Respiratory disorders

1. Respiratory disorders Asthma

2. Prevalence is increasing mainly due to • environmental factors such as: change in indoor environment, smoking, family size, pollution and diet. • Effect of asthma on pregnancy • -some women experience no change in symptoms whereas others have worsening of the disease. • - The mechanisms that contribute to the varying changes in asthma during pregnancy are not well understood, although

3. increases in maternal circulating hormones (cortisol, oestradiol and progesterone), • altered β2-adrenoreceptor responsiveness • and immune function • or the presence of a female fetus may be involved • -When asthma is well controlled maternal and fetal outcomes are similar to those in women without asthma. – • -Women with severe disease and those who have poor control of asthma seem to have an increased incidence of adverse maternal and neonatal outcomes including preterm labour

4. Diagnosis • Clinical picture : • chest tightness, dyspnoea, wheezing and coughing. Measuring peak expiratory flow (PEF) using a PEF meter is a useful tool for making a diagnosis and determining how well a person's asthma is controlled • PEF monitors the level of resistance in the airways caused by inflammation or bronchospasm, or both and values are lower than predicted in people with asthma. A range of normal values can be predicted for each person according to sex, height and age

5. . Knowledge of the usual PEF and self-monitoring at home will enable a person with asthma to determine when to take or increase their medication and when to seek medical attention. • Hospital admission is usually required if the PEF is <50% of the normal value and the person is too breathless to complete sentences.

6. Management • Treatment relies on inhaled bronchodilators and inhaled steroids with or without oral steroids. • Nebulized drugs are given during acute attacks of asthma. • Antenatal care • -Care should ideally be provided jointly between the midwife, GP, chest physician and obstetrician

7. At the booking interview the midwife should be able to discuss with the woman the frequency and severity of her asthma, family history, any known asthma triggers and current treatment. • -The main anxiety for women and those providing care relates to the use of asthma medication and its effect on the fetus.

8. -In general, the medications used in the treatment of asthma, including systemic steroids, are considered safe to use in pregnancy • It is crucial that therapy is maintained during pregnancy as a severe asthma attack may result in a deterioration in the maternal condition and a reduction in the oxygen supply to the fetus. • Respiratory tract infections should be diagnosed and treated promptly in order to prevent an acute asthma attack. • If during the pregnancy there are any difficulties in controlling the symptoms of asthma the woman should be admitted to hospital

9. Intrapartum care • An increase in cortisone and adrenaline (epinephrine) from the adrenal glands during labour is thought to prevent attacks of asthma during labour • If an asthma attack does occur this should be treated in the usual way. Women should continue their usual asthma medications during labour and it is important that they remain well hydrated.

10. Maternal and fetal condition should be monitored closely, • namely: • respiratory function, • pulse oximetry, • oxygen therapy • and continuous fetal heart rate monitoring. • All forms of pain relief may be used although regional anaesthesia • reduces hyperventilation and the stress response to pain. • It is also advocated for operative delivery as it avoids the potential complications of ventilating people with asthma • -the use of β2-adrenergic antagonists for the treatment of hypertension and the use of ergometrine or carboprost (prostaglandin F2a) for the management of postpartum haemorrhage. These drugs may cause bronchospasm and should be avoided or used with caution

11. Oxytocin and prostaglandin E2 are safe to use for the induction of labour • Women who have received corticosteroids in pregnancy (>7.5 mg prednisolone/day for >2 weeks prior to the onset of labour) should receive parenteral hydrocortisone 100 mg 6–8-hourly during labour

12. Postnatal care • Breastfeeding should be encouraged, • particularly as it may protect infants from developing certain allergic conditions. • - None of the drugs used in the treatment of asthma is likely to be secreted in breast milk in sufficient quantities to harm the baby

13. Cystic fibrosis • -Cystic fibrosis (CF) • -is an autosomal recessive • -multi-system disorder • - People with CF develop chronic obstructive lung disease decreased oxygen saturation) • -Obstruction of the pancreatic ducts leads to a loss of acinar cells and replacement by fibrous tissue and fat. • - Loss of pancreatic function causes poor digestion, malnutrition and the development of type 1 diabetes.

14. - fertility may be slightly reduced, because of alteration in the chemical make-up of the cervical mucus, • -pregnancies are possible. • Pre-pregnancy care • -if the partner is a carrier there is a one in two chance that their children will have CF. • -Specific changes in respiratory, cardiac and pancreatic function as well as increased nutritional demands during pregnancy increase health risk for many women with CF and should be assessed prior to pregnancy

15. Antenatal care • Midwifery, obstetric, dietetic, medical, nursing and physiotherapy expertise are essential. • -Specific assessment includes: • pulmonary function tests • arterial blood gases • sputum culture • liver function tests • glucose tolerance test • chest radiogram • electrocardiogram • echocardiogram • and monitoring of weight gain.

16. -antibiotic therapy is essential to manage a severe lung infection. • it is important to pay attention to nutrition and CF-related diabetes, the risks of which increase with age and are more likely to be problematic in pregnancy

17. Intrapartum care • monitoring of cardio respiratory function • an anesthetist should be involved • Fluid and electrolyte management requires careful attention to avoid hypovolaemic from the loss of large quantities of sodium in sweat. • Epidural analgesia is the recommended to relief labor pain • general anaesthesia should be avoided because of the potential risks from respiratory complications

18. Postnatal care • -cardio respiratory function often deteriorates following birth ,so careful care is need • -Sodium concentration in breast milk has been found to be similar to women without CF and therefore breastfeeding is permitted. • - well nourished and maintain an adequate calorie intake is important point of breast feeding • -it is recommended that universal neonatal testing is undertaken as part of screening programme

19. Pulmonary tuberculosis: • (TB) is an air-borne infectious disease • caused by the tubercule bacillus, Mycobacterium tuberculosis. • It is transmitted through inhalation of infected air-borne droplets from a person with infectious TB. • Comes from infected cattle through the consumption of milk and dairy products that have not been pasteurized. -The lungs are the organ most commonly affected (pulmonary TB)

20. although it may spread to bones, joints and the lymphatic, genitourinary and central nervous system (extra pulmonary TB). • The primary healthcare workers including midwives are among the first to be involved in the prevention, screening and treatment of TB • factors leading to the increasing incidence of this disease include

21. (1) women and children who have immigrated from areas where TB is endemic, principally South-Asia and African countries • (2) the development of drug-resistant organisms • (3) increases in adults and children who have become infected with HIV .

22. social factors such as poverty, • homelessness, • substance misuse, • poor nutrition • crowded living conditions • TB is primarily a disease of poverty and almost all cases are preventable.

23. Diagnosis • -TB is often gradual symptoms and non-specific: • -fatigue, malaise, loss of appetite • loss of weight, • alteration in bowel habit • low grade fever. • These symptoms like usual symptoms occurring in pregnancy leading to a delay in diagnosis

24. The classic symptoms : • chronic cough • intermittent fever • night sweats, • Haemoptysis • dyspnoea • and chest pain occur quite late in the disease process and are often absent when the TB is extra pulmonary.

25. Early diagnosis; • increase awareness about TB in the immigrant population and in the community, • provide access to medical care • The presence of risk factors requires assessment • the Mantoux tuberculin skin test and • an interferon-γ (secreted by lymphocytes in the presence of antigens to TB) test. • history and physical examination should also be undertaken.

26. A positive tuberculin test should be further evaluated with a chest X-ray, abdominal shielding for this procedure keeps fetal exposure to a minimum. • Microscopic examination and culture of sputum are to confirm active mycobacterial infection and identify drug sensitivity • Once active TB has been diagnosed, the need for

27. 1-contact tracing must be assessed • 2- testing and treatment of asymptomatic household and other close contacts in order to prevent spread of the disease .

28. Management • It is important that is to ensure that the woman is involved in treatment decisions and adheres to the prescribed treatment. • -maternal morbidity and mortality are significantly higher where active TB remains untreated and when treatment is started late in pregnancy.

29. -neonates of women with TB have a higher risk of: • * prematurity • * perinatal death • *low birth weight. • -Standard anti-tuberculous therapy is considered safe in pregnancy

30. TB is treated in two phases: • @ The first involves taking rifampicin, isoniazid (INH), pyrazinamide and ethambutol daily for 2 months. • @ In the second (continuation) phase, rifampicin and isoniazid are taken for a further 4 months

31. -Congenital deafness has been reported in infants with exposure to streptomycin in utero and therefore this anti-tuberculous drug is avoided in pregnancy. • Role of midwife : • -ensure that women are compliant with the drug therapy • -woman understand the importance of adhering to the regimen in order to cure the disease • -prevent the bacillus becoming resistant to the drugs.

32. - a monthly review will be sufficient to monitor progress • -rest, good nutrition and education with regard to preventing the spread of the disease. • - TB usually becomes non-infectious by 2 weeks of treatment. • the treatment is given at the woman's home

33. Some women may require admission to hospital because of • 1- the severity of the illness • 2- adverse effects of drug therapy • -3-obstetric reasons such as the onset of labor • 4- social reasons • 5-further investigations.

34. Risk assessment should be made in order to determine appropriate infection control measures. • -the person with TB is cured. • -In a small number of people, the disease can return if not all bacteria have been killed. • This is more likely to occur where: • - there is poor/no compliance with drug treatment • -where there is multi-drug resistant (MDR) TB.

35. Postnatal care • Following birth, babies born to mothers with infectious TB should be protected from the disease by: • - the prophylactic use of isoniazid syrup (5 mg/kg per day) -pyridoxine (5–10 mg/day) for 6 weeks and then to be tuberculin tested. • -If negative, the neonatal Bacille Calmette–Guérin (BCG) vaccination should be given and drug therapy discontinued

36. If the tuberculin test is positive the baby should be assessed for congenital or perinatal infection and drug therapy continued • - The baby cannot be infected by the mother via the breast milk unless she has tuberculous mastitis. • -add to that , the concentration of the anti-tuberculous drugs in breast milk is insufficient to cause harm in the neonate

37. - the majority of cases breastfeeding should be encouraged . • -Midwives should explain that poor nutrition, stress and overtiredness will encourage a recurrence of active disease. • - for a woman with TB to avoid further pregnancies until she has been disease-free for at least 2 years. • - the woman needs to be aware that rifampicin reduces the effectiveness of oral contraception • -Long-term medical and social follow-up is necessary. • -The outcome for both mother and baby is improved by early diagnosis and effective treatment.