Restrictive lung disease in pregnancy

Pregnancy in a Patient with Spinal Muscular Atrophy and Severe Restrictive Lung Disease

Spinal muscular atrophy (SMA) is a rare autosomal recessive neuromuscular disease that is often associated with chronic respiratory failure. Few cases have described the antepartum and postpartum course in patients with severely compromised respiratory status. We present a case of a 24-year-old nullipara with a history of SMA type II complicated by surgically corrected kyphoscoliosis and severe restrictive lung disease. Her pregnancy was complicated by progressively worsening dyspnea resulting in increased use of noninvasive positive pressure ventilation, ultimately leading to indicated premature delivery at 28 weeks' gestation via cesarean section under general anesthesia. Women with SMA and severe restrictive lung disease are at high risk of premature delivery secondary to worsening respiratory status. A multidisciplinary approach is vital in treating these patients.

Using Blood Gas Analysis and Capnography to Determine Oxygenation Status in Bottlenose Dolphins (Tursiops truncatus) Following the Deepwater Horizon Oil Spill

Following the Deepwater Horizon (DWH) oil spill in 2010, poor pulmonary health and reproductive failure in bottlenose dolphins (Tursiops truncatus) in the northern Gulf of Mexico were well-documented. One postulated etiology for the increased fetal distress syndrome and pneumonia found in affected perinatal dolphins was maternal hypoxia caused by lung disease. The objective of this study was to evaluate the utility of blood gas analysis and capnography in determining oxygenation status in bottlenose dolphins with and without pulmonary disease. Blood and breath samples were collected from 59 free-ranging dolphins in Barataria Bay, Louisiana (BB), during a capture-release health assessment program, and from 30 managed dolphins from the U.S. Navy Marine Mammal Program in San Diego, CA. The former was the oil-exposed cohort and the latter served as a control cohort with known health histories. Capnography and select blood gas parameters were compared based on the following factors: cohort, sex, age/length class, reproductive status, and severity of pulmonary disease. Animals with moderate-severe lung disease had higher bicarbonate concentrations (p = 0.005), pH (p < 0.001), TCO₂ (p = 0.012), and more positive base excess (p = 0.001) than animals with normal-mild disease. Capnography (ETCO₂) was found to have a weak positive correlation with blood PCO₂ (p = 0.020), with a mean difference of 5.02 mmHg (p < 0.001). Based on these findings, indirect oxygenation measures, including TCO₂, bicarbonate, and pH, show promise in establishing the oxygenation status in dolphins with and without pulmonary disease.

Pregnancy Outcomes in Patients With Interstitial Lung Disease

OBJECTIVE

Women with interstitial lung disease (ILD) are recommended to avoid pregnancy based on limited data. This study seeks to determine maternal and pregnancy outcomes in the largest-to-date cohort of patients with ILD.

METHODS

Medical records in the Duke University Health System were reviewed for pregnancies in patients with a diagnosis of ILD with underlying autoimmune disease. Pregnancies were classified as having very severe, severe, mild-moderate, or normal lung function based on pulmonary function tests (PFTs). Adverse pregnancy outcomes (APOs) were defined using the Predictors of Pregnancy Outcome in Systemic Lupus Erythematosus and Antiphospholipid Syndrome APO (PROMISSE-APO) and Severe PROMISSE-APO criteria.

RESULTS

Among 86 pregnancies in 60 women, 85% women were Black, 71% had sarcoidosis, and 29% had connective tissue disease (CTD)-associated ILD (CTD-ILD). Of the pregnancies with available PFTs (n = 59), 12% had very severe ILD, 25% had severe ILD, 51% had mild-moderate ILD, and 12% had normal lung function. PROMISSE-APOs occurred in 32% of pregnancies, including all pregnancies with very severe ILD (P = 0.02 across severity groups), 56% of pregnancies with CTD-ILD, and 23% with sarcoidosis (P = 0.02). Severe PROMISSE-APOs occurred in 15% of pregnancies, including 60% with very severe ILD and 28% with CTD-ILD. There were no maternal deaths. One woman required an intensive care hospital stay during pregnancy. Three women had volume overload after delivery that resolved with medical management. Seven women received oxygen during delivery, although none were intubated.

CONCLUSION

Although APOs were common in women with very severe ILD and underlying CTD, overall maternal morbidity and mortality were low. These data suggest women with ILD may be able to safely attempt pregnancy.

Low Rates of Reproductive Counseling Documentation in Women With Interstitial Pneumonia With Autoimmune Features

BACKGROUND/OBJECTIVE

Women with interstitial pneumonia with autoimmune features (IPAFs), a subset of interstitial lung disease (ILD), are at risk for pregnancy complications. Family planning discussions improve pregnancy outcomes in women with ILD. The objective of this study was to evaluate the documentation of reproductive counseling in IPAF female patients of childbearing age by pulmonary and rheumatology providers at an academic medical center.

METHODS

We conducted a medical record review study of pulmonary and rheumatology encounters in reproductive-aged women with IPAF to evaluate documentation of family planning discussions and contraceptive use. We used nonparametric measures of association and logistic regression to evaluate the relationship between patient characteristics and the presence of reproductive counseling documentation by providers.

RESULTS

Thirty-one women met IPAF classification and were ≤50 years at initial ILD clinic visit. Twenty-five (81%) of these women had risk factors for adverse pregnancy outcomes. Ten women (32%) had a record of reproductive counseling during any visit with their pulmonary provider. Of the 21 patients who also saw a rheumatology provider, 12 (57%) women had a record of reproductive counseling during any visit with their rheumatology provider. No baseline characteristics were associated with odds of reproductive counseling documentation.

CONCLUSIONS

Neither pulmonary nor rheumatology providers consistently discussed family planning/contraceptive use with reproductive-aged women with IPAF. There was a trend for rheumatology providers to discuss reproductive issues with IPAF patients more frequently than pulmonary providers. Efforts should focus on educating providers about the need for reproductive counseling in women with IPAF of childbearing age.

Spirometry profiles among pregnant and non-pregnant African women: a cross-sectional study

BACKGROUND

Spirometry is a commonly used lung function test. It assesses respiratory functions by measuring the air volume and the rate at which a person can exhale from lungs filled to their total capacity. The most helpful spirometry parameters are: forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and peak expiratory flow (PEF). Pregnancy derives an altered physiological state due to hormonal and anatomical changes that affect the respiratory system. Despite that, spirometry is less commonly done during pregnancy, and if done, test results are evaluated against non-pregnancy references.

OBJECTIVE

This study aimed to explore spirometry profiles in pregnant and non-pregnant women and describe their differences.

METHODOLOGY

This cross-sectional study involved age-matched pregnant and non-pregnant participants recruited from Mnazi Moja ANC and Muhimbili University (MUHAS). A digital spirometer was used to assess respiratory function. Data were entered and analyzed using SPSS version 23. The mean spirometry values of pregnant participants were compared to those of non-pregnant participants using an independent sample t-test. A p-value of < 0.05 was considered statistically significant.

RESULTS

The study included 92 pregnant and 98 non-pregnant participants subjected to spirometry. Both FVC and FEV1 values were significantly lower in pregnant than in non-pregnant participants (2.7 ± 0.5 L vs. 2.9 ± 0.5 L; p < 0.01 and 2.2 ± 0.4 L vs. 2.5 ± 0.4 L; p < 0.01 respectively). In addition, pregnant participants had significantly lower mean PEF values than their non-pregnant counterparts (303 ± 84 L/min versus 353 ± 64 L/min; p < 0.01).

CONCLUSION

Spirometry test values are lower in pregnancy than in non-pregnant participants.

RECOMMENDATIONS

Interpreting the spirometry test values of pregnant women using references obtained from non-pregnant women may be inappropriate. Future studies should evaluate the appropriateness of predicting spirometry values of pregnant women using reference equations derived from non-pregnant women.

Pulmonary disorders in pregnancy: Bronchiectasis, cystic fibrosis, sarcoidosis and interstitial diseases

This chapter aims to provide expert guidance to obstetricians, general practitioners, allied health staff and women with lung disease about the interactions between pregnancy and different lung diseases. This chapter will cover other airway diseases such as bronchiectasis and cystic fibrosis (CF) together with sarcoidosis and interstitial lung disease (ILD), noting that another chapter covers asthma. The physiological changes which occur in pregnancy, such as the changes in airway physiology, resting ventilation and sleep, are summarised in another chapter. This chapter extends the evidence-based approach and clinical expertise of the recent European Respiratory Society/Thoracic Society of Australia and New Zealand (ERS/TSANZ) taskforce. The papers selected were based on the population (pregnant women with lung disease other than asthma) and the effects of these diseases on risks of pregnancy-associated complications and miscarriages, breastfeeding, nutritional considerations, lung function, long-term maternal outcomes and management considerations during pregnancy. As there are very few randomised control trials in the area, the majority of the literature consists of observational studies (prospective or retrospective), cross-sectional surveys and case series. Other guidelines have also recently been published, which may be helpful to the reader.

Peripartum Management of Congenital Fiber Type Disproportion Myopathy With Severe Restrictive Lung Disease

Congenital myopathies raise unique challenges for anesthesiologists during labor and delivery. Apart from having a risk for malignant hyperthermia, this patient population can present with severe restrictive lung disease in the third trimester. Scoliosis and weak pelvic muscles could make regional anesthesia difficult. The common complications in pregnancy include premature labor, preterm delivery, spontaneous abortion, a prolonged first stage of labor, and uterine atony. We report a case of 28-year-old primigravida of 37 weeks gestation diagnosed with congenital fiber type disproportion successfully managed by a team of high-risk obstetricians, anesthesiologists, and pulmonologists. The patient was closely monitored with serial arterial blood gas to determine carbon dioxide retention in a high-risk labor floor with a backup operating room for cesarean delivery. We reserved a malignant hyperthermia cart and a postpartum hemorrhage cart for emergencies. Our patient was able to deliver vaginally with the help of ultrasound-guided regional anesthesia despite having severe restrictive lung disease and scoliosis. We emphasize a multi-disciplinary team approach for a successful outcome for this patient population.

Pregnancy Considerations for Patients With Interstitial Lung Disease

Advances in our understanding of interstitial lung disease (ILD) pathophysiology and natural history have led to the development of guidelines for the diagnosis and management of several of these complex diseases. The demographics of patients with ILD indicate the disease is not restricted to older adults. Connective tissue disease-associated ILD, familial pulmonary fibrosis, and post-COVID-19 fibrosis may affect women of child-bearing age. Recent trials have excluded pregnant women, thereby limiting the applicability of contemporary therapeutic advances to these patients. This review synthesizes the current knowledge of pregnancy outcomes in those with ILD, with a focus on connective tissue disease-associated ILD, and potential treatment implications for patients with ILD who are pregnant or considering pregnancy. Pregnancy considerations for patients with ILD include the need for preconception counseling and planning to ensure disease stability, medication and vaccination optimization, and multidisciplinary involvement of a patient's pulmonologist, obstetrician, and, when indicated, rheumatologist and genetic counselor. Evidence to date suggests that women with ILD can have safe and healthy pregnancies but that complications may occur in those with severe ILD.

Reproductive Issues and Pregnancy Implications in Systemic Sclerosis

Systemic sclerosis (SSc) is a rare systemic autoimmune disease that can influence reproductive health. SSc has a strong female predominance, and the disease onset can occur during fertility age in almost 50% of patients. Preconception counseling, adjustment of treatment, and close surveillance during pregnancy by a multidisciplinary team, are key points to minimize fetal and maternal risks and favor successful pregnancy outcomes. The rates of spontaneous pregnancy losses are comparable to those of the general obstetric population, except for patients with diffuse cutaneous SSc and severe internal organ involvement who may carry a higher risk of abortion. Preterm birth can frequently occur in women with SSc, as it happens in other rheumatic diseases. Overall disease activity generally remains stable during pregnancy, but particular attention should be paid to women with major organ disease, such as renal and cardiopulmonary involvement. Women with such severe involvement should be thoroughly informed about the risks during pregnancy and possibly discouraged from getting pregnant. A high frequency of sexual dysfunction has been described among SSc patients, both in females and in males, and pathogenic mechanisms of SSc may play a fundamental role in determining this impairment. Fertility is overall normal in SSc women, while no studies in the literature have investigated fertility in SSc male patients. Nevertheless, some considerations regarding the impact of some immunosuppressive drugs should be done with male patients, referring to the knowledge gained in other rheumatic diseases.

Postpartum Respiratory Depression

Postpartum respiratory depression is a complex, multifactorial issue that encompasses a patient's baseline preexisting conditions, certain pregnancy-specific conditions or complications, as well as the iatrogenic element of various medications given in the peripartum period. In this review, we discuss many of these factors including obesity, sleep-disordered breathing, chronic lung disease, neuromuscular disorders, opioids, preeclampsia, peripartum cardiomyopathy, postpartum hemorrhage, amniotic fluid embolism, sepsis, acute respiratory distress syndrome (ARDS), and medications such as analgesics, sedatives, anesthetics, and magnesium. Current recommendations for screening, treatment, and prevention are also discussed.

The Importance of Cardiovascular Risk Assessment and Pregnancy Heart Team in the Management of Cardiovascular Disease in Pregnancy

Pregnancy-related maternal morbidity and mortality is increasing because of complications from cardiovascular disease. Pregnancy results in physiologic changes that can adversely impact the cardiovascular system and lead to adverse pregnancy outcomes. A multidisciplinary pregnancy heart team is essential to safely navigate women with heart disease through pregnancy. This role of the pregnancy heart team is to offer preconception counseling, determine pregnancy risks and educate women about those risks, develop a comprehensive antenatal and delivery plan, and ensure appropriate postpartum follow-up. These steps are important to improve cardiovascular outcomes in pregnancy.

French recommendations for the management of systemic sclerosis

Systemic sclerosis (SSc) is a generalized disease of the connective tissue, arterioles, and microvessels, characterized by the appearance of fibrosis and vascular obliteration. There are two main phenotypical forms of SSc: a diffuse cutaneous form that extends towards the proximal region of the limbs and/or torso, and a limited cutaneous form where the cutaneous sclerosis only affects the extremities of the limbs (without passing beyond the elbows and knees). There also exists in less than 10% of cases forms that never involve the skin. This is called SSc sine scleroderma. The prognosis depends essentially on the occurrence of visceral damage and more particularly interstitial lung disease (which is sometimes severe), pulmonary arterial hypertension, or primary cardiac damage, which represent the three commonest causes of mortality in SSc. Another type of involvement with poor prognosis, scleroderma renal crisis, is rare (less than 5% of cases). Cutaneous extension is also an important parameter, with the diffuse cutaneous forms having less favorable prognosis.

Antisynthetase Syndrome with Severe Interstitial Lung Disease in Pregnancy

Antisynthetase syndrome is a rare multisystem autoimmune disorder which clinically manifests with myositis, arthritis, interstitial lung disease, Raynaud phenomenon, and skin hyperkeratosis. Lung involvement represents the most severe form of disease and has rarely been reported in pregnancy. We present the case of a 22-year-old woman with antisynthetase syndrome and severe restrictive pulmonary disease who experienced a successful pregnancy and delivery. We discuss anesthetic considerations and highlight the importance of a multidisciplinary team approach in caring for parturients with multifactorial medical conditions.

Guideline No. 416: Labour, Delivery, and Postpartum Care for People with Physical Disabilities

OBJECTIVE

To describe evidence-based practice for managing the labour, delivery, and postpartum care of people with physical disabilities in Canada.

TARGET POPULATION

This guideline addresses the needs of people with physical disabilities, with a focus on conditions that affect strength and mobility, as well as those that affect neurological or musculoskeletal function or structure. Although aspects of this guideline may apply to people with solely intellectual, developmental, or sensory disabilities (e.g., hearing and vision loss), the needs of this population are beyond the scope of this guideline.

OUTCOMES

Safe and compassionate care for people with physical disabilities who are giving birth.

BENEFITS, HARMS, AND COSTS

Implementation of this guideline will improve health care provider awareness of specific complications people with physical disabilities may experience during labour, delivery, and the postpartum period and therefore increase the likelihood of a safe birth.

EVIDENCE

A literature review was conducted using MEDLINE (474), Embase (36), and the Cochrane Central Register of Controlled Trials (CENTRAL; 28) databases. The results have been filtered for English language, publication date of 2013 to present, observational studies, systematic reviews, meta-analyses, and guidelines and references in these publications were also reviewed.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

Maternal-fetal medicine specialists, obstetricians, family physicians, nurses, midwives, neurologists, physiatrists, and those who care for people with physical disabilities.

RECOMMENDATIONS

First Report of Spinal Anesthesia for Cesarean Delivery in a Parturient With Jeune Syndrome: A Case Report

Jeune syndrome, also known as asphyxiating thoracic dystrophy, is a rare form of autosomal recessive skeletal dysplasia. Respiratory distress due to thoracic and lung dysplasia is the primary complication associated with this disorder in neonates. Women with Jeune syndrome seldom conceive and give birth, as only a few survive until adulthood. Herein, we report the world's first case of a cesarean delivery under spinal anesthesia in a pregnant woman with Jeune syndrome with a history of chest wall reconstruction and spinal fusion surgeries.

Is There an Effect of Fetal Mesenchymal Stem Cells in the Mother-Fetus Dyad in COVID-19 Pregnancies and Vertical Transmission?

Because of the polysystemic nature of coronavirus disease 2019 (COVID-19), during the present pandemic, there have been serious concerns regarding pregnancy, vertical transmission, and intrapartum risk. The majority of pregnant patients with COVID-19 infection present with mild or asymptomatic course of the disease. Some cases were hospitalized, and few needed intensive care unit admission, or mechanical ventilation. There have also been scarce case reports where neonates required mechanical ventilation post COVID-19 pregnancies. Without approved therapies other than dexamethasone, advanced mesenchymal cell therapy is one immunomodulatory therapeutic approach that is currently explored and might hold great promise. We suggest that the circulating fetal stem cells might have an immune-protective effect to mothers and contribute to the often mild and even asymptomatic post-COVID-19 pregnancies. Thus, COVID-19 pregnancies come forth as a paradigm to be further and more comprehensively approached, to understand both the mechanism and action of circulating stem cells in immunoprotection and hypoxia in microcirculation.

The Effect of Maternal Pulmonary Function Test Parameters on Umbilical Cord Blood Gas and the Duration of Labor

OBJECTIVE

To evaluate the relationship between the maternal pulmonary function test (PFT) and the Apgar score of the newborn, umbilical cord blood (UCB) gas values and the duration of delivery.

MATERIAL AND METHODS

The present study included 41 volunteer nulliparous pregnant women who presented to our obstetrics clinic and PFTs were performed by using spirometry.

RESULTS

A significant positive correlation was observed between 5^th-minute Apgar scores and maternal FEV1 (forced expiratory volume in the first second) (lt), FEV1%, FVC (lt), FVC% (r=0.509, p=0.003; r=0.47, p=0.007; r=0.434, p=0.013; r=0.417, p=0.017; respectively). A significant positive correlation was observed between UCB pH value and maternal FEV1 (lt), FVC (lt) (r=0.515, p=0.003; r=0.351, p=0.049; respectively).

CONCLUSION

Our results showed that FEV1 and FVC values, which indicate maternal respiratory functions, may affect Apgar scores of the newborn and UCB gas values.

A case report of idiopathic pleuroparenchymal fibroelastosis with severe respiratory failure in pregnancy

Background

Idiopathic pleuroparenchymal fibroelastosis (IPPFE) is a rare lung disease that manifests as parenchymal fibrosis of the upper lung lobe and pleura. There have been no reports of IPPFE complicating pregnancy. Here, we report a case of IPPFE that deteriorated rapidly during pregnancy.

Case presentation

A 29-year-old woman presented with dyspnea and dry cough at 19 weeks of gestation. IPPFE with acute exacerbation was suspected on chest computed tomography (CT). Despite steroid treatment, her condition progressed. A cesarean section was performed at 28 weeks of gestation. On postoperative day 26, she underwent living-donor lung transplantation. She was discharged a year after transplantation.

Conclusion

Our experience suggested that when pregnancy is complicated by PPFE, the disease may deteriorate rapidly. In this case, even though IPPFE with acute exacerbation was diagnosed during pregnancy, live birth was achieved, and the mother survived after lung transplantation. Lung transplantation should be considered in these patients because, once advanced, pulmonary lesions may be irreversible.

Anaesthetic management of a parturient with spondylothoracic dysostosis

Spondylothoracic dysostosis is a rare congenital disorder characterised by multiple vertebral malformations, shortening of the spine and fusion of the ribs at the costovertebral junction. These abnormalities create anaesthetic challenges due to difficult airway, severe restrictive lung disease and spine deformity necessitating a multidisciplinary approach and careful perioperative planning. We present the perianaesthetic management of a parturient with spondylothoracic dysostosis who successfully underwent preterm caesarean delivery under general anaesthesia with awake videolaryngoscopy-assisted tracheal intubation.

Jet Ventilation in the Pregnant Patient with Airway Stenosis: Surgical Safety and Outcomes

OBJECTIVE

To review pregnancy outcomes and the safety of jet ventilation use in the gravid patient undergoing surgical airway intervention.

METHODS

A multi-institutional retrospective review of medical records was performed to identify women who underwent low-frequency jet ventilation during pregnancy for surgical treatment of airway stenosis. Postoperative complications were noted, and patients were interviewed regarding pregnancy outcomes.

RESULTS

Six women were included in this series. No immediate complications relating to anesthesia or surgical intervention were noted in five of the six women. One patient with a well-known history of uncontrolled seizures experienced seizure activity postoperatively. One patient returned to the operating room at a later date for debridement of tracheal crusts. Five mothers delivered via cesarean section and one via spontaneous vaginal delivery. The mean gestation age was 37.3 weeks. One of the six infants delivered prematurely and three were delivered at low birth weight. Three of the six infants required elevated care immediately post-delivery but, at present, all are in good health.

CONCLUSION

Low-frequency jet ventilation and surgical management of airway stenosis should be recognized as a safe treatment option in the gravid patient. Surgical intervention should not be delayed in patients with severe symptoms, particularly given the potential risk associated with prolonged corticosteroid use.

LEVEL OF EVIDENCE

4.

Adaptation of lung, chest wall, and respiratory muscles during pregnancy: preparing for birth

A plethora of physiological and biochemical changes occur during normal pregnancy. The changes in the respiratory system have not been as well elucidated, in part because radioimaging is usually avoided during pregnancy. We aimed to use several noninvasive methods to characterize the adaptation of the respiratory system during the full course of pregnancy in preparation for childbirth. Eighteen otherwise healthy women (32.3 ± 2.8 yr) were recruited during early pregnancy. Spirometry, optoelectronic plethysmography, and ultrasonography were used to study changes in chest wall geometry, breathing pattern, lung and thoraco-abdominal volume variations, and diaphragmatic thickness in the first, second, and third trimesters. A group of nonpregnant women were used as control subjects. During the course of pregnancy, we observed a reorganization of rib cage geometry, in shape but not in volume. Despite the growing uterus, there was no lung restriction (forced vital capacity: 101 ± 15% predicted), but we did observe reduced rib cage expansion. Breathing frequency and diaphragmatic contribution to tidal volume and inspiratory capacity increased. Diaphragm thickness was maintained (1st trimester: 2.7 ± 0.8 mm, 3rd trimester: 2.5 ± 0.9 mm; P = 0.187), possibly indicating a conditioning effect to compensate for the effects of the growing uterus. We conclude that pregnancy preserved lung volumes, abdominal muscles, and the diaphragm at the expense of rib cage muscles.NEW & NOTEWORTHY Noninvasive analysis of the kinematics of the chest wall and the diaphragm during resting conditions in pregnant women revealed significant changes in the pattern of thoracoabdominal breathing across the trimesters. That is, concomitant with the progressive changes of chest wall shape, the diaphragm increased its contribution to both spontaneous and maximal breathing, maintaining its thickness despite its lengthening due to the growing uterus. These results suggest that during pregnancy the diaphragm is conditioned to optimize its active role provided during parturition.

Anesthetic considerations for cesarean section in a parturient complicated by Scimitar syndrome-like pathophysiology

Background

Pre-existing poor respiratory function is a significant challenge for women to successfully continue pregnancy and accomplish delivery.

Case

Pregnancy and delivery were successfully managed without any maternal or neonatal complications, in a 26-year-old woman with severely impaired respiratory function, due to a unilateral hypoplastic lung, accompanying Scimitar syndrome-like circulation. Hyperventilation, normally observed even at the first trimester, was absent by the end of the second trimester. This would indicate her ventilation must have reached utmost capacity. Premature delivery by the mode of elective cesarean section delivery was, therefore, the most reasonable option. General anesthesia, combined with a continuous epidural infusion of low-concentrate local anesthetics, containing opioid, was sufficient to avoid the need for unexpected mechanical ventilation in intra- and early postoperative periods and to provide excellent post-partum analgesia.

Conclusion

This combination can be a potent alternative in tailoring anesthesia for cesarean section in women with extremely impaired pulmonary reserve.

Obstetric and offspring risks of women's morbid conditions linked to prior anticancer treatments

BACKGROUND

Literature shows the effects of type of cancer and/or anticancer treatment on live birth percentages and/or pregnancy and neonatal complications in female cancer survivors. However, studies analyzing the obstetric and offspring risks of the morbid conditions associated with previous anti-cancer treatments are missing. The present review aims to uncover these risks.

METHODS

A literature search based on publications up to March 2016 identified by PubMed and references cited in relevant articles.

RESULTS

The morbid conditions associated with prior anticancer treatments including chemotherapy, radiotherapy, surgery, and/or hematopoietic stem-cell transplant may induce not only obstetric and neonatal complications but also long-term effects on offspring. Whereas some risks are predominantly evidenced in untreated women others are observed in both treated and untreated women. These risks may be superimposed on those induced by the current women's trend in Western societies to postpone maternity.

CONCLUSIONS

Medical professionals should be aware and inform female cancer survivors wishing to have a child not only of the short- and long-term risks to themselves and their prospective offspring of previous anticancer treatments, fertility-preservation technologies, and pregnancy itself, but also of those risks linked to the morbid conditions induced by prior anticancer treatments. Once female cancer survivors wishing to have a child have been properly informed about the risks of reproduction, they will be best placed to make decisions of whether or not to have a biological or donor-conceived child. In addition, when medical professionals be aware of these risks, they will be also best placed to provide appropriate treatments before/during pregnancy in order to prevent or alleviate the impact of these morbid conditions on maternal and offspring health.

Respiratory physiology of pregnancy: Physiology masterclass

During healthy pregnancy, pulmonary function, ventilatory pattern and gas exchange are affected through both biochemical and mechanical pathways, as summarised in figure 1.

Physiology masterclass: respiratory physiology of pregnancyhttp://ow.ly/UvYXt

Multidisciplinary Team Approach Is Key for Managing Pregnancy and Delivery in Patient with Rare, Complex MPS I

A 23-year-old primiparous lady (Ms S) was referred to preconception clinic with known Hurler-Scheie syndrome (mucopolysaccharidosis 1). Ms S had been under the care of the adult inherited metabolic disorder physicians prior to becoming pregnant. She and her partner received prenatal counselling and following spontaneous conception was closely managed by a multidisciplinary team involving foetomaternal obstetricians, anaesthetists, cardiologists, geneticists and endocrinologists in two tertiary referral hospitals throughout her pregnancy. She went on to deliver a live male child at 37/40 by elective caesarean section. As far as we are aware, this is the first case report of a term pregnancy in a woman with moderate to severe mucopolysaccharidosis 1 (MPS 1).

Acute respiratory failure in pregnancy

Respiratory failure affects up to 0.2% of pregnancies, more commonly in the postpartum period. Altered maternal respiratory physiology affects the assessment and management of these patients. Respiratory failure may result from pregnancy-specific conditions such as preeclampsia, amniotic fluid embolism or peripartum cardiomyopathy. Pregnancy may increase the risk or severity of other conditions, including thromboembolism, asthma, viral pneumonitis, and gastric acid aspiration. Management during pregnancy is similar to the nonpregnant patient. Endotracheal intubation in pregnancy carries an increased risk, due to airway edema and rapid oxygen desaturation following apnea. Few data are available to direct prolonged mechanical ventilation in pregnancy. Chest wall compliance is reduced, perhaps permitting slightly higher airway pressures. Optimizing oxygenation is important, but data on the use of permissive hypercapnia are limited. Delivery of the fetus does not always improve maternal respiratory function, but should be considered if benefit to the fetus is anticipated.