Question

Your patient is a 23-year-old female. She presents with coughing and wheezing which she stated started about three weeks ago. She is currently 25 weeks pregnant. Her last prenatal visit was one month ago in another state. She has an appointment with the prenatal care provider next week, however her respiratory symptoms brought her to your office today.

History - Chickenpox as a child. Asthma as a child, diagnosed at age 8 for which she used a SABA when needed. She has not had the need to use an inhaler since she was 19. She takes only her prenatal vitamin. No other acute or chronic problems. She advises you that she is up to date on all immunizations except she has not had a flu shot (it is October).

Social - Non-smoker, no drug use. She relocated to your state two weeks ago to get away from an abusive domestic situation. She has no support network in this area and has not yet found employment. She has no medical insurance.

HPA - Non-productive cough x 3 weeks. Wheezing audible from across the room. She states it is like this all day and wakes her from sleep every night. She reports that she is fatigued even in the morning. No other complaints.

PE/ROS - Pt appears disheveled but clean. Wheezing in all lung fields. T 98, P 82 regular, R 28 no stridor. FH 130 regular. The remainder of the patient's health history is WNL.

** How would you diagnose and treat this patient, please? Thank you.  

Answer 1

A 23 year old female patient,currently 25weeks pregnant,presents with coughing(Non productive) and wheezing since last three weeks.

Past history of illness:

• Had chickenpox as a child
• Diagnosed to have asthma at the age of 8.She is using short acting beta agonist(SABA)whenever it is needed.Since she was 19,she has not had the need to use inhalers.

Present illness:

• Non productive cough × 3 weeks
• Wheezing(audible across the room)
• Paroxymal nocturnal dyspnea(wakes up in night due to feeling of short of breath)
• Fatigue even in morning

Physical Examination & Review of Systems:

• Patient appears disheveled but clean.
• Wheezing in all lung fields.
• Temp:98F
• Pulse:82beats/min
• Respiratory rate:28breath cycles/min(Tachypnea),No stridor
• Fetal heart Rate:130beats/min and regular

Based on the given details the patient is diagnosed to have -

Asthma(acute exacerbation) in Pregnancy

Asthma is one of the most common chronic medical condition,which is most likely to worsen during gestational age of 24 to 36 weeks.

Excerbations are major clinical problem in pregnants with asthma occuring in 20-36%

Excerbation of Asthma in Pregnancy is mainly due to:

• Upward displacement of diaphragm by 4-5cm(reduced thoracic volume) with enalarging uterus and increased abdominal pressure.
• Hormonal changes in pregnancy affect upper respiratory tract and mucosa causing hyperemia,mucosal edema,hypersecretion and increased mucosal friability.

Diagnosis of Asthma in Pregnancy:

• Assessing clinical manifestation :

Patient is having non productive cough since last 3weeks

Wheezing

Paroxymal nocturnal dyspnea

Fatigue

Tachypnea:Respiration :28breath/min

• ​​​​​​Assessing lung function (PEFR)

• Blood Eosinophil count

Treatment of Asthma in Pregnancy:

Initially treat Acute attacks of Asthma:

• ​​​​​​Oxygen inhalation with mask
• Selective beta 2symathomimetic drug such as:

​1)Epinephrine-------0.3-0.5ml of a 1:1000 solution subcutaneously,at interval of 20minutes for three such

OR

2)Terbutaline------250microgram subcutaneously every 15min for three such.

• Corticosteroids:Intravenous hydrocortisone 200mg stat and to be repeated if needed after 4hours.
• Intravenous aminophylline 250mg slowly.

Once after settling of patients condition,she can be shifted to

• Low dose of inhaled corticosteroids and Long acting beta agonist to prevent further occurance of Excerbation of asthma.
• If patient complaints of repeated excerbation mild dose of inhaled corticosteroid s can be preferred in place of low dose along with long acting beta agonists.
• In severe persistent asthma ,patient can be prescribed with high dose inhaled corticosteroids and long acting inhaled beta agonists,if needed corticosteroid tablets or syrup long term(2mg/kg per day not to exceed 60mg per day)can be given.​

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​​​​​​​Taking short acting bronchodilators 2-4puffs (whenever it is needed)can be advised in patient to overcome acute shortness of breath once the patient is sent home.