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In the Name of God Obstetrics Study Guide 4 Mitra Ahmad Soltani 2008 Med-ed-online.org References 1  ACOG committee opinion. Ethics in Obstetrics and Gynecology.second edition.2004 Anderoli Thomas E, et al. Cecil Essentials of Medicine. 5th edition. W.B.Saunders; 2001

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in the name of god
In the Name of God

Obstetrics Study Guide 4

Mitra Ahmad Soltani

2008

Med-ed-online.org

references 1
References 1
  •  ACOG committee opinion. Ethics in Obstetrics and Gynecology.second edition.2004
  • Anderoli Thomas E, et al. Cecil Essentials of Medicine. 5th edition. W.B.Saunders; 2001

See:www.merckmedicus.com/ppdocs/us/common/cecils/chapters/106_006.htm

  • British guideline on the management of asthma in adults, The British Thoracic Society & Scottish Intercollegiate Guidelines Network Thorax 2008 May; 63 (Suppl 4) : 1-121.

See: http://www.brit-thoracic.org.uk/ClinicalInformation/ Asthma/AsthmaGuidelines/tabid/83/Default.aspx

  • www.cdc.gov/asthma/speakit/slides/managing_asthma
  • Braunwald Eugene, et al. Harrison's Principles of Internal Medicine. 16th edition. McGrawHill; 2005
  • Braunwald et al. IHD clinical practice guidelines. 2002
  • Cunningham G, Gant N, Leveno K, et al. Williams Obsterics. 22nd Ed . New York : Mc Graw Hill, 2005.
  • Gibson P. HTN in Pregnancy. emedicine.DEC 13. 2007
  • Hogg K, Dawson D, Mackway K. Outpatient diagnosis of pulmonary embolism: the MIOPED (Manchester Investigation Of Pulmonary Embolism Diagnosis) study .2006

See: emj.bmjjournals.com/cgi/content/full/23/2/123

  • Iranian Council for Graduate Medical Education. Exam questions.1998-2007
  • Iranian Council for graduate Medical Education. Board and pre-board Exam questions for OBS and Gyn .2001-2006
  • Katzung Bertram G. Pharmacology: Examinatoin & Board Review.7th edition Mcgrawhill. 2005
  • Marsha D. Ford. Cecil text book of medicine. Acid-Base disorder. Saunders company.2004
  • Massel D, Klein GJ. Guidelines & Policies At The London Health Sciences Centre. 2002. see: www.lhsc.on.ca/uwodoc/pages/policy.htm
  • Yanowitz.ECG learning center.2006
  • Regional ALS Treatment Protocols and Procedures.EMT-Paramedics,1998
  • Safeer ,Richard S., Lacivita ,Cynthia L. Choosing Drug Therapy for Patients with Hyperlipidemia American Family Physician. Vol. 61/No. 11 (June 1, 2000)
references 2
References 2
  • mentor.wnmeds.ac.nz/groups/rmo/asthma/asthma5.htm(2006)
  • www.rnceus.com/abgs/abgmethod.html. ABG interpretation method.(2006)
  • www.umary.edu/faculty/rschulte/ABG web page cases.doc. (2006)
  • www.lakesidepress.com/pulmonary/books/physiology/chap10a.htm.(2006)
  • www.en.wikipedia.org/wiki/mechanical_ventilation.

(2006)

  • www.hoslink.com/ Laboratory Findings in Heart Disease. Cardiac Enzymes .(2006)
the process of making decision for a pregnant case
The process of making decisionfor a pregnant case

For Obstetrics cases, a physician faces complexities stemming from the fetus, a woman in a narrower definition of health indices, and the setting. All these are proceeding dynamically interacting with one another. There are priorities that should be considered. This makes “ethics” of outmost importance in Obstetrics.

ethical approaches
Ethical approaches

1-Principle-based approach: It seeks to identify the principles and rules pertinent to a case.

2-A virtue-based approach : It is focusing on one course of action would best express the character of a good physician.

3-Ethic of care: It situates a doctor’s duties in the context of a pregnant woman’s values and concerns instead of specifying abstract principles.

ethical approaches cont
Ethical Approaches- cont.

4- Feminist Ethics approach: seeks to change factors that limit a woman’s options.

5-A case-based approach: It considers if there are any relevantly similar cases that constitute precedents for a given case.

a case
A case

A 22 wk pregnant woman is a known case of ROM. FHR can be heard. She had a 10 year history of infertility. She says:” I want to put my life in danger for the very rare chance that may be the leakage stop”. So she rejects the option of pregnancy termination. What are possible managements?

A- Termination of pregnancy despite the woman’s objection. (Principle-based approach)

B-continuation of pregnancy with close observation (Feminist Ethics approach)

C-Termination of pregnancy telling the woman that her fetal heart is no longer heard.(This is against virtue-based approach!)

slide8

For a better understanding of how to implement our knowledge of internal medicine in a pregnant case, this section of Obstetrics comes with cases.

slide10

A 25 year old 28 week pregnant woman has developed weight gain, head-ache and peripheral edema within the last week. Her BP is 150/105 mmHg. Which drug should not be prescribed for her?

a- Methyldopa

b- ACE inhibitor

c- Hydralazine

d- Nifedipine

Answer:b

what drug is not used for the treatment of pre eclampcia
What drug is not used for the treatment of pre-eclampcia?

a- Betablocker

b- Methyldopa

c- ACE inhibitor

d- Hydralazine

Answer:C

which statement about treatment of htn with ace inhibitors is wrong
Which statement about treatment of HTN with ACE inhibitors is wrong?

a- They are drugs of choice in diabetics.

b- They can be used in mild renal failure.

c- In unilateral renal artery stenosis, they can be prescribed if the other kidney has a normal function

d- They are drugs of choice for pregnancy

Answer:D

what is the accepted screening test for diagnosis of pih
What is the accepted screening test for diagnosis of PIH?

A-Rollover test

B-nitric oxide measurement

C-vascular endothelial growth factor

D-angiotensin test

Ans:A

slide14

For a case of severe preeclampsia (BP=180/95) Mg SO4 and C/S is ordered. An hour after C/S BP falls to 110/75. What is the reason of BP fall?

A-Delivery removes the effect of vasospasm

B-anesthetic drugs

C-hemorrhage

D-MgSO4 effect

Ans: C

which is true about edema of preeclmpsia
Which is true about edema of preeclmpsia?

A- it has an unknown etiology

B-it is because of increased aldosterone level

C- it worsens the prognosis of preeclampsia

D- it is because of increased DOC

Ans:A

slide16

A woman 48 yrs old/ G3/ BP=150/115/ has a high cholesterol level . Her sister and brother had heart attacks in the age of 40. Which is wrong about the management of this case?

A-Beta blocker

B- diet

C-methyl dopa

D-regular checking of lab results

Ans: A

in a woman with chronic htn which factor has the least effect in development of superimposed pih
In a woman with chronic HTN Which factor has the least effect in development of superimposed PIH?

A- PIH history

B- low dose aspirin

C- severity of HTN

D-the need for combined drug therapy

Ans:B

what is the most common complication of eclampsia
What is the most common complication of eclampsia?

A- abruption

B-aspiration pneumonia

C-pulmonary edema

D- direct maternal mortality

Ans:A

which is true about blindness after eclampsia
Which is true about blindness after eclampsia?

A-It has a bad prognosis

B-It lasts about 1 month

C-it is transient and lasts from 4 hours to 8 days

D-in some people it causes permanent blindness

Ans:C

which is wrong about eclampsia
Which is wrong about eclampsia?

A- eclampsia can cause coma without seizure

B- All patients with eclamsia have had signs of preeclampsia

C-After seizures respiratory rate is reduced and cyanosis happens

D- In all cases of eclampsia severe proteinuria is present

Ans:C

which therapy can prevent preeclampsia
Which therapy can prevent preeclampsia?

A-Low dose aspirin

B-calcium

C-fish oil

D-Antioxidants

Ans:D

slide22
A 40 years old woman / G3/P2 /GA=35 wks/ BP=210/110 is in seizure. What is the best way to control her seizure?

A-Phenytoin loading dose of 1000 mg/h IV

B- Diazepam and creatinin measurement

C- amobarbital sodium 250 mg IV

D- MgSO4 4-6 gr as loading dose

Ans:D

what is the cause of platelet change in preeclampsia
What is the cause of platelet change in preeclampsia?

A- increased production

B- decreased consumption

C- increased platelet aggregation

D- decreased platelet- adhering IG

Ans:A

a woman 25 years old g1 suffers hellp syndrome what is true about her next pregnancy
A woman 25 years old / G1 suffers HELLP syndrome. What is true about her next pregnancy?

A- there is no increased risk in her next pregnancy

B-the is increased risk of abruption and preeclampsia

C-there is no increased risk of preterm labor or C/S

D-there is no increased risk of IUGR

Ans:B

which test has a more ppv for detecting pih
Which test has a more PPV for detecting PIH?

A-urinary excretion of Kallikrein

B- roll over test

C- angiotensin II

D- hypocalciuria

Ans:A

slide26

A pregnant woman GA=29 wks / severe headache/ blurred vision/ BP= 200/120 has gone through routine tests and MgSO4 infusion. What other steps should be taken?

A-IV hydralazine 20 mg + IV verapamil 10 mg

B-IV hydralazine 5 mg

C- IV labetalol 80 mg

D- sublingual nifedipine 10 mg +thiazide 10 mg

Ans:B

slide27
A case of eclampsia with seizure is given MgSO4. She is agitated. What drug is appropriate for her agitated state?

A-2 gr MgSO4 IV

B- 250 mg amobarbital IV

C- 10 mg diazepam IM

D-no treatment is needed

Ans:B

“A” would be appropriate if a second seizure occurs

slide28

A woman with high blood pressure, proteinuria, Cr>1.5 mg/dl, has an episode of seizure after 4 hours from her delivery. What treatment do you suggest?

A-14 gr of MgSO4as the loading dose and then 2.5 gr q4h up to 24 h after delivery

B-7 gr of MgSO4 as the loading dose and then 2.5 grq4h up to 24 h after the last seizure

C-14 gr of MgSO4 as the loading dose and then 2.5 gr q4h up to 24h after the last seizure

D-7 gr of MgSO4 as the loading dose and then 2.5 gr q4h up to 24h after delivery

Ans:C

which is not among pathophysiological changes of preeclampsia
Which is not among pathophysiological changes of preeclampsia?

A-reduction in PGE2

B-reduction in prostacyclin

C-increased thromboxane A2

D-increased resistance to angiotensin

Ans: D

which is wrong about proteinuria of preeclampsia
Which is wrong about proteinuria of preeclampsia?

A-Some women deliver before proteinuria occurs

B-1+ proteinuria equals 300 mg protein in a 24 hour sample

C-NPV of a trace or negative dipstick test is about 30 %

D-PPV of 3+/4+ proteinuria is 70%

Ans:D

slide31

For a primigravida in 30 weeks gestation a roll-over test is done. An increase of 35 mmHG has occurred in diastolic BP. Which is wrong for this case?

A- She has a high probability of developing HTN

B-She is abnormally sensitive to angiotensin II

C-increased BP is because of hyperactivity of parasympathetic system

D-33% of these patients will develop preeclampsia

Ans:C

which is wrong for visual disturbances of preeclampsia
Which is wrong for visual disturbances of preeclampsia?

A-it is because of occipital region lesions

B-if blindness does not resolve within a week , it will remain permanently

C- It is because of retinal artery spasm that can resolve by MgSO4

D-it is because of retinal detachment that is most often unilateral

Ans:B

which is wrong about superimposed preeclampsia
Which is wrong about superimposed preeclampsia?

A-it occurs earlier in pregnancy and most often is accompanied by IUGR

B- BP changes remain through life

C-some women have increased BP after 24 weeks gestation

D- above 90% of them have a history of essential HTN

Ans:B

slide34

A woman GA=38 wks/G2/L1/history of chronic HTN is diagnosed as a case of severe preeclampsia. Her pregnancy is terminated. Her BP and proteinuria and edema are improved but she has developed orthopnea. What is your first diagnosis?

A-ATN and overload

B- hypoalbuminemia

C-peripartum cardiomyopathy

D-MS signs aggravated by fluid shift

Ans:C

what drug has the complication of tachycardia
What drug has the complication of tachycardia?

A-methyl dopa

B-propranolol

C-nifedipine

D-hydralazine

Ans: D

27 which does not happen in preeclampsia
27-Which does not happen in preeclampsia?

A-reduced renal perfusion and GFR

B-increased renin-angiotensin level

C-constant electrolyte concentration

D- increased microangiopathic hemolysis

Ans:B

slide37

A woman 32 years old/ NP /obese / 38 wks GA/ mild preeclampsia delivers her child . BP does not decrease after several IV doses of hydralazine. Which is not a good management?

A-Im hydralazine

B-oral labetalol

C-thiazides

D-IV MgSO4

Ans:D

which is true about a 12 wk pregnant woman with eisenmenger syndrome
Which is true about a 12 wk pregnant woman with Eisenmenger syndrome?

A- therapeutic abortion is indicated

B-heparin throughout pregnancy should be given

C-pregnancy should be terminated when the fetus is viable

D- she has to be hospitalized throughout pregnancy

Ans:A

slide45
A pregnant woman with artificial valve on heparin has undergone C/S. When should the anticouagulant be started after the operation?

A- 6 hours

B- 8 hours

C-24 hours

D- immediately after C/S

Ans:c

-24 hrs after C/S and 6 hrs after vaginal delivery.

(Warfarin has no contraindication during lactation)

which is wrong about idiopathic cardiomyopathy in pregnancy
Which is wrong about idiopathic cardiomyopathy in pregnancy?

A- terbutaline is a predisposing factor

B-ICM has the symptoms of congestive heart failure

C-ICM is more prevalent in pregnancy than non pregnant state

D-dyspnea is an important symptom

Ans: c

Therapy is hydralazine and heparin. ACE inhibitors are contraindicated during pregnancy

which is more fatal to a pregnant woman
Which is more fatal to a pregnant woman?

A-bioprosthetic valve replacement

B-corrected fallot tetralogy

C-pulmonary or tricuspid disease

D- mitral stenosis with AF

Ans:D

risks of various types of heart dis
Risks of various types of heart dis.

Group 1-min risk:

ASD,

VSD,

PDA,

Pul or tri dis

FT corrected

MS NYHA I, II

Group 2-mod :

MS class III,IV

AS

Aortic Coarctation

FT uncorrected

MI HX

Marfan syn.

MS with AF

Artificial valve

Group3-major:

Pul. HTN

Coarctation +valve involvement

Marfan +aortic involvement

slide49

A 39 wk pregnant woman in labor has a history of VSD corrected without a patch. She states a history of bradycardia and permanent pacemaker six months prior to her pregnancy. What is true about this case?

A- There is no need for endocarditis prophylaxis.

B- She is in moderate risk group and needs prophylaxis.

C-She is high risk and needs prophylaxis.

D- Prophylaxis depends on her heart functional class.

Ans:A

slide50
A patient with Mitral Stenosis in class II NYHA suffers hypotension and tachycardia during labor. Which is a better management?

A- fluid and electrolyte administration

B-spinal analgesia to reduce pain

C-immediate pregnancy termination

D- beta blocker to reduce heart rate

Ans:D

AF caused by MS is treated by 5-10 mg verapamil IV or cardioversion

slide51

An 8 wk pregnant woman is a known case of Marfan disease . She has MVP without regurgitation . AR is not present either. Which is true about this case?

A- Termination of pregnancy is not indicated.

B-She is in class 2B NYHA.

C- The best route of delivery is C/S.

D- The probability of her child suffering from the same illness is 10%.

Ans:A

which is wrong about arrhythmia in pregnancy
Which is wrong about arrhythmia in pregnancy?

A-arrhythmia is increased by pregnancy.

B-most arrhythmias in pregnant women are not because of organic lesions.

C-Arrhythmia treatment is the same for pregnant and non pregnant.

D- women with pacemaker should terminate pregnancy.

Ans:D

which is not recommended for a pregnant woman with mitral stenosis
Which is not recommended for a pregnant woman with Mitral Stenosis?

A-Spinal analgesia and IV fluid

B-Beta blockers in tachyarrhythmia

C-heparin for AF

D-cardioversion for AF

Ans: A

slide54
The fetus of a 34 wk pregnant woman under general anesthesia shows persistent bradycardia for 4 hours. What should be done?

A- C/S

B-no intervention except for vital stability in the mother

C- glucocorticoids and induction of labor

D- emergency color Doppler for fetal circulation

Ans:B

which is an indication for c s
Which is an indication for C/S ?

A-fallot tetralogy

B- aortic stenosis

C-Marfan with aorta involvement

D- prosthetic mitral valve

Ans:C

slide56
A 37 year old woman suffers cardiac disease. She is G3/ P3/ with GA=38wks. She had an NVD. She asks for TL. Which is not necessary for TL?

A- temperature should be normal

B-anemia should not be present

C- mother should not be in class III or IV

D-48 hrs should pass from delivery

Ans:D

which is wrong about pregnant women with aortic stenosis
Which is wrong about pregnant women with aortic stenosis?

A-preload should not decrease and output should be stable.

B-epidural anesthesia with narcotics should be used.

C-endocarditis prophylaxis is necessary.

D-surgery is recommended for those resistant to medical therapy.

Ans:D

slide58

A pregnant woman is under heparin therapy for PE. She is a case of ROM /GA=35 wks /presentation=complete breech. Which is the best route for pregnancy termination?

A-vaginal delivery+ heparin

B- C/S + FFP + heparin

C- d/c of heparin, vena cava filter , C/S

D-d/c of heparin + protamine sulfate+ C/S

Ans: C

which is not a good therapy for an idiopathic cardiomyopathy in pregnancy
Which is not a good therapy for an idiopathic cardiomyopathy in pregnancy?

A- salt restriction and diuretic

B-digoxin if arrhythmia is not present

C- low dose heparin

D- enalapril to reduce afterload

Ans:D

slide60

A 35 year old woman with exertional dyspnea in the 4th week after NVD comes to ED. JVP raised with prominant X and Y waves. Kussmul sign is positive. S1 and S2 plus another high pitched extra sound can be heard on the apex. Pulsus Paradox is not detected. Which is the best diagnosis?

a- Tamponade

b-Constrictive pericarditis

c-Restrictive cardiomyopathy

d- Right ventricle infarct

Ans:B

what sign is the least prevalent for constrictive pericarditis
What sign is the least prevalent for constrictive pericarditis?

a- kussmul sign

b- prominent Y wave

c- prominent X wave

4- pulsus paradox

Ans: D

what is among the signs of temponade
What is among the signs of Temponade?

a- Kussmul

b-prominent X

c-pericardial knock

d-4th heart sound

Ans:B

for what type of heart failure carvodilol is a betablocker of choice
For what type of heart failure Carvodilol is a betablocker of choice?

a- class IV

b- Failure with a normal Ejection Fraction

c- previous pulmonary edema stable at present

d- within a short interval of MI

Ans:C

slide64
All of the following can be used for cases of pulmonary edema with systolic left ventricular dysfunction except:

a- IV Digoxin

b-loop diuretic is the diuretic of choice

c-aminophilyne to enhance heart contractility

d-ACE inh to lower afterload

Ans:D

slide65

A pregnant woman had seizure after delivery . When her condition was stabilized she complained of dyspnea and exertional chest pain. BP=160/100 mmHg / PR=90 bpm heart rhythm= irregular JVP= raised Pitting edema =2+Rales are present. Liver is palpable and tender. No pericardial effusion is detected. No stenosis or regurgitations of valves can be detected. What should not be prescribed for this case?

a- Digoxin

b- Nitrates

c- Betablockers

d- Diuretic

Ans:A

slide66

Differential Diagnosis of S3 And S4.(DCMP=dilated cardiomyopathy/ JVP= jugular vein pressure/ HCMP=hypertrophic cardiomyopathy/ RCMP=restrictive cardiomyopathy)

try to diagnose and suggest treatment for the following ecg strips in pregnant cases
Try to diagnose and suggest treatment for the following ECG strips in pregnant cases.

ECG strips are taken from the site:

Yanowitz.ECG learning center.2006

With permission

slide79

ECG1

ECG2

ECG3

slide80

ECG4

ECG5

ECG6

ECG7

slide81

ECG8

ECG9

ECG10

ECG11

slide84

QRS>=150

P>QRS

P<QRS

P waves=QRS

PAT with block

P=150-250

Flutter

P=250-350

AF

P=350-600

VT

PSVT

P=150-250

Sinus tachycardia

P= 100-150

slide88

Prophylaxis of endocarditis

GI or GU

High Risk patient

Moderate Risk

Standard

Standard

Allergy

Ampicillin +Gentamycin before the procedure and have to repeat Ampicillin after 6 hours

Amoxycillin

Allergy

Vancomycine

Should be infused One hour before to 3 minutes after the procedure

Gentamycine + Vancomycine

slide89

A woman develops chest pain for three days after her delivery. The peak lasted for 3 hours. In her ECG, Q wave can be seen in leads V1-V4. what lab test is good for a diagnosis?

A- SGOT

B-CPK-MB

C-LDH

D-ESR

Ans:C 

which one is not considered as acute coronary syndrome
Which one is not considered as acute coronary syndrome?

A-Non-Q wave MI

B- Stable Angina Pectoris

C- Q wave MI

D-Unstable Angina

  • Ans:B
which does not imply a poor prognosis for angina pectoris
Which does not imply a poor prognosis for angina pectoris:

A- S3

B-S4

C-MR murmurs

D-lower lung rales

Ans:B

which is not among the absolute contraindications for thrombolytic agents in acute mi
Which is not among the absolute contraindications for thrombolytic agents in acute MI?

A- SBP> 180 mmHg with chest pain

B- Cerebral Hemorrhage 3 years ago

C- pregnancy

D-Aortic dissection

Ans:C

tall r in lead v1 points to the diagnosis of
Tall R in lead V1 points to the diagnosis of:

A- Posterior MI

B- Inf MI

C- Anterior Mi

D- Right Ventricular MI

Ans:A

which is not used as a secondary prevention in mi
Which is not used as a secondary prevention in MI?

A- beta blockers

B- CCB

C- ACE inhibitors

D- anti platelet drugs

Ans:B

slide95

A 20 year old woman has the chief complaint of palpitations. Each episode lasts for some hours with a chest pain. What is the most probable diagnosis?

A- WPW syndrome

B- HCMP

C- Prolonged QT syndrome

D- Psychogenic

Ans:D

indications for echocardiography
Indications for echocardiography
  • Holosystolic or late systolic murmur
  • Grade 3 or midsystolic murmurs
  • Murmurs associated with an abnormal ECG or chest x-ray
  • Physical signs of LV dysfunction or CHF
  • Enlarged cardiac silhouette and/or signs of pulmonary venous congestion on chest x-ray
  • New Q-waves in 2 or more contiguous leads or new LBBB
how do you manage these cases of hyperlipidemia
How do you manage these cases of hyperlipidemia:

22- 45 year old woman with no adverse history, TG=300 ,HDL=40, Total Cholesterol=200?

Ans:DX=hypertriglyceridemia/TX=niacin&gemfibrozil

23- 45 year old woman with chronic hepatitis, TG=148 ,HDL=45 ,Total Chol=292?

Ans:Dx23-DX=hypercholesterolemia/TX=cholestyramine

24- 45 year old woman with a CAD history, TG=450,HDL=40,Total chol=450?

Ans:DX=dysbetalipoproteinemia/TX=Niacin&Gemfibrozil&

Statins

25-45 year old woman with DM and obesity, TG=280, HDL=36, total chol=220?

25-DX=hypertriglyceridemia/TX=Niacine&Gemfibrozil

slide99

Estimate LDL level according to risk factors*

Low LDL

High LDL

High TG

(>150 mg/dl)

(hypertriglyceridemia)

VLDL/TG<3/10

(Dysbetalipoproteinemia)

High TG

(Hyperlipidemia)

Normal TG

(hypercholesterolemia)

Niacin

Gemfibrozil

statins

Niacin

gemfibrozil

Niacin

Gemfibrozil

statins

Niacin

Statin

cholestyramine

slide101

A 17 wk pregnant woman had contact with an active TB patient. She had no BCG vaccine. Her PPD test measures 7 mm . Her CXR is normal. Which is true about this patient?

A-PPD is negative. No action is needed.

B- She should receive INH prophylaxis for one year after her delivery at term.

C-one month INH ,then repeat of PPD

D-PPD should be repeated after delivery at term.

Ans:B

When CXR is normal no treatment is necessary until after delivery.

treatment
Treatment
  • +PPD and no evidence of active TB are not treated until postpartum.
  • Known recent skin-test convertors are treated.
  • Skin test positive women exposed to active infection are treated.
  • HIV positive women are treated.
treatment is 9 months hre
Treatment is 9 months “HRE”:
  • Isoniazide 5mg/kg with pyridoxine 50 mg daily
  • +Rifampine 10 mg/kg
  • +Ethambutol 5-20 mg/kg daily

--------------------------------------------------------------

  • Streptomycin is contraindicated in pregnancy
  • Pyrazinamide is only given to HIV infected women who should not receive rifampin.
  • Isoniazide should be discontinued if liver enzymes is increased fivefold over normal level.
slide105
An 8 wk pregnant woman is HIV positive. Her PPD test is 5 mm and she has abnormal CXR. What is your mangement?

A-treatment should be delayed till after delivery

B-HRE for 9 months

C-treatment should be started 3 to 6 months after delivery

D- treatment should be started 12 wks after delivery.

Ans:B

slide106

A 26 wks pregnant woman complains of dypnea. Vital capacity and tidal volume are increased. Functional residual capacity and residual volume is reduced. What is the etiology of her dyspnea?

A- These are physiological changes in pregnancy

B-These are signs of chronic pulmonary disease.

C-These are signs of heart failure

D-These are signs of ARDS due to pulmonary fibrosis.

Ans:A

Respiratory rate is not changed during preg.

slide107

A pregnant woman has the history of bronchial asthma. Her ABG results shows: PH=7.55 and reduced PaO2 and PaCO2. Her ABG half an hour after treatment is: no change in PaO2 but a normal level PaCO2. PH is now 7.30. Which is true for this case?

A-She is recovering. IV should be changed to PO

B-She is deteriorating and needs mechanical ventilation

C-ABG should be repeated six hours later

D-She is recovering. IV route should be continued.

Ans:B

which is wrong about cystic fibrosis
Which is wrong about cystic fibrosis?

A- pregnancy can happen despite high rate of infertility

B- abnormal cervical mucus and delayed puberty are the causes of infertility

C-the most common colonized microorganism is staph aureus

D- All patient suffer lung involvement

Ans:C

slide109

A 28 wk pregnant woman T=38.5 c /RR=32 per min/rales in the right lung/productive cough/hb=10 g/dl and Cr=1.8 mg/dl. What is your management?

A-erythromycin 400-1000 mg PO out patient

B-cefotaxime or ceftizoxime for one week

C-beta lactam for three days

D-cefotaxime and erythromycin after hospitalization

Ans:D

Leukocytosis in pregnancy is defined as more than 15000 WBC in mL

slide110

A 20 wk pregnant woman has severe left calf muscle pain. In physical Exam her left foot is edematous and Homan sign is positive . There is diminished pulsations in the affected foot. What is the best diagnostic procedure?

A-Impedance Plethysmography

B- Magnetic Rresonance Imaging

C- venography

D-real time and doppler US

Ans:D

slide111
A 30 year old 16 wk pregnant woman had close contact with an active TB. PPD is 5 mm. CXR is negative. What is your management?

A-INH prophylaxis

B- HRE

C- no prophylaxis

D-streptomycin 1 gr daily for 10 days

Ans:B

slide112

A 30 wk pregnant woman complains of coughT T=39 c and chest pain after a cold. RR is 34 per min. CXR shows radiologic changes of pneumonia in both lungs lower lobes. What should be done?

A- This is viral pneumonia. Rest and fluid is all needed.

B- Erythromycin 1 gr q6hrs IV . If not responsive amantadine 200 mg daily

C-hospitalization and administration of ceftizoxime.

D-Levofloxacin PO BD. If not responsive hospitalization and erythromycin IV

Ans:C

slide113
A 25 year old G1/GA=39 wk pregnant asthmatic woman is in labor. She takes oral coricosteroid. Which is a correct management?

A- she needs stress dose of steroid stat and that should be repeated q8hrs

B-meperidine or morphine are the drugs of choice for analgesia.

C-general anesthesia is a good choice is she has to undergo C/S

D-PGF2 is a good treatment of postpartum hemorrhage.

Ans:A

which is the earliest sign of ards
Which is the earliest sign of ARDS?

A- hyperventilation

B-radiologic changes

C-alveolar edema

D-hypoxemia

Ans:A

slide115
A 30 wk pregnant woman is diagnosed to suffer from ARDS after severe hemorrhage. Which can reduce her chance of moratlity?

A- surfectant

B-NO

C- Methylprednisolone

D-immunotherapy

Ans:C

which is a cause of cardiac arrest in ards
Which is a cause of cardiac arrest in ARDS?

A-metabolic and respiratory Acidosis

B-increased residual volume

C-interalveolar fibrosis

D-intra pulmonary shunts

Ans:A

which is not happening in the fetus of an asthmatic pregnant woman with hypoxemia
Which is not happening in the fetus of an asthmatic pregnant woman with hypoxemia?

A-reduced umbilical blood flow

B-increased systemic vascular resistance

C-reduced pulmonary vascular resistance

D-reduced cardiac output

Ans:C

which is correct about dvt
Which is correct about DVT?

A-MRI is a common diagnostic procedure

B-DVT is accompanied by PE in prenatal period

C-PE due to DVT is more in postpartum period compared to prenatal period

D-DVT is usually manifested by diminished pulsation

Ans:C

which is a better analgesic in an asthmatic patient
Which is a better analgesic in an asthmatic patient?

A- fentanyl

B-meperidine

C-morphine

D-valium

Ans:A

which is wrong about status asthmaticus
Which is wrong about status asthmaticus?

A-It doesn’t respond to treatment

B- PGE2 is better tolerated than PGF2

C-stress dose of a steroid is needed in a patient who takes systemic steroid for more than 4 wks

D-fentanyl is contraindicated for analgesia

Ans:D

slide121

A 25 year old 7wk pregnant woman with history of infertility receives heparin for DVT. Her platelet is 50000. Which statement is wrong about heparin-induced thrombocytopenia?

A-It will turn to normal state after 5 days from the cessation of heparin.

B-In severe cases it may cause thrombosis.

C-platelets should be count in the first 5 days after initiation of treatment and then after two wks.

D-Heparin should be d/c and LMWH should be initiated.

Ans:B

which is a better indicator of asthma severity in a 28 wk pregnant woman
Which is a better indicator of asthma severity in a 28 wk pregnant woman?

A-oxygen therapy duration

B-respond to beta agonists

C-ABG

D-FEV1 measurement

Ans:B

which is true about amniotic fluid embolism
Which is true about amniotic fluid embolism?

A-The first sign is Hypotension

B-detecting trophoblasts and meconium in blood is the best way of diagnosis

C- right ventricle becomes contracted and smaller

D-fetal survival is about 70 %

Ans:D

what is the side effect of lmwh
What is the side effect of LMWH?

A- fetal abnormality

B- LBW

C-IUFD

D-maternal osteopenia

Ans:D

what drug triggers bronchospasm in asthma
What drug triggers bronchospasm in asthma?

A-salysylamide

B-propoxyphen

C-Mefenamic acid

D-choline salycylate

Answer:c

slide126
A 30 year old woman after delivery suffers a sudden attack of dyspnea and chest pain. What can R/O the PE better?

A- ventilation scan

B- Echocardiography

C- CT scan

D- D-dimer and ultrasound of the lower limb

Ans:A 

which drug is safe in an asthma patient
Which drug is safe in an asthma patient?

A-Timolol for glucoma

B-Atenolol beta1 receptor blocker

C- Propoxyphen

D-Tartrazine

Ans:C

what asthma drug can be used during pregnancy
What asthma drug can be used during pregnancy?

A-Salbutamol and beclomethasone

B-salbutamol

C-Beclomethasone

D- Neither can be used

Ans:A 

slide129

An obese woman suffers dyspnea after delivery. BP=115/75 mmHg/ PR=110bpm .RR=22/min. Lung auscultation is normal. Her perfusion scan is normal. Which statement about her is correct?

A- PE is R/O by a negative perfusion scan

B- Perfusion scan should be repeated

C-Ventilation scan should be done

D- LMWH should be prescribed

Ans:A

a 35 year old woman has an acute asthma attack what is the most effective treatment
A 35 year old woman has an acute asthma attack. What is the most effective treatment?

A- Glucocorticoids IV

B- Aminophyline IV

C- Adrenaline SC

D- beta agonist aerosol

Ans:D

which mechanical ventilation is better for a post thoracic surgery patient
Which mechanical ventilation is better for a post thoracic surgery patient?

A- Assist Control Mode

B- Positive End Expiratory Pressure Ventilation +Intermittent Mandatory Ventilation

C- Pressure Control Ventilation

D- Intermittent Mandatory Ventilation

Ans:C

slide132

An asthmatic patient uses beclomethasone aerosol 8 puffs every 6 hours and salbutamol 2 puffs PRN. He states he uses sabutamol 4 times a day. He has two dyspnea attack at night each week. What should be done for him?

A- adding salmetrol 2 puffs /12 hours

B- adding Beclomethasone 12 puffs /6 hours

C- prednisolone PO 10 mg /day

D- leukotrien antagonists 2 tablets/day

Ans:C

slide133

A near drowning pregnant woman is in ED. CPR is done. She is ventilated by mask and ambu bag. She is alert. BP=90/60 mmHg /T=36c / PR=120 bpm /Rr=30 /min.Her cardiac rhythm is sinus tachycardia. Pulse oximetry shows SaO2=83%. Which is the best way to restore her respiratory function?

A-Bicarbonate

B- Acetazolamide

C- Oxygen

D- CPAP +oxygen

E- Suction of aspirated material and Oxygen

Ans:D

slide134
A patient with ARDS is treated by PEEP of 10 cmH2O. Now she develops pneumothorax. What is her best treatment at this stage?

A- Assist Control Mode

B- Positive End Expiratory Pressure Ventilation +Intermittent Mandatory Ventilation

C- Pressure Control Ventilation

D- Intermittent Mandatory Ventilation

Ans:C

causes of pulmonary edema in pregnancy
Causes of pulmonary edema in pregnancy
  • Preeclampsia
  • Preterm labor
  • Fetal surgery
  • Infection
  • Use of beta agonists to forestall labor
causes of ards in pregnancy
Causes of ARDS in pregnancy
  • Pneumonia
  • Sepsis
  • Hemorrhage
  • Arsenic poisoning
  • Preeclampsia
  • Embolism
  • Connective tissue disease substance abuse
  • Irritant inhalation and burns
  • Pancreatitis
  • pheochromocytoma
which of the following cases would warrant immediate intubation and mechanical ventilation
Which of the following cases would warrant immediate intubation and mechanical ventilation?

a. A comatose patient from drug overdose. PaCO2 51 mm Hg, PaO2 76 mm Hg, and pH 7.31

b. A 29-year-old woman who is alert but in respiratory distress; she is breathing 42 times/min. PaCO2 is 38 mm Hg. pH is 7.42, and PaO2 is 47 mm Hg while breathing 60% oxygen through a face mask

c. A woman who has severe emphysema who is alert but is in moderate respiratory distress; RR=24/min. PaO2 is 75 mm Hg while breathing nasal oxygen at 2 L/min, PaCO2 is 59 mm Hg, and the pH is 7.37. Her chest x-ray is clear.

Cont.

slide138

d. A 29-year-old woman suffering from diabetic ketoacidosis. Her pH is 7.10, PaCO2 is 26 mm Hg and PaO2 is 110 mm Hg while breathing room air.

e. A 31-year-old drug addict who responds briefly to administration of Narcan by opening her eyes and crying out and then lapses back into a state of semi-stupor. PaCO2 is 31 mm Hg. pH is 7.38, and PaO2 is 89 mm Hg while breathing nasal oxygen at 3 L/min.

Answers: Cases a, b, d need mechanical ventilation+intubation

slide139

A comatose 20­year­ old patient is brought to the emergency room following an overdose of sleeping pills. Because of very shallow respirations and cyanosis, the patient is intubated before her blood gas results are known. Initial ventilator settings include a tidal volume (VT) of 700 cc, a respiratory rate (RR) of 12/min, and an FIO2 of 0.50. The patient has no spontaneous breathing. Blood gas results obtained (1) before intubation and (2) 20 minutes later show the following:

pH---PaCO2---PaO2 ----FIO2 ---------VT------ RR

(1) 7.10 79 38 Room air 0 0

(2) 7.25 56 117 50% oxygen 700 12

Following the second blood gas analysis, would you change the FIO2, the tidal volume, or the respiratory rate'? If so, what settings would you choose?

answer
Answer
  • a= <0.4/ b=700 /c=50 /d=18 / e= / PEEP is not needed
slide141

State whether each of the following is true or false .

Mechanical ventilation is indicated for any patient with a

PaCO2 above 50 mm Hg and a pH less than 7.30.

Answer:false

During controlled positive pressure ventilation, each breath is initiated by the patient.

Answer:false

During ventilation with positive end­expiratory pressure (PEEP), the pressure in the upper airways is always above atmospheric pressure.

Answer:true

slide142

A patient receiving intermittent mandatory ventilation (IMV) is able to alternate spontaneous breathing with machine breaths.

Answer:true

  Continuous positive airway pressure (CPAP) is defined as a PEEP pressure maintained above 10 cm H2O.

Answer:false

slide143

The appropriate FIO2 during the initial stages of

mechanical ventilation is always 1.00 (100%).

Answer:false

Successful ventilatory weaning requires the patient to have a VD/VT of less than 0.45

Answer:false

slide144

A 35-year-old single mother, just getting off the night shift reports to the ED in the early morning with shortness of breath. She has cyanosis of the lips. She has had a productive cough for 2 weeks. Her temperature is 102.2, blood pressure 110/76, heart rate 108, respirations 32, rapid and shallow. Breath sounds are diminished in both bases, with coarse rhonchi in the upper lobes. Chest X-ray indicates bilateral pneumonia. Define the problem and suggest a solution.

ABG results are: pH= 7.44 /PaCO2= 28 /HCO3= 24 /PaO2= 54

slide145

Problems:

  • PaCO2 is low.
  • pH is on the high side of normal, therefore compensated respiratory alkalosis.
  • Also, PaO2 is low, probably due to mucous displacing air in the alveoli affected by the pneumonia.

Solutions:

  • She most likely has ARDS along with her pneumonia.
  • The alkalosis need not be treated directly. She is hyperventilating to increase oxygenation, which is incidentally blowing off CO2. Improve PaO2 and a normal respiratory rate should normalize the pH.
  • High FiO2 can help, but if she has interstitial lung fluid, she may need intubation and PEEP, or a BiPAP to raise her PaO2.
  • Expect orders for antibiotics, and possibly steroidal anti-inflammatory agents.
  • Chest physiotherapy and vigorous coughing or suctioning will help the patient clear her airways of excess mucous and increase the number of functioning alveoli.
slide146

A 52-year-old widow is retired and living alone. She enters the ED complaining of shortness of breath and tingling in fingers. Her breathing is shallow and rapid. She denies diabetes; blood sugar is normal. There are no EKG changes. She has no significant respiratory or cardiac history. She takes several antianxiety medications. While being worked up for chest pain an ABG is done:

ABG results are:

pH= 7.48 , PaCO2= 28, HCO3= 22, PaO2= 85

Define the problem and suggest a solution.

slide147

Problem:

  • pH is high,
  • PaCO2 is low
  • respiratory alkalosis.

Solution:

  • If she is hyperventilating from an anxiety attack, the simplest solution is to have her breathe into a paper bag. She will rebreathe some exhaled CO2.This will increase PaCO2 and trigger her normal respiratory drive to take over breathing control.
  • * this will not work on a person with chronic CO2 retention, such as a COPD patient. These people develop a hypoxic drive, and do not respond to CO2 changes.
slide148

You are in critical care unit about to receive a 24-year-old DKA (diabetic ketoacidosis) patient from the ED. The medical diagnosis tells you to expect acidosis. In report you learn that her blood glucose on arrival was 780. She has been started on an insulin drip and has received one amp of bicarb. You will be doing finger stick blood sugars every hour.

ABG results are:

pH= 7.33 , PaCO2= 25, HCO3=12, PaO2= 89

Define the problem and suggest a solution.

slide149

Problem:

  • The pH is acidotic,
  • PaCO2 is 25 (low) which should create alkalosis.
  • This is a respiratory compensation for the metabolic acidosis.
  • The underlying problem is, of course, a metabolic acidosis.

Solution:

  • Insulin, so the body can use the sugar in the blood and stop making ketones, which are an acidic by-product of protein metabolism.
  • In the mean time, pH should be maintained near normal so that oxygenation is not compromised .
slide150

A 26 year-old pregnant woman complains of severe vomiting for five days. She appears extremely fatigued, and has sunken eyes, dry mucous membranes, a heart rate of 110 and a blood pressure of 90/50. When she stands, her blood pressure falls, and her heart rate increases.

ABG is :PH= 7.50 /PaCO2= 47 /PaO2= 80 / HCO3=38

Identify this condition in regard to the ABG Data.

Answer: metabolic acidosis not compensated

slide151

A 35 year old woman is under mechanical ventilation for severe pulmonary infection. Her RR increases and right sided pneumothorax develops. What should be done?

a- needle drainage

b- observation

c- small bore catheter

d- chest tube

Ans: D

respiratory arrest imminent respiratory arrest intubation
RESPIRATORY ARREST/IMMINENT RESPIRATORY ARREST/INTUBATION

1. Airway control with intubation, 100% O2 with BVM.

2. EKG Monitoring.

3. IV of Normal Saline at KVO.

4. Refer to appropriate protocol for further assessment and treatment.

MEDICAL CONTROL OPTIONS

* DIAZEPAM 5-10mg IVP

* MORPHINE SULFATE 2-10mg IVP

* MIDAZOLAM 0.5-2.0mg Slow IVP

* LIDOCAINE 1.0-1.5mg/kg IVP

obstructed airway unconscious
OBSTRUCTED AIRWAY, UNCONSCIOUS

 1. BLS procedure.

2. Direct laryngoscopy and remove foreign body using Magill forceps.

3. If unable to ventilate, intubate.

4. If unable to intubate because of obstruction, cricothyrotomy with large bore over-the-needle catheter.

5. Refer to appropriate protocol, or contact medical control.

respiratory distress asthma bronchospasm copd
RESPIRATORY DISTRESS ASTHMA /BRONCHOSPASM/ COPD

1. Airway control and O2.

2. EKG Monitor.

3. IV of Normal Saline at KVO if clinically indicated.

4. If asthma is working diagnosis, ALBUTEROL 2.5mg/3cc normal saline via nebulizer, may repeat once in 15 minutes.

slide155

* ALBUTEROL 2.5mg/3cc normal saline via nebulizer, repeat as directed.

* METAPROTERENOL 0.1-0.3cc/3cc normal saline via nebulizer, repeat as directed.

* TERBUTALINE 0.25mg subcutaneous, repeat as directed.

* EPINEPHRINE 1:1,000 0.3mg subcutaneous, repeat as directed.

* MAGNESIUM SULFATE 1-2gm IV over 5 minutes.

* METHYLPREDNISOLONE 125mg/50cc normal saline over 3-5 minutes.

CAUTION: Use Epinephrine with caution in patients with history of or presence of hypertension, heart disease, current pregnancy, beta blockers. Avoid Methylprednisolone if suspect varicella.

slide156
STATUS EPILEPTICUS(Two or more seizures without a lucid interval or a continuous seizure lasting more than 5 minutes).

1. Routine Medical Care .

2. O2, IV of Normal Saline, EKG Monitor, Blood Sample if possible (glucose level).

3. If the patient is having sustained seizures, DIAZEPAM is administered 5-10mg IV over 1-2 minutes. If IV route not available, give rectally, via syringe w/out needle up to 10mg; may be repeated once after 10 minutes.

slide157

4. For suspected hypoglycemia, DEXTROSE 50% 50cc IVP or GLUCAGON 1mg IM; THIAMINE 100mg slow IVP or IM.

5. If above actions do not terminate seizure, or respirations are depressed, attempt intubation.

* DIAZEPAM 5-10mg IV injection, may be repeated up to 20mg or rectally via syringe w/out needle, up to 20mg.

* NALOXONE 2.0mg IV injection, may be repeated up to 8mg.

  • INTUBATION.
systemic allergic reactions anaphylaxis
SYSTEMIC ALLERGIC REACTIONS, ANAPHYLAXIS

1. Routine Medical Care / 2. O2, EKG Monitor.

3. If signs of shock or imminent airway obstruction, EPINEPHRINE 1:1,000 0.3cc SQ; may be repeated once after five (5) minutes.

4. If generalized urticaria or anaphylaxis DIPHENHYDRAMINE 25-50mg IM or IV.

5. IV of Normal Saline at KVO if no signs of shock, wide open if signs of shock

slide159

* EPINEPHRINE 1:10,000 0.1-1.0mg is given slow IVP or via ET. May be repeated every 5 minutes per Medical Control.

* EPINEPHRINE 1:1,000 0.1-0.5mg is given subcutaneously. May be repeated every 5 minutes per Medical Control.

* DIPHENHYDRAMINE 25-50mg IM or IV.

* ALBUTEROL 2.5mg via nebulizer.

  • DOPAMINE INFUSION 400mg/250cc Normal Saline and started at 5-10mcg/kg/min. then titrated to desired BP (maximum of 25mcg/kg/min.).
  • * GLUCAGON 1mg IV or IM.
slide160

Is PaO2 increased?

Yes=hypoventilation

Is PAO2-PaO2 increased?

If yes then find out

if low PO2 is correlatable with O2?

Is PAo2-PaO2 increased?

Decreased inspired PO2

Yes=hypoventilation +another mechanism

Hypoventilation alone

Yes=V/Q mismatch

Shunt

slide161

Reduced Vital Capacity

Low FEV1/FVC

But

Normal TLC

Normal FEV1/FVC

But

Low TLC

Normal Mean Inspiratory Pressure

Bronchial obstruction

Low Mean Inspiratory Pressure

Muscular etiology

(Residual Volume is increased)

Low RV

Parenchymal disease

High RV

Chest wall disease

slide162

Tachypnea + fine crackles + clubbing

With fever:

Hypersensitive Pneumonitis

X ray- Induced

Sarcoidosis

Eosinophilic Granuloma

Drug induced

BOOP

Without fever:

Pneumoconiosis

Rheumatoid Arthritis

Lymphangioleiomyomatosis

Alveolar Proteinosis

slide166

Check if the blood is from an artery (CO2=15+HCO3)

Calculate Anion Gap

(AG=Na – (Cl +HCO3)

Calculate if the response is compensatory or not

If there’s no significant AG (more than10-12), then it must be either RTA or GI loss. In GI loss this formula applies => Urinary Cl>Urinary Na +K

pneumonia treatment in pregnancy
Pneumonia treatment in pregnancy
  • Uncomlicated: erythromycin 500-1000 mg every 6 hours
  • Haemophilia:cefotaxime,ceftizoxime,

Cefuroxime

  • Penicilline resistance: levofloxacin
  • Influanza:amantadine 200 mg daily if begun within 48 hours of symptoms
  • Varicella:acyclovir iv 10 mg/kg every 8 hours
  • VZIG:within 96 hrs of exposure 125u/10kg im
slide169

Pneumonia

Community acquired

Hospital acquired

Low risk out patient

High risk out patient

No risk factor

Anaerobic

Staph

Psuedo.

Ceftriaxone

Clarithro. + Amoxiclav

Ceftriaxone + Aminoglycosides

Clarithro.

Ceftriaxone + Clinda

Ceftriaxone +

Vanco

slide170

Asthma

Adapted from:British guideline on the management of asthma in adults, The British Thoracic Society & Scottish Intercollegiate Guidelines Network Thorax 2008 May; 63 (Suppl 4) : 1-121 with permission

slide171

Definition of asthma

“A chronic inflammatory disorder of the airways … in susceptible individuals, inflammatory symptoms are usually associated with widespread but variable airflow obstruction and an increase in airway response to a variety of stimuli. Obstruction is often reversible, either spontaneously or with treatment.”

slide172

Symptoms (episodic/variable)

  • wheeze
  • shortness of breath
  • chest tightness
  • cough

Consider the diagnosis of asthma in patients with some or all of these features

slide173

Diagnosis of asthma in adults

  • Symptoms (episodic/variable)
  • wheeze
  • shortness of breath
  • chest tightness
  • cough
  • Signs
  • none (common)
  • wheeze – diffuse, bilateral, expiratory ( inspiratory)
  • tachypnea

Consider the diagnosis of asthma in patients with some or all of these features

slide174

Helpful additional information

  • personal/family history of asthma or atopy
  • history of worsening after aspirin/NSAID, blocker use
  • recognised triggers – pollens, dust, animals, exercise, viral infections, chemicals, irritants
  • pattern and severity of symptoms and exacerbations

Diagnosis of asthma in adults

  • Signs
  • none (common)
  • wheeze – diffuse, bilateral, expiratory ( inspiratory)
  • tachypnea

Consider the diagnosis of asthma in patients with some or all of these features

slide175

Objective measurements

  • >20% diurnal variation on 3 days ina week for 2 weeks on PEF diary
  • or FEV115% (and 200ml) increase after short acting ß2 agonist or steroid tablets
  • or FEV1 15% decrease after 6 minutes of running exercise
  • histamine or methacholine challenge in difficult cases

Diagnosis of asthma in adults

  • Symptoms (episodic/variable)
  • wheeze
  • shortness of breath
  • chest tightness
  • cough

Consider the diagnosis of asthma in patients with some or all of these features

  • Helpful additional information
  • personal/family history of asthma or atopy
  • history of worsening after aspirin/NSAID, blocker use
  • recognised triggers – pollens, dust, animals, exercise, viral infections, chemicals, irritants
  • pattern and severity of symptoms and exacerbations
slide177

Indications for referral ofadults with suspected asthma

  • Diagnosis unclear or in doubt
  • Unexpected clinical findings e.g. crackles, clubbing, cyanosis, heart failure
  • Spirometry or PEF measurements do not fit the clinical picture
  • Suspected occupational asthma
  • Persistent shortness of breath (not episodic, or without associated wheeze)
  • Unilateral or fixed wheeze
  • Stridor
  • Persistent chest pain or atypical features
  • Weight loss
  • Persistent cough and/or sputum production
  • Non-resolving pneumonia
slide184

Add inhaled long-acting 2 agonists rather than increasing the dose of inhaled steroids (above 800mcg/day in adults and 400mcg/day in children)

  • Step down therapy to lowest level consistent with maintained control
slide187
5 to 9 percent of pregnant women suffer from asthma
  • PGF2 alfa is contraindicated in asthmatic women/ LT inhibitors are contraindicated in pregnancy
  • Asthma is a risk factor for preeclampsia, preterm labor, LBW babies, and perinatal mortality
changes in respiratory system in pregnancy
Changes in respiratory system in pregnancy
  • Reduced FRC
  • PCO2 more than 35 is considered as abnormal (non pregnant state is 40 mmHg)
  • No change in PEF or FEV1
  • Stress dose of hydrocortisone (100 mg IV TDS) for those who receive systemic steroids
  • Fentanyl as narcotic
  • NVD is preferred- Epidural is a better choice than general anesthesia