jump to navigation
Free Trial Subscription

Pregnant asthmatic… May 22, 2013

Posted by Andy Jagoda, MD in : Respiratory Emergencies , trackback

While establishing IV access and calling respiratory therapy for your first patient, a 24-year-old Hispanic female with a history of asthma who is 15 weeks pregnant presents with tachypnea and acute shortness of breath with audible wheezing. She has been taking albuterol and fluticasone at home with no relief of symptoms. She has a blood pressure of 110/78 mm Hg, heart rate of 110 beats/ min, respiratory rate of 40 breaths/min, and pulse oximetry of 93% on room air. Physical exam demonstrates accessory respiratory muscle usage, decreased breath sounds, and expiratory wheezing. You recognize that your patient is at risk for deteriorating, and you wonder which interventions are safest to use in pregnancy…

How would you approach this patient’s treatment?

(Enter to win a free copy of the June 2013 issue of Emergency Medicine Practice, which features this case, by submitting your answer to the question above. To do so, simply enter your response in the comments box. The deadline to enter is June 6th.)

Not a current subscriber and want more? Learn more about a subscription.

Comments»

1. Rct - June 1, 2013

systemic steroids, continuous albuterol, oxygen, terbutalline drip, consider mgso4

2. Jo Stanage - June 1, 2013

Use the normal ER protocol for asthmatic adults..oxygen, nebulizer , and corticosteroids to begin with…monitor for improved breathing.. and increased sats. Newest ACOG guidelines suggest it is safe to treat with most asthma meds in pregnancy, and it is better for fetus to use medications than not. A list of meds not to use is readily available.

3. jmitch - June 1, 2013

oxygen, albuterol, Atrovent, IV methylprednisolone – these are all safe in pregnancy, and doing what’s best for the mother is also doing what’s best for the baby. If mother needs intubating, can use ketamine.

4. Hillary Harper - June 1, 2013

Albuterol 5 mg continuous, ipratropium, solumedrol or po prednisone to start
Consider nippv and magnesium 2 grams

5. Marie Samuels - June 1, 2013

Approach to treatment:
IV, O2, Monitor, albuterol, salumedrol, labs including d-dimer, ABG (is intubation impending? ), PT/PTT/INR/type and screen.
(recognizing that d-dimer could be elevated in pregnancy.
Since pregnancy does create a hyper-coagulable state, must consider PE as a possible differential dx.
If no response to treatment, even if d-dimer is normal, must consider searching for PE, so do a VQ scan, get consent, could do VQ with perfusion only study.
If pt is deteriorating and strongly suspect PE, could give heparin in mean time.
Also consider the possibility of a saddle embolus, if there is heart strain, consider bedside echo etc.
Of course, depending on vitals of the patient, and other symptoms like abdomenal pain, vag bleed, must consider amniotic fluid embolus, (though unlikely cause); (saddle embolus, –should TPA be given etc).
I’m curious to see others’ responses

6. David Hamel, PA - June 1, 2013

Aggressively treat her presumed asthma exacerbation like any other with inhaled albuterol and in this case probably parenteral glucocorticoids. Contact RT for possible use of non invasive PPV and availability of ventilator. Perform difficult airway assesment and prepare for possible RSI with Ketamine for induction, possibly with awake intubation. Re-assess success of initial therapeutic modalities and if not effective consider alternative diagnosis, especially PE.

7. Rizwan Aziz - June 1, 2013

While giving her all standard treatment I will prefer to start BIPAP as early as possible & will give her a combination Neb of Ipratropium bromide & salbutamol through BIPAP.
The rest of standard measures are 100% O2, Hydrocortisone , Magnesium sulphate
If no signs of improvement then the last resort of Intubation & ventilation .

8. Dr. Jorge Edward T. Masa - June 1, 2013

Asthma exacerbation in pregnancy should be treated aggressively to avoid fetal hypoxia. Oxygen delivery is the priority in this case.

Oxygen supplementation should be given to maintain an O2 saturation of more than 95%.

Rapid-acting inhaled B2-agonist is given every 20 minutes or continuously in 1 hour. Data on use of albuterol in pregnant women is reassuring.

If there is persistent wheezing and shortness of breath or PEF is 50-80% of predicted, then short-acting B2-agonist should be continued and oral corticosteroid added. glucocorticosteroids speed the resolution of exacerbations, as effective as those given intravenously, and usually take 4 hours to produce clinical improvement.

Oral systemic corticosteroid use during the first trimester is associated with increased risk for isolated cleft lip with or without cleft palate. The patient must be informed of this risk.

If patient is severely dyspneic, corticosteroid may be given intravenously to avoid aspiration.

If PEF after initial treatment is less than 50% of predicted, then short-acting B2-agonist should be given every hour with inhaled ipratropium bromide.

ABG analysis should be done. If PCO2 is more than 42mmHg, patient should be admitted to the intensive care unit. The same is true if PEF remains less than 50% predicted despite treatment.

If PEF is between 50-70%, patient may be admitted to a regular ward.

9. Peter Murphy - June 1, 2013

There is nothing in my medical armamentarium inappropriate for this patient because of her pregnancy. I would start with three albuterol nebs concomittantly with three ipratropium nebs. I would place an i.v. and give her solumedrol, 100 mg i.v. No reason to wait with this sick patient: I would give her magnesium sulfate, one gram i.v. over twenty minutes and then one liter of normal saline over thirty minutes. The purpose of the IVF bolus is to fill up her tank in case things go south and I am forced to use PPV. She must be closely monitored for further deterioration, but most respond well to the above described “cocktail” all administered in the first 60 minutes in the ED. If this patient does not appear to be responding then the therapies that I would introduce in my hope to avoid PPV would include continuous albuterol nebs (20 mg over one hour) concomittant with high flow O2 by nasal cannula. If still no response, I would choose terbutaline over aminophylline, though I hate each one of them more than the other. Induction for intubation after this valiant effort would be with ketamine and succinylcholine.

10. Matilda PERKINS - June 1, 2013

Work up for PE
ABGs, O2, ECG, Cardiac US, ETT If necessary,hepainize

11. Rochelle Flynn, MD - June 1, 2013

IV prednisone and albuterol, oxygen to keep her oxygen high enough to get adequate oxygen through to placenta (maybe keep her above 95-96%), Really, she wouldn’t need any change than regular asthma care. Plus, CXR is not indicated for majority of asthma, so no concerns of radiation risk..

12. Alfred L. Woodard Jr. - June 2, 2013

Albuterol/ atrovent 1 hr heart neb
steroids IV or PO
2gms magnesium sulfespiratory statate
1 liter NS
supplemental oxygen
re-evaluate respiratory status after 30-45 minutes

13. Anthony Gerasklis, Internal Medicine - Emergency Department Rhodes General Hospital - GREECE - June 2, 2013

I have a 24 year old pregnant female at the begining of second trimester regarding gestation age, with a past medical history of asthma.
She is in acute respiratory distress (uses accessory muscle of respiration – has a respiratory rate of 40 breaths/min – audible wheezing) but with good blood pressure and mild tachycardia and satisfactory pulse oximetry reading on room air.

Actions to take:
Administer supplemental oxygen via face mask at 6-10 L/min
Additional nebulized b2 receptor agonist bronchodilator
Draw an arterial blood gas sample (to detrmine PCO2 level and pH)
Connect the patient to monitoring device
Consider MgSO4 infusion
Differential Diagnosis: Rule out Pulmonary Embolism (Order D-Dimers)
On vigilence for patient deterioration and possible ET intubation

14. Robert B Fulton, MD - June 2, 2013

Albuterol 5mg inebulized q20 minutes to 3 doses and Atrovent 0.5 mg nebulized and Solumedrol 125 mg IV.

15. Roy C. Brown - June 3, 2013

Treatment of asthma in pregnancy is directed at restoring normal respiration as soon as possible. If the mother is breathing poorly so is the fetus. Treatment is progressive advancing treatment as needed.
Albuterol is used first if that fails. Inhaled corticosteriods are used. If that fails and patient is worsening admission and pulmonary consultation is considered.

16. Harold Mayeri - June 4, 2013

The patient a known asthmatic was unresponsive to asthma medications at home indicating possible physiological involvement.
Check fever (no indication this was already done) Order appropriate pregnancy xrays as well as blood tests for elevated WBC count to determine possible pulmonary infection. Administer IV albuterol. Supplemental o2. Check fetus for possible distress from lower o2 levels in mother.

17. Harold Mayeri - June 5, 2013

hispanics are prone to lower respiratory infections. Should have mentioned that before

18. Matee yartu Morris - June 6, 2013

Dx: Alter respiration, related to the asthmatic crisis as manifested by increase breath rate per minute.
1. Ensure ABC
2. Place her in proper position
3. Elevate the head of the bed @ 45*
4. Collect blood sample to check for overdose

19. wajahat hussain - June 6, 2013

She need intravenous hydrocortisone

20. Dr SureshNaidu - June 7, 2013

ABC as usual.
iv hydrocort , iv magnesium sulphate , arterial blood gas,

investigate to rule out pneumonia, pulmonary embolism,
Cxr only if absolutely neccessary . Ultrasound is safe in pregnancy can aid in diagnosing pulmonary embolism or pneumothorax.

All comments are held for approval.



About EB Medicine:

Products:

Accredited By:

ACCME ACCME
AMA AMA
ACEP ACEP
AAFP AAFP
AOA AOA
AAP AAP

Endorsed By:

AEMAA AEMAA
HONcode HONcode
STM STM

 

Last Modified: 09-20-2019
© EB Medicine