Suchen und Finden
Preface
6
Contents
7
Acknowledgments
9
Contributors
10
Part I: Normal Pregnancy
13
Physiological Transition from Fetal to Neonatal Life in Pregnancy
14
Evolution of Air-Breathing Respiration
14
Fetal Respiration
15
Lung Growth and Development
19
Importance of Surfactant
21
Surface Tension
21
Cellular Morphology and Morphogenesis
25
Cells Derived from Entoderm
25
Cells Derived from Mesoderm
26
Summary of Lung Development In Utero and Beyond
27
References
29
Respiratory Physiology in Pregnancy
30
Introduction
30
Chest Wall and Lung Mechanics in Pregnancy
30
Airflow Mechanics
31
Ventilation and Gas Exchange
31
Physiologic Dyspnea of Pregnancy
33
Summary and Conclusions
34
Abbreviations
35
References
35
High Altitude, Chronic Hypoxia, and Pregnancy
38
Respiratory Physiology at High Altitude
38
Pregnancy Outcomes Associated with High Altitude
40
Uteroplacental Circulation and Oxygen Transport
42
Chronic Hypoxia and Effect on the Placenta
43
References
44
Sleep Physiology in Pregnancy
47
Sleep Physiology in Pregnancy
47
Overview of Sleep Stages
47
The Sleep-Wakefulness Cycle
48
Overview of Sleep in Pregnancy
48
Mechanical and Somatic Factors Affecting Sleep Initiation and Sleep Maintenance
49
Gastroesophageal Factors
49
Urinary Factors
49
Musculoskeletal Factors
49
Obstetric Factors
49
Anatomic Changes Predisposing to Sleep-Disordered Breathing
50
Upper airway Changes
50
Hormonal Factors Affecting Sleep in Pregnancy
50
Progesterone
50
Estrogen
53
Corticotropin Releasing Hormone (CRH) and Cortisol
53
Growth Hormone (GH)
54
Melatonin
54
Prolactin
54
Oxytocin
55
Human Gonadotropic Hormone (HCG)
55
Cytokines
55
Nitric oxide
56
Oxygenation During Sleep in Pregnancy
57
Control of Breathing During Sleep in Pregnancy
58
Sleep Measures in Normal Pregnancy
59
Summary
60
References
60
Part II: General Management Principles in Pregnancy
66
Diagnostic Imaging in Pregnancy
67
Ionizing Radiation
67
Teratogenicity
68
Radiation Dose
68
Timing of Radiation Exposure
68
Method of Administration
72
Intrauterine Fetal Death
72
Oncogenicity
72
Use of Contrast Agents
73
Ultrasound
74
Magnetic Resonance Imaging (MRI)
74
Nuclear Medicine
75
Informed Consent
75
Summary
75
References
76
Prescribing in Pregnancy and Lactation
78
The Myth of the Placental Barrier
78
The Myth of the ‘‘Safe’’ Period
78
Drug Safety Data in Pregnancy
79
Animal Studies
79
Case Reports and Case Series
79
Pregnancy Registries
80
Case Control Studies
80
Physiologic Changes of Pregnancy Affecting Pharmacokinetics
82
Choosing Medication in Pregnancy
82
Breast Feeding and Medications
83
Conclusion
94
Abbreviations
95
References
95
Monitoring Fetal Well-Being in the Critical Care Setting
96
Introduction to Electronic Fetal Monitoring
96
EFM Descriptions
97
Ancillary Methods to Assess Fetal Status
109
Timing of Monitoring
109
Interventions for a Non-Reassuring FHR
110
Perimortem Cesarean Section
110
References
111
Anesthetic Considerations in Pregnant Patients with Pulmonary Disorders
113
Introduction
113
Airway Management
115
Neuraxial Blockade and Pulmonary Function
119
General Anesthesia and Pulmonary Function
121
Anesthesia for Specific Pulmonary Disorders
122
References
123
Part III: Pulmonary Disorders in Pregnancy
127
Obstructive Sleep Apnea in Pregnancy
128
Definitions of Obstructive Sleep Apnea Syndrome (OSAS)
128
Alterations of Pregnancy and OSAS
128
Anatomic and Physiologic Sleep Changes During Pregnancy
128
Changes Protective Against Sleep Disorder Breathing
129
Adverse Changes During Pregnancy Contributing to Sleep-Disordered Breathing
129
Hypoxemia During Sleep and Pregnancy
129
Incidence of Snoring and Sleep-Disordered Breathing During Pregnancy
130
Complications from OSAS in Pregnancy
131
Risks to the Mother
131
Risks to the Fetus
133
Screening for OSAS in Pregnancy
134
Treatment of OSAS in Pregnancy
134
Benefits of Treatment
134
Conclusions
135
References
135
Restless Legs Syndrome and Periodic Limb Movement Disorder in Pregnancy
139
Introduction
139
RLS Definition
139
RLS Epidemiology and Diagnosis
140
Pathophysiology
141
Clinical and Polysomnographic Evaluation
143
Treatment
143
Periodic Limb Movement Disorder
145
References
145
Asthma in Pregnancy
147
Introduction
147
Epidemiology: The Prevalence of Asthma During Pregnancy
147
Clinical Description: What Happens to Asthma During Pregnancy
148
Changes in Asthma Symptoms During Pregnancy
148
Changes in Lung Function During Pregnancy
148
Changes in Asthma During Labor
149
Mechanisms for the Effect of Pregnancy on Maternal Asthma
149
Hormonal Influences
149
Maternal Inflammation and Immune Function
149
The Influence of Fetal Sex
150
Complications of Asthma During Pregnancy: Exacerbations
150
Prevalence of Exacerbations
151
Risk Factors for Exacerbations
151
Severe Asthma
152
Viral Infection
152
Inadequate Prenatal Care
152
Obesity
152
Inadequate Medication Use
152
Timing of Exacerbations
153
Association of Asthma with Adverse Pregnancy Outcomes
153
The Effect of Exacerbations on Low Birth Weight
154
The Effect of Exacerbations on Preterm Delivery
154
The Effect of Exacerbations on Pre-eclampsia and Pregnancy-Induced Hypertension
155
The Effect of Exacerbations on Perinatal Mortality
155
Management and Treatment of Asthma During Pregnancy
156
Safety of Drug Treatments for Asthma
156
Risk of Congenital Malformations
156
beta2-Agonists
157
Inhaled Corticosteroids
157
Oral Corticosteroids
158
Leukotriene Receptor Antagonists
158
Treatment of Exacerbations During Pregnancy
159
Health Behavior
160
Cessation of Inhaled Steroid Use During Pregnancy
160
Education and Self-Management of Asthma During Pregnancy
161
Smoking During Pregnancy
162
Anxiety and Depression During Pregnancy
163
Conclusions
163
References
164
Tuberculosis and Pregnancy
169
Introduction
169
Evaluation
170
Skin Testing
170
Methods and Special Circumstances
170
Interpretation and Guidelines
170
Serum Quantiferon Testing
170
Roentgenography
171
Sputum Analysis
171
Specific Treatment Situations
172
Preventive Therapy
172
Latent Tuberculosis
172
Active Tuberculosis
172
Current Guidelines
172
Agents Used for the Treatment of Tuberculosis
173
First-Line Agents
173
Isoniazid
173
Rifampin
173
Ethambutol
174
Pyrazinamide
174
Streptomycin
174
Second-Line Agents
175
Amikacin
175
Capreomycin
175
Clofazimine
175
Cycloserine
175
Dapsone
175
Ethionamide
176
Para-Aminosalicylic Acid
176
Fluoroquinolones
176
Rifabutin
176
Thalidomide
176
Other Agents
177
Pyridoxine
177
Dexamethasone
177
Breast Feeding
177
Tuberculosis Transmission
178
Pulmonary Tuberculosis
178
Extra-Pulmonary Tuberculosis
178
References
178
Pneumonia in the Pregnant Patient
181
Epidemiology
181
Risk Factors
182
Pathogenesis of Pneumonia and its Complications in Pregnancy
183
Bacteriology
186
Clinical Features and Management of Specific Respiratory Infections
188
Bacterial Pneumonia
188
Viral Pneumonias
191
Influenza Virus
191
Varicella Pneumonia
193
Fetal and Neonatal Effects
194
Other Viruses
194
Fungal Pneumonia
195
Aspiration Pneumonia
195
Prevention of Pneumonia
196
Pneumonia Complicating Human Immunodeficiency Virus (HIV) Infection
196
Summary
197
References
197
Chronic Pulmonary Disease and Pregnancy
201
Respiratory Physiology of Normal Pregnancy
201
Introduction to Chronic Lung Disease in Pregnancy
202
Lymphangioleiomyomatosis and Pregnancy
202
Pulmonary Langerhans Cell Histiocytosis and Pregnancy
204
Sarcoidosis
204
Overview of Disease
204
Outcomes in Pregnancy and Sarcoidosis
204
Management of Sarcoidosis During Pregnancy
205
Idiopathic Pulmonary Fibrosis in Pregnancy
205
Kyphoscoliosis
206
Overview of Disease
206
Kyphoscoliosis and Effects on Pulmonary Function
207
Kyphoscoliosis and Pregnancy
207
Lung Transplantation and Pregnancy
207
Smoking Cessation and Pregnancy
208
Anti-Smoking Interventions
209
Counseling
209
Pharmacologic Therapy
210
Lung Cancer in Pregnancy
210
Diagnosis
211
Treatment
211
Summary
212
References
212
Neuromuscular and Chest Wall Diseases in Pregnancy
216
Introduction
216
Neuromuscular Diseases
216
Chest Wall Diseases
217
Complications in Neuromuscular and Chest Wall Diseases During Pregnancy
217
Pregnancy
218
Labor
219
Postpartum
219
Management of Pregnancy in Neuromuscular and Chest Wall Diseases
219
Monitoring During Pregnancy
220
Respiratory Muscles Aids
221
Inspiratory Muscle Aids: Non-invasive Ventilation
221
IPPV Mouthpiece
222
IPPV Nasal
222
Expiratory Muscle Aids and Assisted Coughing
223
Manually Assisted Coughing
223
Mechanically Assisted Coughing
224
Glossopharyngeal Breathing
225
Pregnancy in Bulbar Neuromuscular Patients
225
Complications During Pregnancy that Can Affect Respiratory Function
225
Abbreviations
226
References
226
Pregnancy and the Cystic Fibrosis Patient
230
Introduction-Cystic Fibrosis
230
Sexual Health
231
Fertility
231
Bioethics and Pregnancy in the CF Patient
232
How Cystic Fibrosis Exerts Changes on Pregnancy
232
Perinatal Mortality
232
Maternal Morbidity and Mortality
233
How Pregnancy Exerts Changes on CF
234
Lung Function
234
Nutritional and Metabolic Changes
234
Cardiopulmonary Changes
235
Immunity
236
Factors in the Care of the Pregnant CF Patient
236
Nutritional and Metabolic Aspects
236
Labor and Delivery
236
Breastfeeding and Postpartum Care
237
Pharmacological Aspects and the Pregnant CF Patient
237
Lung Transplant and the Pregnant CF Patient
238
Summary
238
References
239
Pulmonary Complications of Collagen Vascular Disease in Pregnancy
241
Immunity and Pregnancy
241
Respiratory Physiology During Pregnancy
242
Systemic Sclerosis
243
The Effect of Pregnancy on Systemic Sclerosis
243
The Effect of Systemic Sclerosis on Pregnancy and Fetal Outcome
244
Systemic Lupus Erythematosus
245
The Effect of Pregnancy on SLE
245
The Effect of SLE on Pregnancy and Fetal Outcome
245
Antiphospholipid Antibody Syndrome
246
Obstetric Complications
247
Thrombosis
247
The Catastrophic aPL Syndrome
248
Treatment of Pregnant Women with Antiphospholipid Syndrome
248
Rheumatoid Arthritis
248
The Effect of Pregnancy on RA
249
The Effect of RA on Pregnancy and Fetal Outcome
249
Spondyloarthropathies (SA):
249
Sjögren’s Syndrome
249
The Effect of Pregnancy on Sjögren’s Syndrome
249
The Effect of Sjögren’s Syndrome on Pregnancy and Fetal Outcome
249
Polymyositis and Dermatomyositis
250
The Effect of Pregnancy on Myositis
250
The Effect of Myositis on Pregnancy and Fetal Outcome
250
Conclusion
250
References
251
Venous Thromboembolism in Pregnancy
255
Introduction
255
Epidemiology
255
Preconception Counseling
257
Risk Factors
257
Activated Protein C Resistance and Factor V Leiden
258
Prothrombin Gene Variant
258
Protein C, Protein S, and Antithrombin Deficiencies
259
Antiphospholipid Antibodies
259
Hyperhomocysteinemia
259
Elevated Factor VIII
260
Compound Heterozygotes
260
Diagnosis
260
Clinical Predictors
261
Diagnostic Procedures
261
Arterial Blood Gases
261
Electrocardiography
262
Imaging Procedures
262
Radiation Exposure and Fetal Safety
262
Chest Radiography
262
Ventilation-Perfusion Scans
262
CT Pulmonary Angiograms
263
CTPA and Pregnancy
263
Fetal Radiation Exposure
264
Breast Radiation Exposure
264
Isolated Subsegmental Emboli
264
Pulmonary Angiography
265
Magnetic Resonance Imaging
265
Imaging of the Lower Extremities
265
Impedence Plethysmography
265
Compression Ultrasonography
266
Lower Extremity Venograms
267
Conventional Venograms
267
CT Venograms
268
MR Venograms
268
2-D Echocardiography
268
Laboratory Tests
268
D-Dimers
268
Prognostic Biomarkers
269
Other Thromboses
269
Management
270
Treatment
270
Pharmacologic Therapy
270
Pharmacokinetics, Dosing, and Monitoring
270
Complications
272
Fetal Safety
273
Duration of Therapy
273
Management of Anticoagulation Around Labor and Delivery
273
Non-pharmacologic Therapy
274
Thrombolytic Therapy
274
Prophylaxis for Thromboembolic Disease
274
Normal Pregnant Women
274
Thrombophilic Women with No Prior History of VTE or Prior Obstetric Complication
275
Ante-Partum Period
275
Post-Partum Period
275
Women with Previous VTE
275
Patients with Previous History of VTE
275
Patients with Current or Recent VTE, Currently on Treatment
276
Conclusion
277
References
277
Pulmonary Arterial Hypertension in Pregnancy
287
Introduction
287
The Pulmonary Circulation in Healthy Adults
288
Pulmonary Hypertension
289
The Pulmonary Circulation in Pregnancy
293
Association of Pulmonary Hypertension with Pregnancy
293
Evaluation of Pulmonary Hypertension in the Pregnant Patient
295
Treatment of Pulmonary Hypertension
298
Management of Pulmonary Hypertension in the Pregnant Patient
301
Management of Labor and Delivery in the Pulmonary Hypertensive Patient
303
Management of Pulmonary Hypertension in the Post-partum Patient
306
Summary and Conclusions
308
References
308
Pulmonary Procedures During Pregnancy
315
Introduction
315
Interventional Pulmonology
316
Multidisciplinary Approach
317
Pre-procedure Considerations
317
Positioning of the Patient
318
Topical Anesthesia and Conscious Sedation
319
Topical Anesthesia
319
Conscious Sedation
319
Patient and Fetal Monitoring
321
Bronchoscopy
322
Fluoroscopy
324
Pleural Procedures
325
Pleural Effusion
325
Thoracentesis
325
Pleural Space Drainage
327
Pleural Biopsy
328
References
328
Critical Illness in Pregnancy
332
Introduction
332
The Physiology of Pregnancy
333
General ICU Assessment
334
Circulatory Disorders in the Gravid Patient
335
Hypovolemic Shock
335
Causes of Hypovolemic Shock Unique to Pregnancy
337
Placental Abruption
337
Placenta Previa
337
Uterine Rupture
337
Uterine Atony
337
Septic Shock
338
Introduction
338
Management
338
General Principles
338
Early Goal Directed Therapy
339
Insulin Therapy for ‘‘Tight’’ Glucose Control
341
Drotrecogin Alpha (Activated Protein C)
341
Corticosteroids
342
Chorioamnionitis
342
Cardiogenic Shock
342
Introduction
342
General Management
343
Cardiac Dysfunction Acquired During Pregnancy
344
Peripartum Cardiomyopathy
344
Aortic Dissection
344
Critical Care Syndromes Specific to Pregnancy
344
Preeclampsia
344
Eclampsia
345
HELLP Syndrome
346
Pulmonary Embolism
346
Amniotic Fluid Embolism
348
Cardiopulmonary Arrest
348
Trauma
349
Summary
349
Clinical Pearls
349
Example Cases
350
Case One
350
Case Two
351
Case Three
351
References
352
Acute Lung Injury in Pregnancy
356
Introduction
356
Definition
356
Epidemiology
357
Clinical Features
357
Etiology
358
Pathogenesis
359
Hypoxemia During Pregnancy: Risks and Protections
360
Differential Diagnosis
362
Variants of Pulmonary Edema
362
Preeclampsia
362
Tocolytic-Induced Pulmonary Edema
362
Cardiogenic Pulmonary Edema
364
Rare in Pregnancy: Mimics of ARDS
366
Management
367
Monitoring
367
Ventilator Strategy
368
Non-invasive Positive Pressure Ventilation
370
Positive End-Expiratory Pressure (PEEP)
371
Oxygen Therapy
371
Circulatory Management
372
Experimental Therapy
373
Timing of Delivery
374
Outcomes
375
References
375
Airway Management and Mechanical Ventilation in Pregnancy
385
Introduction
385
Anatomic and Physiological Changes During Pregnancy
386
Airway Assessment
387
Preeclampsia and Airway-Related Changes
387
Morbid Obesity in Pregnancy and Airway
387
Aspiration of Gastric Contents
388
Obstetricians’ Role in Management of Airway
389
Incidence of Failed Intubation
389
Anesthesia and Maternal Mortality
389
Cesarean Section: Recognized Difficult Airway
389
Regional Anesthesia
389
Awake Intubation
390
Acute Fetal Distress
390
Cesarean Section: Unrecognized Difficult Airway
391
Airway Devices
391
Laryngeal Mask Airway
391
Proseal-LMA (PLMA)
392
Intubating Laryngeal Mask Airway (ILMA)
393
Combitube
393
Mechanical Ventilation in Pregnancy
394
Volume Control Type
394
Pressure Control Type
395
Dual Control Ventilators
395
Modes of Mechanical Ventilation
395
Controlled Mechanical Ventilation
395
Assist Control Mode (A/C)
395
Synchronized Intermittent Mandatory Ventilation (SIMV)
396
Pressure Support Ventilation
396
Continuous Positive Airway Pressure (CPAP)
396
PEEP
396
Oxygenation Goal
396
Ventilation Goal
397
Respiratory Physiology Issues in Pregnancy
397
Ventilator Setup: Choose
398
Calculations Important for Respiratory Monitoring
398
Weaning
399
Weaning Parameters
399
Conclusion
400
References
400
Index
404
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