a cough, breathlessness, and chest tightness that began 4 weeks ago

[unseennude]

A 26-year-old woman is being evaluated for symptoms of a cough, breathlessness, and chest tightness that began 4 weeks ago. She is 18 weeks' gestation of her first pregnancy. The patient reports a history of respiratory difficulties in childhood that improved during adolescence. Physical examination reveals mild congestion of the nasal mucosa, normal breath sounds, no wheezes or crackles, normal heart sounds, and no murmur. Spirometry shows her forced expiratory volume in 1 second (FEV1) to be 2.4 L/s and her forced expiratory capacity (FVC) to be 3.6 L. After 2 puffs of albuterol, FEV1 and FVC increase to 2.8 L/s and 3.8 L, respectively.
What is the diagnosis? Which medication will give her the best likelihood for a good perinatal outcome?
Hint:Approximately 30% of women with this pregnancy-related condition improve during term.

[Oak]

I guess its Asthma, as there is a childhood history of similar episode and FEV improvement after taking albuterol on spirometry.

Supportive, patient education and symptomatic treatment might improve this condition. Drugs like B2 agonist, inhalled corticosteroid will be helpful.

[de.malady]

having history of respiratory difficulties in childhood and the present chief complaints of cough, breathlessness, chest tightness, significance of -salbuterol- suggests, it must be a case of -Asthma-; ;

short-acting B2 antagonists are needed [ salbutamol];
high concentration o2 therapy may also be useful in her case;
if condition does not improve, oral corticosteriods should be given [prednisolone];
she should visit her doctor frequently for review of medications and necessary teachings to prevent any incident
regarding her pregnancy..

[unseennude]

Yeh! thats correct! its a case of Asthma.

Asthma in pregnancy: This patient has possibly had a remote history of mild asthma, but she now has worsening of asthma in pregnancy. Her symptoms are nonspecific; however, spirometry demonstrates reversible moderate airflow obstruction, as evidenced by a 16% improvement in FEV1 with albuterol. Asthma is diagnosed on the basis of the patient^s symptoms and spirometric findings. Among patients with asthma, the severity worsens in 20-35% of pregnant patients, remains stable in 40-50%, and improves in 30%.

Asthma is a chronic inflammatory disease of the airways and is associated with airway constriction; airway edema; mucus plugging; and infiltration with eosinophils, neutrophils, and lymphocytes. Leukotrienes, histamine, and cytokines trigger and mediate the airway inflammation via multiple pathways.

Asthma is a complication in 5% of pregnancies. Untreated, asthma in pregnancy has high rates of perinatal complications, such as perinatal fetal loss, premature labor, preeclampsia, and low birth weight. Pregnant patients may present with atypical asthma symptoms, which can be mistaken for symptoms of typical pregnancy-associated dyspnea. Physical examination may be unreliable in patients with asthma; therefore, an objective spirometric assessment should be performed to confirm asthma and to assess the response to therapy. In severe asthma attacks, the fetal heart rate should also be measured. A proactive approach to the management of asthma improves perinatal outcomes for the mother and the baby. Treatment goals in pregnant patients with asthma are symptom resolution and optimization of FEV1 or peak expiratory flow rate (PEFR). Close follow-up during pregnancy and the postpartum period should be arranged. A treatment summary is outlined in the image above.

The treatment of asthma depends on its severity, as reflected by the symptoms, use of reliever medications, and spirometric results. Supportive measures include appropriate asthma education and avoidance of allergens, tobacco smoke, and other irritants. Prompt pharmacotherapy should be directed toward symptom relief and control of airway inflammation. Short-acting b-agonists, such as albuterol, are prescribed on an as-needed basis; the mainstay therapy is anti-inflammatory medication.

Inhaled steroids are known to interrupt the inflammatory pathway by blocking the synthesis of mediators such as cytokines and leukotrienes. Several studies have documented the efficacy of inhaled steroids in pregnancy; reductions in asthma exacerbations and improved perinatal outcomes are reported. For pregnant asthma patients not treated with inhaled steroids, neonatal birth weights are 25% less than those of neonates born to treated patients.

The inhaled steroids currently available are beclomethasone, triamcinolone, budesonide, flunisolide, and fluticasone. Safety data are not available for all the inhaled steroids; however, budesonide is the only medication that is in pregnancy category B (ie, no evidence of risk in humans).

Patients whose asthma is still uncontrolled after moderate-to-high doses of inhaled steroids may also require a long-acting b-agonist (eg, salmeterol, formoterol), leukotriene receptor antagonists, or theophylline. The last 2 are also in pregnancy category B. Systemic corticosteroids are used for acute exacerbations or at low doses for severe asthma unresponsive to other measures. Finally, all patients must be given a written asthma action plan, and co-care with an internist, family physician, or pulmonologist is a requisite.