Transcript الشريحة 1

 Prevalence is increasing mainly due to
 environmental factors such as: change in indoor
environment, smoking, family size, pollution and diet.
 Effect of asthma on pregnancy
 -some women experience no change in symptoms
whereas others have worsening of the disease.
 - The mechanisms that contribute to the varying changes
in asthma during pregnancy are not well understood,
although
 increases in maternal circulating hormones (cortisol,
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oestradiol and progesterone),
altered β2-adrenoreceptor responsiveness
and immune function
or the presence of a female fetus may be involved
-When asthma is well controlled maternal and fetal outcomes
are similar to those in women without asthma. –
-Women with severe disease and those who have poor control
of asthma seem to have an increased incidence of adverse
maternal and neonatal outcomes including preterm labour
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Diagnosis
 Clinical picture :
 chest tightness, dyspnoea, wheezing and coughing.
Measuring peak expiratory flow (PEF) using a PEF
meter is a useful tool for making a diagnosis and
determining how well a person's asthma is controlled
 PEF monitors the level of resistance in the airways
caused by inflammation or bronchospasm, or both
and values are lower than predicted in people with
asthma. A range of normal values can be predicted for
each person according to sex, height and age
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 . Knowledge of the usual PEF and self-monitoring at
home will enable a person with asthma to determine
when to take or increase their medication and when to
seek medical attention.
 Hospital admission is usually required if the PEF is
<50% of the normal value and the person is too
breathless to complete sentences.
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Management
 Treatment relies on inhaled bronchodilators and
inhaled steroids with or without oral steroids.
 Nebulized drugs are given during acute attacks of
asthma.
 Antenatal care
 -Care should ideally be provided jointly between the
midwife, GP, chest physician and obstetrician
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 At the booking interview the midwife should be able
to discuss with the woman the frequency and severity
of her asthma, family history, any known asthma
triggers and current treatment.
 -The main anxiety for women and those providing care
relates to the use of asthma medication and its effect
on the fetus.
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 -In general, the medications used in the treatment of
asthma, including systemic steroids, are considered safe to
use in pregnancy
 It is crucial that therapy is maintained during pregnancy
as a severe asthma attack may result in a deterioration in
the maternal condition and a reduction in the oxygen
supply to the fetus.
 Respiratory tract infections should be diagnosed and
treated promptly in order to prevent an acute asthma
attack.
If during the pregnancy there are any difficulties in 
controlling the symptoms of asthma the woman should be
admitted to hospital
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Intrapartum care
 An increase in cortisone and adrenaline (epinephrine)
from the adrenal glands during labour is thought to
prevent attacks of asthma during labour
 If an asthma attack does occur this should be treated
in the usual way. Women should continue their usual
asthma medications during labour and it is important
that they remain well hydrated.
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 Maternal and fetal condition should be monitored
closely,
 namely:
 respiratory function,
 pulse oximetry,
 oxygen therapy
 and continuous fetal heart rate monitoring.
 All forms of pain relief may be used although regional
anaesthesia
 reduces hyperventilation and the stress response to
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pain.
 Oxytocin and prostaglandin E2 are safe to use for the
induction of labour
 Women who have received corticosteroids in
pregnancy (>7.5 mg prednisolone/day for >2 weeks
prior to the onset of labour) should receive parenteral
hydrocortisone 100 mg 6–8-hourly during labour
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 Postnatal care
 Breastfeeding should be encouraged,
 particularly as it may protect infants from developing
certain allergic conditions.
 - None of the drugs used in the treatment of asthma is
likely to be secreted in breast milk in sufficient
quantities to harm the baby
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 Cystic fibrosis
 -Cystic fibrosis (CF)
 -is an autosomal recessive
 -multi-system disorder
 - People with CF develop chronic obstructive lung disease
decreased oxygen saturation)
 -Obstruction of the pancreatic ducts leads to a loss of
acinar cells and replacement by fibrous tissue and fat.
 - Loss of pancreatic function causes poor digestion,
malnutrition and the development of type 1 diabetes.
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 - fertility may be slightly reduced, because of alteration in the
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chemical make-up of the cervical mucus,
-pregnancies are possible.
Pre-pregnancy care
-if the partner is a carrier there is a one in two chance that their
children will have CF.
-Specific changes in respiratory, cardiac and pancreatic function
as well as increased nutritional demands during pregnancy
increase health risk for many women with CF and should be
assessed prior to pregnancy
 Antenatal care
 Midwifery, obstetric, dietetic, medical, nursing and
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physiotherapy expertise are essential.
-Specific assessment includes:
pulmonary function tests
arterial blood gases
sputum culture
liver function tests
glucose tolerance test
chest radiogram
electrocardiogram
echocardiogram
and monitoring of weight gain.
 -antibiotic therapy is essential to manage a severe lung
infection.
 it is important to pay attention to nutrition and CFrelated diabetes, the risks of which increase with age
and are more likely to be problematic in pregnancy
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Intrapartum care
monitoring of cardio respiratory function
an anesthetist should be involved
Fluid and electrolyte management requires careful
attention to avoid hypovolaemic from the loss of large
quantities of sodium in sweat.
 Epidural analgesia is the recommended to relief labor
pain
 general anaesthesia should be avoided because of the
potential risks from respiratory complications
 Postnatal care
 -cardio respiratory function often deteriorates
following birth ,so careful care is need
 -Sodium concentration in breast milk has been found
to be similar to women without CF and therefore
breastfeeding is permitted.
 - well nourished and maintain an adequate calorie
intake is important point of breast feeding
 -it is recommended that universal neonatal testing is
undertaken as part of screening programme
Pulmonary tuberculosis:
 (TB) is an air-borne infectious disease
 caused by the tubercule bacillus, Mycobacterium
tuberculosis.
 It is transmitted through inhalation of infected airborne droplets from a person with infectious TB.
 Comes from infected cattle through the consumption
of milk and dairy products that have not been
pasteurized. -The lungs are the organ most commonly
affected (pulmonary TB)
 although it may spread to bones, joints and the
lymphatic, genitourinary and central nervous system
(extra pulmonary TB).
 The primary healthcare workers including midwives
are among the first to be involved in the prevention,
screening and treatment of TB
 factors leading to the increasing incidence of this
disease include
 (1) women and children who have immigrated from
areas where TB is endemic, principally South-Asia and
African countries
 (2) the development of drug-resistant organisms
 (3) increases in adults and children who have become
infected with HIV .
 social factors such as poverty,
 homelessness,
 substance misuse,
 poor nutrition
 crowded living conditions
 TB is primarily a disease of poverty and almost all
cases are preventable.
 Diagnosis
 -TB is often gradual symptoms and non-specific:
 -fatigue, malaise, loss of appetite
 loss of weight,
 alteration in bowel habit
 low grade fever.
 These symptoms like usual symptoms occurring in
pregnancy leading to a delay in diagnosis
 The classic symptoms :
 chronic cough
 intermittent fever
 night sweats,
 Haemoptysis
 dyspnoea
 and chest pain occur quite late in the disease process
and are often absent when the TB is extra pulmonary.
 Early diagnosis;
 increase awareness about TB in the immigrant
population and in the community,
 provide access to medical care
 The presence of risk factors requires assessment
 the Mantoux tuberculin skin test and
 an interferon-γ (secreted by lymphocytes in the
presence of antigens to TB) test.
 history and physical examination should also be
undertaken.
 A positive tuberculin test should be further evaluated
with a chest X-ray, abdominal shielding for this
procedure keeps fetal exposure to a minimum.
 Microscopic examination and culture of sputum are to
confirm active mycobacterial infection and identify
drug sensitivity
 Once active TB has been diagnosed, the need for
 1-contact tracing must be assessed
 2- testing and treatment of asymptomatic household
and other close contacts in order to prevent spread of
the disease .
Management
 It is important that is to ensure that the woman is
involved in treatment decisions and adheres to the
prescribed treatment.
 -maternal morbidity and mortality are significantly
higher where active TB remains untreated and when
treatment is started late in pregnancy.
 -neonates of women with TB have a higher risk of:
 * prematurity
 * perinatal death
 *low birth weight.
 -Standard anti-tuberculous therapy is considered safe
in pregnancy
 TB is treated in two phases:
 @ The first involves taking rifampicin, isoniazid
(INH), pyrazinamide and ethambutol daily for 2
months.
 @ In the second (continuation) phase, rifampicin and
isoniazid are taken for a further 4 months
 -Congenital deafness has been reported in infants with
exposure to streptomycin in utero and therefore this
anti-tuberculous drug is avoided in pregnancy.
 Role of midwife :
 -ensure that women are compliant with the drug
therapy
 -woman understand the importance of adhering to the
regimen in order to cure the disease
 -prevent the bacillus becoming resistant to the drugs.
 - a monthly review will be sufficient to monitor
progress
 -rest, good nutrition and education with regard to
preventing the spread of the disease.
 - TB usually becomes non-infectious by 2 weeks of
treatment.
 the treatment is given at the woman's home
 Some women may require admission to hospital
because of
 1- the severity of the illness
 2- adverse effects of drug therapy
 -3-obstetric reasons such as the onset of labor
 4- social reasons
 5-further investigations.
 Risk assessment should be made in order to determine
appropriate infection control measures.
 -the person with TB is cured.
 -In a small number of people, the disease can return if
not all bacteria have been killed.
 This is more likely to occur where:
 - there is poor/no compliance with drug treatment
 -where there is multi-drug resistant (MDR) TB.
 Postnatal care
 Following birth, babies born to mothers with
infectious TB should be protected from the disease by:
 - the prophylactic use of isoniazid syrup (5 mg/kg per
day) -pyridoxine (5–10 mg/day) for 6 weeks and then
to be tuberculin tested.
 -If negative, the neonatal Bacille Calmette–Guérin
(BCG) vaccination should be given and drug therapy
discontinued
 If the tuberculin test is positive the baby should be
assessed for congenital or perinatal infection and drug
therapy continued
 - The baby cannot be infected by the mother via the
breast milk unless she has tuberculous mastitis.
 -add to that , the concentration of the antituberculous drugs in breast milk is insufficient to
cause harm in the neonate
 - the majority of cases breastfeeding should be encouraged .
 -Midwives should explain that poor nutrition, stress and
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overtiredness will encourage a recurrence of active disease.
- for a woman with TB to avoid further pregnancies until she has
been disease-free for at least 2 years.
- the woman needs to be aware that rifampicin reduces the
effectiveness of oral contraception
-Long-term medical and social follow-up is necessary.
-The outcome for both mother and baby is improved by early
diagnosis and effective treatment.