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PRACTICE: Evelyne Rey and Louis-Philippe Boulet Asthma in pregnancy BMJ 2007; 334: 582-585 [Full text]

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peripartum coronary artery disseaction has the potential to be "the great impersonator" in the differential diagnosis of peripartum acute dyspnoea

oscar,m jolobe   (17 March 2007)

Mitral stenosis can also cause wheezing during pregnancy

oscar,m jolobe   (18 March 2007)

Asthma in labour

Michael de Swiet   (21 March 2007)

New & Appropriate terminology

Zubair Rauf   (23 March 2007)

peripartum coronary artery disseaction has the potential to be "the great impersonator" in the differential diagnosis of peripartum acute dyspnoea 17 March 2007
oscar,m jolobe, retired geriatrician 1 The Lodge, 842 Wilmslow Road, Didsbury, Manchester, M20 2RN Send response to journal: Re: peripartum coronary artery disseaction has the potential to be "the great impersonator" in the differential diagnosis of peripartum acute dyspnoea	Given the fact that myocardial infarction(MI) can be atypical, not only in its symptomatology(1), but also in its electrocardiographic manifestations(2), when this diagnosis is attributable to peripartum coronary artery dissection(3)(4)(5) it has the potential to be one of the great impersonators in the differential diagnosis of peripartum asthma, left ventricular failure, and pulmonary embolism(these three featured in Box 3)(6).Coronary artery dissection can occur, not only during pregnancy, sometimes as early as the 9th week(3) or as late as the 36th week(4), but also as late as 4 months post partum(5).Symptoms can range from typical retrosternal pain in the absence of commonly recognised risk factors for coronary artery disease(3), to non-specific recent-onset "diaphoresis, dyspnea, and tingling substernal discomfort"(4) reminiscent, for example, of pulmonary embolism. Recognistion is important because treatmnet options are highly specific and include angioplasty and intracoronary stent placement(5) References (1) Panju AA., Hemmelgarn BR., Guyatt GH., Simel DL Is this patient having a myocardial infarction? JAMA 1998:280:1256-63 (2) Welch RD., Zalenski RJ., Frederick PD et al Prognostic value of a normal or non-specific initial electrocardiogram in acute myocardial infarction JAMA 2001:286:1977-84 (3) Kearney P., Singh H., Hutter J et al Spontaneous coronary artery dissection: a report of three cases and review of the literature Postgrad Med J 1993:69:940-5 (4) McKechnie RS., Patel D., Eitzman DT., Rajagopalan S., Murthy TH Spontaneous coronary artery dissection in a preganant woman Obstet Gynecol 2001:98:899-902 (5) De Maio SJ., Kinsella SH., Silverman ME Clinical course and lomg-term prognosis of spontaneous coronary artery dissection Am J Cardiol 1986:64:471-4 (6)Rey E., Boulet L-P Asthma in pregnancy BMJ 2007:334:582-5 Competing interests: None declared
Mitral stenosis can also cause wheezing during pregnancy 18 March 2007
oscar,m jolobe, retired geriatrician 1 The Lodge, 842 Wilmslow Road, didsbury,manchester, M20 2RN Send response to journal: Re: Mitral stenosis can also cause wheezing during pregnancy	Symptomatic mitral stenosis for which female sex is a predisposing factor(1) remains one of the one of the "prime suspects" in the differential diagnosis outlined by the authors(2,)when a distinction has to be made between "allergic" asthma and "cardiac" asthma during episodes of bronchitis complicating mitral stenosis(1). Bronchial hyperreactivity is a feature common to allergic asthma and mitral stenosis, and, as in allergic asthma, bronchial hyperrectivity associated with mitral stenosis can be ameliorated by inhaled corticosteroids(3). Furthermore, given the fact that patients with cardiac asthma respond favourably to inhaled bronhodilators(4), the same can be expected to occur when this complication occurs in mitral stenosis. Diagnostic confusion between allergic and cardiac asthma is compounded by the fact that, in certain circumstances, the murmur of mitral stenosis can become softer(1)(5), thereby making it more difficult to elicit in the presence of wheezing. The answer to that problem is to go back and elicit the murmur using the recommended clinical manouvres(5), between episodes of wheezing in all patients at risk of mitral stnosis. References (1) Braunwald E Valvular heart disease Chapter 237 in Harrison's Principles of Internal Medicine14th edition 1998 Editors Fauci AS., Braunwald E., Isselbacher KJ et al McGraw Hill Health Professions Division New York St Louis San Francisco (2)Rey E., Boulet L-P Asthma in Pregnancy BMJ 2007:334:582-5 (3) Cieslewicz G., Juszczyk G., Foremny J et al Inhaled corticosteroid improves bronchial hyperreactivity and decreases symptoms in patients with mitral stenosis CHEST 1998:114:1070-4 (4)Plotz M Bronchial spasm in cardiac asthma Ann Intern Med 1947:26:521-5 (5) Schrire V Rheumatic fever and rheumatic heart disease:Mitral Stenosis Chapter 10 Clinical Cardiology Third edition 1971 Editor Schrire V Staples Press London Competing interests: None declared
Asthma in labour 21 March 2007
Michael de Swiet, emeritus professor of obstetric medicine retired Send response to journal: Re: Asthma in labour	I am delighted that BMJ is running a series on obstetric medicine and enjoyed reading the article by Rey and Boulet. However I was concerned to read that 10%-20% of women experience an exacerbation of asthma during labour.In 40 years practice as an obstetric physician,I never saw an attck of asthma in labour; and nor have other obstetricians and respiratory physicians that I have questioned at conferences. I wonder if any of the BMJ's readers have personal experience of managing asthma attacks in labour? This is importantant because women with asthma are very frightened of not being able to cope with asthma at delivery. Up to now I have reassured patients that this is very unlikely to be a problem Competing interests: None declared
New & Appropriate terminology 23 March 2007
Zubair Rauf, ST-1 Obs & Gynae Noble Hospital Isle Of Man Send response to journal: Re: New & Appropriate terminology	''Asthma In Pregnancy'' is a very well presented article. The term ''abortion'' has been used in Box 5 ''Procedures and Medications during labour.'' I would just like to impress on the need of using relevant and appropriate terminologies as per latest guidelines. The recommended medical term for pregnancy loss under 24 weeks is miscarriage as per new guidelines(1),(2)and it is preferable to use these new terms. References: 1.Royal College Of Obstetricians and Gynaecologists: The Management Of Early Pregnancy Loss.Guideline No. 25. London. RCOG (2006) 2.Farquharson RG, Jauniaux E, Exalto N; ESHRE Special Interest Group for Early Pregnancy (SIGEP). Updated and revised nomenclature for description of early pregnancy events. Hum Reprod. 2005 Nov;20(11):3008- 11. Competing interests: None declared