Lung & pregnancy
imangalal
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Apr 12, 2014
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Slide Content
Ass. Professor Iman GalalAss. Professor Iman Galal
Pulmonary Medicine DepartmentPulmonary Medicine Department
Ain Shams UniversityAin Shams University
Lungs & PregnancyLungs & Pregnancy
In Health & DiseaseIn Health & Disease
Pulmonary Medicine DepartmentPulmonary Medicine Department
Ain Shams UniversityAin Shams University
Lungs & PregnancyLungs & Pregnancy
In Health & DiseaseIn Health & Disease
Page 2
Introduction:Introduction:
●Pregnancy induces profound changes in the mother, Pregnancy induces profound changes in the mother,
resulting in significant alterations in normal physiology.resulting in significant alterations in normal physiology.
●The anatomical & functional changes affect the respiratory & The anatomical & functional changes affect the respiratory &
cardiovascular systems. cardiovascular systems.
●Management of respiratory diseases in pregnancy requires Management of respiratory diseases in pregnancy requires
an understanding of these changes for interpretation of an understanding of these changes for interpretation of
clinical & laboratory manifestations of disease states.clinical & laboratory manifestations of disease states.
Introduction:Introduction:
●Pregnancy induces profound changes in the mother, Pregnancy induces profound changes in the mother,
resulting in significant alterations in normal physiology.resulting in significant alterations in normal physiology.
●The anatomical & functional changes affect the respiratory & The anatomical & functional changes affect the respiratory &
cardiovascular systems. cardiovascular systems.
●Management of respiratory diseases in pregnancy requires Management of respiratory diseases in pregnancy requires
an understanding of these changes for interpretation of an understanding of these changes for interpretation of
clinical & laboratory manifestations of disease states.clinical & laboratory manifestations of disease states.
Respiratory PhysiologyRespiratory Physiology
Page 4
Anatomical ChangesAnatomical Changes::
●Hormonal changes in pregnancy affect the URT & airway Hormonal changes in pregnancy affect the URT & airway
mucosa, producing mucosa, producing hyperemiahyperemia, , mucosal edemamucosal edema , ,
hypersecretionhypersecretion, & , & increased mucosal friability.increased mucosal friability.
●EstrogenEstrogen is responsible for producing is responsible for producing tissue edematissue edema, ,
capillary congestioncapillary congestion, & , & hyperplasiahyperplasia of of mucous mucous
glands.glands.
●The enlarging uterus & the hormonal effects produce The enlarging uterus & the hormonal effects produce
anatomical changes to the thoracic cage. As the uterus anatomical changes to the thoracic cage. As the uterus
expands, the expands, the diaphragmdiaphragm is is displaced cephaladdisplaced cephalad by as by as
much as much as 4 cm4 cm; the ; the A/PA/P & & transverse diametertransverse diameter of the of the
thorax thorax increasesincreases, which enlarges chest wall circumference. , which enlarges chest wall circumference.
●Diaphragm function remains Diaphragm function remains normalnormal, & diaphragmatic , & diaphragmatic
excursion is excursion is not reduced.not reduced.
Anatomical ChangesAnatomical Changes::
●Hormonal changes in pregnancy affect the URT & airway Hormonal changes in pregnancy affect the URT & airway
mucosa, producing mucosa, producing hyperemiahyperemia, , mucosal edemamucosal edema , ,
hypersecretionhypersecretion, & , & increased mucosal friability.increased mucosal friability.
●EstrogenEstrogen is responsible for producing is responsible for producing tissue edematissue edema, ,
capillary congestioncapillary congestion, & , & hyperplasiahyperplasia of of mucous mucous
glands.glands.
●The enlarging uterus & the hormonal effects produce The enlarging uterus & the hormonal effects produce
anatomical changes to the thoracic cage. As the uterus anatomical changes to the thoracic cage. As the uterus
expands, the expands, the diaphragmdiaphragm is is displaced cephaladdisplaced cephalad by as by as
much as much as 4 cm4 cm; the ; the A/PA/P & & transverse diametertransverse diameter of the of the
thorax thorax increasesincreases, which enlarges chest wall circumference. , which enlarges chest wall circumference.
●Diaphragm function remains Diaphragm function remains normalnormal, & diaphragmatic , & diaphragmatic
excursion is excursion is not reduced.not reduced.
Page 5
Pulmonary FunctionPulmonary Function::
●Anatomical changes to the thorax produce a progressive Anatomical changes to the thorax produce a progressive
decreasedecrease in in FRCFRC, which is , which is reducedreduced 10-20%10-20% by by term.term.
●The The RVRV can can decreasedecrease slightly during pregnancy, but this slightly during pregnancy, but this
finding is not consistent; decreased expiratory reserve finding is not consistent; decreased expiratory reserve
volume definitely changes. volume definitely changes.
●The increased circumference of the thoracic cage allows the The increased circumference of the thoracic cage allows the
VCVC to remain unchanged, & the to remain unchanged, & the TLC decreasesTLC decreases only only
minimally by term. minimally by term.
●Hormonal changes do not significantly affect airway function. Hormonal changes do not significantly affect airway function.
●Pregnancy does not change lung compliance, but Pregnancy does not change lung compliance, but chest wallchest wall
& & total respiratory compliancetotal respiratory compliance are are reducedreduced at term. at term.
Pulmonary FunctionPulmonary Function::
●Anatomical changes to the thorax produce a progressive Anatomical changes to the thorax produce a progressive
decreasedecrease in in FRCFRC, which is , which is reducedreduced 10-20%10-20% by by term.term.
●The The RVRV can can decreasedecrease slightly during pregnancy, but this slightly during pregnancy, but this
finding is not consistent; decreased expiratory reserve finding is not consistent; decreased expiratory reserve
volume definitely changes. volume definitely changes.
●The increased circumference of the thoracic cage allows the The increased circumference of the thoracic cage allows the
VCVC to remain unchanged, & the to remain unchanged, & the TLC decreasesTLC decreases only only
minimally by term. minimally by term.
●Hormonal changes do not significantly affect airway function. Hormonal changes do not significantly affect airway function.
●Pregnancy does not change lung compliance, but Pregnancy does not change lung compliance, but chest wallchest wall
& & total respiratory compliancetotal respiratory compliance are are reducedreduced at term. at term.
Page 6
VentilationVentilation::
●The The MVMV increases significantly, beginning in the first increases significantly, beginning in the first
trimester & reaching trimester & reaching 20-40%20-40% above baseline at term. above baseline at term.
●Alveolar ventilationAlveolar ventilation increasesincreases by by 50-70%.50-70%.
●The The increaseincrease in in ventilationventilation occurs because of occurs because of increased increased
metabolic CO2 productionmetabolic CO2 production & because of increased & because of increased
respiratory drive due to the high serum respiratory drive due to the high serum progesteroneprogesterone
level. level.
●The The VTVT increasesincreases by by 30-35%. 30-35%.
●The The respiratory raterespiratory rate remains relatively remains relatively constantconstant or or
increasesincreases slightly. slightly.
VentilationVentilation::
●The The MVMV increases significantly, beginning in the first increases significantly, beginning in the first
trimester & reaching trimester & reaching 20-40%20-40% above baseline at term. above baseline at term.
●Alveolar ventilationAlveolar ventilation increasesincreases by by 50-70%.50-70%.
●The The increaseincrease in in ventilationventilation occurs because of occurs because of increased increased
metabolic CO2 productionmetabolic CO2 production & because of increased & because of increased
respiratory drive due to the high serum respiratory drive due to the high serum progesteroneprogesterone
level. level.
●The The VTVT increasesincreases by by 30-35%. 30-35%.
●The The respiratory raterespiratory rate remains relatively remains relatively constantconstant or or
increasesincreases slightly. slightly.
Page 7
Arterial Blood GasesArterial Blood Gases::
●Physiological hyperventilationPhysiological hyperventilation results in respiratory results in respiratory
alkalosis with compensatory renal excretion of alkalosis with compensatory renal excretion of
bicarbonate. bicarbonate.
●The The arterial CO2 pressurearterial CO2 pressure reaches a plasma level of reaches a plasma level of
28-32 mmHg28-32 mmHg & & bicarbonatebicarbonate is is ↓↓ to 18-21 mmol/L to 18-21 mmol/L, ,
maintaining an maintaining an arterial pHarterial pH in the range of in the range of 7.40-7.47. 7.40-7.47.
●Mild hypoxemiaMild hypoxemia might occur when the patient is in the might occur when the patient is in the
supinesupine position. position.
Arterial Blood GasesArterial Blood Gases::
●Physiological hyperventilationPhysiological hyperventilation results in respiratory results in respiratory
alkalosis with compensatory renal excretion of alkalosis with compensatory renal excretion of
bicarbonate. bicarbonate.
●The The arterial CO2 pressurearterial CO2 pressure reaches a plasma level of reaches a plasma level of
28-32 mmHg28-32 mmHg & & bicarbonatebicarbonate is is ↓↓ to 18-21 mmol/L to 18-21 mmol/L, ,
maintaining an maintaining an arterial pHarterial pH in the range of in the range of 7.40-7.47. 7.40-7.47.
●Mild hypoxemiaMild hypoxemia might occur when the patient is in the might occur when the patient is in the
supinesupine position. position.
Page 8
Arterial Blood GasesArterial Blood Gases::
●Oxygen consumptionOxygen consumption ↑↑ at the beginning of the first at the beginning of the first
trimester & trimester & ↑↑ by 20-33% by term because of fetal demands & by 20-33% by term because of fetal demands &
↑↑ maternal metabolic processes. maternal metabolic processes.
●In active labor, In active labor, hyperventilation hyperventilation ↑↑ & & tachypneatachypnea caused caused
by pain & anxiety might result in marked by pain & anxiety might result in marked hypocapnia hypocapnia &&
respiratory alkalosisrespiratory alkalosis, adversely affecting fetal , adversely affecting fetal
oxygenation by reducing uterine blood flow. In some patients, oxygenation by reducing uterine blood flow. In some patients,
severe pain & anxiety can lead to severe pain & anxiety can lead to rapid shallow rapid shallow
breathingbreathing with with alveolar hypoventilationalveolar hypoventilation, , atelectasisatelectasis, ,
& & mild hypoxemia.mild hypoxemia.
Arterial Blood GasesArterial Blood Gases::
●Oxygen consumptionOxygen consumption ↑↑ at the beginning of the first at the beginning of the first
trimester & trimester & ↑↑ by 20-33% by term because of fetal demands & by 20-33% by term because of fetal demands &
↑↑ maternal metabolic processes. maternal metabolic processes.
●In active labor, In active labor, hyperventilation hyperventilation ↑↑ & & tachypneatachypnea caused caused
by pain & anxiety might result in marked by pain & anxiety might result in marked hypocapnia hypocapnia &&
respiratory alkalosisrespiratory alkalosis, adversely affecting fetal , adversely affecting fetal
oxygenation by reducing uterine blood flow. In some patients, oxygenation by reducing uterine blood flow. In some patients,
severe pain & anxiety can lead to severe pain & anxiety can lead to rapid shallow rapid shallow
breathingbreathing with with alveolar hypoventilationalveolar hypoventilation, , atelectasisatelectasis, ,
& & mild hypoxemia.mild hypoxemia.
Alterations In Normal Alterations In Normal
Physiology During Pregnancy Physiology During Pregnancy
Physiology During Pregnancy Physiology During Pregnancy
Page 10
Hemodynamic ChangesHemodynamic Changes ::
●Changes begin in the Changes begin in the 11
stst
trimester trimester of pregnancy & continue of pregnancy & continue
into the into the postpartumpostpartum period. period.
●Maternal blood volume Maternal blood volume ↑↑ progressively, peaking at a progressively, peaking at a
value of approximately value of approximately 40%40% above baseline by the above baseline by the 33
rdrd
trimester.trimester. Plasma volume Plasma volume ↑↑ byby 45-50% 45-50%, & , & red cell red cell
mass mass ↑↑ by by 20-30%20-30%, resulting in , resulting in anemiaanemia of pregnancy. of pregnancy.
●The The ↑↑ blood volume blood volume is associated with is associated with ↑↑ cardiac output cardiac output
by by 30-50%30-50% above baseline levels by above baseline levels by 25 wks.25 wks.
Hemodynamic ChangesHemodynamic Changes ::
●Changes begin in the Changes begin in the 11
stst
trimester trimester of pregnancy & continue of pregnancy & continue
into the into the postpartumpostpartum period. period.
●Maternal blood volume Maternal blood volume ↑↑ progressively, peaking at a progressively, peaking at a
value of approximately value of approximately 40%40% above baseline by the above baseline by the 33
rdrd
trimester.trimester. Plasma volume Plasma volume ↑↑ byby 45-50% 45-50%, & , & red cell red cell
mass mass ↑↑ by by 20-30%20-30%, resulting in , resulting in anemiaanemia of pregnancy. of pregnancy.
●The The ↑↑ blood volume blood volume is associated with is associated with ↑↑ cardiac output cardiac output
by by 30-50%30-50% above baseline levels by above baseline levels by 25 wks.25 wks.
Page 11
Hemodynamic ChangesHemodynamic Changes ::
●The The heart rate heart rate ↑↑ & reaches a & reaches a maximalmaximal value of value of 10-30%10-30%
above baseline values by above baseline values by 32 wks.32 wks.
●Systemic blood pressure Systemic blood pressure ↓↓ slightly during pregnancy, with slightly during pregnancy, with
the the diastolic pressure fallingdiastolic pressure falling approximately approximately 10-20%10-20% & &
reaching a nadir at reaching a nadir at 28 wks.28 wks.
●Plasma colloid oncotic pressure Plasma colloid oncotic pressure ↓↓ because of the dilution because of the dilution
of plasma proteins; the of plasma proteins; the critical pulmonary capillary critical pulmonary capillary
pressurepressure at which pulmonary edema forms also at which pulmonary edema forms also ↓↓. .
●SVR SVR && PVR PVR ↓↓ by by 20-30%.20-30%.
Hemodynamic ChangesHemodynamic Changes ::
●The The heart rate heart rate ↑↑ & reaches a & reaches a maximalmaximal value of value of 10-30%10-30%
above baseline values by above baseline values by 32 wks.32 wks.
●Systemic blood pressure Systemic blood pressure ↓↓ slightly during pregnancy, with slightly during pregnancy, with
the the diastolic pressure fallingdiastolic pressure falling approximately approximately 10-20%10-20% & &
reaching a nadir at reaching a nadir at 28 wks.28 wks.
●Plasma colloid oncotic pressure Plasma colloid oncotic pressure ↓↓ because of the dilution because of the dilution
of plasma proteins; the of plasma proteins; the critical pulmonary capillary critical pulmonary capillary
pressurepressure at which pulmonary edema forms also at which pulmonary edema forms also ↓↓. .
●SVR SVR && PVR PVR ↓↓ by by 20-30%.20-30%.
Page 12
Dyspnea During PregnancyDyspnea During Pregnancy ::
●Dyspnea during pregnancy is quite common, occurring in Dyspnea during pregnancy is quite common, occurring in
approximately approximately 60%60% of women of women with exertionwith exertion & & < 20% at < 20% at
rest. rest.
●Physiologic dyspneaPhysiologic dyspnea can occur can occur earlyearly in pregnancy & in pregnancy &
does notdoes not interfere with daily activities. Although interfere with daily activities. Although
mechanical impediment by the gravid uterus is often mechanical impediment by the gravid uterus is often
blamed, blamed, hyperventilationhyperventilation due to due to ↑↑ progesterone progesterone levels levels
is the most important mechanism. is the most important mechanism.
Dyspnea During PregnancyDyspnea During Pregnancy ::
●Dyspnea during pregnancy is quite common, occurring in Dyspnea during pregnancy is quite common, occurring in
approximately approximately 60%60% of women of women with exertionwith exertion & & < 20% at < 20% at
rest. rest.
●Physiologic dyspneaPhysiologic dyspnea can occur can occur earlyearly in pregnancy & in pregnancy &
does notdoes not interfere with daily activities. Although interfere with daily activities. Although
mechanical impediment by the gravid uterus is often mechanical impediment by the gravid uterus is often
blamed, blamed, hyperventilationhyperventilation due to due to ↑↑ progesterone progesterone levels levels
is the most important mechanism. is the most important mechanism.
Page 13
Dyspnea During PregnancyDyspnea During Pregnancy ::
●Distinguishing physiologic dyspnea from breathlessness Distinguishing physiologic dyspnea from breathlessness
caused by disorders complicating pregnancy or diseases that caused by disorders complicating pregnancy or diseases that
might coexist with pregnancy is essential. might coexist with pregnancy is essential.
●Actual exercise toleranceActual exercise tolerance despite dyspnea is despite dyspnea is not not
greatly affected. greatly affected.
●The presence of other symptoms & signs of The presence of other symptoms & signs of
cardiopulmonary disease indicates a possible pathologic cardiopulmonary disease indicates a possible pathologic
nature of dyspnea, & the patient should be evaluated.nature of dyspnea, & the patient should be evaluated.
Dyspnea During PregnancyDyspnea During Pregnancy ::
●Distinguishing physiologic dyspnea from breathlessness Distinguishing physiologic dyspnea from breathlessness
caused by disorders complicating pregnancy or diseases that caused by disorders complicating pregnancy or diseases that
might coexist with pregnancy is essential. might coexist with pregnancy is essential.
●Actual exercise toleranceActual exercise tolerance despite dyspnea is despite dyspnea is not not
greatly affected. greatly affected.
●The presence of other symptoms & signs of The presence of other symptoms & signs of
cardiopulmonary disease indicates a possible pathologic cardiopulmonary disease indicates a possible pathologic
nature of dyspnea, & the patient should be evaluated.nature of dyspnea, & the patient should be evaluated.
Pulmonary Pharmacology Pulmonary Pharmacology
During PregnancyDuring Pregnancy
During PregnancyDuring Pregnancy
Page 15
Absorption During PregnancyAbsorption During Pregnancy ::
●Both the Both the rate of gastric emptyingrate of gastric emptying & the & the rate of rate of
gastric motilitygastric motility are are decreaseddecreased in the gravid patient. in the gravid patient.
Thus, Thus, absorptionabsorption properties are usually properties are usually altered. altered.
●The The decreased intestinal motilitydecreased intestinal motility can favor can favor
increased absorption. increased absorption.
●First-pass metabolismFirst-pass metabolism by the by the portal circulationportal circulation is is
unchangedunchanged in pregnancy. in pregnancy.
Absorption During PregnancyAbsorption During Pregnancy ::
●Both the Both the rate of gastric emptyingrate of gastric emptying & the & the rate of rate of
gastric motilitygastric motility are are decreaseddecreased in the gravid patient. in the gravid patient.
Thus, Thus, absorptionabsorption properties are usually properties are usually altered. altered.
●The The decreased intestinal motilitydecreased intestinal motility can favor can favor
increased absorption. increased absorption.
●First-pass metabolismFirst-pass metabolism by the by the portal circulationportal circulation is is
unchangedunchanged in pregnancy. in pregnancy.
Page 16
Distribution During PregnancyDistribution During Pregnancy::
●The distribution of a drug is affected by The distribution of a drug is affected by the rate of the rate of
perfusion of blood to the individual organsperfusion of blood to the individual organs ,, lipid lipid
solubilitysolubility, &, & the degree of binding to the proteins the degree of binding to the proteins oror
tissue receptors. tissue receptors.
●Because the physiologic volume of distribution is larger in Because the physiologic volume of distribution is larger in
pregnancy, pregnancy, high loading doseshigh loading doses of the drug might be of the drug might be
needed.needed.
Distribution During PregnancyDistribution During Pregnancy::
●The distribution of a drug is affected by The distribution of a drug is affected by the rate of the rate of
perfusion of blood to the individual organsperfusion of blood to the individual organs ,, lipid lipid
solubilitysolubility, &, & the degree of binding to the proteins the degree of binding to the proteins oror
tissue receptors. tissue receptors.
●Because the physiologic volume of distribution is larger in Because the physiologic volume of distribution is larger in
pregnancy, pregnancy, high loading doseshigh loading doses of the drug might be of the drug might be
needed.needed.
Page 17
Protein Binding During PregnancyProtein Binding During Pregnancy ::
●During pregnancy, During pregnancy, plasma protein bindingplasma protein binding usually usually
decreases.decreases.
●This can cause This can cause higher circulating levels of free drughigher circulating levels of free drug
when normally protein-bound medication is administered.when normally protein-bound medication is administered.
Protein Binding During PregnancyProtein Binding During Pregnancy ::
●During pregnancy, During pregnancy, plasma protein bindingplasma protein binding usually usually
decreases.decreases.
●This can cause This can cause higher circulating levels of free drughigher circulating levels of free drug
when normally protein-bound medication is administered.when normally protein-bound medication is administered.
Page 18
Elimination During PregnancyElimination During Pregnancy ::
●The clearance of drugs via The clearance of drugs via direct extraction by the liverdirect extraction by the liver
is is not alterednot altered; however, pregnancy can ; however, pregnancy can increaseincrease the the
hepatic metabolismhepatic metabolism of certain drugs, resulting in a of certain drugs, resulting in a
decrease in plasma concentration.decrease in plasma concentration.
●Because the Because the glomerular filtration rateglomerular filtration rate increasesincreases
during gestation, drugs primarily eliminated by renal during gestation, drugs primarily eliminated by renal
excretion are excretion are cleared more rapidlycleared more rapidly during pregnancy. during pregnancy.
Elimination During PregnancyElimination During Pregnancy ::
●The clearance of drugs via The clearance of drugs via direct extraction by the liverdirect extraction by the liver
is is not alterednot altered; however, pregnancy can ; however, pregnancy can increaseincrease the the
hepatic metabolismhepatic metabolism of certain drugs, resulting in a of certain drugs, resulting in a
decrease in plasma concentration.decrease in plasma concentration.
●Because the Because the glomerular filtration rateglomerular filtration rate increasesincreases
during gestation, drugs primarily eliminated by renal during gestation, drugs primarily eliminated by renal
excretion are excretion are cleared more rapidlycleared more rapidly during pregnancy. during pregnancy.
Pulmonary Medications Pulmonary Medications
During PregnancyDuring Pregnancy
During PregnancyDuring Pregnancy
Page 20
Drugs & Pregnancy:Drugs & Pregnancy:
Category (A)Category (A) Drugs which have been taken by a large number of pregnant women & women of Drugs which have been taken by a large number of pregnant women & women of
childbearing age without any proven increase in the frequency of malformations or childbearing age without any proven increase in the frequency of malformations or
other direct or indirect harmful effects on the fetus having been observed. other direct or indirect harmful effects on the fetus having been observed.
Category (B)Category (B) Drugs that have been taken by only a limited number of pregnant women & women Drugs that have been taken by only a limited number of pregnant women & women
of childbearing age, without an increase in the frequency of malformation or other of childbearing age, without an increase in the frequency of malformation or other
direct or indirect harmful effects on the human fetus having been observed. direct or indirect harmful effects on the human fetus having been observed.
Category (C)Category (C) Drugs that, owing to their pharmacological effects, have caused, or may be suspected Drugs that, owing to their pharmacological effects, have caused, or may be suspected
of causing harmful effects on the human fetus or neonate without causing of causing harmful effects on the human fetus or neonate without causing
malformations. These effects may be reversible.malformations. These effects may be reversible.
Category (D)Category (D) Drugs that have caused, are suspected to have caused, or may be expected to cause an Drugs that have caused, are suspected to have caused, or may be expected to cause an
increased incidence of human fetal malformations, or irreversible damage. These increased incidence of human fetal malformations, or irreversible damage. These
drugs may also have adverse pharmacological effects.drugs may also have adverse pharmacological effects.
Category (X)Category (X) Drugs that have such a high risk of causing permanent damage to the fetus that they Drugs that have such a high risk of causing permanent damage to the fetus that they
should not be used in pregnancy, or when there is a possibility of pregnancy should not be used in pregnancy, or when there is a possibility of pregnancy
Drugs & Pregnancy:Drugs & Pregnancy:
Category (A)Category (A) Drugs which have been taken by a large number of pregnant women & women of Drugs which have been taken by a large number of pregnant women & women of
childbearing age without any proven increase in the frequency of malformations or childbearing age without any proven increase in the frequency of malformations or
other direct or indirect harmful effects on the fetus having been observed. other direct or indirect harmful effects on the fetus having been observed.
Category (B)Category (B) Drugs that have been taken by only a limited number of pregnant women & women Drugs that have been taken by only a limited number of pregnant women & women
of childbearing age, without an increase in the frequency of malformation or other of childbearing age, without an increase in the frequency of malformation or other
direct or indirect harmful effects on the human fetus having been observed. direct or indirect harmful effects on the human fetus having been observed.
Category (C)Category (C) Drugs that, owing to their pharmacological effects, have caused, or may be suspected Drugs that, owing to their pharmacological effects, have caused, or may be suspected
of causing harmful effects on the human fetus or neonate without causing of causing harmful effects on the human fetus or neonate without causing
malformations. These effects may be reversible.malformations. These effects may be reversible.
Category (D)Category (D) Drugs that have caused, are suspected to have caused, or may be expected to cause an Drugs that have caused, are suspected to have caused, or may be expected to cause an
increased incidence of human fetal malformations, or irreversible damage. These increased incidence of human fetal malformations, or irreversible damage. These
drugs may also have adverse pharmacological effects.drugs may also have adverse pharmacological effects.
Category (X)Category (X) Drugs that have such a high risk of causing permanent damage to the fetus that they Drugs that have such a high risk of causing permanent damage to the fetus that they
should not be used in pregnancy, or when there is a possibility of pregnancy should not be used in pregnancy, or when there is a possibility of pregnancy
Page 21
Methylxanthines During PregnancyMethylxanthines During Pregnancy ::
●Both theophylline & aminophylline readily Both theophylline & aminophylline readily cross the cross the
placentaplacenta, but , but no fetal ill effectsno fetal ill effects or or malformationsmalformations
have been reported. have been reported.
●Theophylline pharmacokineticsTheophylline pharmacokinetics are are unaffected unaffected by by
pregnancy, and this drug is also pregnancy, and this drug is also secretedsecreted in in breast milk.breast milk.
Methylxanthines During PregnancyMethylxanthines During Pregnancy ::
●Both theophylline & aminophylline readily Both theophylline & aminophylline readily cross the cross the
placentaplacenta, but , but no fetal ill effectsno fetal ill effects or or malformationsmalformations
have been reported. have been reported.
●Theophylline pharmacokineticsTheophylline pharmacokinetics are are unaffected unaffected by by
pregnancy, and this drug is also pregnancy, and this drug is also secretedsecreted in in breast milk.breast milk.
Page 22
Beta Agonists During PregnancyBeta Agonists During Pregnancy ::
●ββ-agonists have -agonists have little systemic absorptionlittle systemic absorption & a & a more more
potent bronchodilatorypotent bronchodilatory effect via effect via inhalation.inhalation.
●Data on the use of Data on the use of inhaledinhaled ββ -agonists showed -agonists showed no no
differencedifference in in perinatal mortalityperinatal mortality, , congenital congenital
malformationsmalformations, , birth weightbirth weight, or , or Apgar scores.Apgar scores.
Beta Agonists During PregnancyBeta Agonists During Pregnancy ::
●ββ-agonists have -agonists have little systemic absorptionlittle systemic absorption & a & a more more
potent bronchodilatorypotent bronchodilatory effect via effect via inhalation.inhalation.
●Data on the use of Data on the use of inhaledinhaled ββ -agonists showed -agonists showed no no
differencedifference in in perinatal mortalityperinatal mortality, , congenital congenital
malformationsmalformations, , birth weightbirth weight, or , or Apgar scores.Apgar scores.
Page 23
Anticholinergics during PregnancyAnticholinergics during Pregnancy::
●The use of The use of anticholinergicsanticholinergics proved to be proved to be safesafe during during
pregnancy & have been associated with pregnancy & have been associated with no adverse fetal no adverse fetal
outcomes.outcomes.
Anticholinergics during PregnancyAnticholinergics during Pregnancy::
●The use of The use of anticholinergicsanticholinergics proved to be proved to be safesafe during during
pregnancy & have been associated with pregnancy & have been associated with no adverse fetal no adverse fetal
outcomes.outcomes.
Page 24
Bronchodilators In PregnancyBronchodilators In Pregnancy ::
Generic NameGeneric Name Safety Category Safety Category
TheophyllinesTheophyllines CC
SalmeterolSalmeterol CC
IpratropiumIpratropium BB
TiotropiumTiotropium No data availableNo data available
TerbutalinTerbutalin BB
FormoterolFormoterol CC
MontelukastMontelukast BB
Bronchodilators In PregnancyBronchodilators In Pregnancy ::
Generic NameGeneric Name Safety Category Safety Category
TheophyllinesTheophyllines CC
SalmeterolSalmeterol CC
IpratropiumIpratropium BB
TiotropiumTiotropium No data availableNo data available
TerbutalinTerbutalin BB
FormoterolFormoterol CC
MontelukastMontelukast BB
Page 25
Corticosteriods During PregnancyCorticosteriods During Pregnancy ::
●The use of corticosteroids during pregnancy continues to be The use of corticosteroids during pregnancy continues to be
controversial, although numerous reports confirm their use controversial, although numerous reports confirm their use
without adverse fetal effects. without adverse fetal effects.
●In 3 reports on human pregnancies, In 3 reports on human pregnancies, no congenital no congenital
malformationsmalformations or or adverse fetal effectsadverse fetal effects were found from were found from
ICS.ICS.
●PrednisonePrednisone has been used extensively during pregnancy for a has been used extensively during pregnancy for a
variety of conditions. It is associated with an variety of conditions. It is associated with an increased increased
incidence of incidence of cleft palatescleft palates in in animalsanimals but not in humans. but not in humans.
Corticosteriods During PregnancyCorticosteriods During Pregnancy ::
●The use of corticosteroids during pregnancy continues to be The use of corticosteroids during pregnancy continues to be
controversial, although numerous reports confirm their use controversial, although numerous reports confirm their use
without adverse fetal effects. without adverse fetal effects.
●In 3 reports on human pregnancies, In 3 reports on human pregnancies, no congenital no congenital
malformationsmalformations or or adverse fetal effectsadverse fetal effects were found from were found from
ICS.ICS.
●PrednisonePrednisone has been used extensively during pregnancy for a has been used extensively during pregnancy for a
variety of conditions. It is associated with an variety of conditions. It is associated with an increased increased
incidence of incidence of cleft palatescleft palates in in animalsanimals but not in humans. but not in humans.
Page 26
Corticosteroids In PregnancyCorticosteroids In Pregnancy::
Generic NameGeneric Name Safety Category Safety Category
BudesonideBudesonide BB
FluticasoneFluticasone CC
BeclomethasoneBeclomethasone CC
HydrocortisoneHydrocortisone CC
PrednisolonePrednisolone CC
DexamethasoneDexamethasone CC
BetamethasoneBetamethasone CC
Corticosteroids In PregnancyCorticosteroids In Pregnancy::
Generic NameGeneric Name Safety Category Safety Category
BudesonideBudesonide BB
FluticasoneFluticasone CC
BeclomethasoneBeclomethasone CC
HydrocortisoneHydrocortisone CC
PrednisolonePrednisolone CC
DexamethasoneDexamethasone CC
BetamethasoneBetamethasone CC
Page 27
Antibiotics in Respiratory InfectionsAntibiotics in Respiratory Infections::
●The major antibiotics considered safe during pregnancy are The major antibiotics considered safe during pregnancy are
penicillinpenicillin, , cephalosporinscephalosporins, & , & erythromycin.erythromycin.
●Although penicillin & ampicillin readily cross the placenta, no Although penicillin & ampicillin readily cross the placenta, no
adverse effects to the fetus are reported. adverse effects to the fetus are reported.
●CephalosporinsCephalosporins traverse the traverse the placentaplacenta to a moderate degree, to a moderate degree,
but but nono adverse adverse fetal fetal effects occur. effects occur.
●Erythromycin crosses the placenta to a low degree but achieves Erythromycin crosses the placenta to a low degree but achieves
high levels in breast milk. The high levels in breast milk. The estolateestolate formulation is formulation is
contraindicatedcontraindicated due to potential maternal due to potential maternal hepatic toxicity.hepatic toxicity.
●Antibiotics that have relative contraindications include Antibiotics that have relative contraindications include
sulfonamidessulfonamides,, trimethoprim trimethoprim ,, aminoglycosides aminoglycosides ,,
nitrofurantoinnitrofurantoin,, tetracyclines tetracyclines, &, & quinolones quinolones..
Antibiotics in Respiratory InfectionsAntibiotics in Respiratory Infections::
●The major antibiotics considered safe during pregnancy are The major antibiotics considered safe during pregnancy are
penicillinpenicillin, , cephalosporinscephalosporins, & , & erythromycin.erythromycin.
●Although penicillin & ampicillin readily cross the placenta, no Although penicillin & ampicillin readily cross the placenta, no
adverse effects to the fetus are reported. adverse effects to the fetus are reported.
●CephalosporinsCephalosporins traverse the traverse the placentaplacenta to a moderate degree, to a moderate degree,
but but nono adverse adverse fetal fetal effects occur. effects occur.
●Erythromycin crosses the placenta to a low degree but achieves Erythromycin crosses the placenta to a low degree but achieves
high levels in breast milk. The high levels in breast milk. The estolateestolate formulation is formulation is
contraindicatedcontraindicated due to potential maternal due to potential maternal hepatic toxicity.hepatic toxicity.
●Antibiotics that have relative contraindications include Antibiotics that have relative contraindications include
sulfonamidessulfonamides,, trimethoprim trimethoprim ,, aminoglycosides aminoglycosides ,,
nitrofurantoinnitrofurantoin,, tetracyclines tetracyclines, &, & quinolones quinolones..
Page 28
Teratogens used in Pulmonary DiseasesTeratogens used in Pulmonary Diseases ::
●These drugs include These drugs include iodine-containing compoundsiodine-containing compounds . .
BrompheniramineBrompheniramine , , antihistamineantihistamine, & , & coumarincoumarin cause cause
various various teratogenic effects.teratogenic effects.
●CiprofloxacinCiprofloxacin,, sulfonamides sulfonamides ,, tetracyclines tetracyclines ,,
chloramphenicolchloramphenicol,, streptomycin streptomycin, &, & rifampin rifampin have have
been associated with various effects. been associated with various effects.
Teratogens used in Pulmonary DiseasesTeratogens used in Pulmonary Diseases ::
●These drugs include These drugs include iodine-containing compoundsiodine-containing compounds . .
BrompheniramineBrompheniramine , , antihistamineantihistamine, & , & coumarincoumarin cause cause
various various teratogenic effects.teratogenic effects.
●CiprofloxacinCiprofloxacin,, sulfonamides sulfonamides ,, tetracyclines tetracyclines ,,
chloramphenicolchloramphenicol,, streptomycin streptomycin, &, & rifampin rifampin have have
been associated with various effects. been associated with various effects.
Page 29
Antibiotics In PregnancyAntibiotics In Pregnancy::
Generic NameGeneric Name Safety Category Safety Category
PenicillinPenicillin BB
CephalosporinsCephalosporins BB
Imipenem/cilastatinImipenem/cilastatin CC
MeropenemMeropenem BB
AztreonamAztreonam BB
MetronidazoleMetronidazole BB
ClindamycinClindamycin BB
ClarithromycinClarithromycin CC
Erythromycin/AzithromycinErythromycin/Azithromycin BB
TetracyclinesTetracyclines DD
Sulfonamides/TrimethoprimSulfonamides/Trimethoprim CC
QuinolonesQuinolones CC
VancomycinVancomycin CC
ChloramphenicolChloramphenicol CC
Antibiotics In PregnancyAntibiotics In Pregnancy::
Generic NameGeneric Name Safety Category Safety Category
PenicillinPenicillin BB
CephalosporinsCephalosporins BB
Imipenem/cilastatinImipenem/cilastatin CC
MeropenemMeropenem BB
AztreonamAztreonam BB
MetronidazoleMetronidazole BB
ClindamycinClindamycin BB
ClarithromycinClarithromycin CC
Erythromycin/AzithromycinErythromycin/Azithromycin BB
TetracyclinesTetracyclines DD
Sulfonamides/TrimethoprimSulfonamides/Trimethoprim CC
QuinolonesQuinolones CC
VancomycinVancomycin CC
ChloramphenicolChloramphenicol CC
Page 30
Antihistaminic In PregnancyAntihistaminic In Pregnancy::
Generic NameGeneric Name Safety Category Safety Category
ChlorpheniramineChlorpheniramine BB
LoratadineLoratadine BB
EbastineEbastine Not establishedNot established
DesloratadineDesloratadine Not establishedNot established
CetrizineCetrizine Not establishedNot established
Antihistaminic In PregnancyAntihistaminic In Pregnancy::
Generic NameGeneric Name Safety Category Safety Category
ChlorpheniramineChlorpheniramine BB
LoratadineLoratadine BB
EbastineEbastine Not establishedNot established
DesloratadineDesloratadine Not establishedNot established
CetrizineCetrizine Not establishedNot established
Page 31
Cough Preparations In PregnancyCough Preparations In Pregnancy ::
Generic NameGeneric Name Safety Category Safety Category
BromhexineBromhexine Not establishedNot established
AcetylcysteineAcetylcysteine BB
AmbroxolAmbroxol Not establishedNot established
Cough Preparations In PregnancyCough Preparations In Pregnancy ::
Generic NameGeneric Name Safety Category Safety Category
BromhexineBromhexine Not establishedNot established
AcetylcysteineAcetylcysteine BB
AmbroxolAmbroxol Not establishedNot established
Page 32
Teratogens used in Pulmonary DiseasesTeratogens used in Pulmonary Diseases ::
●Ionizing radiation exposure to the fetus is associated with Ionizing radiation exposure to the fetus is associated with
growth retardationgrowth retardation,, CNS effects CNS effects,, microcephaly microcephaly, &, &
eye malformations. eye malformations.
●Maternal radiation exposure of Maternal radiation exposure of <0.05Gy<0.05Gy is associated with is associated with
no adverse effects,no adverse effects, a dose of a dose of 0.05-0.1Gy0.05-0.1Gy is considered the is considered the
gray zonegray zone & exposure to & exposure to>0.1Gy>0.1Gy is associated with is associated with
significant fetal effects. significant fetal effects.
●Fetal ionizing radiation might cause Fetal ionizing radiation might cause ↑↑ in childhood in childhood leukemia.leukemia.
●A A CXRCXR results in results in 0.002Gy0.002Gy exposure; exposure; perfusion lung scanperfusion lung scan
0.002Gy0.002Gy; ; ventilation lung scanventilation lung scan 0.004Gy0.004Gy; ; pulmonary pulmonary
angiographyangiography 0.004Gy0.004Gy & & venography 0.004Gy.venography 0.004Gy.
Teratogens used in Pulmonary DiseasesTeratogens used in Pulmonary Diseases ::
●Ionizing radiation exposure to the fetus is associated with Ionizing radiation exposure to the fetus is associated with
growth retardationgrowth retardation,, CNS effects CNS effects,, microcephaly microcephaly, &, &
eye malformations. eye malformations.
●Maternal radiation exposure of Maternal radiation exposure of <0.05Gy<0.05Gy is associated with is associated with
no adverse effects,no adverse effects, a dose of a dose of 0.05-0.1Gy0.05-0.1Gy is considered the is considered the
gray zonegray zone & exposure to & exposure to>0.1Gy>0.1Gy is associated with is associated with
significant fetal effects. significant fetal effects.
●Fetal ionizing radiation might cause Fetal ionizing radiation might cause ↑↑ in childhood in childhood leukemia.leukemia.
●A A CXRCXR results in results in 0.002Gy0.002Gy exposure; exposure; perfusion lung scanperfusion lung scan
0.002Gy0.002Gy; ; ventilation lung scanventilation lung scan 0.004Gy0.004Gy; ; pulmonary pulmonary
angiographyangiography 0.004Gy0.004Gy & & venography 0.004Gy.venography 0.004Gy.
Pregnancy-Specific Pregnancy-Specific
Pulmonary DisordersPulmonary Disorders
Pulmonary DisordersPulmonary Disorders
Page 34
Amniotic Fluid Embolism:Amniotic Fluid Embolism:
●Amniotic fluid embolism is a Amniotic fluid embolism is a rare (1 per 8000-80,000)rare (1 per 8000-80,000) but but
potentiallypotentially catastrophic catastrophic complication, with a complication, with a mortality mortality
raterate of of 10-80%. 10-80%.
●This usually occurs with labor & delivery but can be associated This usually occurs with labor & delivery but can be associated
with uterine manipulation, uterine trauma, & the early with uterine manipulation, uterine trauma, & the early
postpartum period. postpartum period.
●Amniotic fluid containing particulate cellular elements enters Amniotic fluid containing particulate cellular elements enters
the the vascular circulationvascular circulation through through endocervical veinsendocervical veins or or
uterine tearsuterine tears, obstructs the pulmonary vessels, & causes , obstructs the pulmonary vessels, & causes
vascular spasms, resulting in vascular spasms, resulting in pulmonary hypertension.pulmonary hypertension.
●Acute left ventricular failureAcute left ventricular failure might occur, probably due might occur, probably due
to humoral events mediated by cytokines.to humoral events mediated by cytokines.
Amniotic Fluid Embolism:Amniotic Fluid Embolism:
●Amniotic fluid embolism is a Amniotic fluid embolism is a rare (1 per 8000-80,000)rare (1 per 8000-80,000) but but
potentiallypotentially catastrophic catastrophic complication, with a complication, with a mortality mortality
raterate of of 10-80%. 10-80%.
●This usually occurs with labor & delivery but can be associated This usually occurs with labor & delivery but can be associated
with uterine manipulation, uterine trauma, & the early with uterine manipulation, uterine trauma, & the early
postpartum period. postpartum period.
●Amniotic fluid containing particulate cellular elements enters Amniotic fluid containing particulate cellular elements enters
the the vascular circulationvascular circulation through through endocervical veinsendocervical veins or or
uterine tearsuterine tears, obstructs the pulmonary vessels, & causes , obstructs the pulmonary vessels, & causes
vascular spasms, resulting in vascular spasms, resulting in pulmonary hypertension.pulmonary hypertension.
●Acute left ventricular failureAcute left ventricular failure might occur, probably due might occur, probably due
to humoral events mediated by cytokines.to humoral events mediated by cytokines.
Page 35
Tocolytic Pulmonary Edema:Tocolytic Pulmonary Edema:
●ββ-adrenergic agonists, particularly -adrenergic agonists, particularly terbutalineterbutaline, are used to , are used to
inhibit uterine contractionsinhibit uterine contractions & & preterm labor.preterm labor.
●These might cause These might cause pulmonary edemapulmonary edema during pregnancy. during pregnancy.
●The The frequencyfrequency varies from varies from 0.3-9%.0.3-9%.
●Mechanisms include Mechanisms include prolonged exposure to prolonged exposure to
catecholaminescatecholamines (which causes myocardial dysfunction), (which causes myocardial dysfunction),
increased capillary permeabilityincreased capillary permeability, & a , & a large volume of large volume of
intravenous fluidintravenous fluid that may have been administered in that may have been administered in
response to maternal tachycardia. response to maternal tachycardia.
●GlucocorticoidsGlucocorticoids administered in preterm labor can also administered in preterm labor can also
contribute to contribute to fluid retention.fluid retention.
Tocolytic Pulmonary Edema:Tocolytic Pulmonary Edema:
●ββ-adrenergic agonists, particularly -adrenergic agonists, particularly terbutalineterbutaline, are used to , are used to
inhibit uterine contractionsinhibit uterine contractions & & preterm labor.preterm labor.
●These might cause These might cause pulmonary edemapulmonary edema during pregnancy. during pregnancy.
●The The frequencyfrequency varies from varies from 0.3-9%.0.3-9%.
●Mechanisms include Mechanisms include prolonged exposure to prolonged exposure to
catecholaminescatecholamines (which causes myocardial dysfunction), (which causes myocardial dysfunction),
increased capillary permeabilityincreased capillary permeability, & a , & a large volume of large volume of
intravenous fluidintravenous fluid that may have been administered in that may have been administered in
response to maternal tachycardia. response to maternal tachycardia.
●GlucocorticoidsGlucocorticoids administered in preterm labor can also administered in preterm labor can also
contribute to contribute to fluid retention.fluid retention.
Page 36
Gestation Trophoblastic Disease:Gestation Trophoblastic Disease:
●Pulmonary hypertensionPulmonary hypertension & & pulmonary edemapulmonary edema can can
complicate complicate benign hydatidiform pregnancybenign hydatidiform pregnancy due to due to
trophoblastic pulmonary embolism.trophoblastic pulmonary embolism.
●This commonly occurs This commonly occurs during evacuationduring evacuation of the of the uterusuterus, & , &
the the incidenceincidence of of pulmonary complicationspulmonary complications is is higherhigher in in
later gestations.later gestations.
●Molar pregnancyMolar pregnancy can be associated with can be associated with
choriocarcinomachoriocarcinoma, which commonly produces , which commonly produces multiple multiple
discrete pulmonary metastasesdiscrete pulmonary metastases & occasional & occasional pleural pleural
effusions.effusions.
Gestation Trophoblastic Disease:Gestation Trophoblastic Disease:
●Pulmonary hypertensionPulmonary hypertension & & pulmonary edemapulmonary edema can can
complicate complicate benign hydatidiform pregnancybenign hydatidiform pregnancy due to due to
trophoblastic pulmonary embolism.trophoblastic pulmonary embolism.
●This commonly occurs This commonly occurs during evacuationduring evacuation of the of the uterusuterus, & , &
the the incidenceincidence of of pulmonary complicationspulmonary complications is is higherhigher in in
later gestations.later gestations.
●Molar pregnancyMolar pregnancy can be associated with can be associated with
choriocarcinomachoriocarcinoma, which commonly produces , which commonly produces multiple multiple
discrete pulmonary metastasesdiscrete pulmonary metastases & occasional & occasional pleural pleural
effusions.effusions.
Asthma & PregnancyAsthma & Pregnancy
Page 38
Asthma in Pregnancy:Asthma in Pregnancy:
●Asthma is one of the most common coexisting medical Asthma is one of the most common coexisting medical
conditions affecting reproductive-aged woman. conditions affecting reproductive-aged woman.
●The course of asthma during pregnancy is variable; The course of asthma during pregnancy is variable; one one
thirdthird of patients of patients improveimprove, , one thirdone third remain remain stablestable, & , &
one third worsen.one third worsen.
●In patients with symptomatic asthma, In patients with symptomatic asthma, gestational weeks gestational weeks
24-3624-36 tend to be the tend to be the most difficult.most difficult.
Asthma in Pregnancy:Asthma in Pregnancy:
●Asthma is one of the most common coexisting medical Asthma is one of the most common coexisting medical
conditions affecting reproductive-aged woman. conditions affecting reproductive-aged woman.
●The course of asthma during pregnancy is variable; The course of asthma during pregnancy is variable; one one
thirdthird of patients of patients improveimprove, , one thirdone third remain remain stablestable, & , &
one third worsen.one third worsen.
●In patients with symptomatic asthma, In patients with symptomatic asthma, gestational weeks gestational weeks
24-3624-36 tend to be the tend to be the most difficult.most difficult.
Page 39
Asthma in Pregnancy:Asthma in Pregnancy:
●Only Only 10%10% of women experience of women experience asthma exacerbationasthma exacerbation
during laborduring labor & & deliverydelivery, and the , and the severityseverity tends to tends to
revertrevert to that of pregnancy by to that of pregnancy by 3 months' postpartum.3 months' postpartum.
●Asthma is generally expected to follow a Asthma is generally expected to follow a similar coursesimilar course
during during successive pregnancies.successive pregnancies.
●Infant outcomeInfant outcome might be might be worseworse as as asthma severity asthma severity
increasesincreases & that & that outcomeoutcome with with aggressive asthma aggressive asthma
managementmanagement is usually is usually good.good.
Asthma in Pregnancy:Asthma in Pregnancy:
●Only Only 10%10% of women experience of women experience asthma exacerbationasthma exacerbation
during laborduring labor & & deliverydelivery, and the , and the severityseverity tends to tends to
revertrevert to that of pregnancy by to that of pregnancy by 3 months' postpartum.3 months' postpartum.
●Asthma is generally expected to follow a Asthma is generally expected to follow a similar coursesimilar course
during during successive pregnancies.successive pregnancies.
●Infant outcomeInfant outcome might be might be worseworse as as asthma severity asthma severity
increasesincreases & that & that outcomeoutcome with with aggressive asthma aggressive asthma
managementmanagement is usually is usually good.good.
Page 40
Asthma in Pregnancy:Asthma in Pregnancy:
●Asthma exacerbationsAsthma exacerbations occur primarily in the occur primarily in the late late
second trimestersecond trimester & are either & are either triggeredtriggered by by viral viral
infectioninfection or or non-adherence non-adherence toto ICS. ICS.
●Severe exacerbationsSevere exacerbations during pregnancy are a during pregnancy are a
significant risk factorsignificant risk factor for a for a low birth weightlow birth weight baby and baby and
ICSICS use may use may reduce the risk.reduce the risk.
●Clinical featuresClinical features of asthma during pregnancy are of asthma during pregnancy are the the
samesame as those in the as those in the non-pregnant non-pregnant patient. patient.
Asthma in Pregnancy:Asthma in Pregnancy:
●Asthma exacerbationsAsthma exacerbations occur primarily in the occur primarily in the late late
second trimestersecond trimester & are either & are either triggeredtriggered by by viral viral
infectioninfection or or non-adherence non-adherence toto ICS. ICS.
●Severe exacerbationsSevere exacerbations during pregnancy are a during pregnancy are a
significant risk factorsignificant risk factor for a for a low birth weightlow birth weight baby and baby and
ICSICS use may use may reduce the risk.reduce the risk.
●Clinical featuresClinical features of asthma during pregnancy are of asthma during pregnancy are the the
samesame as those in the as those in the non-pregnant non-pregnant patient. patient.
Page 41
Fetal Outcome in Asthma with Pregnancy:Fetal Outcome in Asthma with Pregnancy:
●Asthma can have a number of deleterious effects on Asthma can have a number of deleterious effects on
pregnancy outcome. pregnancy outcome.
●An An increasedincreased incidence of incidence of preterm birthspreterm births, , low birth low birth
weightweight, & , & increased prenatal mortalityincreased prenatal mortality largely related largely related
to poor asthma control has been reported. to poor asthma control has been reported.
Fetal Outcome in Asthma with Pregnancy:Fetal Outcome in Asthma with Pregnancy:
●Asthma can have a number of deleterious effects on Asthma can have a number of deleterious effects on
pregnancy outcome. pregnancy outcome.
●An An increasedincreased incidence of incidence of preterm birthspreterm births, , low birth low birth
weightweight, & , & increased prenatal mortalityincreased prenatal mortality largely related largely related
to poor asthma control has been reported. to poor asthma control has been reported.
Page 42
Acute Asthma Exacerbation with Pregnancy:Acute Asthma Exacerbation with Pregnancy:
●Acute exacerbations that necessitate emergency department Acute exacerbations that necessitate emergency department
visits typically require a course of visits typically require a course of systemic systemic
corticosteroids.corticosteroids.
●OxygenOxygen should be used liberally, & the should be used liberally, & the oxygen oxygen
saturationsaturation should be maintained should be maintained ≥ 95%≥ 95% to ensure fetal to ensure fetal
well-being. well-being.
●A A beta-agonistbeta-agonist with or without with or without ipratropiumipratropium should be should be
given via given via MDIMDI with a with a spacer spacer or in or in nebulizednebulized form. form.
●TheophyllineTheophylline has has limited limited use in acute exacerbations. use in acute exacerbations.
Acute Asthma Exacerbation with Pregnancy:Acute Asthma Exacerbation with Pregnancy:
●Acute exacerbations that necessitate emergency department Acute exacerbations that necessitate emergency department
visits typically require a course of visits typically require a course of systemic systemic
corticosteroids.corticosteroids.
●OxygenOxygen should be used liberally, & the should be used liberally, & the oxygen oxygen
saturationsaturation should be maintained should be maintained ≥ 95%≥ 95% to ensure fetal to ensure fetal
well-being. well-being.
●A A beta-agonistbeta-agonist with or without with or without ipratropiumipratropium should be should be
given via given via MDIMDI with a with a spacer spacer or in or in nebulizednebulized form. form.
●TheophyllineTheophylline has has limited limited use in acute exacerbations. use in acute exacerbations.
Venous Thromboembolic Venous Thromboembolic
Disease & PregnancyDisease & Pregnancy
Disease & PregnancyDisease & Pregnancy
Page 44
●The The incidenceincidence of of venous thromboembolismvenous thromboembolism is is
estimated at estimated at 0.76-1.72/1000 pregnancies0.76-1.72/1000 pregnancies, which is , which is fourfour
times as great as the risk in the non-pregnant population.times as great as the risk in the non-pregnant population.
●Current estimates of Current estimates of deathsdeaths from from pulmonary embolismpulmonary embolism
are are 1.1-1.5/100,000 deliveries1.1-1.5/100,000 deliveries in the US & Europe. in the US & Europe.
●Delayed diagnosisDelayed diagnosis , , delayed delayed oror inadequate inadequate
treatmenttreatment, & , & inadequate thromboprophylaxisinadequate thromboprophylaxis
account for many of the deaths due to venous account for many of the deaths due to venous
thromboembolismthromboembolism
Venous Thromboembilic Disease & Pregnancy:Venous Thromboembilic Disease & Pregnancy:
●The The incidenceincidence of of venous thromboembolismvenous thromboembolism is is
estimated at estimated at 0.76-1.72/1000 pregnancies0.76-1.72/1000 pregnancies, which is , which is fourfour
times as great as the risk in the non-pregnant population.times as great as the risk in the non-pregnant population.
●Current estimates of Current estimates of deathsdeaths from from pulmonary embolismpulmonary embolism
are are 1.1-1.5/100,000 deliveries1.1-1.5/100,000 deliveries in the US & Europe. in the US & Europe.
●Delayed diagnosisDelayed diagnosis , , delayed delayed oror inadequate inadequate
treatmenttreatment, & , & inadequate thromboprophylaxisinadequate thromboprophylaxis
account for many of the deaths due to venous account for many of the deaths due to venous
thromboembolismthromboembolism
Venous Thromboembilic Disease & Pregnancy:Venous Thromboembilic Disease & Pregnancy:
Page 45
Diagnostic Algorithm for VTD in Pregnancy:Diagnostic Algorithm for VTD in Pregnancy:
Diagnostic Algorithm for VTD in Pregnancy:Diagnostic Algorithm for VTD in Pregnancy:
Page 46
Venous Thromboembilic Disease & Pregnancy:Venous Thromboembilic Disease & Pregnancy:
Venous Thromboembilic Disease & Pregnancy:Venous Thromboembilic Disease & Pregnancy:
Page 47
Venous Thromboembilic Disease & Pregnancy:Venous Thromboembilic Disease & Pregnancy:
Venous Thromboembilic Disease & Pregnancy:Venous Thromboembilic Disease & Pregnancy:
Page 48
Venous Thromboembilic Disease & Pregnancy:Venous Thromboembilic Disease & Pregnancy:
Venous Thromboembilic Disease & Pregnancy:Venous Thromboembilic Disease & Pregnancy:
ARDS & PregnancyARDS & Pregnancy
Page 50
●Pregnant patients are at risk of developing ARDS from Pregnant patients are at risk of developing ARDS from
obstetric complications & from non-obstetric conditions. obstetric complications & from non-obstetric conditions.
●ObstetricObstetric complications, such as complications, such as amniotic fluid amniotic fluid
embolismembolism, , chorioamnionitischorioamnionitis, , trophoblastic trophoblastic
embolismembolism, & , & placental abruptionplacental abruption, can produce acute , can produce acute
lung injury. lung injury.
●Pregnancy predisposes the patient to other pulmonary Pregnancy predisposes the patient to other pulmonary
insults that can cause ARDS, such as insults that can cause ARDS, such as gastric aspirationgastric aspiration, ,
pneumoniapneumonia, , air embolismair embolism, & , & massive hemorrhage. massive hemorrhage.
ARDS & Pregnancy:ARDS & Pregnancy:
●Pregnant patients are at risk of developing ARDS from Pregnant patients are at risk of developing ARDS from
obstetric complications & from non-obstetric conditions. obstetric complications & from non-obstetric conditions.
●ObstetricObstetric complications, such as complications, such as amniotic fluid amniotic fluid
embolismembolism, , chorioamnionitischorioamnionitis, , trophoblastic trophoblastic
embolismembolism, & , & placental abruptionplacental abruption, can produce acute , can produce acute
lung injury. lung injury.
●Pregnancy predisposes the patient to other pulmonary Pregnancy predisposes the patient to other pulmonary
insults that can cause ARDS, such as insults that can cause ARDS, such as gastric aspirationgastric aspiration, ,
pneumoniapneumonia, , air embolismair embolism, & , & massive hemorrhage. massive hemorrhage.
ARDS & Pregnancy:ARDS & Pregnancy:
Page 51
●An association between An association between pyelonephritispyelonephritis & the development & the development
of of ARDSARDS has been described in pregnancy. has been described in pregnancy.
●The mechanism is The mechanism is unclearunclear, but , but iatrogeniciatrogenic factors, such as factors, such as
excessive fluid administrationexcessive fluid administration & & tocolytic therapytocolytic therapy, ,
might be responsible. might be responsible.
●The The reduced albuminreduced albumin level & resultant level & resultant reduced plasma reduced plasma
oncotic pressureoncotic pressure occurring in pregnancy occurring in pregnancy lowerslowers the the
critical pulmonary capillary pressurecritical pulmonary capillary pressure at which at which
pulmonary edema develops.pulmonary edema develops.
ARDS & Pregnancy:ARDS & Pregnancy:
●An association between An association between pyelonephritispyelonephritis & the development & the development
of of ARDSARDS has been described in pregnancy. has been described in pregnancy.
●The mechanism is The mechanism is unclearunclear, but , but iatrogeniciatrogenic factors, such as factors, such as
excessive fluid administrationexcessive fluid administration & & tocolytic therapytocolytic therapy, ,
might be responsible. might be responsible.
●The The reduced albuminreduced albumin level & resultant level & resultant reduced plasma reduced plasma
oncotic pressureoncotic pressure occurring in pregnancy occurring in pregnancy lowerslowers the the
critical pulmonary capillary pressurecritical pulmonary capillary pressure at which at which
pulmonary edema develops.pulmonary edema develops.
ARDS & Pregnancy:ARDS & Pregnancy:
Page 52
●No major differencesNo major differences exist in the exist in the managementmanagement of of
pregnant & non-pregnant patient with ARDS. pregnant & non-pregnant patient with ARDS.
●Fetal riskFetal risk must be considered when must be considered when pharmacological pharmacological
therapytherapy is administered. is administered.
●Adequate maternal oxygen saturationAdequate maternal oxygen saturation is essential for is essential for
fetal well-being.fetal well-being.
●Excessive alkalosisExcessive alkalosis can have adverse effects on can have adverse effects on placental placental
perfusionperfusion, while , while maternal acidosismaternal acidosis appears to be appears to be
reasonably reasonably well toleratedwell tolerated by the by the fetus.fetus.
●Survival Survival appears appears similarsimilar to ARDS in the general to ARDS in the general
population.population.
ARDS & Pregnancy:ARDS & Pregnancy:
●No major differencesNo major differences exist in the exist in the managementmanagement of of
pregnant & non-pregnant patient with ARDS. pregnant & non-pregnant patient with ARDS.
●Fetal riskFetal risk must be considered when must be considered when pharmacological pharmacological
therapytherapy is administered. is administered.
●Adequate maternal oxygen saturationAdequate maternal oxygen saturation is essential for is essential for
fetal well-being.fetal well-being.
●Excessive alkalosisExcessive alkalosis can have adverse effects on can have adverse effects on placental placental
perfusionperfusion, while , while maternal acidosismaternal acidosis appears to be appears to be
reasonably reasonably well toleratedwell tolerated by the by the fetus.fetus.
●Survival Survival appears appears similarsimilar to ARDS in the general to ARDS in the general
population.population.
ARDS & Pregnancy:ARDS & Pregnancy:
Tuberculosis Tuberculosis
& Pregnancy& Pregnancy
& Pregnancy& Pregnancy
Page 54
●Untreated TB represents a far greater hazard to a pregnant Untreated TB represents a far greater hazard to a pregnant
woman & her fetus than does treatment of the disease.woman & her fetus than does treatment of the disease.
●Infants born to women with untreated TB may be of Infants born to women with untreated TB may be of lower lower
birth weightbirth weight than those born to women without TB &, than those born to women without TB &,
rarelyrarely, the infant may acquire , the infant may acquire congenital TB.congenital TB.
●Thus, treatment of a pregnant woman with suspected TB Thus, treatment of a pregnant woman with suspected TB
should be started if the probability of TB is should be started if the probability of TB is moderate moderate to to
high.high.
●Administration of antituberculosis drugs is Administration of antituberculosis drugs is notnot an indication an indication
for for termination of pregnancy.termination of pregnancy.
Tuberculosis & Pregnancy:Tuberculosis & Pregnancy:
●Untreated TB represents a far greater hazard to a pregnant Untreated TB represents a far greater hazard to a pregnant
woman & her fetus than does treatment of the disease.woman & her fetus than does treatment of the disease.
●Infants born to women with untreated TB may be of Infants born to women with untreated TB may be of lower lower
birth weightbirth weight than those born to women without TB &, than those born to women without TB &,
rarelyrarely, the infant may acquire , the infant may acquire congenital TB.congenital TB.
●Thus, treatment of a pregnant woman with suspected TB Thus, treatment of a pregnant woman with suspected TB
should be started if the probability of TB is should be started if the probability of TB is moderate moderate to to
high.high.
●Administration of antituberculosis drugs is Administration of antituberculosis drugs is notnot an indication an indication
for for termination of pregnancy.termination of pregnancy.
Tuberculosis & Pregnancy:Tuberculosis & Pregnancy:
Page 55
●HIV infection & drug-resistant TB present special challenges in HIV infection & drug-resistant TB present special challenges in
pregnancy.pregnancy.
●Knowledge of drug interactions & teratogenic effects of Knowledge of drug interactions & teratogenic effects of
antiretroviralsantiretrovirals & & 22
ndnd
line antituberculosis agents is needed line antituberculosis agents is needed
to treat these patients properly.to treat these patients properly.
●TB in pregnancy is treated with TB in pregnancy is treated with isoniazidisoniazid & & rifampin & rifampin &
ethambutolethambutol..
●These drugs may These drugs may crosscross the the placentalplacental barrier, but they are barrier, but they are
associated with a associated with a low risklow risk of adverse fetal effects. of adverse fetal effects.
●Streptomycin Streptomycin & other & other injectableinjectable antituberculous drugs are antituberculous drugs are
contraindicatedcontraindicated because of because of fetal toxicityfetal toxicity & potential & potential
teratogenic effects.teratogenic effects.
Tuberculosis & Pregnancy:Tuberculosis & Pregnancy:
●HIV infection & drug-resistant TB present special challenges in HIV infection & drug-resistant TB present special challenges in
pregnancy.pregnancy.
●Knowledge of drug interactions & teratogenic effects of Knowledge of drug interactions & teratogenic effects of
antiretroviralsantiretrovirals & & 22
ndnd
line antituberculosis agents is needed line antituberculosis agents is needed
to treat these patients properly.to treat these patients properly.
●TB in pregnancy is treated with TB in pregnancy is treated with isoniazidisoniazid & & rifampin & rifampin &
ethambutolethambutol..
●These drugs may These drugs may crosscross the the placentalplacental barrier, but they are barrier, but they are
associated with a associated with a low risklow risk of adverse fetal effects. of adverse fetal effects.
●Streptomycin Streptomycin & other & other injectableinjectable antituberculous drugs are antituberculous drugs are
contraindicatedcontraindicated because of because of fetal toxicityfetal toxicity & potential & potential
teratogenic effects.teratogenic effects.
Tuberculosis & Pregnancy:Tuberculosis & Pregnancy:
Page 56
●IsoniazidIsoniazid (Pregnancy Category (Pregnancy Category AA)) may cause may cause cutaneous cutaneous
hypersensitivityhypersensitivity, , hepatitishepatitis, , peripheral neuropathy.peripheral neuropathy.
●The risk of The risk of INH-induced hepatitisINH-induced hepatitis may be may be 2.5 times 2.5 times
higherhigher in pre-natal patients than the general population. in pre-natal patients than the general population.
●Pyridoxine 25 mg/dayPyridoxine 25 mg/day , should be given to pregnant , should be given to pregnant
women receiving women receiving INH.INH.
●INHINH given for treatment of given for treatment of latent TB latent TB
(chemoprophylaxis)(chemoprophylaxis) is considered is considered safesafe & is & is
recommended especially where the risk of developing disease recommended especially where the risk of developing disease
is higher, e.g., with HIV co-infection or with a history of is higher, e.g., with HIV co-infection or with a history of
recent contact.recent contact.
Tuberculosis & Pregnancy:Tuberculosis & Pregnancy:
●IsoniazidIsoniazid (Pregnancy Category (Pregnancy Category AA)) may cause may cause cutaneous cutaneous
hypersensitivityhypersensitivity, , hepatitishepatitis, , peripheral neuropathy.peripheral neuropathy.
●The risk of The risk of INH-induced hepatitisINH-induced hepatitis may be may be 2.5 times 2.5 times
higherhigher in pre-natal patients than the general population. in pre-natal patients than the general population.
●Pyridoxine 25 mg/dayPyridoxine 25 mg/day , should be given to pregnant , should be given to pregnant
women receiving women receiving INH.INH.
●INHINH given for treatment of given for treatment of latent TB latent TB
(chemoprophylaxis)(chemoprophylaxis) is considered is considered safesafe & is & is
recommended especially where the risk of developing disease recommended especially where the risk of developing disease
is higher, e.g., with HIV co-infection or with a history of is higher, e.g., with HIV co-infection or with a history of
recent contact.recent contact.
Tuberculosis & Pregnancy:Tuberculosis & Pregnancy:
Page 57
●Rifampicin Rifampicin (Pregnancy Category (Pregnancy Category CC) causes bleeding due to ) causes bleeding due to
hypoprothrominaemia in infants & mothers especially if hypoprothrominaemia in infants & mothers especially if
adminsterated in late pregnancy.adminsterated in late pregnancy.
●Vitamin KVitamin K is given to both the mother & the infant is given to both the mother & the infant
postpartum if postpartum if rifampicinrifampicin is used in the is used in the last few weekslast few weeks of of
pregnancy.pregnancy.
●RifampicinRifampicin may cause may cause nauseanausea, , vomitingvomiting & & hepatitis.hepatitis.
Tuberculosis & Pregnancy:Tuberculosis & Pregnancy:
●Rifampicin Rifampicin (Pregnancy Category (Pregnancy Category CC) causes bleeding due to ) causes bleeding due to
hypoprothrominaemia in infants & mothers especially if hypoprothrominaemia in infants & mothers especially if
adminsterated in late pregnancy.adminsterated in late pregnancy.
●Vitamin KVitamin K is given to both the mother & the infant is given to both the mother & the infant
postpartum if postpartum if rifampicinrifampicin is used in the is used in the last few weekslast few weeks of of
pregnancy.pregnancy.
●RifampicinRifampicin may cause may cause nauseanausea, , vomitingvomiting & & hepatitis.hepatitis.
Tuberculosis & Pregnancy:Tuberculosis & Pregnancy:
Page 58
●EthambutolEthambutol (Pregnancy Category (Pregnancy Category AA) is recommended for ) is recommended for
use in pregnancy. use in pregnancy.
●Retrobulbar neuritisRetrobulbar neuritis occurs in occurs in <1%<1% of cases on a daily of cases on a daily
dose of dose of 15 mg /kg15 mg /kg of of Ethambutol.Ethambutol.
Tuberculosis & Pregnancy:Tuberculosis & Pregnancy:
●EthambutolEthambutol (Pregnancy Category (Pregnancy Category AA) is recommended for ) is recommended for
use in pregnancy. use in pregnancy.
●Retrobulbar neuritisRetrobulbar neuritis occurs in occurs in <1%<1% of cases on a daily of cases on a daily
dose of dose of 15 mg /kg15 mg /kg of of Ethambutol.Ethambutol.
Tuberculosis & Pregnancy:Tuberculosis & Pregnancy:
Page 59
●There are There are no reportsno reports of of fetal malformationsfetal malformations
attributable to attributable to pyrazinamide.pyrazinamide. The absence of such safety The absence of such safety
data is the reason that the CDC guidelines data is the reason that the CDC guidelines do not endorsedo not endorse
pyrazinamidepyrazinamide in in pregnancy.pregnancy.
●PyrazinamidePyrazinamide may produce may produce gastrointestinal upsetsgastrointestinal upsets, ,
arthralgiaarthralgia, , hyperuricemiahyperuricemia & & hepatitis.hepatitis.
●If If PZAPZA is not included in the is not included in the initialinitial treatment regimen, the treatment regimen, the
minimumminimum duration of therapy is duration of therapy is 9 months.9 months.
Tuberculosis & Pregnancy:Tuberculosis & Pregnancy:
●There are There are no reportsno reports of of fetal malformationsfetal malformations
attributable to attributable to pyrazinamide.pyrazinamide. The absence of such safety The absence of such safety
data is the reason that the CDC guidelines data is the reason that the CDC guidelines do not endorsedo not endorse
pyrazinamidepyrazinamide in in pregnancy.pregnancy.
●PyrazinamidePyrazinamide may produce may produce gastrointestinal upsetsgastrointestinal upsets, ,
arthralgiaarthralgia, , hyperuricemiahyperuricemia & & hepatitis.hepatitis.
●If If PZAPZA is not included in the is not included in the initialinitial treatment regimen, the treatment regimen, the
minimumminimum duration of therapy is duration of therapy is 9 months.9 months.
Tuberculosis & Pregnancy:Tuberculosis & Pregnancy:
Page 60
●StreptomycinStreptomycin may commonly cause may commonly cause vertigovertigo in mother in mother
apart from apart from ototoxicityototoxicity & & nephrotoxicitynephrotoxicity, related to , related to
serum concentrationserum concentration & & total dosetotal dose of administered drug. of administered drug.
Thus it is Thus it is not recommendednot recommended during pregnancy. during pregnancy.
Tuberculosis & Pregnancy:Tuberculosis & Pregnancy:
●StreptomycinStreptomycin may commonly cause may commonly cause vertigovertigo in mother in mother
apart from apart from ototoxicityototoxicity & & nephrotoxicitynephrotoxicity, related to , related to
serum concentrationserum concentration & & total dosetotal dose of administered drug. of administered drug.
Thus it is Thus it is not recommendednot recommended during pregnancy. during pregnancy.
Tuberculosis & Pregnancy:Tuberculosis & Pregnancy:
Page 61
●Breastfeeding Breastfeeding should notshould not be discouraged for women being be discouraged for women being
treated with treated with first-line agentsfirst-line agents, because the small , because the small
concentrations of these drugs in breast milk do not produce concentrations of these drugs in breast milk do not produce
toxic effects in the nursing infant. toxic effects in the nursing infant.
●Conversely, drugs in breast milk should not be considered to Conversely, drugs in breast milk should not be considered to
serve as serve as effectiveeffective treatment for treatment for active TBactive TB or or latent TBlatent TB
infection in a nursing infant. infection in a nursing infant.
Tuberculosis & Breast Feeding:Tuberculosis & Breast Feeding:
●Breastfeeding Breastfeeding should notshould not be discouraged for women being be discouraged for women being
treated with treated with first-line agentsfirst-line agents, because the small , because the small
concentrations of these drugs in breast milk do not produce concentrations of these drugs in breast milk do not produce
toxic effects in the nursing infant. toxic effects in the nursing infant.
●Conversely, drugs in breast milk should not be considered to Conversely, drugs in breast milk should not be considered to
serve as serve as effectiveeffective treatment for treatment for active TBactive TB or or latent TBlatent TB
infection in a nursing infant. infection in a nursing infant.
Tuberculosis & Breast Feeding:Tuberculosis & Breast Feeding:
Page 62
●TheThe use of use of IsoniazidIsoniazid, , RifampicinRifampicin, , EthambutolEthambutol, & , &
PyrazinamidePyrazinamide, has been considered , has been considered safesafe for for breast breast
feedingfeeding, but safety of PAS & injectable forms is unproven., but safety of PAS & injectable forms is unproven.
●Supplementary pyridoxineSupplementary pyridoxine is recommended for the is recommended for the
nursing mother receiving nursing mother receiving INH.INH.
●The administration of the The administration of the fluoroquinolonesfluoroquinolones during during
breastfeeding is breastfeeding is not recommended.not recommended.
●The effect of these drugs gets minimized, if the mother breast The effect of these drugs gets minimized, if the mother breast
feeds before taking the drugs & substitutes the next feed with feeds before taking the drugs & substitutes the next feed with
formula preparation.formula preparation.
Tuberculosis & Breast Feeding:Tuberculosis & Breast Feeding:
●TheThe use of use of IsoniazidIsoniazid, , RifampicinRifampicin, , EthambutolEthambutol, & , &
PyrazinamidePyrazinamide, has been considered , has been considered safesafe for for breast breast
feedingfeeding, but safety of PAS & injectable forms is unproven., but safety of PAS & injectable forms is unproven.
●Supplementary pyridoxineSupplementary pyridoxine is recommended for the is recommended for the
nursing mother receiving nursing mother receiving INH.INH.
●The administration of the The administration of the fluoroquinolonesfluoroquinolones during during
breastfeeding is breastfeeding is not recommended.not recommended.
●The effect of these drugs gets minimized, if the mother breast The effect of these drugs gets minimized, if the mother breast
feeds before taking the drugs & substitutes the next feed with feeds before taking the drugs & substitutes the next feed with
formula preparation.formula preparation.
Tuberculosis & Breast Feeding:Tuberculosis & Breast Feeding:
Obstructive Sleep Obstructive Sleep
Apnea & PregnancyApnea & Pregnancy
Apnea & PregnancyApnea & Pregnancy
Page 64
●High circulating level of High circulating level of progesteroneprogesterone during pregnancy during pregnancy ↑↑
ventilatory driveventilatory drive, which has a potentially protective effect. , which has a potentially protective effect.
●ObesityObesity predisposes to predisposes to SRBDSRBD & & weight gainweight gain & & ↑↑ nasal nasal
obstructionobstruction during pregnancy contributory to during pregnancy contributory to SDB.SDB.
●The The enlarging uterusenlarging uterus alters alters diaphragmatic functiondiaphragmatic function, ,
thus resulting in thus resulting in ↓↓ FRC FRC & causing & causing shuntingshunting & & hypoxemiahypoxemia
leading to leading to hypoxemiahypoxemia during during hypoventilationhypoventilation in sleep. in sleep.
●Pregnancy may Pregnancy may precipitateprecipitate or or worsenworsen sleep apnea. sleep apnea.
OSAS & Pregnancy:OSAS & Pregnancy:
●High circulating level of High circulating level of progesteroneprogesterone during pregnancy during pregnancy ↑↑
ventilatory driveventilatory drive, which has a potentially protective effect. , which has a potentially protective effect.
●ObesityObesity predisposes to predisposes to SRBDSRBD & & weight gainweight gain & & ↑↑ nasal nasal
obstructionobstruction during pregnancy contributory to during pregnancy contributory to SDB.SDB.
●The The enlarging uterusenlarging uterus alters alters diaphragmatic functiondiaphragmatic function, ,
thus resulting in thus resulting in ↓↓ FRC FRC & causing & causing shuntingshunting & & hypoxemiahypoxemia
leading to leading to hypoxemiahypoxemia during during hypoventilationhypoventilation in sleep. in sleep.
●Pregnancy may Pregnancy may precipitateprecipitate or or worsenworsen sleep apnea. sleep apnea.
OSAS & Pregnancy:OSAS & Pregnancy:
Page 65
●Pregnancy, if Pregnancy, if complicatedcomplicated by by OSAOSA, is associated with , is associated with
potential adverse effects for both the mother & the fetus. potential adverse effects for both the mother & the fetus.
●In general, In general, apneaapnea & & hypopneahypopnea are uncommon in pregnancy are uncommon in pregnancy
because of the because of the respiratory stimulatoryrespiratory stimulatory effect of effect of
progesterone.progesterone.
●Nocturnal hypoxemiaNocturnal hypoxemia adversely affects the fetus & poor adversely affects the fetus & poor
fetal growth occurs in patients with this condition. fetal growth occurs in patients with this condition.
●nCPAPnCPAP is a is a safesafe & & effectiveeffective treatment of SDB during treatment of SDB during
pregnancy.pregnancy.
OSAS & Pregnancy:OSAS & Pregnancy:
●Pregnancy, if Pregnancy, if complicatedcomplicated by by OSAOSA, is associated with , is associated with
potential adverse effects for both the mother & the fetus. potential adverse effects for both the mother & the fetus.
●In general, In general, apneaapnea & & hypopneahypopnea are uncommon in pregnancy are uncommon in pregnancy
because of the because of the respiratory stimulatoryrespiratory stimulatory effect of effect of
progesterone.progesterone.
●Nocturnal hypoxemiaNocturnal hypoxemia adversely affects the fetus & poor adversely affects the fetus & poor
fetal growth occurs in patients with this condition. fetal growth occurs in patients with this condition.
●nCPAPnCPAP is a is a safesafe & & effectiveeffective treatment of SDB during treatment of SDB during
pregnancy.pregnancy.
OSAS & Pregnancy:OSAS & Pregnancy:
Thank YouThank You
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