Respiratory Problems in Maternity HDU

Cathy Nelson-Piercy

Consultant Obstetric Physician

Professor of Obstetric Medicine

KCL Division of Women’s Health

Lecture Plan Page 1

Respiratory

Asthma

Pneumonia

Pulmonary oedema

Hypoxia ? Cause

PE

AFE

Cardiopulmonary arrest

Commonest respiratory problems on maternity HDU……

Desaturation post CS

Basal atelectasis

poor respiratory effort post GA

Pain from CS

ileus / constipation / distension / diaphragmatic splinting

Pneumonia

Pulmonary oedema

Page 2

7.8% pregnancies

conceived with ART

Pregnant Post partum

Obstetric 9% 70%

PPH 36%

Pre-eclampsia 2% 4%

HELLP 0.7% 2.5%

Non obstetric 91% 30%

Pneumonia 23% 4.3%

Pulmonary

oedema

1.9% 1.6%

Pelvic infection 1.9%

AKI 0.3% 0.8%

Asthma 8% 0.6%

Cardiovascular 8% 5.6%

GI 10% 4.5%

Neuro 9% 3.5%

Endo 12% 1.6%

Page 5

ICNARC, 2013

There were deficiencies in both routine care and in the treatment of attacks.

There was widespread under-use of preventer inhalers and excessive over-

reliance on reliever inhalers.

10% of those who died did so within one month of discharge from hospital

following treatment for asthma; at least 21% had attended an emergency

department at least once in the previous year.

Over half of those who died were being treated for mild or moderate asthma

at the time; experts concluded that this was mostly because neither

doctors nor patients themselves recognised how serious their asthma

really was.

19% of those who died were smokers and others, including many children,

were exposed to second-hand smoke in the home.

Some patients had not collected their prescriptions for preventative

treatment or did not attend regular asthma check-ups.

National Review of Asthma Deaths (NRAD) – Findings: Page 7

• Every hospital and GP practice should have a designated, named

clinician for asthma services.

• Better monitoring of asthma control; where loss of control is

identified, immediate action is required including escalation of

responsibility, treatment change and arrangements for follow-up.

• Better education is needed for doctors, nurses, patients and carers

to make them aware of the risks. They need to be able to recognise

the warning signs of poor asthma control and know what to do

during an attack.

• All patients should be provided with a personal asthma action plan

(PAAP), which can help them to identify if their asthma is

worsening and tell them how and when to seek help.

National Review of Asthma Deaths (NRAD) – Recommendations:

Stepwise management of asthma Page 9

Revised edition October 2014

Thorax 8th October

Levels of severity of acute asthma attacks in adults

Moderate asthma - Increasing symptoms

- PEF >50–75% best or predicted

- no features of acute severe asthma

Acute severe asthma Any one of:

- PEF 33–50% best or predicted

- respiratory rate ≥25/min

- heart rate ≥110/min

- inability to complete sentences in one breath

Life-threatening asthma Any one of the following in a patient with severe asthma:

Clinical signs Measurements

Altered conscious level PEF <33% best or predicted

Exhaustion SpO2 < 92%

Arrhythmia PaO2 < 8 kPa

Hypotension ’normal’ PaCO2 (4.6–6.0 kPa)

Cyanosis

Silent chest

Poor respiratory effort

Near-fatal asthma Raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures

504-507

Give supplementary oxygen to all hypoxaemic patients with acute severe

asthma to maintain an SpO2 level of 94–98%. Lack of pulse oximetry

should not prevent the use of oxygen.

Use high-dose inhaled β2 agonists as first line agents in patients with

acute asthma and administer as early as possible. Reserve intravenous

β2 agonists for those patients in whom inhaled therapy cannot be used

reliably.

In severe asthma that is poorly responsive to an initial bolus dose of β2

agonist, consider continuous nebulisation with an appropriate nebuliser.

Give steroids in adequate doses in all cases of acute asthma attack.

Add nebulised ipratropium bromide (0.5 mg 4–6 hourly) to b2 agonist

treatment for patients with acute severe or life-threatening asthma or

those with a poor initial response to b2 agonist therapy.

Consider giving a single dose of IV magnesium sulphate to patients with

acute severe asthma (PEF <50% best or predicted) who have not had a

good initial response to inhaled bronchodilator therapy.

Management of acute asthma: Recommendations Page 12

Indications for admission to intensive care or high-dependency units

include patients requiring ventilatory support and those with acute

severe or life-threatening asthma who are failing to respond to therapy,

as evidenced by:

• deteriorating PEF

• persisting or worsening hypoxia

• hypercapnia

• arterial blood gas analysis showing fall in pH or rising H+ concentration

• exhaustion, feeble respiration

• drowsiness, confusion, altered conscious state

• respiratory arrest

REFERRAL TO INTENSIVE CARE

Page 13

Nebulized beta2 agonists + ipratropium

Oxygen – sats 94-98%

Oral / intravenous corticosteroids

Mg SO4

Intravenous theophylline

Intravenous beta 2 agonists

Consider delivery if ventilation required

Acute severe asthma - summary

Acute asthma is very unusual in labour

CXRs are safe in pregnancy

MgS04 is safe for acute severe asthma; 1.2g vs. 4g

Remember

Normal oxygen saturations do not exclude critical illness

Eg. Diabetic ketoacidosis

Serum bicarbonate (18-22 mmol/l)

ABGs

PH

O2

CO2

Bicarbonate

Base excess

Lactate

Arterial Blood Gases

Acidosis is bad

Tachypnoea is sepsis until proved otherwise

6/10/06

Bacterial – same organisms, same treatment

Amoxycillin

Cefuroxime

Clarithromycin

Gentamycin

AVOID tetracycline / doxycycline

Viral

Varicella Zoster

Influenza

Pneumonia

UKOSS study Sept – Dec 2009

All admitted pregnant women with confirmed H1N1

Interim report, n = 182

Cases Controls

BMI >30 29 19

Asthma 16 5

H1N1 in pregnancy

UKOSS study Sept – Dec 2009 (n=256, 1220 controls)

20% admitted to ITU

Fewer symptoms

Less likely to have been treated with antivirals within 2 days of symptoms

Increase risk of preterm delivery

(Pierce et al. BJOG 2011; 342)

Systematic review and meta-analysis (n=610 782)

OR mortality: pandemic flu seasonal flu

Obesity 2.74 (95% CI 1.56-4.8) 30.1 (95% CI 1.74-2.39)

Pregnancy 0.99 (95% CI 0.67-1.46) 1.07 (95% CI 0.79-1.45)

(Mertz et al. BMJ 2013; 347:f5061)

H1N1 in pregnancy

Case 133 year old womanReadmitted day 5 post emLSCS (for pre-eclampsia) c/o SOB and wheezyHad been discharged home day 3 post LSCS – well

O/EBreathless, sweaty SaO2 70% on RA; 100% on 15LBP 170/90 P75 SRUrine: 1+ proteinCVS: Raised JVP, HS normalChest – bilateral wheezing, scattered crepsAbdo – soft, non tenderPeripheral oedema to thighs

AIR

pH 7.49

PaCO2 4.1

PaO2 6.2

BEx 0.6

Echo normal; Diagnosis = postpartum pre-eclampsia

Pre-eclampsia

Reduced colloid osmotic pressure

Iatrogenic

Fluid shifts

Beware syntocinon

Beware NSAIDs

Cardiac

Peripartum cardiomyopathy

Mitral stenosis

Pulmonary oedema

n = 210,631; 16 units; 1999 - 2003.

1087 severe pre-eclampsia or eclampsia (5.2/1000)

151 serious complications

82 (39/10,000) having eclamptic seizures and

49 (23/10,000) requiring ICU admission.

82 eclampsia

45 occurred antenatally (55%)

18 before admission to the maternity unit

11 in labour (13%)

26 following delivery (32%).

25 pulmonary oedema (2.3% of cases)

6 renal dialysis (0.55% of cases).

Yorkshire Critical Care Group

BJOG. 2005; 112:875-80

Sibai et al. AJOG 1987; 156: 1174-9.

9 yrs, n = 37 (78% black)

Incidence = 2.9% (cf. 2.3% Yorkshire)

Higher incidence in older, multigravid patients

30% antepartum (90% pre-existing hypertension)

70% postpartum (Xs colloid / crystalloid)

4 maternal deaths; PNM = 53%

Pulmonary oedema in Pre-eclampsia

Oxygen

Stop IV fluids

Diuretics

Diamorphine

Investigate cause = ECHO

PPCM = Deliver / ACEI

Thromboprophylaxis

Management of pulmonary oedema

• Collaborative clinical leadership at an early stage

is essential for optimal Mx

• Include physicians, microbiology and virology,

intensive care, anaesthesiology, neonatology

• All pregnant women presenting with respiratory

symptoms should have oxygen saturation

performed at admission

• Request lactate / venous gas in suspected sepsis

• Not all breathessness and / or chest pain = PE

• Tachypnoea is sepsis until proved otherwise

Learning points - Respiratory

Thank you for your attention!