Respiratory Disease in Pregnancy

Stephen E. Lapinsky
Mount Sinai Hospital
Toronto, Canada
Respiratory Disorders in Pregnancy

Respiratory physiology in pregnancy

Respiratory diseases in pregnancy

Respiratory failure in pregnancy

Respiratory Disorders in Pregnancy

Respiratory physiology in pregnancy

Respiratory diseases in pregnancy

Respiratory failure in pregnancy

Is the pregnant patient different ?

 Maternal cardio-respiratory
adaptations

 The fetus
 Oxygenation
 physiology
 compensatory mechanisms
 Drug therapy
 Radiation exposure
Is the pregnant patient different ?

 Maternal cardio-respiratory
adaptations

 The fetus
 Oxygenation
 physiology
 compensatory mechanisms
 Drug therapy
 Radiation exposure
Anatomic effects Functional effects

airway edema,
friability

widened AP and
transverse diam.

elevated
diaphragm
widened subcostal
angle

enlarging uterus
Anatomic effects Functional effects
increased respiratory
drive
airway edema,
friability minimal change in TLC
increased Vt
widened AP and reduced FRC
transverse diam.

elevated normal diaphragmatic

diaphragm function
widened subcostal
angle

enlarging uterus
increased O2
consumption and CO2
production
Anatomic effects Functional effects
increased respiratory
drive
airway edema,
friability minimal change in TLC
increased Vt
widened AP and reduced FRC
transverse diam.

elevated normal diaphragmatic

diaphragm function
widened subcostal
angle

enlarging uterus
increased O2
consumption and CO2
production
Blood gases in late pregnancy

pH 7.43
PaCO2 30 mmHg - hyperventilation

PaO2 105 mmHg - normal a-A gradient

HCO3- 20 mEq/L - renal compensation

Decreased oxygen reserve

• reduced FRC
• increase O2 consumption
Is the pregnant patient different ?

 Maternal cardio-respiratory
adaptations

 The fetus
 Oxygenation
 physiology
 compensatory mechanisms
 Drug therapy
 Radiation exposure
 Fetal Oxygenation
Determinants
 placental function
 uterine oxygen delivery
 Fetal Oxygenation
Determinants
 placental function
 uterine oxygen delivery
•Maternal oxygen content
•Uterine blood flow
- normally maximally dilated
- decreased by catecholamines
alkalosis
hypotension
contractions
Fetal Oxygenation
Respiratory Disorders in Pregnancy

Physiology in Pregnancy

Respiratory diseases in pregnancy

Respiratory failure in pregnancy

 Respiratory Diseases
in Pregnancy

 Asthma
 Thromboembolic disease
 Pneumonia
 Interstitial lung disease
 Other chronic respiratory diseases
 Pregnancy induced respiratory disease
 Asthma in Pregnancy

Pregnancy -> 1/3 deteriorate

1/3 improve
1/3 no change

Differentiate from other conditions

 Asthma in Pregnancy

Management
beta-agonists: safe (inhibit labor)
LABA: no data (likely safe)
 similar to non-pregnant
inhaled steroids: safe (budesonide best data)
 do not avoid necessary drugs!
theophylline: safe (crosses placenta)

 Rx GERD montelukast,
if problematic
zafirlukast: safe?
systemic steroids: if benefit outweighs risk
 severe attack worse for fetus than drugs
omeprazole: safe
 systemic steroids when necessary
pantoprazole: safe, less data
 Asthma in Pregnancy

Management
 similar to non-pregnant
 do not avoid necessary drugs!
 Rx GERD if problematic
 severe attack worse for fetus than drugs
 systemic steroids when necessary
 Thromboembolism
Leading cause of morbidity:
 11% of maternal deaths

 Etiology:
 increased coagulation factors (V, VIII, X)
 venous stasis
 local trauma
 bed rest, C-section
 Thromboembolism

Investigations:
 duplex ultrasound
 V/Q scan – begin with Q
 CT angiogram
 Radiological Procedures
Fetal risk
 oncogenicity
 increased incidence of childhood
leukemia (RR 1.5 – 2.0) Fetal exposure (rad)
 associated with 1 – 5 rads chest XR 0.001
V/Q 0.060
 1 childhood cancer death per
CT angio 0.100
1,700 1 rad exposures
CT pelvis/abdo 5.0
 teratogenicity
 fetal exposure 10 to 50 rads
 10 – 20 in first 6 weeks gestation

 neurological development Lowe 2004, Austr NZ J Obstet Gynaecol

National Radiological Protection Board, 1998
 5-30 rad at 8-15 weeks Ratnapalan et al, CMAJ 2008; 179:1293
 Radiological Procedures
Management
 Consider risk-benefit
 Don’t avoid necessary studies, eg. CT angio
 Don’t do unnecessary, eg. daily CXR, lateral
 Remember contrast for CT angio carries risk
 Screen abdomen
 Reduces exposure by 50%, still internal scatter
 Discuss with mother and father
 Perceived risk very high (parents and family doc)
 Can be a major source of concern
Lowe 2004, Austr NZ J Obstet Gynaecol
National Radiological Protection Board, 1998
Ratnapalan et al, CMAJ 2008; 179:1293
 Thromboembolism

Investigations:
 duplex ultrasound
 V/Q scan – begin with Q
 CT angiogram

Management:
 heparin / LMWH
 avoid coumadin until post-partum?
 thrombolysis?
 Other Respiratory Diseases

Pneumonia:
 Etiology - usual pneumonias (incidence not increased)
- increased complications
- varicella more severe
- HIV associated
- Blasto and histo may be more severe
- TB: incidence not increased
 Other Respiratory Diseases
Pneumonia:
 Management - do NOT avoid chest x-rays
- avoid tetracyclines (& quinolones)
- VZIG and acyclovir
- TB: INH, rifampin, ethambutol
PZA (recommended by WHO)
 Other Respiratory Diseases
Other chronic lung disease:
 little data
 eg. CF, bronchiectasis, neuromuscular disease
 increasingly common request
 multidisciplinary team management
 Reduced DCO may affect oxygenation
 Pulmonary hypertension increases risk
Pregnancy-specific respiratory diseases

•Preeclampsia (pulmonary edema)

•Amniotic fluid embolism
•Tocolytic pulmonary edema
•Septic ARDS (chorioamnionitis)
•Trophoblastic embolism
•Fetal intrauterine surgery
 Preeclampsia

 Syndrome of
 hypertension
 proteinuria
 after about 20 weeks gestation

 Etiology unknown: diffuse effect on

maternal endothelium
 Preeclampsia

3% of preeclamptics develop pulmonary edema

Mechanism
 increased afterload
 decreased serum albumin
 volume administration, uterine contraction
 myocardial dysfunction?

More common in obese, hypertensives

Preeclampsia - Management
Well-timed delivery

 Hypertension:
 ONLY to avoid maternal hypertensive complications
 Seizures:
 Rx and prophylaxis with Magnesium sulfate
 Fluid Management:
 usually volume depleted
 careful fluid administration
 avoid over diuresis
 Amniotic Fluid Embolism
Rare: 1/8,000 to 1/80,000
Catastrophic: mortality 10 - 86%

Presentation: cardiorespiratory collapse

fetal distress
cardiac arrest, seizures

Late effects: ARDS & DIC

 Amniotic Fluid Embolism
Pathophysiology:
 amniotic fluid enters venous circulation
 cellular contents and humoral factors
 Acute pulmonary hypertension & myocardial dysfunction

Diagnosis: by exclusion

Management:
 Supportive - ventilation, inotropes
 Steroids ?
 Anticipate ARDS & DIC
ARDS in pregnancy

pre-eclampsia
obstetric sepsis
amniotic fluid embolism
aspiration
major hemorrhage
placental abruption

Smith, et al. West J Med 1990, 153:508

Catanzarite, Obstet Gynecol Survey 1997, 52:381
Respiratory Disorders in Pregnancy

Physiology in Pregnancy

Respiratory diseases in pregnancy

Respiratory failure in pregnancy

Intubation in Pregnancy
?

Benumof et al, Anesthesiology 1997; 8:979

Baraka et al, Anesth Analg 1992; 75:757
Mechanical Ventilation in Pregnancy
Intubation

Indications Remember normal PaCO2 levels

Tube size eg. 6.5 to 7.5

Airway friability Avoid nasal route

Aspiration delayed gastric emptying, increased

abdominal pressure

Oxygen desaturation reduced O2 reserves

 Mechanical Ventilation in Pregnancy
Non-invasive Ventilation

Advantages
 avoids the upper airway
 avoids sedation

Concerns
 nasal congestion
 reduced lower esophageal sphincter tone
 aspiration
 Non-invasive Ventilation - Role

Acute respiratory failure

 Pulmonary edema (preeclampsia, cardiogenic)
 Other (eg. asthma, pneumonia)

Chronic respiratory failure

 Neuromuscular disease
 Kyphoscoliosis
 Bronchiectasis
Bach. Am J Phys Med Rehabil 2003; 82:226
 Non-invasive Ventilation - Role

Acute respiratory failure

 Pulmonary edema (preeclampsia, cardiogenic)
 Other (eg. asthma, pneumonia)

Chronic respiratory failure

 Neuromuscular disease
 Kyphoscoliosis
 Bronchiectasis
Bach. Am J Phys Med Rehabil 2003; 82:226
 Conventional Ventilation

Oxygenation
 optimize: PaO2 > 90 mmHg

Ventilation
 normal PaCO2 30 mmHg
 permissive hypercapnia ?
 avoid alkalosis

 Pressure
 respiratory system compliance
 adequate PEEP
 Conventional Ventilation

Oxygenation
 optimize: PaO2 > 90 mmHg

Ventilation
 normal PaCO2 30 mmHg
 permissive hypercapnia ?
 avoid alkalosis

 Pressure
 respiratory system compliance
 adequate PEEP
 Conventional Ventilation
Hypocapnia
 Limited animal and human data

 Maternal PaCO2 < 25 mmHg is associated with fetal hypoxia

and acidosis, due to reduced uterine blood flow

Group Maternal Fetal APGAR

hyperventilated pH 7.5 pH 7.34
PCO2 23 PO2 23 6.9

hypoventilated pH 7.36 pH 7.29

PCO2 39 PO2 29 8.4

Peng et al, Br J Anasth 1972, 44:1173

Buss Am J Physiol 1975; 228:1497
Clark Anesth Analg 1971; 50:713
 Conventional Ventilation

Hypercapnia
 Very limited data
 Produces fetal acidemia secondary to maternal acidemia, but
NOT fetal hypoxemia
 Fetal distress may occur, but APGARs good
 Maternal PaCO2 of 52 mmHg well tolerated

Bicarbonate therapy
 Crosses the placenta in humans (unlike animals)

Hollemen, Acta Anaesth Scan 1972, 221

Ivankovic et al, Am J Obstet Gynecol 1970
 Conventional Ventilation

Oxygenation
 optimize: PaO2 > 90 mmHg

Ventilation
 normal PaCO2 30 mmHg
 permissive hypercapnia ?
 avoid alkalosis

 Pressure
 respiratory system compliance is reduced
 adequate Vt and PEEP
 Delivery of the fetus
May be considered that delivery of the pregnant
women with respiratory failure is beneficial to
the mother
 Delivery of the fetus
May be considered that delivery of the pregnant
women with respiratory failure is beneficial to
the mother
NOT always the case:
 Some oxygenation improvement
 Little change in compliance or PEEP requirement
Tomlinson MW, et al. Obstet Gynecol. 1998; 91:108-11.
Mabie WC, et al. Am J Obstet Gynecol 1992; 167:950-7
 Delivery of the fetus
May be considered that delivery of the pregnant
women with respiratory failure is beneficial to
the mother
NOT always the case:
 Some oxygenation improvement
 Little change in compliance or PEEP requirement
Tomlinson MW, et al. Obstet Gynecol. 1998; 91:108-11.
C-section Mabie WC, et al. Am J Obstet Gynecol 1992; 167:950-7

 More rapid delivery

 Increased physiological stress
 Delivery of the fetus

 Delivery:
 If fetus is viable and at risk due to maternal hypoxia
 NOT purely to improved maternal hypoxemia

 Plan for delivery

 In event of maternal or fetal deterioration
 Delivery and neonatal equipment available
 OB criteria determine mode of delivery