Surgery Block

SECTION VIII: MEDICAL & SURGICAL COMPLICATIONS

2012

CHAPTER 46
Pulmonary Disorders
Dr.

REVIEW ON MATERNAL PHYSIOLOGY

CARDIOVASCULAR CHANGES IN
Pregnancy

Heart
Changes that occurs as the diaphragm becomes
progressively elevated
 Heart is displaced to the left and upward and rotated
somewhat on its long axis
 Apex is moved somewhat laterally from its usual
position, causing a larger cardiac silhouette on chest
radiograph
⚜ pregnant women normally have some degree of
benign pericardial effusion, which may increase
the cardiac silhouette

Pulmonary Function during Pregancy

RESPIRATORY RATE
 essentially unchanged
INCREASES during Pregnancy
 Vital capacity and inspiratory capacity
⚜  by 20% by late pregnancy
 Tidal volume
⚜  by 40% as a result of the respiratory
stimulant properties of Progesterone
 Minute ventilation
⚜  by 30 to 40% due to  tidal volume
 Arterial pO2
⚜  from 100 to 105 mm Hg
 CARDIAC OUTLINE that occurs in pregnancy.  Carbon dioxide production & diffusion capacity
⚜ BLUE LINES: represent the relations between ⚜  production by 30%
⚜  diffusion capacity
the heart and thorax in the nonpregnant woman
 Ventilation
⚜ BLACK LINES: represent the conditions existing
⚜  d/t deeper but not more frequent breathing
in pregnancy DECREASED during Pregnancy
 Expiratory reserve volume
⚜  from 1300 mL to 1100 mL
RESPIRATORY TRACT CHANGES IN  pCO2
Pregnancy
⚜ w/ alveolar hyperventilation, the pCO2  from
40 to 32 mm Hg
 Residual volume
⚜  by 20% from 1500 mL to 1200 mL
Respiratory Tract Changes
 functional residual capacity
DIAPHRAGM ⚜ sum of expiratory reserve and residual volumes
 rises about 4 cm during pregnancy
⚜  by 10 to 25%
SUBCOSTAL ANGLE
⚜  d/t expanding uterus &  abdominal
 widens appreciably
pressure causing chest wall compliance to  by
 transverse diameter of the thoracic cage  2 cm. rd
1/3
 THORACIC CIRCUMFERENCE
CHANGES presumably are induced by:
  by 6 cm
  basal oxygen consumption
 not sufficiently to prevent a reduction in the residual
lung volume created by the elevated diaphragm. ⚜  incrementally by 20 to 40 mL/min in the
DIAPHRAGMATIC EXCURSION second half of pregnancy.
 greater in pregnant than in nonpregnant women KIDNEYS
  bicarbonate excretion   serum levels to 15 to
20 meq/L
 pH is slightly alkalotic at 7.45
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PULMONARY COMPLICATIONS CLINICAL COURSE

 Clinical illness ranging from mild wheezing to severe
bronchoconstriction
PULMONARY DISORDERS IN  functional result of acute bronchospasm
Pregnancy ⚜ airway obstruction
⚜ decreased airflow
⚜ work of breathing progressively increases
 Patient present with
Pulmonary Disorders ⚜ chest tightness
ASTHMA ⚜ wheezing
 most common ⚜ breathlessness
 affects up to 4 percent of women  Distribution of airway narrowing is uneven 
CA-PNA + Asthma alterations in oxygenation  Ventilation–Perfusion
 accounts for 10% of nonobstetrical antepartum Mismatching
 HYPOXIA
hospitalizations in one managed care plan
⚜ MILD
advanced pregnancy may intensify the  Initially compensated by hyperventilation
pathophysiological effects of some lung diseases  normal arterial pO2, decreased pCO2 
 disparate number of maternal deaths during the Respiratory Alkalosis
influenza pandemics of 1918 and 1957 ⚜ PROGRESSION
 poor tolerance for pregnancy of women with severe  As airway narrowing worsens  
ventilation–perfusion defects  arterial
chronic lung disease
hypoxemia ensues
 With severe obstruction
Asthma ⚜ Ventilation  impaired because fatigue causes
common in young women and therefore is seen early CO2 retention
frequently during pregnancy.  Because of hyperventilation, this may only
asthma prevalence during pregnancy: 4 and 8 percent be seen initially as an arterial pCO2
Chronic inflammatory airway disorder returning to the normal range
PATHOPHYSIOLOGY
 Major hereditary component
⚜  airway responsiveness and persistent
subacute inflammation a/w:
 Chromosomes 5, 11, and 12
 Cytokine gene clusters
 β-adrenergic and glucocorticoid receptor
genes
 T-cell antigen receptor gene
 environmental allergic stimulant
⚜ influenza
⚜ cigarette smoke
 Hallmarks of asthma:
⚜ Reversible airway obstruction from
 bronchial smooth muscle contraction
 Vascular congestion
 Tenacious mucus
 Mucosal edema
 Airway inflammation
⚜ d/t  responsiveness to stimuli
 irritants
 viral infections
 aspirin
 cold air
 exercise
⚜ Inflammatory response caused by:
 mast cells
 eosinophils
 lymphocytes
 bronchial epithelium
 Inflammatory Mediators:
⚜ Histamine
 changes are generally reversible and well tolerated
⚜ Leukotrienes
by the healthy nonpregnant individual
⚜ Prostaglandins
 However, even early stages of asthma may be
⚜ Cytokines
dangerous for the pregnant woman and her fetus
⚜ IgE
⚜ Because the smaller functional residual capacity
 F-series prostaglandins and ergonovine
and increased effective shunt render the woman
⚜ Exacerbate asthma
more susceptible to hypoxia and hypoxemia
⚜ commonly used obstetrical drugs
⚜ should be avoided if possible

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EFFECTS OF PREGANCY ON ASTHMA
 no evidence that pregnancy has a predictable effect
on underlying asthma
⚜ baseline severity correlated with asthma
morbidity during pregnancy
 MILD disease:
 12% w/ exacerbation
 2.3 % require admission
 MODERATE disease:
 26% w/ exacerbation
 7% require admission
 SEVERE Disease:
 52% w/ exacerbation
 27% require admission
⚜ 1/3 each: improved, remained unchanged or
worsened
⚜ 20% w/ Intrapartum Exacerbation among
women w/ MILD to MODERATE asthma
⚜ 18 fold increased risk of exacerbation following
caesarean vs vaginal delivery
Asthma & Pregnancy
ASTHMA Exacerbation (%) Admission (%)
Mild 13-20
Moderate 26
Severe 50
 PREGNANCY OUTCOMES
⚜ MATERNAL & PERINATAL OUTCOMES
 slightly increased incidence of
 preeclampsia
☀  risk in moderate to severe
asthma, regardless of treatment
 preterm labor
☀ increased about twofold in severe
asthma
 low-birthweight infants
 perinatal mortality
 placental abruption
 preterm rupture of membranes
 most obstetrical complications were not
higher in asthmatic women
nonasthmatics, except:
 depression
 miscarriages
 cesarean delivery
 significantly increased morbidity is linked to
 progressively more severe disease
 poor control
 combination of both
 baseline pregnancy forced expiratory
volume at 1 second (FEV1)
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 direct relationship with birthweight
 inverse relationship with rates of
gestational hypertension and preterm
delivery
 Life-threatening complications from status
asthmaticus include
 muscle fatigue with respiratory arrest
 pneumothorax
 pneumomediastinum
 acute cor pulmonale
 cardiac arrhythmias
 Maternal and perinatal mortality rates are
substantively increased when mechanical
ventilation is required
⚜ FETAL EFFECTS
 No significant adverse neonatal sequelae
from asthma
 But when respiratory alkalosis develops
 fetal hypoxemia develops well before
the alkalosis compromises maternal
oxygenation
 Fetal Compromise results from
  uterine blood flow
 decreased maternal venous return
 alkaline induced shift to the left of the
oxyhemoglobin dissociation curve
 Fetal response to Maternal hypoxemia:
  umbilical blood flow
  systemic and pulmonary vascular
resistance
  cardiac output
 incidence of fetal-growth restriction
increases with asthma severity
 hence, need for aggressive
management
 CLINICAL EVALUATION
⚜ subjective severity of asthma frequently does
not correlate with objective measures of airway
function or ventilation
⚜ Clinical examination
2.3
 inaccurate as a predictor of severity
7  Useful clinical signs include
27  labored breathing
 tachycardia
 pulsus paradoxus
 prolonged expiration
 use of accessory muscles
 Signs of a potentially fatal attack
 central cyanosis
 altered consciousness.
⚜ Arterial blood gas analysis
 provides objective assessment of maternal:
 oxygenation
 ventilation
 acid–base status.
 severity of an acute attack can be assessed
 ROUTINE arterial blood gas analysis
 did not help to manage most pregnant
vs women who required admission for
asthma control.
 If used, the results must be interpreted in
relation to normal values for pregnancy
 pCO2 > 35 mm Hg with a pH < 7.35
☀ consistent with hyperventilation
and CO2 retention in a pregnant
woman.
⚜ Pulmonary function testing
 should be routine in the management of
chronic and acute asthma.

SECTION VIII: MEDICAL & SURGICAL COMPLICATIONS
 Sequential measurement of the FEV1 or the
peak expiratory flow rate—PEFR
 best measures of severity
 FEV1
☀ If < 1 L or < 20% of predicted value
❧ correlates with severe disease
defined by
☘ hypoxia
☘ poor response to therapy
☘ high relapse rate
 PEFR
☀ correlates well with the FEV1
☀ can be measured reliably with
inexpensive portable meters
☀ Each woman determines her own
baseline when asymptomatic—
personal best
❧ compared with values when
symptomatic
☀ PEFR did not change during the
course of pregnancy in normal
women.
 MANAGEMENT OF CHRONIC ASTHMA
⚜ Management Guidelines on Asthma &
Pregnancy:
 Objective assessment of pulmonary
function & fetal well being
 monitor with PEFR or FEV1
 Environmental precipitating factors
 Avoidance or control of triggers
 Pharmacological drugs
 to provide baseline control and treat
exacerbations
 Patient education
 general asthma management and its
effect on pregnancy
⚜ women with moderate to severe asthma
 should measure and record either their
FEV1 or PEFR twice daily
 FEV1
☀ Ideally >80 percent of predicted.
 PEFR
☀ predicted values range from 380 to
550 L/min
☀ Each woman has her own baseline
value, & therapeutic adjustments
can be made using this
⚜ Treatment depends on the severity of disease
 β-agonists
 help to abate bronchospasm
 corticosteroids
 treat the inflammatory component
 For mild asthma
 inhaled β-agonists
☀ as needed are usually sufficient
 For persistent asthma
 inhaled corticosteroids
☀ administered every 3 to 4 hours.
☀ Goal:
❧ to  the use of β-agonists for
symptomatic relief
☀  hospitalizations by 80 percent
 55%  in readmissions for severe
exacerbations in pregnant asthmatics
given maintenance inhaled
corticosteroids along with β-agonist
therapy
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STEPWISE THERAPY OF CHRONIC ASTHMA DURING PREGNANCY
SEVERITY STEPWISE THERAPY
MILD INTERMITTENT Inhaled β-agonists (ALBUTEROL) as needed
Low-dose inhaled corticosteroids
(BUDESONIDE)
MILD PERSISTENT
ALTERNATIVE: Cromolyn, leukotriene
antagonists, or theophylline
Low-dose inhaled corticosteroids and long-
acting β-agonists (SALMETEROL) or
medium-dose inhaled steroids and long-
MODERATE PERSISTENT acting β-agonist if needed
Alternative—low-dose (or medium if
needed) inhaled steroids and either
theophylline or leukotriene antagonists
High-dose inhaled corticosteroids and long-
acting β-agonist and oral steroids if needed
SEVERE PERSISTENT ALTERNATIVE: high-dose inhaled
corticosteroids and theophylline and oral
steroids
⚜ ALTERNATIVE DRUGS
 Theophylline
 Methylxanthine
 bronchodilators and possibly anti-
inflammatory agents
 used less frequently since inhaled
corticosteroids became available
 Some theophylline derivatives are
considered useful for oral maintenance
therapy if the initial response is not
optimal to inhaled corticosteroids and
β-agonists
 Leukotriene modifiers
 inhibit their synthesis and include
☀ zileuton
☀ zafirinkast
☀ montelukast
 given orally or by inhalation for
prevention
☀ not effective for acute disease
 For maintenance
☀ used in conjunction with inhaled
corticosteroids to allow minimal
dosing
 not as effective as inhaled
corticosteroids
 Cromolyn and nedocromil
 inhibit mast cell degranulation
 ineffective for acute asthma
 taken chronically for prevention
 not as effective as inhaled
corticosteroids
 been replaced by leukotriene modifiers
 omalizumab
 no experience in pregnant women
 a recombinant humanized monoclonal
anti-IgE antibody
 binds circulating IgE to deactivate it
 MANAGEMENT OF ACUTE ASTHMA
⚜ Similar to that for the nonpregnant asthmatic
 Except for those w/ lowered threshold for
hospitalization
⚜ Intravenous hydration may help clear
pulmonary secretions
⚜ Supplemental oxygen is given by mask
⚜ THERAPEUTIC AIM:
 Maintain the pO2 > 60 mm Hg to NORMAL
with 95-% oxygen saturation
⚜ Baseline pulmonary function testing:
 Includes FEV1 or PEFR
⚜ Continuous pulse oximetry and electronic fetal
monitoring

SECTION VIII: MEDICAL & SURGICAL COMPLICATIONS
⚜ First-line therapy
 β-adrenergic agonist
 given SQ, oral or inhaled
 EXAMPLES
☀ Terbutaline
☀ Albuterol
☀ Isoetharine
☀ Epinephrine
☀ Isoproterenol
☀ Metaproterenol
 bind to specific cell-surface receptors
 activate adenylyl cyclase 
intracellular cyclic AMP  modulate
bronchial smooth muscle relaxation
 Long-acting preparations are used for
outpatient therapy
 Maintenance drug
 Inhaled corticosteroids  intensive β-
agonist therapy
 For Severe exacerbations:
 Inhaled Ipratropium Bromide is given
 Corticosteroids
☀ should be given early to all
patients with severe acute asthma
☀ Given orally or parenteral
☀ IV methylprednisolone
❧ 40 to 60 mg, every 6 hours
☀ Hydrocortisone by infusion
☀ Prednisone orally.
☀ Give along w/ beta agonists for
acute asthma
☀ onset of action is several hours
 For acute asthma
 Corticosteroids β-agonists
⚜ If initial therapy with β-agonists is a/w
improvement of FEV1 or PEFR >70 % of baseline
 discharge can be considered
 Some may benefit from observation.
⚜ for the woman with obvious respiratory distress,
or if the FEV1 or PEFR <70% of predicted after
three doses of β-agonist
 admission is advisable
 Intensive therapy includes
 inhaled β-agonists
 intravenous corticosteroids
 close observation for worsening
respiratory distress or fatigue in
breathing
 woman is cared for in the delivery unit or an
intermediate or intensive care unit
 STATUS ASTHMATICUS AND RESPIRATORY FAILURE
⚜ Severe asthma of any type NOT responding after
30 to 60 minutes of intensive therapy
⚜ Managed in ICU
⚜ Management of nonpregnant patients in an
intensive care setting  good outcome in most
cases
⚜ Consider Early intubation when maternal
respiratory status worsens despite aggressive
treatment
 Indications for mechanical ventilation:
 Fatigue
 Carbon dioxide retention
 Hypoxemia
 LABOR & DELIVERY
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⚜ Maintenance medications are continued
through delivery
⚜ Give anesthesia preferably EPIDURAL
ANESTHESIA
⚜ Stress-dose corticosteroids
 administered with systemic steroid therapy
within the preceding 4 weeks
 Usual dose is 100 mg of HYDROCORTISONE
IV q 8 hours during labor and for 24 hours
after delivery
⚜ PEFR or FEV1
 determined on admission
 serial measurements taken
⚜ Oxytocin or prostaglandins E1 or E2
 Used for cervical ripening and induction of
labor
⚜ Fentanyl:
 Nonhistamine-releasing narcotic
 May be preferable to meperidine for labor,
and epidural analgesia is ideal
⚜ Conduction analgesia
 For surgical delivery
 preferred because tracheal intubation can
trigger severe bronchospasm
⚜ Postpartum hemorrhage
 Treated with oxytocin or prostaglandin E2.
 Prostaglandin F2α or ergotamine derivatives
 CONTRAINDICATED
 may cause significant bronchospasm
Acute Bronchitis
Infection of the large airways
MANIFESTATION
 cough without pneumonitis
common in adults, especially in winter months
Infections are usually caused by viruses commonly:
 influenza A and B
 parainfluenza
 respiratory syncytial
 coronavirus
 adenovirus
 rhinovirus
Bacterial agents causing community-acquired pneumonia
are rarely implicated.
cough
 persists for 10 to 20 days (mean 18 days)
 occasionally lasts for a month or longer
routine antibiotic treatment is not justified
Pneumonia
TYPES OF PNA
 Community Acquired PNA
⚜ encountered in otherwise healthy young
women, including during pregnancy
⚜ relatively common in pregnant women
⚜ caused by a number of bacterial or viral
pathogens
 Healthcare-Associated PNA
⚜ in patients in outpatient care facilities
⚜ more closely resembles hospital-acquired
pneumonia (HAP)
 nursinghome-acquired pneumonia (NHAO)
 ventilator-associated pneumonia (VAP).
accounts for 4.2% of antepartum admissions for
nonobstetrical complications
Mortality from pneumonia
 infrequent in young women
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 during pregnancy severe pneumonitis with ⚜ Outpatient or 23-hour observation is reasonable

appreciable loss of ventilatory capacity is not as well if home care & follow up are optimal
tolerated
 Hypoxemia and acidosis
⚜ poorly tolerated by the fetus
⚜ frequently stimulate preterm labor after
midpregnancy. B
⚜ worsening or persistence of symptoms may
represent developing pneumonia.
 Any pregnant woman suspected of having
pneumonia should undergo chest radiography.
BACTERIAL PNEUMONIA
 Many bacteria that cause community-acquired
pneumonia, such as Streptococcus pneumoniae, are
part of the normal resident flora
 Some Factors that perturb the symbiotic relationship
b/w colonizing bacteria and mucosal phagocytic
defenses include
⚜ acquisition of a virulent strain
⚜ bacterial infections following a viral infection
 Cigarette smoking and chronic bronchitis favor
colonization of:
⚜ S. pneumonia CHEST RADIOGRAPHS in a pregnant woman with RIGHT LOWER LOBE
PNEUMONIA. A. Complete opacification of the right lower lobe (arrows)
⚜ Haemophilus influenza is consistent with the clinical suspicion of pneumonia
⚜ Legionella species
 Risk factors include: CRITERIA FOR SEVERE COMMUNITY ACQUIRED PNEUMONIA
⚜ Asthma CRITERIA VALUES
⚜ binge drinking RESPIRATORY RATE ≥30/min
⚜ human immunodeficiency virus (HIV) infection PaO2/FiO2 ratio ≤250
 INCIDENCE AND CAUSES LUNG INFILTRATES MULTILOBULAR infiltrates
⚜ Pregnancy itself DOES NOT predispose to LEVEL OF CONSCIOUSNESS Confusion/disorientation
pneumonia UREMIA UREMIA
⚜ Hospitalization for pneumonia to be 1.5 per Leukopenia—WBC <4000/µL
1000 deliveries CBC Thrombocytopenia—platelets
<100,000/µL
⚜ > 50% of adult PNA are bacterial
TEMPERATURE Hypothermia—core temperature <36°C
⚜ 75% of the Causes of PNA are:
Hypotension requiring aggressive fluid
 S. pneumoniae (37%) BLOOD PRESSURE
resuscitation
 most common bacterial & overall cause
of PNA ⚜ If w/ SEVERE PNA
 AKA: Pneumococci  admission to an intensive care or
 Influenza A (14%) intermediate care unit is advisable
 MC viral cause of PNA  common cause of acute respiratory distress
 Chlamydophila pneumonia (10%) syndrome during pregnancy
 H. Influenza (5%)  mechanical ventilation maybe necessary
 Mycoplasma pneumoniae (2%) ⚜ Antimicrobial treatment is empirical
 Legionella pneumophila (2%)  MOST ADULT PNA are caused by
⚜ CA-MRSA  Pneumococci
 Cause Necrotizing pneumonia  Mycoplasma
 DIAGNOSIS  Chlamydophilia
⚜ Typical Symptoms include:  Monotherapy initially is with a MACROLIDE:
 Cough  Azithromycin
 Dyspnea  Clarithromycin
 Sputum production  Erythromycin
 Pleuritic chest pain ☀ Given intravenously and then
⚜ Mild upper respiratory symptoms and malaise orally, was effective in 99% of
 Precededs above symptoms women w/ uncomplicated PNA
⚜ Diagnostic Tests  If w/ SEVERE disease:
 CBC:  Respiratory Fluoroquinolone
 Mild leukocytosis ☀ DRUGS
 Chest radiography
❧ Levofloxacin
 Essential to establish dx & help monitor
disease ❧ Moxifloxacin
 Does not accurately predict etiology ❧ Gemifloxacin
⚜ Other Recommended Tests ☀ Teratogenicity risk: LOW
 Rapid Serological Testing (RAST) ❧ given if indicated
 Test for Influenza A & B  β-Lactam + Macrolide
 MANAGEMENT ☀ Preferred β-Lactams:
⚜ Hospitalize all pregnant women w/ ❧ high-dose amoxicillin
radiographically proven PNA ❧ amoxicillin-clavulanate

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☀ Alternatives for MACROLIDE

resistant Pneumococci (25%)
❧ Ceftriaxone
❧ Cefpodoxime
❧ Cefuroxime
❧ Levofloxacin
 CA-MRSA
  vancomycin
⚜ RESOLUTION OF PNA
 Clinical improvement is usually evident in
48 to 72 hours
 Resolution of fever in 2 to 4 days
 Resolution of X-ray abnormalities takes up
to 6 weeks
⚜ Worsening disease
 poor prognostic feature
 follow-up radiography is recommended
if fever persists
 20% of women develop a pleural effusion
⚜ FACTOR that increase the risk of death or
complications w/ CA PNA CHEST RADIOGRAPH of a 30-week pregnant woman with INFLUENZA A
PNEUMONIA. Extensive right lower lung field opacification (arrows),
 Coexisting chronic conditions
which represents parenchymal infiltrate and pleural effusion, obscures
 Clinical Findings the right hemidiaphragm
 RR > 30
 Hypotension
 quickly infects ciliated columnar
 Tachycardia: PR > 125 bpm
 Hypothermia epithelium, alveolar cells, mucus gland
 Temp <36ᵒC or > 40ᵒC cells, and macrophages
 ALOC  ONSET
 Extrapulmonary dse ⚜ 1-4 days after exposure
 LABS  FLU shots recommended in pregnancy
 Leukopenia or leukocytosis  Infection is self-limited
 PREGNANCY OUTCOME  PRIMARY INFLUENZA PNEUMONITIS
rd
⚜ Without antibiotics, 1/3 pregnant women with ⚜ Most severe
pneumonia died ⚜ CHARACTERISTICS
⚜ maternal mortality rate was 0.8 percent of 632  sparse sputum production
women.  radiographic interstitial infiltrates
⚜ 7% required intubation and mechanical  SECONDARY PNEUMONIA
ventilation. ⚜ More Common
⚜ COMMON COMPLICATIONS of PNA during ⚜ Develops from bacterial superinfection by
Pregnancy: Streptococci or Staphylococci after 2 to 3 days
 Prematurely ruptured membranes of initial clinical improvement
 Preterm delivery  MANAGEMENT
 low-birthweight infants ⚜ RECOMMENDED for UNCOMPLICATED PNA
 PREVENTION  Supportive treatment
⚜ Pneumococcal vaccine  Antipyretics
 60-70% protective against its 23 serotypes  Bed rest
  Emergence of drug-resistant ⚜ influenza A
pneumococci  H3N2 strains
 Not recommended for otherwise healthy  Has rapid resistance to
pregnant women ☀ AMANTADINE
 Recommended for: ☀ RIMANTADINE
 Immunocompromised  H1N1 strain
 HIV infection  Resistant to OSELTAMIVIR
 Significant smoking history ⚜ DRUGs for CHEMOPROPHYLAXIS & TREATMENT
 Diabetes  Neuraminidase inhibitors
 Cardiac, pulmonary, or renal disease  given within 2 days of symptoms onset
 Asplenia (sickle-cell disease)  for influenza A and B infection
INFLUENZA PNEUMONIA  MOA
 Respiratory infection ☀ interfere with the release of
⚜ PNEUMONITIS progeny virus from infected host
 PNA cells and thus prevent infection of
 MC complication new host cells
 Caused by RNA viruses of which influenza A and B  Effective for early influenza
form one genus  DRUGS
⚜ Influenza A ☀ Oseltamivir
 Serious, epidemic in winter months ❧ oral, 75 mg BID
 MOA ☀ Zanamivir
⚜ aerosolized droplets ❧ inhalation, 10 mg BID

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
shorten the course of illness by 1 to 2  Should NOT BE GIVEN to women who may
days become pregnant during the month
 may reduce the risk for pneumonitis following each vaccine dose
 PREVENTION  Attenuated vaccine virus is not secreted in
⚜ Vaccination for influenza A breast milk
⚜ Prenatal vaccination affords protection for a  Postpartum vaccination MUST NOT be
third of infants for at least 6 months delayed
 EFFECTS ON PREGNANCY FUNGAL & PARASITIC PNA
⚜ Severe viral pneumonitis is life-threatening  Greatest consequence in immunocompromised
during pregnancy hosts, especially in women with acquired
 FETAL EFFECTS: immunodeficiency syndrome (AIDS).
⚜ No firm evidence causes congenital  Pneumocystis Pneumonia
malformations ⚜ Lung infection with Pneumocystis jiroveci
⚜ Increased neural-tube defects in neonates  aka Pneumocystis carinii
(possibly associated with early hyperthermia) ⚜ Common complication in women with AIDS
⚜ May predispose to schizophrenia in later life ⚜ Causes INTERSTITIAL PNA characterized by:
VARICELLA PNEUMONIA  Dry cough
 AGENT  Tachypnea
⚜ Varicella Zoster Virus  Dyspnea
 Double-stranded DNA herpesvirus  Diffuse radiographic infiltrates
 Attack rate in seronegative individual is 90% ⚜ Management:
 PRIMARY INFECTION  Trimethoprim-sulfamethoxazole
 Chickenpox or Varicella  Pentamidine
☀ CLINICAL MANIFESTATIONS  Tracheal intubation and mechanical
ventilation
❧ 1- to 2-day flulike prodrome
⚜ Prophylaxis
❧ pruritic maculopapular
 Double-strength TRIMETHOPRIM-
vesicular lesions that crust
SULFAMETHOXAZOLE tablet
over in 3 to 7 days
 daily for some HIV-infected pregnant
☀ MORTALITY d/t Varicella PNA women
❧ More severe in adulthood  Fungal Pneumonia
especially during pregnancy ⚜ Usually seen in women with HIV infection
 10% of Pregnancy PNA ⚜ Who are otherwise immunocompromised
 Risk of developing PNA ⚜ Organisms:
⚜ Smoking  Histoplasmosis & Blastomycosis
⚜ >100 skin lesions  not common
 Clinical Manifestations:  more severe during pregnancy
⚜ Symptoms of pneumonia (appear 3 to 5 days)  (+) erythema nodosum
characterized: ☀ symptomatic infection
 Fever, tachypnea, dry cough, dyspnea, and
☀ better overall prognosis
pleuritic pain
 Cryptococcosis
 Nodular infiltrates are similar to other viral
 manifest as MENINGITIS
pneumonias
⚜ Management:
 Fever and compromised pulmonary
 ITRACONAZOLE
function may persist for weeks
 PREFERRED therapy for disseminated
 Diagnosis:
fungal infections
⚜ Performing a Tzanck smear
 INTRAVENOUS AMPHOTERICIN B OR
 Fetal and Neonatal Varicella Infection:
KETOCONAZOLE
⚜ Fetus may develop Congenital Varicella
 Amphotericin B
Syndrome
☀ used extensively in pregnancy with
 Chorioretinitis
no embryo-fetal effects
 Microphthalmia
 FLUCONAZOLE, ITRACONAZOLE, AND
 Cerebral cortical atrophy
KETOCONAZOLE
 Growth restriction
 embryotoxic in large doses in early
 Hydronephrosis
pregnancy
 Skin or bone defects
 ITRACONAZOLE
 Management
⚜ Supportive care ☀ reasonable later in pregnancy
⚜ Intravenous ACYCLOVIR therapy
 For Invasive candidiasis
2
 500 mg/m or 10 to 15 mg/kg every 8 hours  CASPOFUNGIN, MICAFUNGIN, AND
⚜ Serious maternal infection w/sepsis of varicella
ANIDULAFUNGIN
PNA is a/w PRETERM DELIVERY ☀ Embryotoxic and teratogenic in
 VACCINATION laboratory animals
⚜ Attenuated live-virus vaccine—VARIVAX SEVERE ACUTE RESPIRATORY DISTRESS SYNDROME
 2 doses, given 4 to 8 weeks apart  CORONAVIRUS respiratory infection
 recommended for adolescents and adults  ATYPICAL Pneumonitis
with no history of varicella  case-fatality rate :
 NOT RECOMMENDED for pregnant women ⚜ NONPREGNANT: ~ 5%
⚜ PREGNANT: 25%

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2012

 PLACENTAL EFFECT: ⚜ Cycloserine

⚜ abnormal intervillous or subchorionic fibrin ⚜ Para-aminosalicylic acid
deposition TUBERCULOSIS AND PREGNANCY
⚜ extensive fetal thrombotic vasculopathy  OUTCOMES
⚜ dependent on the site of infection and timing of
Tuberculosis diagnosis in relation to delivery
MOT  active pulmonary tuberculosis associated with
 inhalation of Mycobacterium tuberculosis incidences:
⚜ incites a granulomatous pulmonary reaction ⚜ preterm delivery: 2x
In 90% of patients, infection contained and dormant for ⚜ low-birthweight: 2x
long periods ⚜ growth-restricted infants
 reactivated in IMMUNOCOMROMISED patients ⚜ perinatal mortality: 6x
MANIFESTATIONS:
⚜ Preeclampsia: 2x
 Cough with minimal sputum production
 Adverse outcomes correlate with
 Low-grade fever
 Hemoptysis ⚜ Late diagnosis
 Weight loss. ⚜ Incomplete or irregular treatment
 Mediastinal lymphadenopathy ⚜ Advanced pulmonary lesions
LABORATORY FINDINGS  CDC GUIDELINES FOR TB
 Culture ⚜ SKIN TESTING of pregnant women who are in
⚜ Ziehl-Neelsen acid-fast staining any of the high-risk groups
 (+) Acid Fast Bacilli on stained smears of  Purified Protein Derivative (PPD)
sputum  preferred antigen
 Chest radiograph  intermediate strength of 5 tuberculin
⚜ Variety of infiltrative pattern units.
 intracutaneously applied
⚜ Cavitation
 If NEGATIVE
EXTRAPULMONARY TB
 Middle ear ☀ no further evaluation is needed.
 Tonsils  IF POSITIVE
 Lungs ☀ (+) skin test measures > 5 mm in
 Pericardium diameter
 CNS ☀ requires evaluation for active
 Bones, spine, psoas mm disease, including a chest
 Pelvic TB radiograph
⚜ Common ☀ VERY HIGH-RISK patients:
⚜ Amenorrhea, ascites, adhesions ❧ HIV-positive
 Intestine ❧ abnormal chest radiography
 Genitals ❧ recent contact with an active
⚜ especially epididymis case— > 5 mm
 Liver,spleen, peritoneum, ☀ HIGH RISK patients
 Adrenal glands ❧ Foreign-born individuals
 Ureter ❧ intravenous drug users who
 Bladder are HIV-negative
 Adnexa
❧ low-income populations
 Prostate, seminal vesicles
❧ medical conditions that
MILIARY TB
increase the risk for
 40%of affected HIV-positive patients have
tuberculosis— >10 mm
disseminated disease
TREATMENT ☀ For persons with no risk factors but
 Cure rates with 6-month short-course DIRECTLY w/ > 15 mm or greater is defined
OBSERVED THERAPY (DOT) as requiring treatment
 Multidrug-resistant tuberculosis (MDR-TB)
⚜  rapidly as TB incidence fell during the 1990s
FOUR-DRUG REGIMEN for initial empirical treatment:
 Isoniazid
 Rifampin
 Pyrazinamide
 Ethambutol
Extensively Drug-Resistant Tuberculosis—XDR-TB
st
 Resistance in vitro to at least the 1 -line drugs
⚜ Isoniazid
⚜ Rifampin
ND
 Resistance to >3 of the 6 main classes of 2 -LINE
DRUGS
⚜ Aminoglycosides
⚜ Polypeptides
⚜ Fluoroquinolones
⚜ Thioamides

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SECTION VIII: MEDICAL & SURGICAL COMPLICATIONS
2012

⚜ In Vitro Quantiferon-TB Gold Test NEONATAL TUBERCULOSIS

 same indications as skin testing  Tubercular bacillemia can infect the
 useful in identifying patients with latent ⚜ Placenta
TB and at risk for progression to active ⚜ Fetus
disease.  Congenital Tuberculosis
 distinguish between immune responses  d/t aspiration of infected secretions at
delivery
due to infection and responses resulting
 simulates other congenital infections
from bacille Calmette-Guérin (BCG)  MANIFESTATIONS
vaccination ☀ Hepatosplenomegaly
 TREATMENT
☀ respiratory distress
⚜ Principles are similar in pregnant & nonpregnant
☀ fever
 except STREPTOMYCIN NOT ALLOWED in
pregnancy ☀ lymphadenopathy
 unlikely if the mother with active disease has been
⚜ LATENT INFECTION
treated before delivery or if her sputum culture is
 ISONIAZID:
negative
 For Nonpregnant; (+) Tuberculin; < 35
 recommend isolation from the mother suspected of
Years; (-) Evidence Of Active Disease
having active disease
☀ 300 mg orally daily for 1 year
⚜ contradicts EINT
 Considered safe in pregnancy st
 After delivery, NORMALLY, the 1 thing you
 COMPLIANCE is a major problem
is do place the baby on top on mother’s
 Delayed administration until after
chest w/ baby wrapped & dried,
delivery:
 wait for the cord to stop pulsating (around
☀ For possibly increased isoniazid- 2 minutes) before clamping
induced hepatitis risk in  Allows more blood to flow to baby
postpartum women  After 2 mintues, double clamp & cut
☀ Withholding treatment until 3 to 6 umbilical cord
months after delivery  Wait for the baby to crawl & look for nipple
☀ Exceptions to delayed treatment in & latch naturally
pregnancy:  Occurs ~ 20-30 minutes after delivery
❧ Known recent skin-test ⚜ So if mother is w/ tuberculosis
convertors  Recommend to still follow EINT but
❧ Skin-test-positive women MOTHER MUST WEAR MASK FIRST
exposed to active infection  If untreated, the risk of disease in the infant
❧ HIV-positive women born to a woman with active infection is
⚜ ACTIVE INFECTION 50% in the first year
 Recommended initial treatment:
 Three-drug regimen
☀ ISONIAZID
☀ RIFAMPIN
☀ ETHAMBUTOL
 Prevalence of isoniazid-resistant
tuberculosis
☀  PYRAZINAMIDE
 If organism is susceptible:
☀ Regimen is given for 9 months
 Breast feeding is not prohibited
 To decrease hepatic toxicity:
 ISONIAZID  PYRIDOXINE (25 mg/day
orally)
 HIV-INFECTED WOMEN:
 Rifampin or Rifabutin
☀ CONTRAINDICATED If certain
protease inhibitors or non-
nucleoside reverse transcriptase
inhibitors are being administered
 Resistance to rifabutin or rifampin:
☀ Pyrazinamide therapy is given
 Second-line regimens
 CONTRAINDICATED
 ototoxic to the fetus
 Aminoglycosides
☀ Streptomycin
☀ Kanamycin
☀ Amikacin
☀ Capreomycin

10 Williams Obstetrics 23rd Edition