Thread: A 30-year-old G2P1 pregnant woman at 15 weeks gestation presents with worsening Dyspnea

Dyspnea and wheezing in a pregnant patient

Case Study

A 30-year-old G2P1 pregnant woman at 15 weeks gestation presents to an outpatient clinic with worsening dyspnea over the preceding two weeks.

Question 1

Based on the history and objective data provided, what is the most likely cause of the patient’s symptoms?

A. Dyspnea of pregnancy
B. Anxiety
C. Asthma
D. Pulmonary embolus
E. Peripartum cardiomyopathy

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History:

A 30-year-old G2P1 pregnant woman at 15 weeks gestation presents to an outpatient clinic with worsening dyspnea over the preceding two weeks.

Her past medical history is significant for asthma diagnosed in childhood, seasonal allergies, and gastroesophageal reflux disease (GERD) during her previous pregnancy. She notes that her asthma symptoms had been well-controlled on inhaled fluticasone/salmeterol (250mcg/50mcg), albuterol HFA as needed, and a nasal steroid spray prior to pregnancy. However, she discontinued all of her medications when she learned that she was pregnant for fear that they might harm her baby.

The patient works in sales and has not used tobacco since college. She is allergic to cats and dust mites, but currently has no pets in her home. She has no additional medical history other than that described above.

At today’s visit she feels that she is unable to take a deep breath. She also describes one to two episodes of wheezing daily and night time cough two to three times per week. Warm air, dust, and exposure to cats seem to exacerbate her symptoms.

Physical Exam

On physical exam, the patient is in no acute distress. There is erythema of the nares bilaterally with clear rhinorrhea and cobble-stoning of the posterior pharynx. The lungs are clear to auscultation bilaterally. Heart sounds are normal without audible murmurs, gallops, or rubs. The abdomen is gravid and consistent with the patient’s current gestational age. There is trace edema of the lower extremities but no clubbing or cyanosis.

Lab

Spirometry from approximately one year prior to the visit reveals the following:
Pre-bronchodilator forced vital capacity (FVC) 5.11 L (116% predicted), forced expiratory volume in one second (FEV1) 3.12 L (84% predicted), FEV1/FVC 0.61. Post-bronchodilator FVC 5.16 L (1% change), FEV1 3.99 L (27% change), and FEV1/FVC 0.77.

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Answer & Explanation

[HIDE]C. Asthma Correct!

The differential diagnosis of dyspnea in the pregnant patient is broad. Symptoms of cough, wheezing, and chest tightness must be evaluated carefully. The most common etiologies are similar to those found in non-gravid patients and include asthma, GERD, upper airway cough syndrome (UACS), vocal cord dysfunction (VCD), and upper respiratory infection (URI). In addition, dyspnea of pregnancy is a consideration; however, this entity usually gives patients the sensation of dyspnea without cough or wheezing.

There are a number of other physiologic changes that occur during pregnancy which may cause respiratory symptoms. For example, symptoms of rhinitis may worsen due to progesterone-mediated congestion of the nasal mucosa. Sinusitis is six times more common in pregnancy and can exacerbate asthma symptoms as well . Gastroesophageal reflux is often worse due to progesterone-mediated LES relaxation and increased intra-abdominal pressure.

Atopy can also be worse in pregnancy. Viral infections are more common in asthmatic women during pregnancy and are a very common cause of exacerbations. This may be due to impaired cell-mediated immunity during the pregnant state8. Pregnant women have also been found to have a greater incidence of pneumonia than non-pregnant controls9. Less common but serious causes of dyspnea must also be considered and worked up accordingly including venous thromboembolism, congestive heart failure secondary to cardiomyopathy, pulmonary hypertension, and congenital heart defects.

In this patient, asthma is the most likely diagnosis given her clinical history, recent discontinuation of controller medications, and previously documented air-flow obstruction with bronchodilator reversibility. [/HIDE]

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Dyspnea and wheezing in a pregnant patient

Case Study

A 30-year-old G2P1 pregnant woman at 15 weeks gestation presents to an outpatient clinic with worsening dyspnea over the preceding two weeks.

Question 2

Which of the following is not true about the diagnosis of asthma in pregnancy?

A. Spirometry is not helpful because the physiologic changes of pregnancy alter the normal values.

B. Bronchoprovocation testing is contraindicated during pregnancy, but remains useful in the diagnosis after delivery.

C. The diagnosis can be confirmed by identifying the presence of reversible obstruction on spirometry.

D. In the absence of objective air-flow obstruction on spirometry, the diagnosis can be made based on appropriate history and symptoms alone.

E. The diagnosis of asthma in the pregnant patient is similar to that in the non-gravid

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Answer & Explanation

[HIDE] A. Spirometry is not helpful because the physiologic changes of pregnancy alter the normal values. Correct!

The respiratory system undergoes several normal physiologic changes in response to pregnancy4,10,11 (Table 1). Tidal volume and minute ventilation increase, resulting in a slight respiratory alkalosis with metabolic compensation on arterial blood gas evaluation (Table 2). In addition, oxygen consumption increases. By the third trimester, oxygen consumption and minute ventilation can increase by up to 35% and 50% respectively. Dyspnea (of pregnancy) can occur in as many as 70% of normal pregnancies. The mechanism behind this sensation is believed to be the result of the decreased pCO2 which occurs in response to the increased minute ventilation. Elevated levels of estrogen and progesterone are thought to be responsible for the process. Even though there is actually no airway obstruction present, the feeling of breathlessness may exacerbate asthma like symptoms in these patients.
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Explanation - Full details:

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Case Details:


History:

A 30-year-old G2P1 pregnant woman at 15 weeks gestation presents to an outpatient clinic with worsening dyspnea over the preceding two weeks.

Her past medical history is significant for asthma diagnosed in childhood, seasonal allergies, and gastroesophageal reflux disease (GERD) during her previous pregnancy. She notes that her asthma symptoms had been well-controlled on inhaled fluticasone/salmeterol (250mcg/50mcg), albuterol HFA as needed, and a nasal steroid spray prior to pregnancy. However, she discontinued all of her medications when she learned that she was pregnant for fear that they might harm her baby.

The patient works in sales and has not used tobacco since college. She is allergic to cats and dust mites, but currently has no pets in her home. She has no additional medical history other than that described above.

At today’s visit she feels that she is unable to take a deep breath. She also describes one to two episodes of wheezing daily and night time cough two to three times per week. Warm air, dust, and exposure to cats seem to exacerbate her symptoms.

Physical Exam

On physical exam, the patient is in no acute distress. There is erythema of the nares bilaterally with clear rhinorrhea and cobble-stoning of the posterior pharynx. The lungs are clear to auscultation bilaterally. Heart sounds are normal without audible murmurs, gallops, or rubs. The abdomen is gravid and consistent with the patient’s current gestational age. There is trace edema of the lower extremities but no clubbing or cyanosis.

Lab

Spirometry from approximately one year prior to the visit reveals the following:
Pre-bronchodilator forced vital capacity (FVC) 5.11 L (116% predicted), forced expiratory volume in one second (FEV1) 3.12 L (84% predicted), FEV1/FVC 0.61. Post-bronchodilator FVC 5.16 L (1% change), FEV1 3.99 L (27% change), and FEV1/FVC 0.77.

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Question 3

Which of the following statements is true?

A. Pregnancy has little impact on the course of asthma in the majority of patients.

B. Severe asthma exacerbations have not been shown to affect fetal outcomes.

C. Women who have asthma exacerbations during pregnancy are more likely to receive appropriate therapy than non-pregnant women.

D. Underlying asthma severity is one of the greatest risk factors for exacerbations during pregnancy.

E. Women who experience a worsening in asthma control during pregnancy are unlikely to return to their prior level of control after delivery.

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Answer & Explanation

[HIDE] D. Underlying asthma severity is one of the greatest risk factors for exacerbations during pregnancy. Correct!

Twenty percent of women require medical intervention for their asthma during pregnancy and up to 6% require hospitalization. The majority of women will experience a change in the level of control of their asthma during pregnancy, but the direction of the change may be difficult to predict. Approximately one-third of pregnant women will have worsening of their asthma symptoms during pregnancy, approximately one-third will have an improvement in asthma control, and approximately one-third will have no change.

Exacerbations occur most commonly in the late 2nd trimester (rarely before 4 months) and infrequently during the last 4 weeks of the 3rd trimester. After delivery, a patient’s asthma will usually return to her pre-pregnancy level of severity within three months. With subsequent pregnancies, asthma symptoms can be expected to be similar to those experienced during the first pregnancy in most cases.

Identifying those patients at greatest risk for exacerbations during pregnancy has been difficult, but the underlying level of asthma severity seems to be one of the most important factors. The exact mechanisms are not well understood but viral infections (discussed above) and noncompliance seem to be two of the most common causes. Women with severe asthma appear to be at the greatest risk.

Lack of appropriate Inhaled corticosteroid use is a major contributor to poor asthma control during pregnancy. Regular use of these medications can reduce the incidence of exacerbations by up to 75%13. It has also been shown that women who have exacerbations during pregnancy are less likely to receive appropriate therapy with inhaled or oral steroids for acute exacerbations and maintenance therapy of severe disease.

The importance of seeking care for asthma exacerbations and the necessity of adhering to prescribed asthma regimens during pregnancy cannot be overemphasized. Pregnant asthmatics with moderate and severe disease have been found to have exacerbation rates of 25% and 51% with hospitalization rates of 6% and 26% respectively. Suboptimal control of asthma during pregnancy may be associated with increased maternal or fetal risk15. Severe attacks during pregnancy may cause episodes of fetal hypoxia and poorly controlled maternal asthma has recently been shown to be significantly associated with an increased risk of preterm delivery.

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Dyspnea and wheezing in a pregnant patient

Case Study

A 30-year-old G2P1 pregnant woman at 15 weeks gestation presents to an outpatient clinic with worsening dyspnea over the preceding two weeks.

----------------------------------------------------------------

Case Details:


History:

A 30-year-old G2P1 pregnant woman at 15 weeks gestation presents to an outpatient clinic with worsening dyspnea over the preceding two weeks.

Her past medical history is significant for asthma diagnosed in childhood, seasonal allergies, and gastroesophageal reflux disease (GERD) during her previous pregnancy. She notes that her asthma symptoms had been well-controlled on inhaled fluticasone/salmeterol (250mcg/50mcg), albuterol HFA as needed, and a nasal steroid spray prior to pregnancy. However, she discontinued all of her medications when she learned that she was pregnant for fear that they might harm her baby.

The patient works in sales and has not used tobacco since college. She is allergic to cats and dust mites, but currently has no pets in her home. She has no additional medical history other than that described above.

At today’s visit she feels that she is unable to take a deep breath. She also describes one to two episodes of wheezing daily and night time cough two to three times per week. Warm air, dust, and exposure to cats seem to exacerbate her symptoms.

Physical Exam

On physical exam, the patient is in no acute distress. There is erythema of the nares bilaterally with clear rhinorrhea and cobble-stoning of the posterior pharynx. The lungs are clear to auscultation bilaterally. Heart sounds are normal without audible murmurs, gallops, or rubs. The abdomen is gravid and consistent with the patient’s current gestational age. There is trace edema of the lower extremities but no clubbing or cyanosis.

Lab

Spirometry from approximately one year prior to the visit reveals the following:

Pre-bronchodilator forced vital capacity (FVC) 5.11 L (116% predicted), forced expiratory volume in one second (FEV1) 3.12 L (84% predicted), FEV1/FVC 0.61. Post-bronchodilator FVC 5.16 L (1% change), FEV1 3.99 L (27% change), and FEV1/FVC 0.77.

Figures

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Question 4

The patient is started on inhaled budesonide 180 mcg twice daily and nasal fluticasone. At her return visit she continues to complain of wheezing requiring short-acting beta-agonist therapy three to four times weekly but is no longer experiencing nocturnal symptoms. According to current guidelines, which of the following statements is true regarding therapy for this patient?

A. The patient should continue on her current therapy as her symptoms have improved with the initiation of this regimen.

B. It would be appropriate to double the dose of the prescribed inhaled corticosteroid or to consider the addition of a long-acting beta-agonist in this patient.

C. The budesonide should be discontinued due to lack of benefit and potential fetal risk.

D. A course of oral prednisone is indicated because the patient continues to have symptoms on the inhaled corticosteroid prescribed.

E. Additional asthma controller medications such as cromolyn and the leukotriene receptor antagonists are contraindicated in pregnancy.

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Answer & Explanation

[HIDE] B. It would be appropriate to double the dose of the prescribed inhaled corticosteroid or to consider the addition of a long-acting beta-agonist in this patient. Correct!

The pharmacologic approach to the treatment of asthma during pregnancy is similar to that of the nonpregnant patient, with careful attention to the possible effects of medication on the fetus. As discussed above, it is safer for pregnant women to be treated with appropriate therapy than it is for them to have exacerbations or uncontrolled asthma15-18. In fact, adherence to guidelines19,20 where therapy is adjusted according to asthma severity can result in excellent maternal and fetal outcomes15,21. A step-wise approach to asthma therapy is recommended based on the classification of asthma severity and control in accordance with published guidelines19,20. For patients not currently on controller therapy, the severity of their disease should be assessed and appropriate treatment instituted (Figure 1). Patients who are not controlled should receive a step-up in medication therapy. When control has been achieved and sustained for several months, a step-down in medications may be considered (Figure 2). A step-down in therapy should be approached with caution to prevent an asthma exacerbation, and some providers may choose to postpone a reduction in medications until after delivery.

There is little data available for most medications used during pregnancy with few studies large enough to exclude all adverse outcomes or side effects, especially the risk of congenital abnormalities22. Asthma care providers must use the available information to weigh the risks and benefits of specific medications in each patient while considering the potential adverse effects of poorly controlled asthma. Table 3 contains a listing of commonly used medications for asthma and their pregnancy risk category according to drug class.


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