Pulmonary Disorders in Pregnancy
ASTHMA
ACUTE BRONCHITIS
PNEUMONIA
BACTERIAL PNEUMONIA
INFLUENZA PNEUMONIA
TUBERCULOSIS
SARCOIDOSIS
CYSTIC FIBROSIS
CARBON MONOXIDE POISONING
Chronic asthma or an acute exacerbation is the most common
Affects up to 4% of pregnant women.
These disorders along with community-acquired pneumonia accounted for
almost 10% of non-obstetrical hospitalizations in one managed care plan
Pneumonia is also a frequent complication requiring readmission postpartum
Pregnant women, especially those in the last trimester, do not appear to tolerate
severe acute pneumonitis as evidenced by the disparate number of maternal
deaths during the 1918 and 1957 influenza pandemics.
Lung volumes and capacities that are measured directly to assess pulmonary
pathophysiology may be significantly altered.
These change gas concentrations and acid-base values in blood.
Some of the physiological alterations induced by pregnancy
1) Vital capacity and inspiratory capacity increase by approximately 20% by
late pregnancy.
2) Expiratory reserve volume decreases from 1300 mL to approximately
1100 mL.
3) Tidal volume increases approximately 40% as a result of respiratory
stimulation by progesterone.
4) Minute ventilation increases 30-40% due to increased tidal volume.
As a result, arterial Po2 increases from 100 to 105 mm Hg.
5) Increasing metabolic demands cause a 30% increase in carbon dioxide
production, but because of its concomitantly increased diffusion capacity
along with hyperventilation, the arterial Pco2 decreases from 40 to 32 mm
Hg.
6) Residual volume decreases approximately 20% from 1500 mL to
approximately 1200 mL.
7) Chest wall compliance is reduced by a third by the expanding uterus and
increased abdominal pressure, which causes a 10-25% decrease in
Functional Residual Capacity
Sum of expiratory reserve and residual volumes.
The end result of these pregnancy-induced changes is substantively increased
ventilation due to deeper but not more frequent breathing.
Stimulated by basal oxygen consumption as it increases incrementally
from 20 to 40 mL/min in the second half of pregnancy.
ASTHMA
Seen frequently in young women and therefore often complicates pregnancy
Prevalence increased steadily in many countries beginning in the mid-1970s but
may have plateaued in the United States, with a prevalence in adults of
approximately 10%
Estimated asthma prevalence during pregnancy ranges between 4-8%,
and this appears to be increasing
Evidence is accruing that fetal as well as neonatal environmental exposures
may contribute to the origins of asthma in certain individuals
Pathophysiology
Asthma is a chronic inflammatory airway syndrome with a major hereditary
component.
Increased airway responsiveness and persistent subacute inflammation
Have been associated with genes on chromosomes 5q that include cytokine
gene clusters, -adrenergic and glucocorticoid receptor genes, and the T-cell
antigen receptor gene
Asthma is heterogeneous, and there inevitably is an environmental allergic
stimulant such as influenza or cigarette smoke in susceptible individuals
Hallmarks of asthma are
Reversible airway obstruction from bronchial smooth muscle contraction
Vascular congestion
Tenacious mucus
Mucosal edema
There is mucosal infiltration with eosinophils, mast cells, and T lymphocytes that
causes airway inflammation and increased responsiveness to numerous stimuli
including irritants, viral infections, aspirin, cold air, and exercise.
Rem Alfelor Chapter 51: Pulmonary Disorders in Pregnancy
Several inflammatory mediators produced by these and other cells include
histamine, leukotrienes, prostaglandins, cytokines, and many others.
IgE also plays a central role in pathophysiology
Because F-series prostaglandins and ergonovine exacerbate asthma, these
commonly used obstetrical drugs should be avoided if possible.
Clinical Course
Asthma findings range from mild wheezing to severe bronchoconstriction, which
obstructs airways and decreases airflow. These reduce the forced expiratory
volume in 1 second (FEV1)/forced vital capacity (FVC) ratio and the peak
expiratory flow (PEF).
Work of breathing progressively increases
Patients note chest tightness, wheezing, or breathlessness. Subsequent
alterations in oxygenation primarily reflect ventilationperfusion mismatching,
because the distribution of airway narrowing is uneven.
With persistent or worsening bronchial obstruction, stages progress
Hypoxia initially is well augmented by hyperventilation, which maintains arterial
Po2 within a normal range while causing the Pco2 to decrease with resultant
respiratory alkalosis.
As airway narrowing worsens, ventilationperfusion defects increase, and
arterial hypoxemia ensues.
With severe obstruction, ventilation becomes impaired as fatigue causes early
CO2 retention.
Because of hyperventilation, this may only be seen initially as an arterial
Pco2 returning to the normal range.
With continuing obstruction, respiratory failure follows from fatigue.
Although these changes are generally reversible and well tolerated by the
healthy nonpregnant individual, even early asthma stages may be dangerous for
the pregnant woman and her fetus.
This is because smaller functional residual capacity and increased
pulmonary shunting render the woman more susceptible to hypoxia and
hypoxemia.
Effects of Pregnancy on Asthma
There is no evidence that pregnancy has a predictable effect on underlying
asthma.
Exacerbations are more common with severe disease
Baseline severity correlated with asthma morbidity during pregnancy.
With mild disease, 13% of women had an exacerbation and 2.3% required
admission; with moderate disease, these numbers were 26 and 7 %; and
for severe asthma, 52 and 27%
Disparate morbidity in black compared with white women.
Some women have asthma exacerbations during labor and delivery.
Up to 20% of women with mild or moderate asthma have been reported to have
an intrapartum exacerbation
Exacerbations at the time of delivery in only 1% of women
18-fold increased exacerbation risk following cesarean versus vaginal delivery.
Pregnancy Outcome
Women with asthma have had improved pregnancy outcomes during the past
20 years.
Unless disease is severe, pregnancy outcomes are generally excellent
Incidence of spontaneous abortion in women with asthma may be slightly
increased
Some, but not all, incidences of preeclampsia, preterm labor, growth-restricted
infants, and perinatal mortality are slightly increased small rise in the incidence
of placental abruption and in preterm rupture of membranes
Risks for most obstetrical complications were not increased
Inhaled-corticosteroid dosage was quantified and found a non-significant trend
between perinatal complications and increasing dosage.
They concluded that low to moderate doses were not associated with
perinatal risks and noted that more data were needed regarding higher
doses.
Thus, there appears to be significantly increased morbidity linked to
severe disease, poor control, or both.
Delivery before 37 weeks gestation was not increased among the 1687
pregnancies of asthmatics compared with those of 881 controls
But for women with severe asthma, the rate was increased approximately
twofold.
Women with moderate to severe asthma, regardless of treatment, are at
increased risk of preeclampsia.
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 Direct relationship of baseline pregnancy forced expiratory volume at 1 second
(FEV1) with birthweight and an 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
With reasonable asthma control, perinatal outcomes are generally good.
There were no significant adverse neonatal sequelae from asthma
When respiratory alkalosis develops, both animal and human studies suggest
that fetal hypoxemia develops well before the alkalosis compromises maternal
oxygenation
It is hypothesized that the fetus is jeopardized by decreased uterine blood
flow, decreased maternal venous return, and an alkaline-induced leftward
shift of the oxyhemoglobin dissociation curve.
Fetal response to maternal hypoxemia is decreased umbilical blood flow,
increased systemic and pulmonary vascular resistance, and decreased cardiac
output.
Incidence of fetal-growth restriction increases with asthma severity.
Fetus may be seriously compromised as asthma severity increases underscores
the need for aggressive management.
Monitoring the fetal response is, in effect, an indicator of maternal status.
Possible teratogenic or adverse fetal effects of drugs given to control asthma
have been a concern.
No evidence that commonly used anti-asthmatic drugs are harmful
13-54% patient-generated decrease in -agonist and corticosteroid use
between 5-13 weeks gestation.
Clinical Evaluation
Subjective severity of asthma frequently does not correlate with objective
measures of airway function or ventilation.
Clinical examination can also be an inaccurate predictor
Useful clinical signs include
Labored breathing
Tachycardia
Pulsus paradoxus
Prolonged expiration
Use of accessory muscles
Signs of a potentially fatal attack include central cyanosis and altered
consciousness.
Arterial blood gas analysis provides objective assessment of maternal
oxygenation, ventilation, and acid-base status
Routine arterial blood gas analysis did not help to manage most pregnant
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 is consistent with hyperventilation and
CO2 retention in a pregnant woman.
Pulmonary function testing should be routine in the management of chronic and
acute asthma.
Sequential measurement of the FEV1 or the peak expiratory flow rate
(PEFR) is the best measures of severity.
An FEV1 less than 1 L, or less than 20% of predicted value, correlates
with severe disease
Defined by hypoxia, poor response to therapy, and a high relapse
rate.
PEFR correlates well with the FEV1, and it can be measured reliably with
inexpensive portable meters.
Each woman determines her own baseline when asymptomatic (personal best)
to compare with values when symptomatic.
PEFR does not change during the course of normal pregnancy
Management of Chronic Asthma
The management guidelines of the Working Group on Asthma and Pregnancy include:
1) Patient education general asthma management and its effect on pregnancy
2) Environmental precipitating factors: avoidance or control.
Rem Alfelor Chapter 51: Pulmonary Disorders in Pregnancy
Viral infections including the common cold are frequent triggering events
Objective assessment of pulmonary function and fetal well-being monitor
with PEFR or FEV1
3) Pharmacological therapy: in appropriate combinations and doses to provide
baseline control and treat exacerbations.
Compliance may be a problem, and periodic medication reviews are
helpful
In general, women with moderate to severe asthma should measure and record
either their FEV1 or PEFR twice daily.
FEV1 ideally is > 80 percent of predicted.
For PEFR, predicted values range from 380- 550 L/min.
Each woman has her own baseline value, and therapeutic adjustments
can be made using this
Treatment depends on disease severity.
Although -agonists help to abate bronchospasm, corticosteroids treat the
inflammatory component
For mild asthma, inhaled -agonists as needed are usually sufficient.
For persistent asthma, inhaled corticosteroids are administered every 3-4
hours.
The goal is to reduce the use of -agonists for symptomatic relief.
Studies showed that inhaled corticosteroids reduced hospitalizations by
80%
55% reduction in readmissions for severe exacerbations in pregnant
asthmatics given maintenance inhaled corticosteroids along with -agonist
therapy.
Theophylline
A methylxanthine, and its various salts are bronchodilators and possibly
anti-inflammatory agents.
They have been used less frequently since inhaled corticosteroids
became available.
Some theophylline derivatives are considered useful for oral maintenance
therapy if the initial response to inhaled corticosteroids and -agonists is
not optimal
Anti-leukotrienes
Inhibit leukotriene synthesis
Include Zileuton, Zafirlukast, and Montelukast.
These drugs are given orally or by inhalation for prevention, but they are
not effective for acute disease.
For maintenance, they are used in conjunction with inhaled corticosteroids
to allow minimal dosing.
Approximately half of asthmatics will improve with these drugs
They are not as effective as inhaled corticosteroids
There is little experience with theiruse in pregnancy
Cromones
Include Cromolyn and Nedocromil
Inhibit mast cell degranulation.
Ineffective for acute asthma and are taken chronically for prevention.
They are not as effective as inhaled corticosteroids
Used primarily to treat childhood asthma.
Management of Acute Asthma
Treatment of acute asthma during pregnancy is similar to that for the
nonpregnant asthmatic
However, the threshold for hospitalization is significantly lowered.
Intravenous hydration may help clear pulmonary secretions, and supplemental
oxygen is given by mask
Therapeutic aim is to maintain the Po2 > 60 mm Hg, and preferably normal,
along with 95% oxygen saturation.
Baseline pulmonary function testing includes FEV1 or PEFR. Continuous pulse
oximetry and electronic fetal monitoring, depending on gestational age, may
provide useful information.
First-line therapy for acute asthma includes a
-adrenergic agonist: Terbutaline, Albuterol, Isoetharine, Epinephrine,
Isoproterenol, or Metaproterenol
Which is given subcutaneously, taken orally, or inhaled.
These drugs bind to specific cell-surface receptors and activate
adenylyl cyclase to increase intracellular cyclic AMP and modulate
bronchial smooth muscle relaxation.
Long-acting preparations are used for outpatient therapy.
If not previously given for maintenance, inhaled corticosteroids are
commenced along with intensive -agonist therapy.
For severe exacerbations, Magnesium Sulfate may prove efficacious.
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 Corticosteroids should be given early to all patients with severe acute asthma. Ventilator-Associated Pneumonia (VAP)
Unless there is a timely response to bronchodilator and inhaled Community-acquired pneumonia in pregnant women is relatively common
corticosteroid therapy, oral or parenteral corticosteroids are given Caused by several bacterial or viral pathogens
Intravenous Methylprednisolone, 40 to 60 mg, every 6 hours for four Pneumonia accounts for 4.2% of antepartum admissions for non-obstetrical
doses is commonly used. complications.
Equipotent doses of Hydrocortisone by infusion or Prednisone Also a frequent indication for postpartum readmission
orally can be given instead. During influenza season, admission rates for respiratory illnesses double
Because their onset of action is several hours, corticosteroids are given compared with rates in the remaining months
initially along with -agonists for acute asthma. Mortality from pneumonia is infrequent in young women
Further management depends on the response to therapy. During pregnancy severe pneumonitis with appreciable loss of ventilatory
If initial therapy with -agonists is associated with improvement of FEV1 or capacity is not as well tolerated
PEFR to above 70% of baseline, then discharge can be considered. Hold true regardless of the pneumonia etiology.
Some women may benefit from observation. Hypoxemia and acidosis are also poorly tolerated by the fetus and frequently
Alternatively, for the woman with obvious respiratory distress, or if the FEV1 or stimulate preterm labor after midpregnancy.
PEFR is < 70% of predicted after three doses of -agonist, admission is likely Because many cases of pneumonia follow viral upper respiratory illnesses,
advisable worsening or persistence of symptoms may represent developing pneumonia.
Intensive therapy includes inhaled - agonists, intravenous Any pregnant woman suspected of having pneumonia should undergo chest
corticosteroids, and close observation for worsening respiratory distress or
radiography.
fatigue in breathing
Woman is cared for in the delivery unit or an intermediate or intensive
care unit (ICU) Bacterial Pneumonia
Many bacteria that cause community-acquired pneumonia, such as
Status Asthmaticus and Respiratory Failure Streptococcus pneumoniae, are part of the normal resident flora
Severe asthma of any type not responding after 30-60 minutes of intensive Factors that perturb the symbiotic relationship between colonizing bacteria and
therapy is termed Status Asthmaticus mucosal phagocytic defenses include acquisition of a virulent strain or bacterial
Management of nonpregnant patients with status asthmaticus in an infections following a viral infection.
intensive care setting results in a good outcome in most cases. Cigarette smoking and chronic bronchitis favor colonization with S pneumoniae,
Consideration should be given to early intubation when maternal respiratory Haemophilus influenzae, and Legionella species.
status worsens despite aggressive treatment Other risk factors include
Fatigue, carbon dioxide retention, and hypoxemia are indications for mechanical Asthma
ventilation. Binge Drinking
Woman with status asthmaticus in whom cesarean delivery was necessary to Human Immunodeficiency Virus (HIV) Infection
effect ventilation
Incidence and Causes
Labor and Delivery Pregnancy itself does not predispose to pneumonia
For the laboring asthmatic, maintenance medications are continued through Antepartum hospitalization rate for pneumonia in Alberta, Canada, to be 1.5 per
delivery. 1000 deliveries
Stress-dose corticosteroids are administered to any woman given systemic Almost identical to the rate of 1.47 per 1000 for nonpregnant women.
corticosteroid therapy within the preceding 4 weeks. Incidence of 1.5 per 1000 for pneumonia complicating 75,000 pregnancies cared
Usual dose is 100 mg of Hydrocortisone given intravenously every 8 for at Parkland Hospital.
hours during labor and for 24 hours after delivery More than half of adult pneumonias are bacterial
PEFR or FEV1 should be determined on admission, and serial measurements S. pneumoniae is the most common cause
are taken if symptoms develop. Causative agent
Oxytocin or Prostaglandins E1 or E2 are used for cervical ripening and S pneumoniae 37%
induction. influenza A 14%
Non-histamine releasing narcotic such as Fentanyl may be preferable to Chlamydophila pneumoniae 10%
meperidine for labor, and epidural analgesia is ideal. H influenzae 5%
For surgical delivery, conduction analgesia is preferred because tracheal Mycoplasma pneumoniae 2%
intubation can trigger severe bronchospasm. Legionella pneumophila 2%
Postpartum hemorrhage is treated with Oxytocin or Prostaglandin E2.
Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA)
Prostaglandin F2 or ergotamine derivatives are contraindicated
has emerged as the second most common pathogen in non-pregnant adults
because they may cause significant bronchospasm. These staphylococci may cause necrotizing pneumonia

ACUTE BRONCHITIS
Diagnosis
Infection of the large airways is manifest by cough without pneumonitis.
Typical symptoms include cough, dyspnea, sputum production, and pleuritic
It is common in adults, especially in winter months.
chest pain.
Infections are usually caused by viruses influenza A and B, parainfluenza, Mild upper respiratory symptoms and malaise usually precede these symptoms,
respiratory syncytial, coronavirus, adenovirus, and rhinovirus are frequent and mild leukocytosis is usually present.
isolates Chest radiography is essential for diagnosis but does not accurately predict the
Bacterial agents causing community-acquired pneumonia are rarely implicated
etiology
Cough of acute bronchitis persists for 10-20 days (mean 18 days) Responsible pathogen is identified in fewer than half of cases.
Occasionally lasts for a month or longer. Tests to identify a specific agent are optional.
Routine antibiotic treatment is not justified Sputum cultures, serological testing, cold agglutinin identification, and
tests for bacterial antigens are not recommended
PNEUMONIA One exception to this is rapid serological testing for influenza A and
Community-Acquired Pneumonia (CAP) B
Typically encountered in otherwise healthy young women, including during Management
pregnancy. Although many otherwise healthy young adults can be safely treated as
Health-Care-Associated Pneumonia (HCAP) outpatients, at Parkland Hospital we hospitalize all pregnant women with
Develops in patients in outpatient care facilities and more closely radiographically proven pneumonia
resembles hospital-acquired pneumonia (HAP). Outpatient therapy or 23-hour observation is reasonable with optimal follow-up.
Other types are With severe disease, admission to an ICU or intermediate care unit is advisable.
Nursing Home-Acquired Pneumonia (NHAO)
Rem Alfelor Chapter 51: Pulmonary Disorders in Pregnancy Page 3 of 11
 Approximately 20% of pregnant women admitted to Parkland Hospital for Gynecologists, 2013). It is recommended for those who are
pneumonia require this level of care immunocompromised, including those
Severe pneumonia is a relatively common cause of acute respiratory distress
syndrome during pregnancy
with HIV infection; significant smoking history; diabetes; cardiac,
Mechanical ventilation may become necessary pulmonary, or renal disease; and
Antimicrobial treatment is empirical asplenia, such as with sickle-cell disease (Table 9-9, p. 185).
Because most adult pneumonias are caused by Pneumococci, Protection against pneumococcal
Mycoplasma, or Chlamydophila infection in women with chronic diseases may be less efficacious
Monotherapy initially is with a macrolide: Azithromycin, than in healthy patients (Moberley,
Clarithromycin, or Erythromycin. 2013).
Erythromycin monotherapy, given intravenously and then orally, was Influenza Pneumonia
effective in all but one of 99 pregnant women with uncomplicated
pneumonia. Clinical Presentation
For women with severe disease Influenza A and B are RNA viruses that cause respiratory infection,
1) Respiratory Fluoroquinolone: Levofloxacin, Moxifloxacin, or including pneumonitis. Influenza
Gemifloxacin pneumonia can be serious, and it is epidemic in the winter months.
2) Macrolide plus a -lactam: high-dose Amoxicillin or Amoxicillin-
Clavulanate, which are preferred -lactams.
The virus is spread by aerosolized
-lactam alternatives include Ceftriaxone, Cefpodoxime, or droplets and quickly infects ciliated columnar epithelium, alveolar
Cefuroxime. cells, mucus gland cells, and
In areas in which there is high-level resistance of pneumococcal macrophages. Disease onset is 1 to 4 days following exposure
isolates to macrolides, these latter regimens are preferred. (Longman, 2007). In most healthy adults, infection is self-limited.
Teratogenicity risk of fluoroquinolones is low, and these should be given if
indicated
Pneumonia is the most frequent complication of influenza, and it is
If Community Acquired Methicillin-Resistant S aureus is suspected, then difficult to distinguish from
Vancomycin or Linezolid are added bacterial pneumonia. According to the Centers for Disease Control
At this time, such therapy is empirical, and there are no tested regimens and Prevention (2010a), infected
against CA-MRSA pregnant women are more likely to be hospitalized as well as
Clinical improvement is usually evident in 48-72 hours with resolution of fever in
2-4 days.
admitted to an ICU. At Parkland
Radiographic abnormalities may take up to 6 weeks to completely resolve Hospital during the 2003 to 2004 influenza season, pneumonia
Worsening disease is a poor prognostic feature, and follow-up radiography is developed in 12 percent of pregnant
recommended if fever persists. women with influenza (Rogers, 2010). The 2009 influenza pandemic
Even with improvement, approximately 20% of women develop a pleural with the H1N1 strain was
effusion.
Pneumonia treatment is recommended for a minimum of 5 days.
particularly severe. In a Maternal-Fetal Medicine Units Network study,
Treatment failure may occur in up to 15% of cases 10 percent of pregnant or
Wider antimicrobial regimen and more extensive diagnostic testing are postpartum women admitted with H1N1 influenza were cared for in
warranted in these cases. an ICU, and 11 percent of these
ICU patients died (Varner, 2011). Risk factors included late
Pregnancy Outcome with Pneumonia pregnancy, smoking, and chronic
During the pre-antimicrobial era, as many as a third of pregnant hypertension. In California, 22 percent of H1N1-infected women
women with pneumonia died (Finland, required intensive care, and a third
1939). Although much improved, maternal and perinatal mortality of these died.
rates both remain formidable. In Primary influenza pneumonitis is the most severe and is
five studies published after 1990, the maternal mortality rate was 0.8 characterized by sparse sputum production
percent of 632 women. and radiographic interstitial infiltrates. More commonly, secondary
Importantly, almost 7 percent of the women required intubation and pneumonia develops from
mechanical ventilation. bacterial superinfection by streptococci or staphylococci after 2 to 3
Prematurely ruptured membranes and preterm delivery are frequent days of initial clinical
complications and have been improvement. The Centers for Disease Control and Prevention
reported in up to a third of cases (Getahun, 2007; Shariatzadeh, (2007b) reported several cases in
2006). Likely related are older which CA-MRSA caused influenza-associated pneumonitis with a
studies reporting a twofold increase in low-birthweight infants case-fatality rate of 25 percent.
(Sheffield, 2009). In a more recent Other possible adverse effects of influenza A and B on pregnancy
population-based study from Taiwan of nearly 219,000 births, there outcome are discussed in Chapter
were significantly increased 64 (p. 1241).
incidences of preterm and growth-restricted infants as well as Management
preeclampsia and cesarean delivery Supportive treatment with antipyretics and bed rest is recommended
(Chen, 2012). for uncomplicated influenza.
Prevention Early antiviral treatment has been shown to be effective (Jamieson,
Pneumococcal vaccine is 60- to 70-percent protective against its 23 2011). As discussed, influenza
included serotypes. Its use has hospitalizations for those with advanced pregnancy are increased
been shown to decrease emergence of drug-resistant pneumococci compared with nonpregnant women
(Kyaw, 2006). The vaccine is not (Dodds, 2007; Schanzer, 2007). Rapid resistance of influenza A
recommended for otherwise healthy pregnant women (American (H3N2) strains to amantadine or
College of Obstetricians and
Rem Alfelor Chapter 51: Pulmonary Disorders in Pregnancy Page 4 of 11
rimantadine in 2005 prompted the Centers for Disease Control and Experience with dapsone or atovaquone is limited. In some cases,
Prevention (2006) to recommend tracheal intubation and mechanical
against their use. Instead, neuraminidase inhibitors were given within ventilation may be required.
2 days of symptom onset for As prophylaxis, several international health agencies recommend
chemoprophylaxis and treatment of influenza A and B ( Chap. 64, p. one double-strength
1242). The drugs interfere with trimethoprim-sulfamethoxazole tablet orally daily for certain HIV-
release of progeny virus from infected host cells and thus prevent infected pregnant women. These
infection of new host cells include women with CD4+ T-lymphocyte counts < 200/L, those
(Moscona, 2005). Oseltamivir is given orally, 75 mg twice daily, or whose CD4+ T lymphocytes
zanamivir is given by inhalation, constitute less than 14 percent, or if there is an AIDS-defining illness,
10 mg twice daily. Recommended treatment duration with either is 5 particularly oropharyngeal
days. The drugs shorten the candidiasis (Centers for Disease Control and Prevention, 2013a;
course of illness by 1 to 2 days, and they may reduce the risk for Forna, 2006).
pneumonitis (Jamieson, 2011). Our Fungal Pneumonia
practice is to treat all pregnant women with influenza whether or not Any of a number of fungi can cause pneumonia. In pregnancy, this is
pneumonitis is identified. There usually seen in women with HIV
are few data regarding use of these agents in pregnant women, but infection or who are otherwise immunocompromised. Infection is
the drugs were not teratogenic in usually mild and self-limited. It is
animal studies and are considered low risk (Briggs, 2011). characterized initially by cough and fever, and dissemination is
Other concerns for viral resistance are for avian H5N1 and H7N9 infrequent.
strains isolated in Southeast Histoplasmosis and blastomycosis do not appear to be more
Asia. These are candidate viruses for an influenza pandemic with a common or more severe during
projected mortality rate that pregnancy. Data concerning coccidioidomycosis are conflicting
exceeds 50 percent (Beigi, 2007; World Health Organization, 2008). (Bercovitch, 2011; Patel, 2013). In a
Currently, international efforts case-control study from an endemic area, Rosenstein and coworkers
are being made to produce a vaccine effective against both strains. (2001) reported that pregnancy
Preventively, vaccination for influenza A is recommended and is was a significant risk factor for disseminated disease. In another
discussed in detail in Chapter 64 study, however, Caldwell and
(p. 1242). Prenatal vaccination also affords protection for a third of coworkers (2000) identified 32 serologically confirmed cases during
infants for at least 6 months pregnancy and documented
(Zaman, 2008). During the 20122013 flu season, the Centers for dissemination in only three cases. Arsura (1998) and Caldwell (2000)
Disease Control and Prevention and their associates reported
(2013b) reported that only half of pregnant women received the that pregnant women with symptomatic infection had a better overall
vaccine. Varicella Pneumonia prognosis if there was
Infection with varicella-zoster viruschicken poxresults in associated erythema nodosum. Crum and Ballon-Landa (2006)
pneumonitis in 5 percent of pregnant reviewed 80 cases of
women (Harger, 2002). Diagnosis and management are considered coccidioidomycosis complicating pregnancy. Almost all women
in Chapter 64 (p. 1240). diagnosed in the third trimester had
Fungal and Parasitic Pneumonia disseminated disease. Although the overall maternal mortality rate
Pneumocystis Pneumonia was 40 percent, it was only 20
Fungal and parasitic pulmonary infections are usually of greatest percent for 29 cases reported since 1973. Spinello (2007) and
consequence in Bercovitch (2011), with their
immunocompromised hosts, especially in women with acquired associates, have provided reviews of coccidioidomycosis in
immunodeficiency syndrome (AIDS). pregnancy Most cases of cryptococcosis reported during pregnancy
Of these, lung infection with Pneumocystis jiroveci, formerly called have been reported to manifest as
Pneumocystis carinii, is a meningitis. Ely and colleagues (1998) described four otherwise
common complication in women with AIDS. The opportunistic fungus healthy pregnant women with
causes interstitial pneumonia cryptococcal pneumonia. Diagnosis is difficult because clinical
characterized by dry cough, tachypnea, dyspnea, and diffuse presentation is similar to that of other
radiographic infiltrates. Although this community-acquired pneumonias.
organism can be identified by sputum culture, bronchoscopy with The 2007 IDSA/ATS guidelines recommend itraconazole as preferred
lavage or biopsy may be necessary. therapy for disseminated
In a report from the AIDS Clinical Trials Centers, Stratton and fungal infections (Mandell, 2007). Pregnant women have also been
colleagues (1992) described given intravenous amphotericin B
pneumocystis pneumonia as the most frequent HIV-related disorder o r ketoconazole (Hooper, 2007; Paranyuk, 2006). Amphotericin B
in pregnant women. Ahmad and has been used extensively in
coworkers (2001) reviewed 22 cases during pregnancy and cited a pregnancy with no embryo-fetal effects. Because of evidence that
50-percent mortality rate. fluconazole, itraconazole, and
Treatment is with trimethoprim-sulfamethoxazole or the more toxic ketoconazole may be embryotoxic in large doses in early pregnancy,
pentamidine (Walzer, 2005). Briggs and associates (2011)
recommend that first-trimester use should be avoided if possible.
Rem Alfelor Chapter 51: Pulmonary Disorders in Pregnancy Page 5 of 11
Three echinocandin derivativescaspofungin, micafungin, and (2003) now recommends a multidrug regimen for initial empirical
anidulafunginare effective for treatment of patients with
invasive candidiasis (Medical Letter, 2006; Reboli, 2007). They are symptomatic tuberculosis. Isoniazid, rifampin, pyrazinamide, and
embryotoxic and teratogenic in ethambutol are given until
laboratory animals and use in human pregnancies has not been susceptibility studies are performed. Other second-line drugs may
reported (Briggs, 2011). need to be added. Drug
Severe Acute Respiratory Syndrome (SARS) susceptibility is performed on all first isolates.
This coronaviral respiratory infection was first identified in China in In 2005, there was a worldwide emergence of extensively drug-
2002, but no new cases have resistant tuberculosisXDR-TB.
been reported since 2005. It caused atypical pneumonitis with a This is defined as resistance in vitro to at least the first-line drugs
case-fatality rate of approximately 10 isoniazid and rifampin as well as
percent (Dolin, 2012). SARS in pregnancy had a case-fatality rate of to three or more of the six main classes of second-line drugs
up to 25 percent (Lam, 2004; aminoglycosides, polypeptides,
Longman, 2007; Wong, 2004). Ng and coworkers (2006) reported fluoroquinolones, thioamides, cycloserine, and para-aminosalicylic
that the placentas from 7 of 19 acid (Centers for Disease
cases showed abnormal intervillous or subchorionic fibrin deposition Control and Prevention, 2009a). Like their predecessor MDR-TB,
in three, and extensive fetal these extensively resistant strains
thrombotic vasculopathy in two. predominate in foreign-born persons (Tino, 2007).
TUBERCULOSIS Tuberculosis and Pregnancy
Although tuberculosis is still a major worldwide concern, it is The considerable influx of women into the United States from Asia,
uncommon in the United States. The Africa, Mexico, and Central
incidence of active tuberculosis in this country has plateaued since America has been accompanied by an increased frequency of
2000 (Raviglione, 2012). More tuberculosis in pregnant women.
than half of active cases are in immigrants (Centers for Disease Sackoff and coworkers (2006) reported positive-tuberculin tests in
Control and Prevention, 2009b). half of 678 foreign-born women
Persons born in the United States have newly acquired infection, attending perinatal clinics in New York City. Almost 60 percent were
whereas foreign-born persons newly diagnosed. Pillay and
usually have reactivation of latent infection. In this country, colleagues (2004) stress the prevalence of tuberculosis in HIV-
tuberculosis is a disease of the elderly, positive pregnant women. Margono
the urban poor, minority groupsespecially black Americans, and and coworkers (1994) reported that for two New York City hospitals,
patients with HIV infection more than half of pregnant
(Raviglione, 2012). women with active tuberculosis were HIV positive. At Jackson
Infection is via inhalation of Mycobacterium tuberculosis, which Memorial Hospital in Miami, Schulte
incites a granulomatous and associates (2002) reported that 21 percent of 207 HIV-infected
pulmonary reaction. In more than 90 percent of patients, infection is pregnant women had a positive
contained and is dormant for long skin test result. Recall also that silent endometrial tuberculosis can
periods (Zumla, 2013). In some patients, especially those who are cause tubal infertility (Levison,
immunocompromised or who have 2010).
other diseases, tuberculosis becomes reactivated to cause clinical Without antituberculosis therapy, active tuberculosis appears to have
disease. Manifestations usually adverse effects on pregnancy
include cough with minimal sputum production, low-grade fever, (Anderson, 1997; Mnyani, 2011). Contemporaneous experiences are
hemoptysis, and weight loss. few, however, because
Various infiltrative patterns are seen on chest radiograph, and there antitubercular therapy has diminished the frequency of severe
may be associated cavitation or disease. Outcomes are dependent on the
mediastinal lymphadenopathy. Acid-fast bacilli are seen on stained site of infection and timing of diagnosis in relation to delivery. Jana
smears of sputum in and colleagues (1994) from India
approximately two thirds of culture-positive patients. Forms of and Figueroa-Damian and Arrendondo-Garcia (1998) from Mexico
extrapulmonary tuberculosis include City reported that active
lymphadenitis, pleural, genitourinary, skeletal, meningeal, pulmonary tuberculosis was associated with increased incidences of
gastrointestinal, and miliary or preterm delivery, lowbirthweight
disseminated (Raviglione, 2012). Treatment and growth-restricted infants, and perinatal mortality. From her
Cure rates with 6-month short-course directly observed therapy review, Efferen (2007)
DOTapproach 90 percent for cited twofold increased rates of low-birthweight and preterm infants
new infections. Resistance to antituberculosis drugs was first as well as preeclampsia. The
manifest in the United States in the early perinatal mortality rate was increased almost tenfold. Adverse
1990s following the epidemic from 1985 through 1992 (Centers for outcomes correlate with late
Disease Control and Prevention, diagnosis, incomplete or irregular treatment, and advanced
2007a). Strains of multidrug-resistant tuberculosis (MDR-TB) pulmonary lesions. From Taiwan, 761
increased rapidly as tuberculosis pregnant women diagnosed with tuberculosis had a higher incidence
incidence fell during the 1990s. Because of this, the Centers for of low-birthweight and growthrestricted
Disease Control and Prevention infants (Lin, 2010).
Rem Alfelor Chapter 51: Pulmonary Disorders in Pregnancy Page 6 of 11
Extrapulmonary tuberculosis is less common. Jana and coworkers for progression to active disease. Kowada (2014) concluded that
(1999) reported outcomes in these tests are cost effective.
33 pregnant women with renal, intestinal, and skeletal tuberculosis, Essential laboratory methods for detection or verification of infection
and a third had low-birthweight newborns. Llewelyn and associates both active and latent
(2000) reported that nine of 13 pregnant women with include microscopy, culture, nucleic acid amplification assay, and
extrapulmonary disease had delayed diagnoses. Prevost and Fung drug-susceptibility testing (Centers
Kee Fung (1999) reviewed 56 for Disease Control and Prevention, 2009a, 2010b).
cases of tuberculous meningitis in which a third of mothers died. Treatment
Spinal tuberculosis may cause Latent Infection. Different schemes are recommended for latent and
paraplegia, but vertebral fusion may prevent it from becoming active tuberculosis. In
permanent (Badve, 2011; Nanda, nonpregnant tuberculin-positive patients who are younger than 35
2002). Other presentations include widespread intraperitoneal years and who have no evidence of
tuberculosis simulating ovarian active disease, isoniazid, 300 mg orally daily, is given for 9 months.
carcinomatosis and degenerating leiomyoma, and hyperemesis Isoniazid has been used for
gravidarum from tubercular meningitis decades, and it is considered safe in pregnancy (Briggs, 2011; Taylor,
(Kutlu, 2007; Moore, 2008; Sherer, 2005). 2013). Compliance is a major
Diagnosis problem, and Sackoff (2006) and Cruz (2005) and their associates
There are two types of tests to detect latent or active tuberculosis. reported a disappointing 10-
One is the time-honored tuberculin percent treatment completion. One obvious disconnect is that care
skin test (TST), and the others are interferon-gamma release assays for tuberculosis is given in health
(IGRAs) , which are becoming systems different from prenatal care (Zenner, 2012). These
preferred (Horsburgh, 2011). IGRAs are blood tests that measure observations are important because most
interferon-gamma release in recommend that isoniazid therapy be delayed until after delivery.
response to antigens present in M tuberculosis, but not bacille Because of possibly increased
Calmette-Gurin (BCG) vaccine isoniazid-induced hepatitis risk in postpartum women, some
(Ernst, 2007; Levison, 2010). The Centers for Disease Control and recommend withholding treatment until 3
Prevention (2005b, 2010b) to 6 months after delivery. That said, neither method is as effective as
recommend either skin testing or IGRA testing of pregnant women antepartum treatment to prevent
who are in any of the high-risk active infection. Boggess and colleagues (2000) reported that only 42
groups shown in Table 51-4. For those who received BCG percent of 167 tuberculinpositive
vaccination, IGRA testing is used asymptomatic women delivered at San Francisco General Hospital
(Mazurek, 2010). For skin testing, the preferred antigen is purified completed 6-month
protein derivative (PPD) of intermediate strength therapy that was not given until the first postpartum visit.
of 5 tuberculin units. If the intracutaneously applied test result is There are exceptions to delayed treatment in pregnancy. Known
negative, no further evaluation is recent skin-test convertors are
needed. A positive skin test result measures 5 mm in diameter and treated antepartum because the incidence of active infection is 5
requires evaluation for active percent in the first year (Zumla,
disease, including a chest radiograph (Centers for Disease Control 2013). Skin-test-positive women exposed to active infection are
and Prevention, 2005a, 2010b). It treated because the incidence of
also may be interpreted according to risk factors proposed by the infection is 0.5 percent per year.
American Thoracic Society/Centers HIV-positive women are treated because they have an approximate
for Disease Control and Prevention (1990). For very high-risk 10-percent annual risk of
patientsthat is, those who are HIVpositive, active disease. Treatment of these women is of special concern if
those with abnormal chest radiography, or those who have a recent there is antiretroviral naivet. In
contact with an active these circumstances, beginning concomitant therapy with
case5 mm or greater is considered a reason to treat. For those at antituberculosis and antiretroviral therapy
high riskforeign-born can cause the immune reconstitution inflammatory syndrome (IRIS)
individuals, intravenous drug users who are HIV-negative, low- with toxic drug effects (Trk,
income populations, or those with 2011). Recent studies, however, support earlier administration of
medical conditions that increase the risk for tuberculosis10 mm or highly active antiretroviral therapy
greater is considered treatable For persons with none of these risk (HAART)within 2 to 4 weeksafter beginning antituberculosis
factors, 15 mm or greater is defined as requiring treatment. therapy (Blanc, 2011; Havlir,
There are two IGRAs available: QuantiFERON-TB Gold and T- 2011; Karim, 2011).
SPOT.TB tests are recommended Active Infection. Recommended initial treatment for active
by the Centers for Disease Control and Prevention (2005a,b) for the tuberculosis in pregnant patients is a
same indications as skin testing. four-drug regimen with isoniazid, rifampin, ethambutol, and
These tests have not been evaluated as extensively as tuberculin pyrazinamide, along with pyridoxine. In
skin testing. Lalvani (2007) the first 2-month phase, all four drugs are givenbactericidal phase.
reviewed them and found them to be useful in identifying patients This is followed by a 4-month
with latent tuberculosis and at risk phase of isoniazid and rifampincontinuation phase (Raviglione,
2012; Zumla, 2013). Reports of
Rem Alfelor Chapter 51: Pulmonary Disorders in Pregnancy Page 7 of 11
MDR-TB during pregnancy are few, and Lessnau and Qarah (2003) Clinical presentation varies, but more than half of patients have
and Shin and coworkers (2003) dyspnea and a dry cough without
have reviewed treatment options. Breast feeding is not prohibited constitutional symptoms that develop insidiously over months.
during antituberculous therapy. Disease onset is abrupt in about 25
As discussed above, beginning concomitant antituberculosis and percent of patients, and 10 to 20 percent are asymptomatic at
antiretroviral therapy may cause discovery.
the immune reconstitution inflammatory syndrome, and risks versus Pulmonary symptoms are dominant, and more than 90 percent of
benefits are assessed. Also, for HIV-infected women, rifampin or patients have an abnormal chest
rifabutin use may be contraindicated if certain protease inhibitors radiograph at some point (Lynch, 2007). Interstitial pneumonitis is the
or nonnucleoside reverse transcriptase inhibitors are being hallmark of pulmonary
administered. If there is resistance to involvement. Approximately 50 percent of affected patients develop
rifabutin or rifampin, then pyrazinamide therapy is given. Of the permanent radiological changes.
second-line regimens, the Lymphadenopathy, especially of the mediastinum, is present in 75 to
aminoglycosidesstreptomycin, kanamycin, amikacin, and 90 percent of cases, and 25
capreomycinare ototoxic to the fetus percent have uveitis. A fourth have skin involvement, usually manifest
and are contraindicated (Briggs, 2011). as erythema nodosum. In
Neonatal Tuberculosis. Tubercular bacillemia can infect the placenta, women, sarcoid causes about 10 percent of cases of erythema
but it is uncommon that the nodosum (Acosta, 2013; Mert, 2007).
fetus becomes infectedcongenital tuberculosis. The term also Finally, any other organ system may be involved. Confirmation of the
applies to newborns who are diagnosis is with biopsy, and
infected by aspiration of infected secretions at delivery. Each route of because the lung may be the only obviously involved organ, tissue
infection constitutes acquisition is often difficult. The overall prognosis for sarcoidosis is
approximately half of the cases. A rare case of congenital good, and it resolves without treatment in 50 percent of
tuberculosis caused by in vitro fertilization patients. Still, there is diminished quality of life (de Vries, 2007). In
(IVF) was reported (Doudier, 2008). Neonatal tuberculosis simulates the other 50 percent, permanent
other congenital infections and organ dysfunction, albeit mild and nonprogressive, persists. About 10
manifests with hepatosplenomegaly, respiratory distress, fever, and percent die because of their
lymphadenopathy (Smith, 2002). disease.
Cantwell and associates (1994) reviewed 29 cases of congenital Glucocorticoids are the most widely used treatment, and
tuberculosis reported since 1980. methotrexate is second-line medication.
Only 12 of the mothers had active infection, and tuberculosis was Permanent organ derangement is seldom reversed by their use
frequently demonstrated by (Paramothayan, 2002). Thus, the
postpartum endometrial biopsy. Adhikari and colleagues (1997) decision to treat is based on symptoms, physical findings, chest
described 11 South African radiograph, and pulmonary function
postpartum women whose endometrial biopsy was culture-positive. tests. Unless respiratory symptoms are prominent, therapy is usually
Six of their neonates had withheld for a several-month
congenital tuberculosis. observation period. If inflammation does not subside, then
Neonatal infection is unlikely if the mother with active disease has prednisone, 1 mg/kg, is given daily for 4 to
been treated before delivery or 6 weeks (Baughman, 2012). For those with an inadequate response,
if her sputum culture is negative. Because the newborn is susceptible cytotoxic agents or cytokine
to tuberculosis, most authors modulators may be indicated.
recommend isolation from the mother suspected of having active Sarcoidosis and Pregnancy
disease. If untreated, the risk of Because sarcoidosis is uncommon and is frequently benign, it is not
disease in the infant born to a woman with active infection is 50 often seen in pregnancy. De Regt
percent in the first year (Jacobs, (1987) described 14 cases in 20,000 pregnancies during a 12-year
1988). periodalmost 1 in 1500.
SARCOIDOSIS Although sarcoidosis seldom affects pregnancy adversely, serious
Sarcoidosis is a chronic, multisystem disease of unknown etiology complications such as meningitis,
characterized by an accumulation heart failure, and neurosarcoidosis have been described (Cardonick,
of T lymphocytes and phagocytes within noncaseating granulomas 2000; Maisel, 1996; Seballos,
(Baughman, 2012). Predisposition 1994).
to the disease is genetically determined and characterized by an In general, perinatal outcomes are unaffected by sarcoidosis. Selroos
exaggerated response of helper T (1990) reviewed 655
lymphocytes to environmental triggers (Moller, 2007; Spagnolo, patients with sarcoidosis referred to the Mjlbolsta Hospital District in
2007). Pulmonary involvement is Finland. Of 252 women
most common, followed by skin, eyes, and lymph nodes. The between 18 and 50 years, 15 percent had sarcoidosis during
prevalence of sarcoid in the United pregnancy or within 1 year postpartum.
States is 20 to 60 per 100,000, with equal sex distribution, but it is 3 There was no evidence for disease progression in the 26
to 17 times more common for pregnancies in women with active disease.
black compared with white persons (Baughman, 2012). Most patients Three aborted spontaneously, and the other 23 women were
are between 20 and 40 years. delivered at term. In 18 pregnancies in
Rem Alfelor Chapter 51: Pulmonary Disorders in Pregnancy Page 8 of 11
12 women with inactive disease, pregnancy outcomes were good. percent (Aurora, 1999). A few women have successfully undergone
Agha and coworkers (1982) pregnancy following lung
reported similar experiences with 35 pregnancies at the University of transplantation (Kruszka, 2002; Shaner, 2012).
Michigan. Preconceptional Counseling
Active sarcoidosis is treated using the same guidelines as for the Women with cystic fibrosis are subfertile because of tenacious
woman who is not pregnant. cervical mucus. Males have
Severe disease warrants serial determination of pulmonary function. oligospermia or aspermia from vas deferens obstruction, and 98
Symptomatic uveitis, percent are infertile (Ahmad, 2013).
constitutional symptoms, and pulmonary symptoms are treated with Despite this, the North American Cystic Fibrosis Foundation
prednisone, 1 mg/kg orally per estimates that 4 percent of affected
day. women become pregnant every year (Edenborough, 1995). The
CYSTIC FIBROSIS endometrium and tubes express some
One of the most common fatal genetic disorders in whites, cystic CFTR but are functionally normal, and the ovaries do not express the
fibrosis is caused by one of more CFTR gene (Edenborough,
than 1500 mutations in a 230-kb gene on the long arm of 2001). Both intrauterine insemination and IVF have been used
chromosome 7 that encodes an amino acid successfully in affected women
polypeptide (Boucher, 2012). This peptide functions as a chloride (Rodgers, 2000). Several ethical considerations of undertaking
channel and is termed the cystic pregnancy by these women were
fibrosis transmembrane conductance regulator (CFTR) . There is a reviewed by Wexler and colleagues (2007). For male infertility,
wide phenotypic variation, even Sobczyska-Tomaszewska and
among homozygotes for the common F508 mutation (Rowntree, associates (2006) have emphasized the importance of molecular
2003). This is discussed in greater diagnosis.
detail in Chapter 14 (p. 295). Approximately 20 percent of affected Screening
individuals are diagnosed shortly The American College of Obstetricians and Gynecologists (2011)
after birth because of meconium peritonitis (Boucher, 2012). recommends that carrier screening
Currently, nearly 80 percent of females be offered to at-risk couples. This is discussed in detail in Chapter 14
with cystic fibrosis now survive to adulthood, and their median (p. 295). The Centers for
survival is about 30 years (Gillet, Disease Control and Prevention also added cystic fibrosis to
2002). Pathophysiology newborn screening programs (Comeau,
Mutations in the chloride channel cause altered epithelial cell 2007). This is discussed also in Chapter 32 (p. 632) and was the
membrane transport of electrolytes. subject of a Cochrane Database
This affects all organs that express CFTRsecretory cells, sinuses, review (Southern, 2009).
lung, pancreas, liver, and Pregnancy with Cystic Fibrosis
reproductive tract. Disease severity depends on which two alleles are Pregnancy outcome is inversely related to severity of lung
inherited, and homozygosity dysfunction. Severe chronic lung disease, Pathophysiology
for F508 is one of the most severe (McKone, 2003). Mutations in the chloride channel cause altered epithelial cell
Exocrine gland ductal obstruction develops from thick, viscid membrane transport of electrolytes.
secretions (Rowe, 2005). In the This affects all organs that express CFTRsecretory cells, sinuses,
lung, submucosal glandular ducts are affected. Eccrine sweat gland lung, pancreas, liver, and
abnormalities are the basis for the reproductive tract. Disease severity depends on which two alleles are
diagnostic sweat test, characterized by elevated sodium, potassium, inherited, and homozygosity
and chloride levels in sweat. for F508 is one of the most severe (McKone, 2003).
Lung involvement is commonplace and is frequently the cause of Exocrine gland ductal obstruction develops from thick, viscid
death. Bronchial gland secretions (Rowe, 2005). In the
hypertrophy with mucous plugging and small-airway obstruction lung, submucosal glandular ducts are affected. Eccrine sweat gland
leads to subsequent infection that abnormalities are the basis for the
ultimately causes chronic bronchitis and bronchiectasis. For complex diagnostic sweat test, characterized by elevated sodium, potassium,
and not completely explicable and chloride levels in sweat.
reasons, chronic inflammation from Pseudomonas aeruginosa occurs Lung involvement is commonplace and is frequently the cause of
in more than 90 percent of death. Bronchial gland
patients. S aureus, H influenzae, and Burkholderia cepacia are hypertrophy with mucous plugging and small-airway obstruction
recovered in a minority (Rowe, leads to subsequent infection that
2005). Colonization with the last has been reported to signify a worse ultimately causes chronic bronchitis and bronchiectasis. For complex
prognosis, especially in and not completely explicable
pregnancy (Gillet, 2002). Acute and chronic parenchymal reasons, chronic inflammation from Pseudomonas aeruginosa occurs
inflammation ultimately causes extensive in more than 90 percent of
fibrosis, and along with airway obstruction, there is a ventilation patients. S aureus, H influenzae, and Burkholderia cepacia are
perfusion mismatch. Pulmonary recovered in a minority (Rowe,
insufficiency is the end result. Lung or heartlung transplantation has 2005). Colonization with the last has been reported to signify a worse
a 5-year survival rate of 33 prognosis, especially in

Rem Alfelor Chapter 51: Pulmonary Disorders in Pregnancy Page 9 of 11

pregnancy (Gillet, 2002). Acute and chronic parenchymal Lung Transplantation
inflammation ultimately causes extensive Cystic fibrosis is a common antecedent disease leading to lung
fibrosis, and along with airway obstruction, there is a ventilation transplantation. Gyi and coworkers
perfusion mismatch. Pulmonary (2006) reviewed 10 pregnancies in such women and reported nine
insufficiency is the end result. Lung or heartlung transplantation has liveborn infants. Maternal
a 5-year survival rate of 33 outcomes were less favorablethree developed rejection during
percent (Aurora, 1999). A few women have successfully undergone pregnancy, and all three had
pregnancy following lung progressively declining pulmonary function and died of chronic
transplantation (Kruszka, 2002; Shaner, 2012). rejection by 38 months after delivery.
Preconceptional Counseling CARBON MONOXIDE POISONING
Women with cystic fibrosis are subfertile because of tenacious Carbon monoxide is a ubiquitous gas, and most nonsmoking adults
cervical mucus. Males have have a carbon monoxyhemoglobin
oligospermia or aspermia from vas deferens obstruction, and 98 saturation of 1 to 3 percent. In cigarette smokers, levels may be as
percent are infertile (Ahmad, 2013). high as 5 to 10 percent. Carbon
Despite this, the North American Cystic Fibrosis Foundation monoxide is the most frequent cause of poisoning worldwide (Stoller,
estimates that 4 percent of affected 2007). Toxic levels are often
women become pregnant every year (Edenborough, 1995). The encountered in inadequately ventilated areas warmed by space
endometrium and tubes express some heaters.
CFTR but are functionally normal, and the ovaries do not express the Carbon monoxide is particularly toxic because it is odorless and
CFTR gene (Edenborough, tasteless and has a high affinity
2001). Both intrauterine insemination and IVF have been used for hemoglobin binding. Thus, it displaces oxygen and impedes its
successfully in affected women transfer with resultant hypoxia.
(Rodgers, 2000). Several ethical considerations of undertaking Besides acute sequelae including death and anoxic encephalopathy,
pregnancy by these women were cognitive defects develop in as
reviewed by Wexler and colleagues (2007). For male infertility, many as half of patients following loss of consciousness or in those
Sobczyska-Tomaszewska and with carbon monoxide levels >
associates (2006) have emphasized the importance of molecular 25 percent (Weaver, 2002). Hypoxic brain damage has a predilection
diagnosis. for the cerebral cortex and
Screening white matter and for the basal ganglia (Lo, 2007; Prockop, 2007).
The American College of Obstetricians and Gynecologists (2011) Pregnancy and Carbon Monoxide Poisoning
recommends that carrier screening Through several physiological alterations, the rate of endogenous
be offered to at-risk couples. This is discussed in detail in Chapter 14 carbon monoxide production almost
(p. 295). The Centers for doubles in normal pregnancy (Longo, 1977). Although the pregnant
Disease Control and Prevention also added cystic fibrosis to woman is not more susceptible to
newborn screening programs (Comeau, carbon monoxide poisoning, the fetus does not tolerate excessive
2007). This is discussed also in Chapter 32 (p. 632) and was the exposure. With chronic exposure,
subject of a Cochrane Database maternal symptoms usually appear when the carboxyhemoglobin
review (Southern, 2009). concentration is 5 to 20 percent.
Pregnancy with Cystic Fibrosis Symptoms include headache, weakness, dizziness, physical and
Pregnancy outcome is inversely related to severity of lung visual impairment, palpitations, and
dysfunction. Severe chronic lung disease, mother within a few years nausea and vomiting. With acute exposure, concentrations of 30 to
of childbirth. Thorpe-Beeson and associates (2013) reported similar 50 percent produce symptoms of
findings. impending cardiovascular collapse. Levels > 50 percent may be fatal
Fitzsimmons and coworkers (1996) performed a case-control study for the mother.
of 258 women with cystic Because hemoglobin F has an even higher affinity for carbon
fibrosis who had a live birth. The 889 matched controls were women monoxide, fetal carboxyhemoglobin
with cystic fibrosis who had levels are 10 to 15 percent higher than those in the mother. This may
not been pregnant. Pregnancy had no effect on worsening of any be due to facilitated diffusion (Longo, 1977). Importantly, the half-life
serious complications, and 8 percent of carboxyhemoglobin is 2 hours in the mother but 7 hours in
in both groups had died by 2 years. Gillet and colleagues (2002) the fetus. Because carbon monoxide is bound so tightly to
reported 75 pregnancies from the hemoglobin F, the fetus may be hypoxic
French Cystic Fibrosis Registry. Almost 20 percent of infants were even before maternal carbon monoxide levels are appreciably
delivered preterm, and 30 percent elevated. Several anomalies are
had growth restriction. The one maternal death was due to associated with embryonic exposure, and anoxic encephalopathy is
Pseudomonas sepsis in a woman whose the primary sequela of later fetal
prepregnancy FEV1 was 60 percent. Long-term, however, 17 percent exposure (Alehan, 2007; Aubard, 2000).
of women died and four infants Treatment
had confirmed cystic fibrosis. Likewise, in the study by Thorpe- For all victims, treatment of carbon monoxide poisoning is supportive
Beeson (2013) cited above, four of along with immediate
eight women whose FEV1 was < 40 to 50 percent died from 2 to 8 administration of 100-percent inspired oxygen. Indications for
years after delivery. hyperbaric oxygen treatment in
Rem Alfelor Chapter 51: Pulmonary Disorders in Pregnancy Page 10 of 11
nonpregnant individuals are unclear (Kao, 2005). Weaver and oxygen is also controversial (Bar, 2007).
associates (2002) reported that Elkharrat and colleagues (1991) reported successful hyperbaric
hyperbaric oxygen treatment minimized the incidence of cognitive treatments in 44 pregnant women.
defects in adults at both 6 weeks Silverman and Montano (1997) reported successful management of
and 1 year compared with that with normobaric oxygen. Hyperbaric a woman whose abnormal
oxygen is generally neurological and cardiopulmonary findings abated in a parallel
recommended in pregnancy if there has been significant carbon fashion with resolution of associated
monoxide exposure (Aubard, 2000; fetal heart rate variable decelerations. Greingor and coworkers
Ernst, 1998). The problem is how to define significant exposure. (2001) used 2.5-atm hyperbaric 100-
Although maternal carbon monoxide percent oxygen for 90 minutes in a 21-week pregnant woman who
levels are not accurately predictive of those in the fetus, some was delivered of a healthy infant at
clinicians recommend hyperbaric term. According to the Divers Alert NetworkDAN (2013)at Duke
therapy if maternal levels exceed 15 to 20 percent. With fetal heart University, there are 700
rate pattern evaluation, Towers chambers in North and Central America and the Caribbean.
and Corcoran (2009) described affected fetuses to have an elevated Consultation from DAN is available at
baseline, diminished variability, 919-684-9111.
and absent accelerations and decelerations. Treatment of the
affected newborn with hyperbaric

Rem Alfelor Chapter 51: Pulmonary Disorders in Pregnancy Page 11 of 11