This document discusses respiratory disorders that can occur during pregnancy. It begins by outlining the normal physiological changes to respiration that occur during pregnancy, including increased oxygen demand and changes in lung volume. It then examines specific pulmonary diseases like asthma, tuberculosis, influenza, and COVID-19 that can impact pregnant women. For each condition, it describes associated risks, symptoms, diagnosis, effects on pregnancy, and recommended treatment approaches. The goal is to understand how these respiratory disorders present during pregnancy and should be managed while considering the health and safety of both the mother and fetus.

1. RESPIRATORY DISORDERS IN
PREGNANCY
DR. NIRANJAN CHAVAN
PROFESSOR AND HEAD OF UNIT,
LTMMC & LTMGH, SION HOSPITAL,
MUMBAI -400022

3. PHYSIOLOGICAL CHANGES IN
PREGNANCY
• During pregnancy, the pregnant mother undergoes significant anatomical and
physiological changes in order to nurture and accommodate the developing fetus.
• These changes begin after conception and affect every organ system in the body.
• It is important to understand the normal physiological changes occurring in
pregnancy as this will help differentiate from adaptations that are abnormal.

4. RESPIRATORY CHANGES IN PREGNANCY

6. • There is a significant increase in oxygen demand during normal pregnancy. This is due to a 15%
increase in the metabolic rate and a 20% increase consumption of oxygen.
• Diaphragmatic elevation in late pregnancy results in decreased functional residual.
• Inspiratory reserve volume is reduced early in pregnancy, as a result of increased tidal volume, but
increases in the third trimester, as a result of reduced functional residual capacity.
• Peak expiratory flow rate (PEFR) and forced expiratory volume in one second (FEV1) are
unaffected by pregnancy.

7. PULMONARY DISEASES IN PREGNANCYAND
THEIR MANAGEMENT
• ASTHMA
• TUBERCULOSIS
• INFLUENZA FLU
• COVID-19

8. ASTHMA IN PREGNANCY
• Asthma is a common chronic inflammatory condition of the lung airways
characterized by episodes of reversible bronchoconstriction as a result of various
stimuli.

9. RISK FACTORS OF ASTHMA

10. PATHOPHYSIOLOGY OF ASTHMA

11. SYMPTOMS OF ASTHMA

12. DIAGNOSIS OF ASTHMA
• Objectively the diagnosis may be confirmed by measuring the peak expiratory flow rate
(PEFR) or forced expiratory volume in 1s (FEV1) as an indication of the degree of
bronchoconstriction.
• A >20% diurnal variation on ⩾3 days in a week for 2 weeks on PEF diary or FEV1 ⩾15%
increase after a trial of a β 2 agonist or steroid tablets or a similar decrease after 6 minutes of
exercise are diagnostic.
• PEFR and FEV1 are unaffected by pregnancy.

14. EFFECT OF ASTHMA ON
PREGNANCY
• Although a number of small studies have suggested an association of asthma with the
development of pre-eclampsia, intrauterine growth retardation (IUGR), preterm birth, and
low birthweights, most pregnancies are unaffected by the effects of asthma.
• Severe poorly controlled asthma resulting in episodes of maternal hypoxemia could,
however, give rise to such complications.
• It is therefore of concern that many women stop their medication at the start of the
pregnancy because of concerns regarding the safety profile of these drugs for the fetus.

15. 11-BETA HYDROXY STEROID DEHYDROGENASE

16. EFFECT OF PREGNANCY ON
ASTHMA

17. • Endogenous steroids in labor ensure that acute asthma attacks are very uncommon during
labor and delivery. There may be a deterioration postpartum.
• The risk of an asthma exacerbation is high immediately postpartum, but the severity of
asthma usually returns to the preconception level after delivery.
• Changes in β2-adrenoceptor responsiveness and changes in airway inflammation induced by
high levels of circulating progesterone have been proposed as possible explanations for the
effects of pregnancy on asthma.

18. MANAGEMENT OF ASTHMA
• Pregnancy is an ideal opportunity to optimize therapy. Ideally, this should occur pre-pregnancy.
• A pre-conceptional visit would allow time to optimize therapy and educate women regarding the
importance and safety of continuing their medication to ensure good asthma control throughout
pregnancy.

19. • Inhaler techniques should be checked and home peak flow monitoring encouraged.
• Pregnant women should be monitored closely so that any change in course can be matched by
an appropriate change in therapy.
• Smoking should be discouraged.

22. TUBERCULOSIS IN PREGNANCY
• This is an infection caused by Mycobacterium tuberculosis which characteristically causes
caseating granulomas, usually involving the lungs as the primary site.
• The incidence of tuberculosis (TB) worldwide is rising, in part due to the susceptibility to TB
of HIV-infected patients, and in the UK is more prevalent amongst Asian and African
immigrants.

23. • In pregnancy recent studies have suggested a high prevalence (50%) of extra-pulmonary
TB (at sites such as lymph nodes, bone, liver, spleen, bone marrow, caecum, nervous
system, and eye).
• The patient is often asymptomatic but typically can present with a cough, hemoptysis,
weight loss, and night sweats. The diagnosis is confirmed with sputum examination for
acid-fast bacilli (Ziehl–Neelsen stain) and GeneXpert.

25. DIAGNOSIS OF
TUBERCULOSIS

28. • Although pregnancy and TB have little effect on each other, treatment should not be delayed in
pregnancy.
• Because of a rising incidence of drug-resistant TB, treatment is often with prolonged courses of
multiple chemotherapeutic agents at the advice of respiratory physicians.

30. • Streptomycin is associated with eighth nerve damage and should therefore be avoided.
• After delivery the neonate should be given prophylactic isoniazid treatment if the
mother is sputum positive.
• The infant should also be vaccinated as soon as possible. Breastfeeding is not
contraindicated since very little of the drugs are excreted in breast milk.

31. MANAGEMENT OF TUBERCULOSIS
IN PREGNANCY
(NTEP)

34. MANAGEMENT OF DRUG
RESISTANCE -TUBERCULOSIS IN
PREGNANCY

35. MANAGEMENT OF MDR/XDR-
TUBERCULOSIS IN PREGNANCY

36. INFLUENZA
• Influenza A and B are RNA viruses that cause respiratory infections, including pneumonitis.
Influenza pneumonia can be serious, and it is epidemic in the winter months.
• The virus is spread by aerosolized droplets and quickly infects ciliated columnar epithelium,
alveolar cells, mucus gland cells, and macrophages.
• Disease onset is 1 to 4 days following exposure. In most healthy adults, infection is self-
limited.

37. • Pneumonia is the frequent complication of influenza, and it is difficult to distinguish it from
bacterial pneumonia. According to the CDC (2010a), infected pregnant women are more likely
to be hospitalized as well as admitted to an ICU.
• The 2009 influenza pandemic with the H1N1 strain was particularly severe. In a Maternal-
Fetal Medicine Units Network study, 10 percent of pregnant or postpartum women admitted
with H1N1 influenza were cared for in an ICU, and 11 percent of these ICU patients died
(Varner, 2011).

38. • Risk factors included late pregnancy, smoking, and chronic hypertension. Primary influenza
pneumonitis is the most severe and is characterized by sparse sputum production and
radiographic interstitial infiltrates.
• More commonly, secondary pneumonia develops from bacterial superinfection by
streptococci or staphylococci after 2 to 3 days of initial clinical improvement.

40. SYMPTOMS

41. WHEN TO TEST
FOR
INFLUENZA?

42. DIAGNOSTIC TESTS FOR
INFLUENZA

44. MANAGEMENT OF INFLUENZA
Supportive treatment with antipyretics and bed rest is recommended for uncomplicated influenza.
Early antiviral treatment has been shown to be effective. As discussed, influenza hospitalizations
for those with advanced pregnancy are increased compared with nonpregnant women.

46. COVID-19 & PREGNANCY
• Severe acute respiratory syndrome (SARS) is a potentially life-threatening, atypical
pneumonia that results from infection with a novel virus, SARS-associated coronavirus
(SARS-CoV).

47. • SARS-CoV-2 infection could affect all groups irrespective of age and gender.
• However, the most severe and adverse outcomes of COVID-19 have been documented
in geriatric individuals and pregnant women with chronic diseases, including hypertension,
diabetes, and cardiopulmonary problems.
• Several studies have reported more severe and a higher mortality rate due to
some respiratory viral infections in pregnant women compared to non-pregnant women.

48. SYMPTOMS

49. PREGNANCY AND SEVERITY OF
COVID19: PATHOPHYSIOLOGY
• The oxygen deficit in the body is reversed by the stimulation of the respiratory
center through estrogen-dependent progesterone receptors located in
the hypothalamus.
• More severe incidences of covid-19 infection during the third trimester of
pregnancy may be expected due to the rapid multiplication of the virus in the
respiratory system with already compromised mucociliary clearance mechanisms
during pregnancy.
• Moreover, hormonal changes in pregnant women with COVID-19 lead to an
increased immunological response to viral pathogens, with a diversion of the
Th1/Th2 immunological responses towards a Th2-specific response, and favour
more severe outcomes than those in non-pregnant individuals with COVID-19.

51. VERTICAL TRANSMISSION
• Some investigations were unable to detect mother to fetus SARS-CoV-2 transmission, along with
negative test results in breast milk, vaginal swabs, umbilical cord blood, and amniotic fluid.
• A number of studies have found elevated antibodies (IgM and IgG) and cytokine levels in the
blood of neonates of infected mothers, suggesting in utero transmission of SARS-CoV2 .

57. • ICMR is currently doing a project on “Severity of COVID disease and pregnancy
outcome among women with COVID infection with or without COVID vaccination – A
multicentric case-control study”
• The study will be conducted in Govt. Medical colleges from 6 zones of the country, namely
JIPMER (South Zone), Lokamanya Tilak Municipal Medical College in Mumbai (West
Zone), AIIMS Bhubaneswar (East Zone), AIIMS Bhopal (Central Zone), Maulana Azad
Medical College (North Zone), and Tripura Medical College (North-East Zone).
• Principal Investigators would be obstetricians, and CO PIs would be neonatologists as this
study is about maternal and fetal outcomes.
• I am contributing to this research project as I am the Principal Investigator of the West Zone.

58. FIGO STATEMENT ON COVID-19
VACCINATION AND BREASTFEEDING

62. TAKE HOME MESSAGE

63. THANK YOU