Asthma in pregnancy
BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39112.717674.BE (Published 15 March 2007) Cite this as: BMJ 2007;334:582All rapid responses
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests