirm their use
without adverse fetal effects.without adverse fetal effects.
● In 3 reports on human pregnancies,In 3 reports on human pregnancies, no congenitalno congenital
malformationsmalformations oror adverse fetal effectsadverse fetal effects were found fromwere found from
ICS.ICS.
● PrednisonePrednisone has been used extensively during pregnancy for ahas been used extensively during pregnancy for a
variety of conditions. It is associated with anvariety of conditions. It is associated with an increasedincreased
incidence ofincidence of cleft palatescleft palates inin animalsanimals but not in humans.but not in humans.

26. Page  26
Corticosteroids In PregnancyCorticosteroids In Pregnancy::
Generic NameGeneric Name Safety CategorySafety Category
BudesonideBudesonide BB
FluticasoneFluticasone CC
BeclomethasoneBeclomethasone CC
HydrocortisoneHydrocortisone CC
PrednisolonePrednisolone CC
DexamethasoneDexamethasone CC
BetamethasoneBetamethasone CC

27. Page  27
Antibiotics in Respiratory InfectionsAntibiotics in Respiratory Infections::
● The major antibiotics considered safe during pregnancy areThe major antibiotics considered safe during pregnancy are
penicillinpenicillin,, cephalosporinscephalosporins, &, & erythromycin.erythromycin.
● Although penicillin & ampicillin readily cross the placenta, noAlthough penicillin & ampicillin readily cross the placenta, no
adverse effects to the fetus are reported.adverse effects to the fetus are reported.
● CephalosporinsCephalosporins traverse thetraverse the placentaplacenta to a moderate degree,to a moderate degree,
butbut nono adverseadverse fetalfetal effects occur.effects occur.
● Erythromycin crosses the placenta to a low degree but achievesErythromycin crosses the placenta to a low degree but achieves
high levels in breast milk. Thehigh levels in breast milk. The estolateestolate formulation isformulation is
contraindicatedcontraindicated due to potential maternaldue to potential maternal hepatic toxicity.hepatic toxicity.
● Antibiotics that have relative contraindications includeAntibiotics that have relative contraindications include
sulfonamidessulfonamides,, trimethoprimtrimethoprim,, aminoglycosidesaminoglycosides,,
nitrofurantoinnitrofurantoin,, tetracyclinestetracyclines, &, & quinolonesquinolones..

28. Page  28
Teratogens used in Pulmonary DiseasesTeratogens used in Pulmonary Diseases::
● These drugs includeThese drugs include iodine-containing compoundsiodine-containing compounds..
BrompheniramineBrompheniramine,, antihistamineantihistamine, &, & coumarincoumarin causecause
variousvarious teratogenic effects.teratogenic effects.
● CiprofloxacinCiprofloxacin,, sulfonamidessulfonamides,, tetracyclinestetracyclines,,
chloramphenicolchloramphenicol,, streptomycinstreptomycin, &, & rifampinrifampin havehave
been associated with various effects.been associated with various effects.

29. Page  29
Antibiotics In PregnancyAntibiotics In Pregnancy::
Generic NameGeneric Name Safety CategorySafety Category
PenicillinPenicillin BB
CephalosporinsCephalosporins BB
Imipenem/cilastatinImipenem/cilastatin CC
MeropenemMeropenem BB
AztreonamAztreonam BB
MetronidazoleMetronidazole BB
ClindamycinClindamycin BB
ClarithromycinClarithromycin CC
Erythromycin/AzithromycinErythromycin/Azithromycin BB
TetracyclinesTetracyclines DD
Sulfonamides/TrimethoprimSulfonamides/Trimethoprim CC
QuinolonesQuinolones CC
VancomycinVancomycin CC
ChloramphenicolChloramphenicol CC

30. Page  30
Antihistaminic In PregnancyAntihistaminic In Pregnancy::
Generic NameGeneric Name Safety CategorySafety Category
ChlorpheniramineChlorpheniramine BB
LoratadineLoratadine BB
EbastineEbastine Not establishedNot established
DesloratadineDesloratadine Not establishedNot established
CetrizineCetrizine Not establishedNot established

31. Page  31
Cough Preparations In PregnancyCough Preparations In Pregnancy::
Generic NameGeneric Name Safety CategorySafety Category
BromhexineBromhexine Not establishedNot established
AcetylcysteineAcetylcysteine BB
AmbroxolAmbroxol Not establishedNot established

32. Page  32
Teratogens used in Pulmonary DiseasesTeratogens used in Pulmonary Diseases::
● Ionizing radiation exposure to the fetus is associated withIonizing radiation exposure to the fetus is associated with
growth retardationgrowth retardation,, CNS effectsCNS effects,, microcephalymicrocephaly, &, &
eye malformations.eye malformations.
● Maternal radiation exposure ofMaternal radiation exposure of <0.05Gy<0.05Gy is associated withis associated with
no adverse effects,no adverse effects, a dose ofa dose of 0.05-0.1Gy0.05-0.1Gy is considered theis considered the
gray zonegray zone & exposure to& exposure to>0.1Gy>0.1Gy is associated withis associated with
significant fetal effects.significant fetal effects.
● Fetal ionizing radiation might causeFetal ionizing radiation might cause ↑↑ in childhoodin childhood leukemia.leukemia.
● AA CXRCXR results inresults in 0.002Gy0.002Gy exposure;exposure; perfusion lung scanperfusion lung scan
0.002Gy0.002Gy;; ventilation lung scanventilation lung scan 0.004Gy0.004Gy;; pulmonarypulmonary
angiographyangiography 0.004Gy0.004Gy && venography 0.004Gy.venography 0.004Gy.

33. Pregnancy-SpecificPregnancy-Specific
Pulmonary DisordersPulmonary Disorders

34. Page  34
Amniotic Fluid Embolism:Amniotic Fluid Embolism:
● Amniotic fluid embolism is aAmniotic fluid embolism is a rare (1 per 8000-80,000)rare (1 per 8000-80,000) butbut
potentiallypotentially catastrophiccatastrophic complication, with acomplication, with a mortalitymortality
raterate ofof 10-80%.10-80%.
● This usually occurs with labor & delivery but can be associatedThis usually occurs with labor & delivery but can be associated
with uterine manipulation, uterine trauma, & the earlywith uterine manipulation, uterine trauma, & the early
postpartum period.postpartum period.
● Amniotic fluid containing particulate cellular elements entersAmniotic fluid containing particulate cellular elements enters
thethe vascular circulationvascular circulation throughthrough endocervical veinsendocervical veins oror
uterine tearsuterine tears, obstructs the pulmonary vessels, & causes, obstructs the pulmonary vessels, & causes
vascular spasms, resulting invascular spasms, resulting in pulmonary hypertension.pulmonary hypertension.
● Acute left ventricular failureAcute left ventricular failure might occur, probably duemight occur, probably due
to humoral events mediated by cytokines.to humoral events mediated by cytokines.

35. Page  35
Tocolytic Pulmonary Edema:Tocolytic Pulmonary Edema:
● ββ-adrenergic agonists, particularly-adrenergic agonists, particularly terbutalineterbutaline, are used to, are used to
inhibit uterine contractionsinhibit uterine contractions && preterm labor.preterm labor.
● These might causeThese might cause pulmonary edemapulmonary edema during pregnancy.during pregnancy.
● TheThe frequencyfrequency varies fromvaries from 0.3-9%.0.3-9%.
● Mechanisms includeMechanisms include prolonged exposure toprolonged exposure to
catecholaminescatecholamines (which causes myocardial dysfunction),(which causes myocardial dysfunction),
increased capillary permeabilityincreased capillary permeability, & a, & a large volume oflarge volume of
intravenous fluidintravenous fluid that may have been administered inthat may have been administered in
response to maternal tachycardia.response to maternal tachycardia.
● GlucocorticoidsGlucocorticoids administered in preterm labor can alsoadministered in preterm labor can also
contribute tocontribute to fluid retention.fluid retention.

36. Page  36
Gestation Trophoblastic Disease:Gestation Trophoblastic Disease:
● Pulmonary hypertensionPulmonary hypertension && pulmonary edemapulmonary edema cancan
complicatecomplicate benign hydatidiform pregnancybenign hydatidiform pregnancy due todue to
trophoblastic pulmonary embolism.trophoblastic pulmonary embolism.
● This commonly occursThis commonly occurs during evacuationduring evacuation of theof the uterusuterus, &, &
thethe incidenceincidence ofof pulmonary complicationspulmonary complications isis higherhigher inin
later gestations.later gestations.
● Molar pregnancyMolar pregnancy can be associated withcan be associated with
choriocarcinomachoriocarcinoma, which commonly produces, which commonly produces multiplemultiple
discrete pulmonary metastasesdiscrete pulmonary metastases & occasional& occasional pleuralpleural
effusions.effusions.

37. Asthma & PregnancyAsthma & Pregnancy

38. Page  38
Asthma in Pregnancy:Asthma in Pregnancy:
● Asthma is one of the most common coexisting medicalAsthma is one of the most common coexisting medical
conditions affecting reproductive-aged woman.conditions affecting reproductive-aged woman.
● The course of asthma during pregnancy is variable;The course of asthma during pregnancy is variable; oneone
thirdthird of patientsof patients improveimprove,, one thirdone third remainremain stablestable, &, &
one third worsen.one third worsen.
● In patients with symptomatic asthma,In patients with symptomatic asthma, gestational weeksgestational weeks
24-3624-36 tend to be thetend to be the most difficult.most difficult.

39. Page  39
Asthma in Pregnancy:Asthma in Pregnancy:
● OnlyOnly 10%10% of women experienceof women experience asthma exacerbationasthma exacerbation
during laborduring labor && deliverydelivery, and the, and the severityseverity tends totends to
revertrevert to that of pregnancy byto that of pregnancy by 3 months' postpartum.3 months' postpartum.
● Asthma is generally expected to follow aAsthma is generally expected to follow a similar coursesimilar course
duringduring successive pregnancies.successive pregnancies.
● Infant outcomeInfant outcome might bemight be worseworse asas asthma severityasthma severity
increasesincreases & that& that outcomeoutcome withwith aggressive asthmaaggressive asthma
managementmanagement is usuallyis usually good.good.

40. Page  40
Asthma in Pregnancy:Asthma in Pregnancy:
● Asthma exacerbationsAsthma exacerbations occur primarily in theoccur primarily in the latelate
second trimestersecond trimester & are either& are either triggeredtriggered byby viralviral
infectioninfection oror non-adherencenon-adherence toto ICS.ICS.
● Severe exacerbationsSevere exacerbations during pregnancy are aduring pregnancy are a
significant risk factorsignificant risk factor for afor a low birth weightlow birth weight baby andbaby and
ICSICS use mayuse may reduce the risk.reduce the risk.
● Clinical featuresClinical features of asthma during pregnancy areof asthma during pregnancy are thethe
samesame as those in theas those in the non-pregnantnon-pregnant patient.patient.

41. Page  41
Fetal Outcome in Asthma with Pregnancy:Fetal Outcome in Asthma with Pregnancy:
● Asthma can have a number of deleterious effects onAsthma can have a number of deleterious effects on
pregnancy outcome.pregnancy outcome.
● AnAn increasedincreased incidence ofincidence of preterm birthspreterm births,, low birthlow birth
weightweight, &, & increased prenatal mortalityincreased prenatal mortality largely relatedlargely related
to poor asthma control has been reported.to poor asthma control has been reported.

42. Page  42
Acute Asthma Exacerbation with Pregnancy:Acute Asthma Exacerbation with Pregnancy:
● Acute exacerbations that necessitate emergency departmentAcute exacerbations that necessitate emergency department
visits typically require a course ofvisits typically require a course of systemicsystemic
corticosteroids.corticosteroids.
● OxygenOxygen should be used liberally, & theshould be used liberally, & the oxygenoxygen
saturationsaturation should be maintainedshould be maintained ≥ 95%≥ 95% to ensure fetalto ensure fetal
well-being.well-being.
● AA beta-agonistbeta-agonist with or withoutwith or without ipratropiumipratropium should beshould be
given viagiven via MDIMDI with awith a spacerspacer or inor in nebulizednebulized form.form.
● TheophyllineTheophylline hashas limitedlimited use in acute exacerbations.use in acute exacerbations.

43. Venous ThromboembolicVenous Thromboembolic
Disease & PregnancyDisease & Pregnancy

44. Page  44
● TheThe incidenceincidence ofof venous thromboembolismvenous thromboembolism isis
estimated atestimated at 0.76-1.72/1000 pregnancies0.76-1.72/1000 pregnancies, which is, which is fourfour
times as great as the risk in the non-pregnant population.times as great as the risk in the non-pregnant population.
● Current estimates ofCurrent estimates of deathsdeaths fromfrom pulmonary embolismpulmonary embolism
areare 1.1-1.5/100,000 deliveries1.1-1.5/100,000 deliveries in the US & Europe.in the US & Europe.
● Delayed diagnosisDelayed diagnosis,, delayeddelayed oror inadequateinadequate
treatmenttreatment, &, & inadequate thromboprophylaxisinadequate thromboprophylaxis
account for many of the deaths due to venousaccount for many of the deaths due to venous
thromboembolismthromboembolism
Venous Thromboembilic Disease & Pregnancy:Venous Thromboembilic Disease & Pregnancy:

45. Page  45
Diagnostic Algorithm for VTD in Pregnancy:Diagnostic Algorithm for VTD in Pregnancy:

46. Page  46
Venous Thromboembilic Disease & Pregnancy:Venous Thromboembilic Disease & Pregnancy:

47. Page  47
Venous Thromboembilic Disease & Pregnancy:Venous Thromboembilic Disease & Pregnancy:

48. Page  48
Venous Thromboembilic Disease & Pregnancy:Venous Thromboembilic Disease & Pregnancy:

49. ARDS & PregnancyARDS & Pregnancy

50. Page  50
● Pregnant patients are at risk of developing ARDS fromPregnant patients are at risk of developing ARDS from
obstetric complications & from non-obstetric conditions.obstetric complications & from non-obstetric conditions.
● ObstetricObstetric complications, such ascomplications, such as amniotic fluidamniotic fluid
embolismembolism,, chorioamnionitischorioamnionitis,, trophoblastictrophoblastic
embolismembolism, &, & placental abruptionplacental abruption, can produce acute, can produce acute
lung injury.lung injury.
● Pregnancy predisposes the patient to other pulmonaryPregnancy predisposes the patient to other pulmonary
insults that can cause ARDS, such asinsults that can cause ARDS, such as gastric aspirationgastric aspiration,,
pneumoniapneumonia,, air embolismair embolism, &, & massive hemorrhage.massive hemorrhage.
ARDS & Pregnancy:ARDS & Pregnancy:

51. Page  51
● An association betweenAn association between pyelonephritispyelonephritis & the development& the development
ofof ARDSARDS has been described in pregnancy.has been described in pregnancy.
● The mechanism isThe mechanism is unclearunclear, but, but iatrogeniciatrogenic factors, such asfactors, such as
excessive fluid administrationexcessive fluid administration && tocolytic therapytocolytic therapy,,
might be responsible.might be responsible.
● TheThe reduced albuminreduced albumin level & resultantlevel & resultant reduced plasmareduced plasma
oncotic pressureoncotic pressure occurring in pregnancyoccurring in pregnancy lowerslowers thethe
critical pulmonary capillary pressurecritical pulmonary capillary pressure at whichat which
pulmonary edema develops.pulmonary edema develops.
ARDS & Pregnancy:ARDS & Pregnancy:

52. Page  52
● No major differencesNo major differences exist in theexist in the managementmanagement ofof
pregnant & non-pregnant patient with ARDS.pregnant & non-pregnant patient with ARDS.
● Fetal riskFetal risk must be considered whenmust be considered when pharmacologicalpharmacological
therapytherapy is administered.is administered.
● Adequate maternal oxygen saturationAdequate maternal oxygen saturation is essential foris essential for
fetal well-being.fetal well-being.
● Excessive alkalosisExcessive alkalosis can have adverse effects oncan have adverse effects on placentalplacental
perfusionperfusion, while, while maternal acidosismaternal acidosis appears to beappears to be
reasonablyreasonably well toleratedwell tolerated by theby the fetus.fetus.
● SurvivalSurvival appearsappears similarsimilar to ARDS in the generalto ARDS in the general
population.population.
ARDS & Pregnancy:ARDS & Pregnancy:

53. TuberculosisTuberculosis
& Pregnancy& Pregnancy

54. Page  54
● Untreated TB represents a far greater hazard to a pregnantUntreated TB represents a far greater hazard to a pregnant
woman & her fetus than does treatment of the disease.woman & her fetus than does treatment of the disease.
● Infants born to women with untreated TB may be ofInfants born to women with untreated TB may be of lowerlower
birth weightbirth weight than those born to women without TB &,than those born to women without TB &,
rarelyrarely, the infant may acquire, the infant may acquire congenital TB.congenital TB.
● Thus, treatment of a pregnant woman with suspected TBThus, treatment of a pregnant woman with suspected TB
should be started if the probability of TB isshould be started if the probability of TB is moderatemoderate toto
high.high.
● Administration of antituberculosis drugs isAdministration of antituberculosis drugs is notnot an indicationan indication
forfor termination of pregnancy.termination of pregnancy.
Tuberculosis & Pregnancy:Tuberculosis & Pregnancy:

55. Page  55
● HIV infection & drug-resistant TB present special challenges inHIV infection & drug-resistant TB present special challenges in
pregnancy.pregnancy.
● Knowledge of drug interactions & teratogenic effects ofKnowledge of drug interactions & teratogenic effects of
antiretroviralsantiretrovirals && 22ndnd
line antituberculosis agents is neededline antituberculosis agents is needed
to treat these patients properly.to treat these patients properly.
● TB in pregnancy is treated withTB in pregnancy is treated with isoniazidisoniazid && rifampin &rifampin &
ethambutolethambutol..
● These drugs mayThese drugs may crosscross thethe placentalplacental barrier, but they arebarrier, but they are
associated with aassociated with a low risklow risk of adverse fetal effects.of adverse fetal effects.
● StreptomycinStreptomycin & other& other injectableinjectable antituberculous drugs areantituberculous drugs are
contraindicatedcontraindicated because ofbecause of fetal toxicityfetal toxicity & potential& potential
teratogenic effects.teratogenic effects.
Tuberculosis & Pregnancy:Tuberculosis & Pregnancy:

56. Page  56
● IsoniazidIsoniazid (Pregnancy Category(Pregnancy Category AA)) may causemay cause cutaneouscutaneous
hypersensitivityhypersensitivity,, hepatitishepatitis,, peripheral neuropathy.peripheral neuropathy.
● The risk ofThe risk of INH-induced hepatitisINH-induced hepatitis may bemay be 2.5 times2.5 times
higherhigher in pre-natal patients than the general population.in pre-natal patients than the general population.
● Pyridoxine 25 mg/dayPyridoxine 25 mg/day, should be given to pregnant, should be given to pregnant
women receivingwomen receiving INH.INH.
● INHINH given for treatment ofgiven for treatment of latent TBlatent TB
(chemoprophylaxis)(chemoprophylaxis) is consideredis considered safesafe & is& is
recommended especially where the risk of developing diseaserecommended especially where the risk of developing disease
is higher, e.g., with HIV co-infection or with a history ofis higher, e.g., with HIV co-infection or with a history of
recent contact.recent contact.
Tuberculosis & Pregnancy:Tuberculosis & Pregnancy:

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● RifampicinRifampicin (Pregnancy Category(Pregnancy Category CC) causes bleeding due to) causes bleeding due to
hypoprothrominaemia in infants & mothers especially ifhypoprothrominaemia in infants & mothers especially if
adminsterated in late pregnancy.adminsterated in late pregnancy.
● Vitamin KVitamin K is given to both the mother & the infantis given to both the mother & the infant
postpartum ifpostpartum if rifampicinrifampicin is used in theis used in the last few weekslast few weeks ofof
pregnancy.pregnancy.
● RifampicinRifampicin may causemay cause nauseanausea,, vomitingvomiting && hepatitis.hepatitis.
Tuberculosis & Pregnancy:Tuberculosis & Pregnancy:

58. Page  58
● EthambutolEthambutol (Pregnancy Category(Pregnancy Category AA) is recommended for) is recommended for
use in pregnancy.use in pregnancy.
● Retrobulbar neuritisRetrobulbar neuritis occurs inoccurs in <1%<1% of cases on a dailyof cases on a daily
dose ofdose of 15 mg /kg15 mg /kg ofof Ethambutol.Ethambutol.
Tuberculosis & Pregnancy:Tuberculosis & Pregnancy:

59. Page  59
● There areThere are no reportsno reports ofof fetal malformationsfetal malformations
attributable toattributable to pyrazinamide.pyrazinamide. The absence of such safetyThe absence of such safety
data is the reason that the CDC guidelinesdata is the reason that the CDC guidelines do not endorsedo not endorse
pyrazinamidepyrazinamide inin pregnancy.pregnancy.
● PyrazinamidePyrazinamide may producemay produce gastrointestinal upsetsgastrointestinal upsets,,
arthralgiaarthralgia,, hyperuricemiahyperuricemia && hepatitis.hepatitis.
● IfIf PZAPZA is not included in theis not included in the initialinitial treatment regimen, thetreatment regimen, the
minimumminimum duration of therapy isduration of therapy is 9 months.9 months.
Tuberculosis & Pregnancy:Tuberculosis & Pregnancy:

60. Page  60
● StreptomycinStreptomycin may commonly causemay commonly cause vertigovertigo in motherin mother
apart fromapart from ototoxicityototoxicity && nephrotoxicitynephrotoxicity, related to, related to
serum concentrationserum concentration && total dosetotal dose of administered drug.of administered drug.
Thus it isThus it is not recommendednot recommended during pregnancy.during pregnancy.
Tuberculosis & Pregnancy:Tuberculosis & Pregnancy:

61. Page  61
● BreastfeedingBreastfeeding should notshould not be discouraged for women beingbe discouraged for women being
treated withtreated with first-line agentsfirst-line agents, because the small, because the small
concentrations of these drugs in breast milk do not produceconcentrations of these drugs in breast milk do not produce
toxic effects in the nursing infant.toxic effects in the nursing infant.
● Conversely, drugs in breast milk should not be considered toConversely, drugs in breast milk should not be considered to
serve asserve as effectiveeffective treatment fortreatment for active TBactive TB oror latent TBlatent TB
infection in a nursing infant.infection in a nursing infant.
Tuberculosis & Breast Feeding:Tuberculosis & Breast Feeding:

62. Page  62
● TheThe use ofuse of IsoniazidIsoniazid,, RifampicinRifampicin,, EthambutolEthambutol, &, &
PyrazinamidePyrazinamide, has been considered, has been considered safesafe forfor breastbreast
feedingfeeding, but safety of PAS & injectable forms is unproven., but safety of PAS & injectable forms is unproven.
● Supplementary pyridoxineSupplementary pyridoxine is recommended for theis recommended for the
nursing mother receivingnursing mother receiving INH.INH.
● The administration of theThe administration of the fluoroquinolonesfluoroquinolones duringduring
breastfeeding isbreastfeeding is not recommended.not recommended.
● The effect of these drugs gets minimized, if the mother breastThe effect of these drugs gets minimized, if the mother breast
feeds before taking the drugs & substitutes the next feed withfeeds before taking the drugs & substitutes the next feed with
formula preparation.formula preparation.
Tuberculosis & Breast Feeding:Tuberculosis & Breast Feeding:

63. Obstructive SleepObstructive Sleep
Apnea & PregnancyApnea & Pregnancy

64. Page  64
● High circulating level ofHigh circulating level of progesteroneprogesterone during pregnancyduring pregnancy ↑↑
ventilatory driveventilatory drive, which has a potentially protective effect., which has a potentially protective effect.
● ObesityObesity predisposes topredisposes to SRBDSRBD && weight gainweight gain && ↑↑ nasalnasal
obstructionobstruction during pregnancy contributory toduring pregnancy contributory to SDB.SDB.
● TheThe enlarging uterusenlarging uterus altersalters diaphragmatic functiondiaphragmatic function,,
thus resulting inthus resulting in ↓↓ FRCFRC & causing& causing shuntingshunting && hypoxemiahypoxemia
leading toleading to hypoxemiahypoxemia duringduring hypoventilationhypoventilation in sleep.in sleep.
● Pregnancy mayPregnancy may precipitateprecipitate oror worsenworsen sleep apnea.sleep apnea.
OSAS & Pregnancy:OSAS & Pregnancy:

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● Pregnancy, ifPregnancy, if complicatedcomplicated byby OSAOSA, is associated with, is associated with
potential adverse effects for both the mother & the fetus.potential adverse effects for both the mother & the fetus.
● In general,In general, apneaapnea && hypopneahypopnea are uncommon in pregnancyare uncommon in pregnancy
because of thebecause of the respiratory stimulatoryrespiratory stimulatory effect ofeffect of
progesterone.progesterone.
● Nocturnal hypoxemiaNocturnal hypoxemia adversely affects the fetus & pooradversely affects the fetus & poor
fetal growth occurs in patients with this condition.fetal growth occurs in patients with this condition.
● nCPAPnCPAP is ais a safesafe && effectiveeffective treatment of SDB duringtreatment of SDB during
pregnancy.pregnancy.
OSAS & Pregnancy:OSAS & Pregnancy:

66. Thank YouThank You