Progressive intrapartum respiratory insufficiency due to pulmonary alveolar proteinosis. Amelioration by therapeutic whole-lung bronchopulmonary lavage

Pulmonary Alveolar Proteinosis and Pregnancy: A Review of the Literature and Case Presentation

Pulmonary Alveolar Proteinosis (PAP) is a rare, usually autoimmune, disease, where surfactant accumulates within alveoli due to decreased clearance, causing dyspnea and hypoxemia. The disease is even more rare in pregnancy; nevertheless, it has been reported in pregnant women and can even appear for the first time during pregnancy as an asthma-like illness. Therefore, awareness is important. Similarly to many autoimmune diseases, it can worsen during pregnancy and postpartum, causing maternal and fetal/neonatal complications. This paper offers a narrative literature review of PAP and pregnancy, while illustrating a case of a pregnant patient with known PAP who developed preeclampsia in the third trimester but had an overall fortunate maternal and neonatal outcome.

Infiltrative lung diseases in pregnancy

Pregnancy may affect the diagnosis, management, and outcome of infiltrative lung disease (ILD). Conversely, ILD may affect pregnancy. ILD may occur as a result of drugs administered commonly or specifically during pregnancy. Most ILDs predominate in patients older than 40 years and are thus rare in pregnant women. During pregnancy ILD may arise de novo and preexisting ILD may be exacerbated or significantly worsened. Some ILDs generally do not alter the management of pregnancy, labor, or delivery. Preexisting ILD no longer contraindicates pregnancy systematically, but thorough evaluation of ILD before pregnancy is required to identify potential contraindications and adapt monitoring.

[Successful pregnancy in a severely hypoxemic patient with pulmonary alveolar proteinosis]

Pulmonary alveolar proteinosis (PAP) is a rare disorder characterized by abnormal accumulation of a lipoproteinaceous material in the alveoli, which may lead to respiratory failure and has an associated high risk for infections. The mainstay treatment for PAP is whole lung lavage. A pregnant woman, previously diagnosed with primary PAP, the most common form of PAP, was admitted with dyspnea and worsening respiratory function. In one month period, a whole-lung bronchopulmonary lavage was performed twice, with clinical and functional improvement. Pregnancy was carried to term and a healthy baby was delivered. The mechanisms of respiratory impairment are discussed as well as treatment options and response.

Pulmonary alveolar proteinosis: progress in the first 44 years

Pulmonary alveolar proteinosis is a rare clinical syndrome that was first described in 1958. Subsequently, over 240 case reports and small series have described at least 410 cases in the literature. Characterized by the alveolar accumulation of surfactant components with minimal interstitial inflammation or fibrosis, pulmonary alveolar proteinosis has a variable clinical course ranging from spontaneous resolution to death with pneumonia or respiratory failure. The most effective proven treatment--whole lung lavage--was described soon after the first recognition of this disease. In the last 8 years, there has been rapid progress toward elucidation of the molecular mechanisms underlying both the congenital and acquired forms of pulmonary alveolar proteinosis, following serendipitous discoveries in gene-targeted mice lacking granulocyte-macrophage colony-stimulating factor (GM-CSF). Impairment of surfactant clearance by alveolar macrophages as a result of inhibition of the action of GM-CSF by blocking autoantibodies may underlie many acquired cases, whereas congenital disease is most commonly attributable to mutations in surfactant protein genes but may also be caused by GM-CSF receptor defects. Therapy with GM-CSF has shown promise in approximately half of those acquired cases treated, but it is unsuccessful in congenital forms of the disease, consistent with the known differences in disease pathogenesis.

Successful pregnancy after spontaneous remission of familial pulmonary alveolar proteinosis

In this report we describe a case of a successful pregnancy in a 19-year-old patient suffering from the familial form of pulmonary alveolar proteinosis, a very rare pulmonary disorder. The pregnancy course was complicated by preterm labour. The outcome and management are discussed.

Oxygen consumption and ventilation during normal labor

Oxygen consumption (VO2) and minute ventilation (VE) were measured breath-by-breath for 10 min periods in the third trimester of pregnancy in 16 healthy women. These measurements were repeated during the first stage of labor in eight of the women. The 10-min mean VO2 was 3.56 ml/kg/min (+/- 0.82 SD) at term and 4.28 ml/kg/min (+/- 0.93) during labor, for an average increase of 23 percent (+/- 28 percent, p = 0.04) from third trimester to labor. The mean VE was 0.15 L/kg/min (+/- 0.03) at term and increased significantly (p = 0.05) to 0.24 L/kg/min (+/- 0.11) during labor for an average increase in VE of 65 percent (+/- 78 percent). Peak VO2 and VE occurred during contractions with five-breath average peak VO2 being 86 percent (+/- 53%) above the 10-min mean value at term and VE increasing 167 percent (+/- 154 percent) from third trimester to peak values during labor. These data may be useful in identifying patients at risk for developing respiratory insufficiency during labor. We propose an algorithm for approaching the obstetric patient with respiratory disease.

Pregnancy in a woman with severe pulmonary fibrosis secondary to hard metal disease

The effect of interstitial pulmonary fibrosis on pregnancy is unclear. We present the findings in a 31-year-old woman with severe pulmonary fibrosis (vital capacity, 37 percent of predicted) secondary to hard metal disease who went through a successful term pregnancy. The patient was a grinder of tungsten-carbide drill bits who developed pneumonitis and subsequent fibrosis. Her therapy required steroids and cyclophosphamide for stabilization of her pulmonary function prior to her pregnancy. At six months' gestation, right heart catheterization showed normal cardiac output and pulmonary arterial and wedge pressures. Stage 2 exercise study demonstrated a maximum oxygen consumption of 1.17 L/min (53 percent of predicted). The patient was able to exercise to a maximum workload of 300 kpm/min (32 percent of predicted). She became hypoxemic (arterial oxygen pressure, 54 mm Hg) at 150 kpm/min. Her pregnancy concluded with an uncomplicated normal vaginal delivery requiring only supplemental oxygen and spinal anesthesia. Review of the few similar cases suggests that a woman can have a successful pregnancy despite severe pulmonary dysfunction.