Semin Respir Crit Care Med 2017; 38(02): 123-134
DOI: 10.1055/s-0037-1602167
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

General Management Principles of the Pregnant Woman

Amanpreet Kaur
1   Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
,
Margaret Miller
2   Department of Medicine, Women's Medicine Collaborative, The Miriam Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
› Author Affiliations
Further Information

Publication History

Publication Date:
22 May 2017 (online)

Abstract

Pregnancy is a dynamic process that consists of profound physiological changes mediated by hormonal, mechanical, and circulatory pathways. Understanding of changes in physiology is essential for distinguishing abnormal and normal signs and symptoms in a pregnant patient. These physiological changes also have important pharmacotherapeutic considerations for a pregnant patient. Although there are limited data to guide decisions regarding medications and diagnostic procedures in pregnancy, a careful review of risks should be balanced with review of risk of withholding a medication or procedure. Interventional pulmonary procedures can be safely performed in pregnant women while keeping in mind the maternal anatomic and physiologic changes. Furthermore, management of a maternal cardiopulmonary arrest requires important modifications in patient positioning and intravenous access to ensure adequate efficacy of chest compressions, circulation, and airway management. This review will provide an overview of maternal physiologic changes with a focus on cardiopulmonary physiology, pharmacotherapeutic considerations, diagnostic and interventional pulmonary procedures during pregnancy, and cardiopulmonary resuscitation in pregnancy.

 
  • References

  • 1 Contreras G, Gutiérrez M, Beroíza T. , et al. Ventilatory drive and respiratory muscle function in pregnancy. Am Rev Respir Dis 1991; 144 (04) 837-841
  • 2 Gilroy RJ, Mangura BT, Lavietes MH. Rib cage and abdominal volume displacements during breathing in pregnancy. Am Rev Respir Dis 1988; 137 (03) 668-672
  • 3 Jensen D, Duffin J, Lam YM. , et al. Physiological mechanisms of hyperventilation during human pregnancy. Respir Physiol Neurobiol 2008; 161 (01) 76-86
  • 4 Lyons HA, Antonio R. The sensitivity of the respiratory center in pregnancy and after the administration of progesterone. Trans Assoc Am Physicians 1959; 72: 173-180
  • 5 Bayliss DA, Millhorn DE. Central neural mechanisms of progesterone action: application to the respiratory system. J Appl Physiol (1985) 1992; 73 (02) 393-404
  • 6 Jensen D, Wolfe LA, Slatkovska L, Webb KA, Davies GA, O'Donnell DE. Effects of human pregnancy on the ventilatory chemoreflex response to carbon dioxide. Am J Physiol Regul Integr Comp Physiol 2005; 288 (05) R1369-R1375
  • 7 Liberatore SM, Pistelli R, Patalano F, Moneta E, Incalzi RA, Ciappi G. Respiratory function during pregnancy. Respiration 1984; 46 (02) 145-150
  • 8 Hannhart B, Pickett CK, Moore LG. Effects of estrogen and progesterone on carotid body neural output responsiveness to hypoxia. J Appl Physiol (1985) 1990; 68 (05) 1909-1916
  • 9 Bourjeily G, Mazer J, Levinson A. Pulmonary disorders and pregnancy. In: Grippi MA. , ed. Fishman's Pulmonary Diseases and Disorders, 5th ed. New York: McGraw-Hill Education; 2015: 1479-1495
  • 10 Weinberger SE, Weiss ST, Cohen WR, Weiss JW, Johnson TS. Pregnancy and the lung. Am Rev Respir Dis 1980; 121 (03) 559-581
  • 11 Goldsmith LT, Weiss G, Steinetz BG. Relaxin and its role in pregnancy. Endocrinol Metab Clin North Am 1995; 24 (01) 171-186
  • 12 Sherwood OD, Downing SJ, Guico-Lamm ML, Hwang JJ, O'Day-Bowman MB, Fields PA. The physiological effects of relaxin during pregnancy: studies in rats and pigs. Oxf Rev Reprod Biol 1993; 15: 143-189
  • 13 Marx GF, Murthy PK, Orkin LR. Static compliance before and after vaginal delivery. Br J Anaesth 1970; 42 (12) 1100-1104
  • 14 Hegewald MJ, Crapo RO. Respiratory physiology in pregnancy. Clin Chest Med 2011; 32 (01) 1-13 , vii
  • 15 Baldwin GR, Moorthi DS, Whelton JA, MacDonnell KF. New lung functions and pregnancy. Am J Obstet Gynecol 1977; 127 (03) 235-239
  • 16 Brancazio LR, Laifer SA, Schwartz T. Peak expiratory flow rate in normal pregnancy. Obstet Gynecol 1997; 89 (03) 383-386
  • 17 Milne JA, Mills RJ, Howie AD, Pack AI. Large airways function during normal pregnancy. Br J Obstet Gynaecol 1977; 84 (06) 448-451
  • 18 Milne JA, Mills RJ, Coutts JR, Macnaughton MC, Moran F, Pack AI. The effect of human pregnancy on the pulmonary transfer factor for carbon monoxide as measured by the single-breath method. Clin Sci Mol Med 1977; 53 (03) 271-276
  • 19 Bedell GN, Adams RW. Pulmonary diffusing capacity during rest and exercise. A study of normal persons and persons with atrial septal defect, pregnancy, and pulmonary disease. J Clin Invest 1962; 41 (10) 1908-1914
  • 20 Nørregaard O, Schultz P, Ostergaard A, Dahl R. Lung function and postural changes during pregnancy. Respir Med 1989; 83 (06) 467-470
  • 21 McCormack MC, Wise RA. Respiratory physiology in pregnancy. In: Rosene-Montella K, Bourjeily G. , eds. Pulmonary Problems in Pregnancy. New York: Humana Press; 2009: 19-27
  • 22 Milne JA, Howie AD, Pack AI. Dyspnoea during normal pregnancy. Br J Obstet Gynaecol 1978; 85 (04) 260-263
  • 23 Chapman AB, Abraham WT, Zamudio S. , et al. Temporal relationships between hormonal and hemodynamic changes in early human pregnancy. Kidney Int 1998; 54 (06) 2056-2063
  • 24 Mahendru AA, Everett TR, Wilkinson IB, Lees CC, McEniery CM. A longitudinal study of maternal cardiovascular function from preconception to the postpartum period. J Hypertens 2014; 32 (04) 849-856
  • 25 Grindheim G, Estensen ME, Langesaeter E, Rosseland LA, Toska K. Changes in blood pressure during healthy pregnancy: a longitudinal cohort study. J Hypertens 2012; 30 (02) 342-350
  • 26 Cheung KL, Lafayette RA. Renal physiology of pregnancy. Adv Chronic Kidney Dis 2013; 20 (03) 209-214
  • 27 Kristiansson P, Wang JX. Reproductive hormones and blood pressure during pregnancy. Hum Reprod 2001; 16 (01) 13-17
  • 28 Lumbers ER, Pringle KG. Roles of the circulating renin-angiotensin-aldosterone system in human pregnancy. Am J Physiol Regul Integr Comp Physiol 2014; 306 (02) R91-R101
  • 29 Brunton PJ, Arunachalam S, Russel JA. Control of neurohypophysial hormone secretion, blood osmolality and volume in pregnancy. J Physiol Pharmacol 2008; 59 (Suppl. 08) 27-45
  • 30 Jepson JH, Lowenstein L. Role of erythropoietin and placental lactogen in the control of erythropoiesis during pregnancy. Can J Physiol Pharmacol 1968; 46 (04) 573-576
  • 31 Robson SC, Hunter S, Boys RJ, Dunlop W. Serial study of factors influencing changes in cardiac output during human pregnancy. Am J Physiol 1989; 256 (4 Pt 2): H1060-H1065
  • 32 Hunter S, Robson SC. Adaptation of the maternal heart in pregnancy. Br Heart J 1992; 68 (06) 540-543
  • 33 Cutforth R, MacDonald CB. Heart sounds and murmurs in pregnancy. Am Heart J 1966; 71 (06) 741-747
  • 34 Carruth JE, Mivis SB, Brogan DR, Wenger NK. The electrocardiogram in normal pregnancy. Am Heart J 1981; 102 (6 Pt 1): 1075-1078
  • 35 Robson SC, Hunter S, Moore M, Dunlop W. Haemodynamic changes during the puerperium: a Doppler and M-mode echocardiographic study. Br J Obstet Gynaecol 1987; 94 (11) 1028-1039
  • 36 Ducas RA, Elliott JE, Melnyk SF. , et al. Cardiovascular magnetic resonance in pregnancy: insights from the cardiac hemodynamic imaging and remodeling in pregnancy (CHIRP) study. J Cardiovasc Magn Reson 2014; 16: 1
  • 37 Campos O, Andrade JL, Bocanegra J. , et al. Physiologic multivalvular regurgitation during pregnancy: a longitudinal Doppler echocardiographic study. Int J Cardiol 1993; 40 (03) 265-272
  • 38 Costantine MM. Physiologic and pharmacokinetic changes in pregnancy. Front Pharmacol 2014; 5: 65
  • 39 Mitchell AA, Gilboa SM, Werler MM, Kelley KE, Louik C, Hernández-Díaz S. ; National Birth Defects Prevention Study. Medication use during pregnancy, with particular focus on prescription drugs: 1976-2008. Am J Obstet Gynecol 2011; 205 (01) 51.e1-51.e8
  • 40 Lupattelli A, Spigset O, Twigg MJ. , et al. Medication use in pregnancy: a cross-sectional, multinational web-based study. BMJ Open 2014; 4 (02) e004365
  • 41 Feghali M, Venkataramanan R, Caritis S. Pharmacokinetics of drugs in pregnancy. Semin Perinatol 2015; 39 (07) 512-519
  • 42 Mehta N, Newstead-Angel J, Powrie R. Prescribing in pregnancy and lactation. In: Rosene-Montella K, Bourjeily G. , eds. Pulmonary Problems in Pregnancy. New York: Humana Press; 2009: 71-88
  • 43 Wagner L, Lester R, Saldana L. Exposure of the Pregnant Patient to Diagnostic Radiation: A Guide to Medical Management, 2nd ed. Madison, WI: Medical Physics Publishing; 1997
  • 44 Miller M, Larson L. Diagnostic imaging in pregnancy. In: Rosene-Montella K, Bourjeily G. , eds. Pulmonary Problems in Pregnancy. New York: Humana Press; 2009: 59-71
  • 45 Patel SJ, Reede DL, Katz DS, Subramaniam R, Amorosa JK. Imaging the pregnant patient for nonobstetric conditions: algorithms and radiation dose considerations. Radiographics 2007; 27 (06) 1705-1722
  • 46 Bourjeily G, Paidas M, Khalil H, Rosene-Montella K, Rodger M. Pulmonary embolism in pregnancy. Lancet 2010; 375 (9713): 500-512
  • 47 Bourjeily G, Chalhoub M, Phornphutkul C, Alleyne TC, Woodfield CA, Chen KK. Neonatal thyroid function: effect of a single exposure to iodinated contrast medium in utero. Radiology 2010; 256 (03) 744-750
  • 48 Kanal E, Barkovich AJ, Bell C. , et al; Expert Panel on MR Safety. ACR guidance document on MR safe practices: 2013. J Magn Reson Imaging 2013; 37 (03) 501-530
  • 49 Ray JG, Vermeulen MJ, Bharatha A, Montanera WJ, Park AL. Association between MRI exposure during pregnancy and fetal and childhood outcomes. JAMA 2016; 316 (09) 952-961
  • 50 Adam A, Dixon AK, Gillard JH, Schaefer-Prokop C, Allison DJ, Grainger RG. Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging. Edinburgh: Churchill Livingstone/Elsevier; 2015
  • 51 American College of Obstetricians and Gynecologists' Committee on Obstetric Practice. Committee opinion no. 656: guidelines for diagnostic imaging during pregnancy and lactation. Obstet Gynecol 2016; 127 (02) e75-e80
  • 52 Pilkington S, Carli F, Dakin MJ. , et al. Increase in Mallampati score during pregnancy. Br J Anaesth 1995; 74 (06) 638-642
  • 53 Kuczkowski KM, Reisner LS, Benumof JL. Airway problems and new solutions for the obstetric patient. J Clin Anesth 2003; 15 (07) 552-563
  • 54 Morgan RK, Ernst A. Interventional chest procedures in pregnancy. Clin Chest Med 2011; 32 (01) 61-74 , viii
  • 55 British Thoracic Society Bronchoscopy Guidelines Committee, a Subcommittee of Standards of Care Committee of British Thoracic Society. British Thoracic Society guidelines on diagnostic flexible bronchoscopy. Thorax 2001; 56 (Suppl. 01) i1-i21
  • 56 Abu-Hijleh M. Pulmonary procedures during pregnancy. In: Rosene-Montella K, Bourjeily G. , eds. Pulmonary Problems in Pregnancy: Clinical and Research Aspects. Totowa, NJ: Humana Press; 2009: 313-329
  • 57 Tang SJ, Mayo MJ, Rodriguez-Frias E. , et al. Safety and utility of ERCP during pregnancy. Gastrointest Endosc 2009; 69 (3 Pt 1): 453-461
  • 58 Baumann MH, Strange C, Heffner JE. , et al; AACP Pneumothorax Consensus Group. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest 2001; 119 (02) 590-602
  • 59 Reid CJ, Burgin GA. Video-assisted thoracoscopic surgical pleurodesis for persistent spontaneous pneumothorax in late pregnancy. Anaesth Intensive Care 2000; 28 (02) 208-210
  • 60 Brace V, Penney G, Hall M. Quantifying severe maternal morbidity: a Scottish population study. BJOG 2004; 111 (05) 481-484
  • 61 Lewis G, Drife JO. Why Mothers Die 2000–2002: The Sixth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. London: RCOG; 2004
  • 62 Bennett TA, Katz VL, Zelop CM. Cardiac arrest and resuscitation unique to pregnancy. Obstet Gynecol Clin North Am 2016; 43 (04) 809-819
  • 63 Ramsay G, Paglia M, Bourjeily G. When the heart stops: a review of cardiac arrest in pregnancy. J Intensive Care Med 2013; 28 (04) 204-214
  • 64 Jeejeebhoy FM, Zelop CM, Lipman S. , et al; American Heart Association Emergency Cardiovascular Care Committee, Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Cardiovascular Diseases in the Young, and Council on Clinical Cardiology. Cardiac arrest in pregnancy: a scientific statement from the American Heart Association. Circulation 2015; 132 (18) 1747-1773
  • 65 Nanson J, Elcock D, Williams M, Deakin CD. Do physiological changes in pregnancy change defibrillation energy requirements?. Br J Anaesth 2001; 87 (02) 237-239
  • 66 Crochetière C. Obstetric emergencies. Anesthesiol Clin North America 2003; 21 (01) 111-125
  • 67 Bern S, Weinberg G. Local anesthetic toxicity and lipid resuscitation in pregnancy. Curr Opin Anaesthesiol 2011; 24 (03) 262-267
  • 68 Weinberg GL. Treatment of local anesthetic systemic toxicity (LAST). Reg Anesth Pain Med 2010; 35 (02) 188-193
  • 69 Einav S, Kaufman N, Sela HY. Maternal cardiac arrest and perimortem caesarean delivery: evidence or expert-based?. Resuscitation 2012; 83 (10) 1191-1200
  • 70 Benson MD, Padovano A, Bourjeily G, Zhou Y. Maternal collapse: challenging the four-minute rule. EBioMedicine 2016; 6: 253-257
  • 71 Sharma NS, Wille KM, Bellot SC, Diaz-Guzman E. Modern use of extracorporeal life support in pregnancy and postpartum. ASAIO J 2015; 61 (01) 110-114
  • 72 Moore SA, Dietl CA, Coleman DM. Extracorporeal life support during pregnancy. J Thorac Cardiovasc Surg 2016; 151 (04) 1154-1160
  • 73 Grimme I, Winter R, Kluge S, Petzoldt M. Hypoxic cardiac arrest in pregnancy due to pulmonary haemorrhage. BMJ Case Rep 2012; DOI: 10.1136/bcr-2012-006741.