Table Of ContentPulmonary Problems in Pregnancy
R M
ESPIRATORY EDICINE
Sharon R. Rounds, , S E
MD ERIES DITOR
PulmonaryProblemsinPregnancy,editedbyGhadaBourjeilyandKarenRosene-Montella,2009
Pulmonary Problems
in Pregnancy
Edited by
Ghada Bourjeily, MD
AssistantProfessorofMedicine
TheWarrenAlpertMedicalSchoolofBrownUniversity
DepartmentofMedicine
PulmonaryandCriticalCareMedicine
WomenandInfantsHospitalofRhodeIsland
Karen Rosene-Montella, MD
ProfessorofMedicineandOb/Gyn
TheWarrenAlpertMedicalSchoolofBrownUniversity
ChiefofMedicine
DepartmentofMedicine
WomenandInfantsHospitalofRhodeIsland
Editors
GhadaBourjeily KarenRosene-Montella
AssistantProfessorofMedicine ProfessorofMedicineandOb/Gyn
TheWarrenAlpertMedicalSchoolof TheWarrenAlpertMedicalSchoolof
BrownUniversity BrownUniversity
DepartmentofMedicine ChiefofMedicine
PulmonaryandCriticalCareMedicine DepartmentofMedicine
WomenandInfantsHospitalofRhode WomenandInfantsHospitalofRhode
Island Island
Providence,RI Providence,RI
[email protected] [email protected]
ISBN978-1-934115-12-1 e-ISBN978-1-59745-445-2
DOI10.1007/978-1-59745-445-2
LibraryofCongressControlNumber:2008938362
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Preface
Pregnancy is associated with physiologic changes that help compensate for the
increasingdemandsofthefetusandplacenta.Clinically,pregnancyactsasastress
test that unmasks maternal disease and may have long term implications for
maternal and fetal health. General obstetricians are often hesitant to care for
complex medical problems, and internists to care for pregnant patients, which
may create a gap into which sick pregnant women will fall at a time when they
aremostvulnerable.
Investigation and treatment of pregnant patients with pulmonary disorders is
oftenhinderedbybothafearofdoingharmtothefetusandbythepaucityofdata
needed to make recommendations. At Women and Infants Hospital, the tertiary
women’steachinghospitalatBrownUniversity,10,000deliveriesoccureveryyear.
The editors of this textbook are members in the division of obstetric and
consultative medicine, a group of obstetric internists and medical specialists that
provide consultation to obstetricians on complex medical and pulmonary
problems. Most pulmonary and critical care training programs provide little
exposure to this population. Despite this, pulmonologists and intensivists are
oftencalledupontoprovideconsultationtocriticallyillpregnantwomen.
As editors, our hope was to gather pulmonologists, intensivists, obstetric
internists, high risk obstetricians and obstetric anesthesiologists from across the
globe to shed light on some common or complex pulmonary issues occurring in
pregnancy.Thebook isdividedinto threeparts.Thefirstfewchaptersintroduce
the reader to the normal physiologic changes that occur during pregnancy. The
chapter on high altitude is included to illustrate the consequences of chronic
hypoxia on maternal and fetal outcomes, to help extrapolate to the effects of
chronic pulmonary conditions. The second part reviews general management
principles, including diagnostic imaging and prescribing in pregnancy. The final,
longest part includes multiple chapters on specific pulmonary disorders. The
specific chapters are intended to summarize the available literature, linking
science to bedside, and make management recommendations whenever possible.
Ourgoalisthatthecarefulreadingofthistextwillstimulatefurtherinvestigation
intothisfascinatingandunderexploredareaofmedicine.
GhadaBourjeily,MD
KarenRosene-Montella,MD
v
Contents
Preface.................................................................................. v
Acknowledgments .................................................................... ix
Contributors........................................................................... xi
PartI. NormalPregnancy ......................................................... 1
1 PhysiologicalTransitionfromFetaltoNeonatalLife
inPregnancy ..................................................................... 3
AlanR.Leff
2 RespiratoryPhysiologyinPregnancy ........................................ 19
MeredithC.McCormackandRobertA.Wise
3 HighAltitude,ChronicHypoxia,andPregnancy .......................... 27
GhadaBourjeily
4 SleepPhysiologyinPregnancy ................................................ 37
GhadaBourjeilyandVahidMohsenin
PartII. GeneralManagementPrinciplesinPregnancy......................... 57
5 DiagnosticImaginginPregnancy............................................. 59
MargaretMillerandLuciaLarson
6 PrescribinginPregnancyandLactation ..................................... 71
NiharikaMehta,JillNewstead-AngelandRaymondO.Powrie
7 MonitoringFetalWell-BeingintheCriticalCareSetting................. 89
KristenCotterandMathewSermer
8 AnestheticConsiderationsinPregnantPatientswith
PulmonaryDisorders........................................................... 107
RichardN.Wissler
vii
viii Contents
PartIII. PulmonaryDisordersinPregnancy .................................... 121
9 ObstructiveSleepApneainPregnancy....................................... 123
KathleenAkgunandFrancoiseJ.Roux
10 RestlessLegsSyndromeandPeriodicLimbMovement
DisorderinPregnancy.......................................................... 135
KelvinLamandCarolynM.D’Ambrosio
11 AsthmainPregnancy........................................................... 143
VanessaE.MurphyandPeterG.Gibson
12 TuberculosisandPregnancy................................................... 165
JohnB.BassandJamesN.Byrd
13 PneumoniainthePregnantPatient........................................... 177
SamarKhanandMichaelS.Niederman
14 ChronicPulmonaryDiseaseandPregnancy ................................ 197
ShirleyF.Jones,MarieM.BudevandAlejandroC.Arroliga
15 NeuromuscularandChestWallDiseasesinPregnancy ................... 213
JohnRobertBachandJesu´sSancho
16 PregnancyandtheCysticFibrosisPatient .................................. 227
SamirMalhotraandPearceG.Wilcox
17 PulmonaryComplicationsofCollagenVascularDisease
inPregnancy ..................................................................... 239
Ste´phaniePouwels-Fry,IsabelleTillie-LeblondandBenoıˆtWallaert
18 VenousThromboembolisminPregnancy.................................... 253
KarenRosene-MontellaandGhadaBourjeily
19 PulmonaryArterialHypertensioninPregnancy............................ 285
BrianCasserlyandJamesR.Klinger
20 PulmonaryProceduresDuringPregnancy................................... 313
MuhannedAbu-Hijleh
21 CriticalIllnessinPregnancy ................................................... 331
D.KyleHogarthandJesseHall
22 AcuteLungInjuryinPregnancy.............................................. 355
NualaJ.MeyerandGregoryA.Schmidt
23 AirwayManagementandMechanicalVentilation
inPregnancy ..................................................................... 385
UmaMunnur,VenkataDPBandiandMichaelA.Gropper
Index.................................................................................... 405
Acknowledgments
GhadaBourjeily.Myheartfeltgratitudeanddeepestappreciationtomyhusband
Fadlo,andmychildrenChristopherandNayafortheirtremendoussupportand
understanding through the time it took to get this work to completion; to my
motherandlatefather,fortheirencouragementandnurturing;GwenLarivierefor
hertechnicalandsecretarialassistancewiththistextbook.
IamalsoindebtedtoDr.MichaelPaglia,ahighriskobstetricianatWomenand
InfantsHospitalofRhodeIslandandBrownUniversityandDr.MatthewSermer,
a high risk obstetrician at Mount Sinai Hospital and University of Toronto for
theirassistancewithobstetricalandfetalissues.
Lastbutnotleast,IamdeeplygratefultoDr.AbrahamRudolph,aperinato-
logistandfetalphysiologistattheUniversityofCalifornia,SanFrancisco,forhis
invaluableguidanceandhelpwithfetalmatters.
KarenRosene-Montella.MymostsinceregratitudetomyhusbandMark,and
mychildrenBrianandJuliawhohavesharedmewithacademicmedicineformany
years;Dr.AlanLeffforhissupportandencouragement;DoreenHoogasianforher
secretarialandtechnicalassistance.
ix
Contributors
Muhanned Abu-Hijleh, MD, FCCP, Interventional Pulmonology and Special
Procedures Unit, The Division of Pulmonary, Critical Care and Sleep Medicine,
RhodeIslandHospital,TheWarrenAlpertMedicalSchoolofBrownUniversity,
Providence,RI
Kathleen Akgun, MD, Pulmonary and Critical Care Section, Yale School of
Medicine,NewHaven,CT
Alejandro C. Arroliga, MD, Division of Pulmonary Medicine and Critical Care
Medicine,ScottandWhiteHospital&Clinic,TexasA&MUniversityHealthand
ScienceCenter,Temple,TX
John Robert Bach, MD, Department of Physical Medicine and Rehabilitation,
The New Jersey Medical School, University of Medicine and Dentistry of New
Jersey,NewarkNJ
VenkataDPBandi,MD,DepartmentofMedicine,PulmonaryandCriticalCare,
BaylorCollegeofMedicine,Houston,TX
John B. Bass, Jr., MD, Department of Internal Medicine, College of Medicine,
UniversityofSouthAlabama,Mobile,AL
Ghada Bourjeily, MD, Department of Medicine, The Warren Alpert Medical
School of Brown University, Women & Infants Hospital, Pulmonary and Critical
CareMedicine,Providence,RI
MarieM.Budev,DO,MPH,TheClevelandClinic,Cleveland,OH
James N. Byrd, Jr., MD, Division of Pulmonary Medicine, University of South
Alabama,Mobile,AL
Brian Casserly, MD, Division of Pulmonary, Critical Care and Sleep Medicine,
Warren Alpert Medical School of Brown University, Rhode Island Hospital,
Providence,RI
Kristen Cotter, MD, MPH, Department of Obstetrics and Gynecology, Women
andInfantsHospitalofRhodeIsland
CarolynM.D’Ambrosio,MD,MS,DABSM,TheCenterforSleepMedicine,Tufts-
NewEnglandMedicalCenter,TuftsUniversitySchoolofMedicine,Boston,MA
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