LOGIN 
 

JOIN
 

RENEW
 

CME/MOC

 

SEARCH

Clinical Cases

Home â–¶ Professionals â–¶ Clinical Resources â–¶ Clinical Cases â–¶ Dyspnea and wheezing in a pregnant patient


Dyspnea and wheezing in a pregnant patient

Reviewed By Allergy, Immunology & Inflammation Assembly

Submitted by

Brent P. Riscili, MD

Fellow

Pulmonary and Critical Care Medicine

The Ohio State University Medical Center

Columbus, Ohio

Jennifer W. McCallister, MD

Assistant Professor of Internal Medicine

Division of Pulmonary, Allergy, Critical Care and Sleep Medicine

The Ohio State University Medical Center

Columbus, Ohio

Submit your comments to the author(s).

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


Classifying asthma severity

Stepwise approach to therapy for asthma

Question 1

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

References

  1. Dombrowski MP and Schatz M. ACOG practice bulletin: clinical management guidelines for obstetrician-gynecologists: asthma in pregnancy. Obstet Gynecol 2008;111:457-464.
  2. Gluck JC and Gluck PA. The effect of pregnancy on the course of asthma. Immunol Allergy Clin North Am 2006;26:63-80.
  3. Sorri M, Hartikainen-Sorri AL, Karja J. Rhinitis during pregnancy. Rhinology 1980;18:83-86.
  4. Chesnutt AN. Physiology of normal pregnancy. Crit Care Clin 2004;20:609-615.
  5. Henderson CE, Ownby DR, Trumble A, DerSimonian R, Kellner LH. Predicting asthma severity from allergic sensitivity to cockroaches in pregnant inner city women. J Reprod Med 2000;45:341-344.
  6. Finn R, St Hill CA, Govan AJ, Ralfs IG, Gurney FJ, Denye V. Immunological responses in pregnancy and survival of fetal homograft. Br Med J 1972;3:150-152.
  7. Murphy VE, Clifton VL, Gibson PG. Asthma exacerbations during pregnancy: incidence and association with adverse pregnancy outcomes. Thorax 2006;61:169-176.
  8. Gluck JC and Gluck P. The effects of pregnancy on asthma: a prospective study. Ann Allergy 1976;37:164-168.
  9. Munn MB, Groome LJ, Atterbury JL, Baker SL, Hoff C. Pneumonia as a complication of pregnancy. J Matern Fetal Med 1999;8:151-154.
  10. Unterborn J. Pulmonary function testing in obesity, pregnancy, and extremes of body habitus. Clin Chest Med 2001;22:759-767.
  11. Wise RA, Polito AJ, Krishnan V. Respiratory physiologic changes in pregnancy. Immunol Allergy Clin North Am 2006;26:1-12.
  12. Schatz M, Harden K, Forsythe A, Chilingar L, Hoffman C, Sperling W, Zeiger RS. The course of asthma during pregnancy, post partum, and with successive pregnancies: a prospective analysis. J Allergy Clin Immunol 1988;81:509-517.
  13. Stenius-Aarniala BS, Hedman J, Teramo KA. Acute asthma during pregnancy. Thorax 1996;51:411-414.
  14. Cydulka RK, Emerman CL, Schreiber D, Molander KH, Woodruff PG, Camargo CA, Jr. Acute asthma among pregnant women presenting to the emergency department. Am J Respir Crit Care Med 1999;160:887-892.
  15. Dombrowski MP, Schatz M, Wise R, Momirova V, Landon M, Mabie W, Newman RB, McNellis D, Hauth JC, Lindheimer M, Caritis SN, Leveno KJ, Meis P, Miodovnik M, Wapner RJ, Paul RH, Varner MW, O'Sullivan MJ, Thurnau GR, Conway DL. Asthma during pregnancy. Obstet Gynecol 2004;103:5-12.
  16. Jana N, Vasishta K, Saha SC, Khunnu B. Effect of bronchial asthma on the course of pregnancy, labour and perinatal outcome. J Obstet Gynaecol 1995;21:227-232.
  17. Schatz M, Zeiger RS, Hoffman CP, Harden K, Forsythe A, Chilingar L, Saunders B, Porreco R, Sperling W, Kagnoff M, . Perinatal outcomes in the pregnancies of asthmatic women: a prospective controlled analysis. Am J Respir Crit Care Med 1995;151:1170-1174.
  18. Bakhireva LN, Schatz M, Jones KL, Chambers CD, for the Organization of Teratology Information Specialists Collaborative Research Group. Asthma control during pregnancy and the risk of preterm delivery or impaired fetal growth. Ann Allergy Asthma Immunol 2008;101:137-143.
  19. National Asthma Education and Prevention Program. Expert Panel Report--Update 2004. NAEPP expert panel report: managing asthma during pregnancy: recommendations for pharmacologic treatment--update 2004. Bethesda, MD.: National Institutes of Health and National Heart, Lung, and Blood Institute; 2004.
  20. National Asthma Education and Prevention Program. Expert Panel Report 3: guidelines for the diagnosis and management of asthma. Bethesda, MD.: National Institutes of Health and National Heart, Lung, and Blood Institute; 2007.
  21. Bracken MB, Triche EW, Belanger K, Saftlas A, Beckett WS, Leaderer BP. Asthma symptoms, severity, and drug therapy: a prospective study of effects on 2205 pregnancies. Obstet Gynecol 2003;102:739-752.
  22. Chambers C. Safety of asthma and allergy medications in pregnancy. Immunol Allergy Clin North Am 2006;26:13-28.
  23. Wilton LV, Pearce GL, Martin RM, Mackay FJ, Mann RD. The outcomes of pregnancy in women exposed to newly marketed drugs in general practice in England. Br J Obstet Gynaecol 1998;105:882-889.
  24. Wilton LV and Shakir SA. A post-marketing surveillance study of formoterol (Foradil): its use in general practice in England. Drug Saf 2002;25:213-223.
  25. Alexander S, Dodds L, Armson BA. Perinatal outcomes in women with asthma during pregnancy. Obstet Gynecol 1998;92:435-440.
  26. Kallen B, Rydhstroem H, Aberg A. Congenital malformations after the use of inhaled budesonide in early pregnancy. Obstet Gynecol 1999;93:392-395.
  27. Norjavaara E and de Verdier MG. Normal pregnancy outcomes in a population-based study including 2,968 pregnant women exposed to budesonide. J Allergy Clin Immunol 2003;111:736-742.
  28. Czeizel AE and Rockenbauer M. Population-based case-control study of teratogenic potential of corticosteroids. Teratology 1997;56:335-340.
  29. Rodriguez-Pinilla E and Martinez-Frias ML. Corticosteroids during pregnancy and oral clefts: a case-control study. Teratology 1998;58:2-5.
  30. Schatz M, Zeiger RS, Harden K, Hoffman CC, Chilingar L, Petitti D. The safety of asthma and allergy medications during pregnancy. J Allergy Clin Immunol 1997;100:301-306.
  31. Schatz M, Dombrowski MP, Wise R, Momirova V, Landon M, Mabie W, Newman RB, Hauth JC, Lindheimer M, Caritis SN, Leveno KJ, Meis P, Miodovnik M, Wapner RJ, Paul RH, Varner MW, O'Sullivan MJ, Thurnau GR, Conway DL. The relationship of asthma medication use to perinatal outcomes. J Allergy Clin Immunol 2004;113:1040-1045
  32. Schatz M, Dombrowski MP, Wise R, Thom EA, Landon M, Mabie W, Newman RB, Hauth JC, Lindheimer M, Caritis SN, Leveno KJ, Meis P, Miodovnik M, Wapner RJ, Paul RH, Varner MW, O'Sullivan MJ, Thurnau GR, Conway D, McNellis D. Asthma morbidity during pregnancy can be predicted by severity classification. J Allergy Clin Immunol 2003;112:283-288.