Col Michael F Tenholder MD FCCP; an...

Col Michael F Tenholder MD FCCP; and Maj. Jeannette E South-Paul, MD

CASE PRESENTATION

Dr South-Paul: We have chosen a patient for this management interview who presented initially at another institution and was transferred for further treatment with a frequent complication of pregnancy. We will use this patient as an example to discuss more [i]or[/i] less of the management principles that apply to a woman who readys with dyspnea during pregnancy.

A 27-year-old, gravida 2 para 1 woman was at 31 weeks' gestation and had an estimated date of confinement of Jan 1 1988 She existinged to the emergency room with increasing shortness of breath, diaphoresis, and cough productive of clear sputum that had lasted sum of two units days. She had similar symptoms and wheezing at 22 weeks' gestation. She was diagnosed as probably having Mycoplasma pneumonia and was treated with erythromycin. When evaluated onward Oct 5, she was still symptomatic. A chest roentgenogram was obtained and antibiotic therapy changed to amoxicillin. individual week later, a terbutaline inhaler was added for persistent wheezing after pulmonary function ordeals showed reactive airways disease. The patient go [i]or[/i] come backed to the emergency room in succession October 29 and 30. Therapy with amoxicillin and the terbutaline inhaler was continued and theophylline (300 mg twice daily) was added. She was admitted the nearest day with dyspnea, cough, wheezing, and fatigue. She had been using her inhalation bronchodilator forward a frequent basis for 24 h

Her previous pregnancy (1985) was uncomplicated, with a spontaneous vaginal delivery of a normal male infant at 38 weeks' gestation. She had had no prior surgical history and no known physic allergies or atopic history. She was a nonsmoker and denied front to passive smoke or other inhalational irritants.

The physical examination upon admission included the following findings: she was afebrile; had tachycardia (rate, 124 bpm); her kindred pressure was 118/50 mm Hg and respiratory rate 22 breaths/min at stillness She was alert and oriented with tripod posturing. The mucous membranes were slightly arid with no sinus tenderness, and the neck was flexile without adenopathy. There were diffuse bilateral wheezes and retractions with dullnes to percussion in the two bases, but no rales were exposeed Tachycardia was present with sole an occasional ectopic beat and no mutters There was no jugular venous distention or bruits. The abdomen was smooth and nontender, with a 31-cm fundus and active bowel goods Good capillary refill was not away with no cyanosis or clubbing of the extremities.

Initial laboratory examples revealed a hemoglobin of 93 hematocrit reading, 289; WBC account 10,200/cu mm, with 10 percent eosinophils, and 309000 platelets. The serum sodium flush was 135 mEq/L; potassium, 4 mEq/L; chloride, 104 mEq/L; and bicarbonate, 19 mEq/L Serum theophylline concentration was 106 [unkeyable]g/ml. Arterial kindred gas (4 L oxygen at nasal cannula) analysis showed [PaO.sub.2], 606 mm Hg; [PaCO.sub.2], 295 mm Hg; pH 74; and saturation, 91 percent Urinalysis was normal, and the ECG showed sinus tachycardia.

INTRODUCTION

Dr Tenholder: We single outed this case for discussion because asthma and pneumonia are as well-as; not only-but also; not only-but; not alone-but common problems that internists and chest physicians papal court in evaluating patients who are pregnant and dyspneic. Internal medicine house staff are also to a high degree likely to be consulted according to the obstetric service when pregnancy is complicated according to many situations in which dyspnea is the chief complaint. We will discuss this patient first and go in the rear [i]or[/i] in the wake of with a review of the general topic of dyspnea in pregnancy.

The internist must ask himself three same important questions when he views any pregnant patient with pulmonary disease. for what reason will the pregnancy affect the disease itself? to what extent will the disease affect the course of the pregnancy and the health of the fetus? to what degree does management differ from that of the nonpregnant patient?[1]

We realize that medical management in pregnancy is complicated because we must consider those medicines that cross the placenta and the weight they will have on the fetus. Substances with molecular weight >1000 daltons do not cros the placenta. chiefly of the medicines we use in our general practice have a molecular weight between 250 and 400 daltons, and in such a manner they will cross the placenta.[2] undivided must also consider how protein binding or the ionized fraction of a particular medicine will contribute to placental transfer. The dose and duration of the chemical is also critical in determining its teratogenetic event If we can give employment to nonpharmacologic management, this option should be considered.

The fetus is at greatest risk from principally medications during the first trimester. Unfortunately, most numerous drugs have been tested sole in animal models; so the physicians' Desk allusion will mention the safety of these medicines as suggested by these animal patterns It is very important to remind ourselves and the mother that alcohol, caffeine, and tobacco are put drugs intos The fetus is probably actively involved according to the products of cigarette smoking as oppos to passive smoking, which is receiving appropriate attention in the medical literature today.