prevent recurrence Thoracoscopy
Thoracoscopy to Tube
prevent recurrence thoracostomy
Observation Stable pneumo Tube
PNEUMOTHORAX Unstable pneumo
and O2 < 15% thoracostomy
Thoracoscopy to Thoracoscopy
Figure 4.8 Acute management of pneumothorax.
with hypoventilation and hypoxia primarily during sleep.184
Miscellaneous respiratory disorders
These patients have negligible or absent ventilatory sensitivity
Tracheal stenosis to hypoxia and hypercapnia.185 If left untreated, chronic hypoxia
can lead to pulmonary hypertension and, eventually, cor pulmo-
Tracheal stenosis can be idiopathic or secondary to previous
nale. Although the etiology is unknown, there is considerable
trauma. In nonpregnant patients, signs of upper airway obstruc-
evidence to support a genetic mechanism.186,187 The diagnosis
tion are absent until 75% narrowing occurs. However, during
of CCHS is one of exclusion. Most patients require lifelong venti-
pregnancy, airway engorgement can increase the severity of pre-
existing tracheal stenosis.180 Parturients with uncorrected steno- latory support during sleep, while a few patients require such
support 24 hours a day. Options for ventilatory support include
sis will not tolerate the increased ventilatory demands of labor.
positive-pressure ventilation via tracheostomy, positive-pressure
Sutcliffe et al. described a patient with uncorrected tracheal ste-
ventilation via nasal or face mask, bilevel positive airway pressure
nosis who underwent uneventful C/S under regional anesthesia
(BiPAP), or diaphragmatic pacing.184
but died postpartum from airway obstruction.181
Endogenous progesterone levels are raised during pregnancy.
Management options for tracheal stenosis include balloon dila-
Although progesterone is a respiratory stimulant that increases
tion, tracheal stenting, laser excision, or tracheal resection with
reconstruction.182 Persistent obstruction despite the aforemen- central chemoreceptor sensitivity, no improvement in ventilatory
response to hypercapnia has been demonstrated during preg-
tioned interventional methods may warrant tracheostomy.
nancy.188 Of all the options for ventilatory support, diaphragmatic
Regional anesthesia avoids instrumentation of the trachea and
has been utilized for labor analgesia.180 Mask-inhalation induc- pacing has been used successfully during pregnancy, despite the
potential for diaphragmatic impairment from uterine growth.
tion with sevoflurane has been used for operative delivery in a
parturient with tracheal stenosis.183 However, parturients must be closely monitored with regular poly-
somnograms to assess the need for adjustments in pacer settings.
The use of epidural anesthesia for C/S has been described in
Congenital central hypoventilation syndrome
parturients with CCHS treated with diaphragmatic pacing. In such
patients, all central nervous system depressants must be avoided.
Congenital central hypoventilation syndrome (CCHS) stems
Furthermore, following C/S, incisional pain often prevents the use
from failure of autonomic control of breathing and manifests
of diaphragmatic pacing during which time BiPAP ventilation is
utilized until diaphragmatic pacing can be resumed.
Respiratory disorders in pregnancy have the potential to worsen
with the physiologic and hormonal stresses that occur. It is
Pulmonary lymphangioleiomyomatosis important for obstetric anesthesiologists to see these women
early in pregnancy and to review any special investigations that
Pulmonary lymphangioleiomyomatosis (LAM) is characterized
have been performed. Timely consultation with pulmonologists
by the hamartomatous proliferation of smooth muscle of the
and perinatologists is important in providing the best anesthetic
pulmonary bronchioles, arterioles, and lymphatic vessels result-
care to pregnant women with pulmonary disease.
ing in cystic degeneration of lung tissue with variable progressive
loss of pulmonary function.189 Rupture of peripheral lung cysts
can lead to pneumothorax, which is a common presenting fea-
ture.190 Disruption of pulmonary lymph drainage can lead to 1. Catanzarite, V., Willms, D., Wong, D. et al. Acute respiratory distress syn-
drome in pregnancy and the puerperium: causes, courses, and outcomes.
chylous pleural effusions. Extrathoracic manifestations include
Obstet. Gynecol. 2001; 97: 760â€“4.
chylous ascites; hepatic and renal angiomyolipomas; and uterine
2. Perry, K. G., Jr, Martin, R. W., Blake, P. G., Roberts, W. E. & Martin, J. N.,
leiomyomas.191,192 Jr. Maternal mortality associated with adult respiratory distress syndrome.
There is no curative treatment for this condition, although South. Med. J. 1998; 91: 441â€“4.
hormonal therapy appears promising.193 Supportive therapy 3. Mabie, W. C., Barton, J. R. & Sibai, B. M. Adult respiratory distress syndrome
in pregnancy. Am. J. Obstet. Gynecol. 1992; 167: 950â€“7.
includes standard treatments for obstructive lung disease and
4. Cole, D. E., Taylor, T. L., McCullough, D. M., Shoff, C. T. & Derdak, S.
pneumothorax. Advanced disease may require lung transplanta-
Acute respiratory distress syndrome in pregnancy. Crit. Care Med. 2005; 33:
tion.194 A small pneumothorax can be managed conservatively S269â€“78.
but there is the risk for recurrence. A large or symptomatic pneu- 5. Jenkins, T. M., Troiano, N. H., Graves, C. R., Baird, S. M. & Boehm, F. J.
Mechanical ventilation in an obstetric population: characteristics and
mothorax requires intercostal drainage followed by definitive
delivery rates. Am. J. Obstet. Gynecol. 2003; 188: 549â€“52.
therapy (see earlier).
6. Piantadosi, C. A. & Schwartz, D. A. The acute respiratory distress syndrome.
Epidural analgesia should be utilized during labor to minimize
Ann. Intern. Med. 2004; 141: 460â€“70.
fluctuations in intrathoracic pressure during painful contractions 7. Ware, L. B. & Matthay, M. A. The acute respiratory distress syndrome.
and to facilitate emergency C/S without the need for GA.189 N. Engl. J. Med. 2000; 342: 1334â€“49.
8. Bernard, G., Artigas, A., Brigham, K. L. et al. The American-European con-
Assisted vaginal delivery is preferable to avoid high intrapleural
sensus conference on ARDS: definitions, mechanisms, relevant outcomes,
pressures associated with pushing, especially in parturients with
and clinical trial coordination. Am. J. Respir. Crit. Care Med. 1994; 149:
a history of surgically untreated pneumothorax. Regional
anesthesia has been used successfully for C/S in parturients 9. Marini, J. J. & Gattinoni, L. Ventilatory management of acute respiratory
with LAM.189 General anesthesia has been used for emergency distress syndrome: a consensus of two. Crit. Care Med. 2004; 32: 250â€“5.
10. Artigas, A., Benard, G. R., Carlet, J. et al. The American-European consensus
C/S and in these situations it is advisable to avoid nitrous oxide.
conference on ARDS, part 2. Ventilatory, pharmacologic, supportive ther-
apy, study design strategies, and issues related to recovery and remodeling.
Interstitial lung disease Acute Respiratory Distress Syndrome. Am. J. Respir. Crit. Care Med. 1998;
Interstitial lung disease (ILD) is characterized by varying degrees 11. Anonymous. Ventilation with lower tidal volumes as compared with tradi-
tional tidal volumes for acute lung injury and the acute respiratory distress
of inflammation and fibrosis resulting in loss of alveolar-capillary
syndrome. The Acute Respiratory Distress Syndrome Network. N. Engl. J.
units and lung volumes, with subsequent development of chronic
Med. 2000; 342: 1301â€“8.
hypoxemia and pulmonary hypertension. A variety of disorders
12. Taylor, R. W., Zimmerman, J. L., Dellinger, R. P. et al. Inhaled nitric oxide in
can result in ILD and these include idiopathic pulmonary fibrosis, ARDS study group: low-dose inhaled nitric oxide in patients with acute lung
sarcoidosis, hypersensitivity pneumonitis, drug-induced alveoli- injury: a randomized controlled trial. J.A.M.A. 2004; 291: 1603â€“9.
tis, and connective tissue disorders.195 During pregnancy, basal 13. Dellinger, R. P., Zimmerman, J. L., Taylor, R. W. et al. Effects of inhaled nitric
oxide in patients with acute respiratory distress syndrome: results of a
atelectasis from the elevated diaphragm and increased O2
randomized phase II trial. Crit. Care Med. 1998; 26: 15â€“23.
consumption increase V/Q mismatching and can worsen
14. Bugge, J. F. & Tanbo, T. Nitric oxide in the treatment of fulminant pulmon-
hypoxemia. ary failure in a young pregnant woman with varicella pneumonia. Eur. J.
Management of parturients with ILD includes baseline pul- Anaesthesiol. 2000; 17: 269â€“72.
15. Adhikari, N. & Granton, J. T. Inhaled nitric oxide for acute lung injury: no
monary function testing; careful monitoring; and aggressive
place for NO? J.A.M.A. 2004; 291: 1629â€“31.
treatment of underlying disease and superimposed infections.
16. Spragg, R. G., Lewis, J. F., Walmrath, H. D. et al. Effect of recombinant
Central hemodynamic monitoring should be reserved to optimize
surfactant protein C-based surfactant on the acute respiratory distress
fluid management and to monitor cardiac function in those with syndrome. N. Engl. J. Med. 2004; 351: 884â€“92.
significant pulmonary hypertension and for those with severe 17. Anzueto, A., Baughman, R. P., Guntupalli, K. K. et al. Aerosolized surfactant
in adults with sepsis-induced acute respiratory distress syndrome. Exosurf
hypoxemia. Anesthetic management should emphasize pain
Acute Respiratory Distress Syndrome Sepsis Study Group. N. Engl. J. Med.
management in order to reduce O2 consumption, and this is
1996; 334: 1417â€“21.
achieved with neuraxial anesthesia. Neuraxial anesthesia has
18. Abraham, E., Baughman, R., Fletcher, E. et al. Liposomal prostaglandin E1
been used successfully for labor analgesia and C/S in women (TLC C-53) in acute respiratory distress syndrome: a controlled, rando-
with ILD.195 General anesthesia can be associated with prolonged mized, double-blind, multicenter clinical trial. TLC C-53 ARDS Study
Group. Crit. Care Med. 1999; 27: 1478â€“85.
postoperative mechanical ventilation.
1 Cardiovascular and respiratory disorders
19. Zeiher, B. G., Artigas, A., Vincent, J. L. et al. Neutrophil elastase inhibition in 43. Lehrer, S., Stone, J., Lapinski, R. et al. Association between pregnancy
acute lung injury: results of the STRIVE study. Crit. Care Med. 2004; 32: induced hypertension and asthma during pregnancy. Am. J. Obstet.
1695â€“1702. Gynecol. 1993; 168: 1463â€“6.
20. Weidemann, H. P., Fisher, C. J., Jr, Komara, J. et al. Ketoconazole for early 44. Perlow, J. H., Montgomery, D., Morgan, M. A. et al. Severity of asthma and
treatment of acute lung injury and acute respiratory distress syndrome: a perinatal outcome. Am. J. Obstet. Gynecol. 1992; 167: 963â€“7.
randomized controlled trial. The ARDS Network. J.A.M.A. 2000; 283: 45. Shapiro, D. S. & Owen, C. A. ADAM-33 surfaces as an asthma gene. N. Engl.
1995â€“2002. J. Med. 2002; 347: 936â€“8.
21. Bernard, G. R., Wheeler, A. P., Russell, J. A. et al. The effects of ibuprofen on 46. Tattersfield, A. E., Knox, A. J., Britton, J. R. et al. Asthma. Lancet 2002; 360:
the physiology and survival of patients with sepsis. The Ibuprofen in Sepsis 1313â€“22.
Study Group. N. Engl. J. Med. 1997; 336: 912â€“18. 47. Nelson-Piercy, C. Asthma in pregnancy. Thorax 2001; 56: 325â€“8.
22. Bernard, G. R., Wheeler, A. P., Arons, M. M. et al. A trial of antioxidants N- 48. Schatz, M. The efficacy and safety of asthma medications during preg-
acetylcysteine and procysteine in ARDS. The Antioxidant in ARDS Study nancy. Semin. Perinatol. 2001; 25: 145â€“52.
Group. Chest 1997; 112: 164â€“72. 49. Gluck, P. A. & Gluck, J. C. A review of pregnancy outcome after exposure to
23. Weidemann, H. P., Arrliga, A. C., Komara, J. et al. Randomized, placebo- orally inhaled or intranasal budesonide. Curr. Med. Opin. 2005; 21: 1075â€“84.
controlled trial of lisofylline for early treatment of acute lung injury and 50. Rhen, T. & Cidlowski, J. A. Anti-inflammatory action of glucocorticoids â€“
acute respiratory distress syndrome. The ARDS Clinical Trials Network. new mechanisms for old drugs. N. Engl. J. Med. 2005; 353: 1711â€“23.
Crit. Care Med. 2002; 30: 1â€“6. 51. National Asthma Education and Prevention Program Expert Panel Report 2:
24. Meduri, G. U., Headley, S., Golden, E. et al. Effect of prolonged methylpred- Guidelines for the diagnosis and management of asthma. NHLBI, NIH
nisolone therapy in unresolving acute respiratory distress syndrome. Publication No. 97â€“4051, April 1997.
A randomized controlled trial. J.A.M.A. 1998; 280: 159â€“65. 52. Dombrowski, M. P., Schatz, M., Wise, R. et al. Randomized trial of inhaled
25. Cunningham, J. A., Devine, P. C. & Jelic, S. Extracorporeal membrane oxy- beclomethasone diproprionate versus theophylline for moderate asthma
genation in pregnancy. Obstet. Gynecol. 2006; 108: 792â€“5. during pregnancy. Am. J. Obstet. Gynecol. 2004; 190: 737â€“44.
26. Schultz, M. J., De Jonge, E. & Kesecioglu, J. Selective decontamination of the 53. Ducharme, F. M. Anti-leukotrienes as add-on therapy to inhaled glucocor-
digestive tract reduces mortality in critically ill patients. Critical Care 2003; ticoids in patients with asthma: systematic review of current evidence.
7: 107â€“10. B.M.J. 2002; 324: 1545â€“63.
27. Catanzarite, V. A. & Willms, D. Adult respiratory distress syndrome in 54. National Heart, Lung and Blood Institute: Report of the Working Group on
pregnancy :report of three cases and review of the literature. Obstet. Asthma and Pregnancy: Executive Summary: Management of Asthma
Gynecol. Surv. 1997; 52: 381â€“92. During Pregnancy. National Asthma Education Program: NIH publication
28. Chen, C-Y., Chen, P., Wang, K-G., Kuo, S-C. & Su, T-H. Factors implicated in 93â€“3279 A, March 1993.
the outcome of pregnancies complicated by acute respiratory failure. 55. Wendel, P. J., Ramin, S. M., Hamm, C. B. et al. Asthma treatment in preg-
J. Reprod. Med. 2003; 48: 641â€“8. nancy: a randomized controlled study. Am. J. Obstet. Gynecol. 1996; 175:
29. Sosin, D., Krasnow, J., Moawad, A. & Hall, J. B. Successful spontaneous 150â€“4.
vaginal delivery during mechanical ventilatory support for the adult 56. Braman, S. S. & Kaemmerlen, J. T. Intensive care of status asthmaticus. A 10-
respiratory distress syndrome. Obstet. Gynecol. 1986; 68: S19â€“23. year experience. J.A.M.A. 1990; 264: 366â€“8.
30. Daily, W. H., Katz, A. R., Tonnesen, A. & Allen, S. T. Beneficial effect of 57. Hirshman, C. A., Kriegler, W., Littlejohn, G., Lee, R. & Julien, R. Ketamine-
delivery in a patient with adult respiratory distress syndrome. aminophylline-induced decrease in seizure threshold. Anesthesiology 1982;
Anesthesiology, 1990; 72: 383â€“6. 56: 464â€“7.
31. Kaufman, B. S., Kaminsky, S. J., Rackow, E. C. & Weil, M. H. Adult respiratory 58. Pizov, R., Brown, R. H., Weiss, Y. S. et al. Wheezing during induction of
distress syndrome following orogenital sex during pregnancy. Crit. Care general anesthesia in patients with and without asthma. Anesthesiology
Med. 1987; 15: 703â€“4. 1995; 82: 1111â€“16.
32. Ackerman, W. E., 3rd, Molnar, J. M. & Juneja, M. M. Beneficial effect of 59. Hagerdal, M., Morgan, C. W., Sumner, A. E. et al. Minute ventilation and
epidural anesthesia on oxygen consumption in a parturient with adult oxygen consumption during labor with epidural analgesia. Anesthesiology
respiratory distress syndrome. South. Med. J. 1993; 86: 361â€“4. 1983; 59: 425â€“7.
33. Kwon, H. L., Belanger, K. & Bracken, M. B. Asthma prevalence among preg- 60. Younker, D., Clark, R., Tessem, J. et al. Bupivacaine-fentanyl epidural
nant and childbearing-aged women in the United States. Estimates from analgesia for a parturient in status asthmaticus. Can. J. Anaesth. 1987; 34:
national health surveys. Ann. Epidemiol. 2003; 13: 317â€“24. 609â€“12.
34. Stenius-Aarniala, B., Piirila, P. & Teramo, K. Asthma and pregnancy: a 61. Collis, R. E., Baxandall, M. L., Srikantharajah, I. D. et al. Combined spinal
prospective study of 198 pregnancies. Thorax 1988; 43: 12â€“18. epidural (CSE) analgesia: technique, management and outcome of 300
35. Dombrowski, M. P. Asthma in pregnancy. Obstet. Gynecol. 2006; 108: mothers. Int. J. Obstet. Anesth. 1994; 3: 75â€“81.
667â€“81. 62. Mallampati, S. R. Bronchospasm during spinal anesthesia. Anesth. Analg.
36. Clark, S. L. Asthma in pregnancy. Obstet. Gynecol. 1993; 82: 1036â€“40. 1981; 60: 839â€“40.
37. Schatz, M., Dombrowski, M. P., Wise, R. et al. Asthma morbidity during 63. Greenberger, P. A. & Patterson, R. Management of asthma during preg-
pregnancy can be predicted by severity classification. J. Allergy Clin. nancy. N. Engl. J. Med. 1985; 312: 897â€“902.
Immunol. 2003; 112: 283â€“8. 64. Piggott, S. E., Bogod, D. G., Rosen, M. et al. Isoflurane with either 100%
38. Mabie, W. C., Barton, J. R., Wasserstrum, N. & Sibai B. M. Clinical oxygen or 50% nitrous oxide in oxygen for Caesarean section. Br. J.
observations on asthma in pregnancy. Obstet. Gynecol. Surv. 1992; Anaesth. 1990; 65: 325â€“9.
47: 464â€“6. 65. Rooke, A., Choi, J. H. & Bishop, M. J. The effect of isoflurane, halothane,
39. Moore-Gillon, J. C. Pregnancy and the asthmatic (Editorial). Respir. Med. sevoflurane, and thiopental/nitrous oxide on respiratory resistance after
1991; 85: 451â€“2. tracheal intubation. Anesthesiology 1997; 86; 1294â€“9.
40. Dombrowski, M. P. Outcomes of pregnancy in asthmatic women. Immunol. 66. Hankins, G. D., Berryman, G. K., Scott, R. T. et al. Maternal arterial desatura-
Allergy Clin. North Am. 2006; 26: 81â€“92. tion with 15-methyl prostaglandin F2 alpha for uterine atony. Obstet.
41. Bracken, M. B., Triche, E. W., Belanger, K. et al. Asthma symptoms, severity, Gynecol. 1988; 72: 367â€“70.
and drug therapy: a prospective study of effects on 2205 pregnancies. 67. Chang, J., Elam-Evans, L. D., Berg. C. J. et al. Pregnancy-related mortality
Obstet. Gynecol. 2003; 102: 739â€“52. surveillance â€“ United States, 1991â€“1999. M.M.W.R. 2003; 52 (SSâ€“2); 4.
42. Triche, E. W., Saftlas, A. F., Belanger, K., Leaderer, B. P. & Bracken, M. B. 68. James, A. H., Jamison, M. G., Brancazio, L. R. & Myers, E. R. Venous throm-
Association of asthma diagnosis, severity, symptoms, and treatment with boembolism during pregnancy and the postpartum period: incidence, risk
risk of preeclampsia. Obstet. Gynecol. 2004; 104: 585â€“93. factors, and mortality. Am. J. Obstet. Gynecol. 2006; 194: 1311â€“15.
69. Melis, F., Vandenbrouke, J. P., Buller, H. R. et al. Estimates of risk of venous 94. Jones, T. K., Barnes, R. W. & Greenfield, J. Greenfield vena caval
thrombosis during pregnancy and puerperium are not influenced by diag- filter: rationale and current indications. Ann. Thoracic 1986; 42: S48â€“55.
nostic suspicion and referral basis. Am. J. Obstet. Gynecol. 2004; 191: 825â€“9. 95. Kawamata, K., Chiba, Y., Tanaka, R., Higashi, M. & Nishigami, K.
70. Polak, J. F. & Wilkinson, D. L. Ultrasonographic diagnosis of symptomatic Experience of temporary inferior vena cava filters inserted in the perinatal
deep venous thrombosis in pregnancy. Am. J. Obstet. Gynecol. 1991; 165: period to prevent pulmonary embolism in pregnant women with deep
625â€“9. vein thrombosis. J. Vasc. Surg. 2005; 41: 652â€“6.
71. Gherman, R. B., Goodwin, T. M., Leung, B. et al. Incidence, clinical char- 96. Declos, G. L. & Davila, F. Thrombolytic therapy for pulmonary embolism in
acteristics, and timing of objectively diagnosed venous thromboembolism pregnancy: a case report. Am. J. Obstet. Gynecol. 1986; 155: 375â€“6.
during pregnancy. Obstet. Gynecol. 1999; 94: 730â€“4. 97. Fagher, B., Ahlgren, M. & Astedt, B. Acute massive pulmonary embolism
72. Refuzero, J. S., Hechtman, J. L., Redman, M. E. & Whitty, J. E. Venous throm- treated with streptokinase during labor and the early puerperium. Acta
boembolism during pregnancy: clinical suspicion warrants evaluation. J. Obstet. Gynecol. Scand. 1990; 69: 659â€“61.
Reprod. Med. 2003; 49; 767â€“70. 98. Kramer, W. B., Belfort, M., Saade, G. R., Surani, S. & Moise, K. J., Jr.
73. Lewis, G., Drife, J., Bolting, B. et al. (eds). Why Mothers Die 1997â€“1999 The Successful urokinase treatment of massive pulmonary embolism in preg-
Confidential Enquiries into Maternal Deaths in the United Kingdom. nancy. Obstet. Gynecol. 1995; 86: 660â€“2.
London: R.C.O.G. Press, 2001. 99. Flossdorf, T., Breulmann, M. & Hopf, H. B. Successful treatment of massive
74. Jacob, S., Bloebaum, L., Shah, G. & Varner, M. W. Maternal mortality in pulmonary embolism with recombinant tissue type plasminogen activator
Utah. Obstet. Gynecol. 1998; 91: 187â€“91. (rt-PA) in a pregnant woman with intact gravidity and preterm labour.
75. Stirling, Y., Woolf, L., North, W. R. S. et al. Haemostasis in normal preg- Intensive Care Med. 1990; 16: 454â€“6.
nancy. Thromb. Haemost. 1984; 52: 176â€“82. 100. Wulf, H. Epidural anaesthesia and spinal haematoma. Can. J. Anaesth.
76. Norris, L. A., Sheppard, B. L. & Bonnar, J. Increased whole blood platelet 1996; 43: 1260â€“71.
aggregation in normal pregnancy can be prevented in vitro by aspirin and 101. Harik, J., Raichle, M. E. & Reis, D. J. Spontaneously remitting spinal epi-
dazmergel (UK 38485). Br. J. Obstet. Gynaecol. 1992; 99: 253â€“7. dural hematoma in a patient on anticoagulants. N. Engl. J. Med. 1971; 284:
77. Friederich, P. W., Sanson, B. J., Simioni, P. et al. Frequency of pregnancy- 1355â€“7.
related venous thrombembolism in anticoagulant factor-deficient women: 102. Horlocker, T. T., Wedel, D. J., Benzon, H. et al. Regional anesthesia in the
implications for prophylaxis. Ann. Intern. Med. 1996; 125: 955â€“60. anticoagulated patient: defining the risks. (The second ASRA Consensus
78. Nelson, S. M. & Greer, I. A. Thrombophilia and the risk for venous throm- Conference on Neuraxial Anesthesia and Anticoagulation). Reg. Anesth.
boembolism during pregnancy, delivery and the puerperium. Obstet. Pain Med. 2003; 28: 172â€“97.
Gynecol. Clin. North Am. 2006; 33: 413â€“27. 103. Handler, J. S. & Bromage, P. R. Venous air embolism during cesarean
79. Greer, I. A. Prevention and management of venous thromboembolism in delivery. Reg. Anesth. 1990; 15: 170â€“3.
pregnancy. Clin. Chest Med. 2003; 24: 123â€“37. 104. Fong, J., Gadalla, F. & Druzin, M. Venous emboli occurring during
80. Chan, W. S. & Ginsberg, J. S. Diagnosis of deep vein thrombosis and pul- cesarean section: the effect of patient position. Can. J. Anaesth. 1991;
monary embolism in pregnancy. Thromb. Res. 2003; 107: 85â€“91. 38: 191â€“5.
81. American College of Obstetricians and Gynecologists: Prevention of deep vein 105. Karuparthy, V. R., Downing, J. W., Husain, F. J. et al. Incidence of venous
thrombosis and pulmonary embolism. October 2001; Practice Bulletin No. 21. air embolism during cesarean section is unchanged by the use of a 5â€“10
82. Davis, J. D. Prevention, diagnosis, and treatment of venous thromboem- head-up tilt. Anesth. Analg. 1989; 69: 620â€“3.
bolic complications of gynecologic surgery. Am. J. Obstet. Gynecol. 2001; 106. Gronert, G. A., Messick, J. M., Cucchiara, R. F. & Michenfelder, J. D.
184: 759â€“75. Paradoxical air embolism from a patent foramen ovale. Anesthesiology
83. Chunilal, S. D. & Ginsberg, J. S. Advances in the diagnosis of venous throm- 1979; 50: 548â€“9.
boembolism â€“ a multimodal approach. J. Thromb. Thrombolysis 2001; 12: 107. Hill, B. F. & Jones, J. S. Venous air embolism following orogenital sex
53â€“7. during pregnancy. Am. J. Emerg. Med. 1993; 11: 155â€“7.
84. Kearon, C. Diagnosis of pulmonary embolism. C.M.A.J. 2003; 168: 183â€“94. 108. Younker, D., Rodriguez, V. & Kavanagh, J. Massive air embolism during
85. The PIOPED Investigators: Value of the ventilation/perfusion scan in acute cesarean section. Anesthesiology 1986; 65: 77â€“9.
pulmonary embolism: Results of the Prospective Investigation of 109. Gei, A. F., Vadhera, R. B. & Hankins, G. D. Embolism during pregnancy:
Pulmonary Embolism Diagnosis (PIOPED). J.A.M.A. 1990; 263: 2753â€“9. thrombus, air and amniotic fluid. Anesthesiol. Clin. North America 2003;
86. Winer-Muram, H. T., Boone, J. M., Brown, H. L. et al. Pulmonary embolism 21: 165â€“82.
in pregnant patients: fetal radiation dose with helical CT. Radiology 2002; 110. Peters, S. G. Mediastinal air-fluid level and respiratory failure. Chest 1988;
224: 487â€“92. 94: 1063â€“4.
87. Rosenberg, J. M., Lefor, A. T., Kenien, G., Marrosti, M. & Obeid, A. 111. Clark, S. L. New concepts of amniotic fluid embolism: a review. Obstet.
Echocardiographic diagnosis and surgical treatment of postpartum pul- Gynecol. Surv. 1990; 45: 360â€“8.
monary embolism. Ann. Thoracic Surg. 1990; 49: 667â€“9. 112. Clark, S. L, Hankins, G. D. V., Dudley, D. A., Dildy, G. A. & Porter, T. F.
88. Meaney, J. F., Weg, J. G., Chenevert, T. L. et al. Diagnosis of pulmonary Amniotic fluid embolism: analysis of the national registry. Am. J. Obstet.
embolism with magnetic resonance angiography. N. Engl. J. Med. 1997; Gynecol. 1995; 172: 1158â€“67.
336: 1422â€“7. 113. Malhotra, P., Agarwal, R., Awasthi, A. et al. Delayed presentation of amnio-
89. Bates, S. M. & Ginsberg, J. S. How we manage venous thromboembolism tic fluid embolism: lessons from a case diagnosed at autopsy. Respirology
during pregnancy. Blood 2002; 100: 3470â€“8. 2007; 12: 148â€“50.
90. Hunt, B. J., Doughty, H. A., Majumdar, G. et al. Thromboprophylaxis with 114. Reis, R. L., Pierce, W. S. & Behrendt, D. M. Hemodynamic effects of amnio-
low molecular-weight heparin (Fragmin) in high risk pregnancies. Thromb. tic fluid embolism. Surg. Gynecol. Obstet. 1969; 129: 45â€“8.
Haemost. 1997; 77: 39â€“43. 115. Bellar, F. K., Douglas, G. W., Debrovner, C. H. & Robinson, R. The fibrino-
91. Dolovich, L. R., Ginsberg, J. S., Dpiletos, J. D., Holbrook, A. & Cheah, G. A lytic system in amniotic fluid embolism. Am. J. Obstet. Gynecol. 1963; 87:
meta-analysis comparing low-molecular-weight heparins with unfraction- 48â€“55.
ated heparin in the treatment of venous thromboembolism. Arch. Intern. 116. Moore, J. & Baldisseri, M. R. Amniotic fluid embolism. Crit. Care Med.
Med. 2000; 160: 181â€“8. 2005; 33: S279â€“85
92. Greer, I. A. Anticoagulants in pregnancy. J. Thromb. Thrombolysis 2006; 21: 117. Oâ€™shea, A. & Eappen, S. Amniotic fluid embolism. Int. Anesthesiol. Clin.
57â€“65. 2007; 45: 17â€“28.
93. Sephton, V., Farquharson, R. G., Topping, J. et al. A longitudinal study of 118. Cromey, M. G., Taylor, P. J. & Cumming, D. C. Probable amniotic fluid
maternal dose response to low molecular weight heparin in pregnancy. embolism after first trimester pregnancy termination. J. Reprod. Med.
Obstet. Gynecol. 2003; 101: 1307â€“11. 1983; 28: 209â€“11.
1 Cardiovascular and respiratory disorders
119. Mallory, G. K., Blackburn, N., Sparling, J. & Nickerson, D. A. Maternal 144. Dray, X., Bienvenu, T., Desmazes-Dufeu, N. et al. Distal intestinal obstruc-
pulmonary embolism by amniotic fluid. Report of three cases and discus- tion syndrome in adults with cystic fibrosis. Clin. Gastroenterol. Hepatol.
sion of the literature. N. Engl. J. Med. 1950; 243: 583â€“7. 2004; 2: 498â€“503.
120. Kanayama, N., Yamazaki, T., Naruse, H. et al. Determining zinc copropor- 145. Van der Schans, C., Prasad, A. & Main, E. Chest physiotherapy compared to
phyrin in maternal plasma â€“ a new method for diagnosing amniotic fluid no chest physiotherapy for cystic fibrosis. Cochrane Database Syst. Rev.
embolism. Clin. Chem. 1992; 38: 526â€“9. 2000; 2: CD001401.
121. Kobayashi, H., Ohi, H. & Terao, T. A simple, noninvasive, sensitive method 146. Cropp, G. J. Effectiveness of bronchodilators in cystic fibrosis. Am. J. Med.
for diagnosis of amniotic fluid embolism by monoclonal antibody TKH-2 1996; 100: S19â€“29.
that recognizes NeuAc alpha 2â€“6 GalNAc. Am. J. Obstet. Gynecol. 1993; 168: 147. Ramsey, B. W., Pepe, M. S., Quan, J. M. et al. Intermittent administration of
848â€“53. inhaled tobramycin in patients with cystic fibrosis. N. Engl. J. Med. 1999;
122. Esposito, R. A., Grossi, E. A., Coppa, G. et al. Successful treatment of post- 340: 23â€“30.
partum shock caused by amniotic fluid embolism with cardiopulmonary 148. Breen, L. & Aswani, N. Elective versus symptomatic intravenous anti-
bypass and pulmonary artery thromboembolectomy. Am. J. Obstet. biotic therapy for cystic fibrosis. Cochrane Database Syst. Rev. 2001; 4:
Gynecol. 1990; 163: 572â€“4. CD002767.
123. Weksler, N., Ovadia, L., Stav, A., Luchtman, M. & Ribac, L. Continuous 149. Fuchs, H. J., Borowitz, D. S., Christiansen, D. H. et al. Effect of aerosolized
arteriovenous hemofiltration in the treatment of amniotic fluid embolism. recombinant human DNase on exacerbations of respiratory symptoms
Int. J. Obstet. Anesth. 1994; 3: 92â€“6. and on pulmonary function in patients with cystic fibrosis. The
124. Sprung, J., Cheng, E. Y., Patel, S. & Kampine, J. P. Understanding and Pulmozyme Study Group. N. Engl. J. Med. 1994; 331: 637â€“42.
management of amniotic fluid embolism. J. Clin. Anesth. 1992; 4: 235â€“40. 150. Hubbard, R. C., McElvaney, N. G., Birrer, P. et al. A preliminary study of
125. Lindeque, B. G., Schoeman, H.S, Dommisse, G. F., Boeyens, M. C. & Vlok, aerosolized recombinant human deoxyribonuclease I in the treatment of
A. L. Fat embolism and the fat embolism syndrome. A double-blind ther- cystic fibrosis. N. Engl. J. Med. 1992; 326: 812â€“15.
apeutic study. J. Bone Joint Surg. 1987; 69: 128â€“31. 151. Yankaskas, J. R. & Mallory, G. B., Jr. Lung transplantation in cystic fibrosis:
126. Riska, E. B. & Myllynen, P. Fat embolism in patients with multiple injuries. consensus conference statement. Chest 1998; 113: 217â€“26.
J. Trauma 1982; 22: 891â€“4. 152. Shennib, H., Adoumie, R. & Noirclerc, M. Current status of lung transplan-
127. ten Duis, H. J., Nijsten, M. W., Klasen, J. H. & Binnendijk, B. Fat embolism tation for cystic fibrosis. Arch. Intern. Med. 1992; 152: 1585â€“8.
in patients with an isolated fracture of the femoral shaft. J. Trauma 1988; 153. Gyi, K. M., Hodson, M. E. & Yacoub, M. Y. Pregnancy in cystic fibrosis
28: 383â€“90. lung transplant recipients: case series and review. J. Cyst. Fibros. 2006;
128. Lozman, J., Deno, C., Feustel, P. J. et al. Pulmonary and cardiovascular 5: 171â€“5.
consequences of immediate fixation or conservative management of long- 154. Rosenfeld, M. A. & Collins, F. S. Gene therapy for cystic fibrosis. Chest 1996;
bone fractures. Arch. Surg. 1986; 121: 992â€“9. 109: 241â€“52.
129. Jones, M. B. Pulmonary fat emboli associated with acute fatty liver of 155. Ackerman, M. J. & Clapham, D. E. Ion channels: basic science and clinical
pregnancy. Am. J. Gastroenterol. 1993; 88: 791â€“2. disease. N. Engl. J. Med. 1997; 336: 1575â€“86.
130. Han, D., Lee, K. S., Franquet, T. et al. Thrombotic and nonthrombotic 156. Caplen, N. J., Alton, E. W., Middleton, P. G. et al. Liposome-mediated CFTR
pulmonary arterial embolism: spectrum of image findings. Radiographics gene transfer to the nasal epithelium of patients with cystic fibrosis.
2003; 23: 1521â€“39. Nature Medicine 1995; 1: 39â€“46.
131. Caplan, L. M., Miller, S. M. & Patel, K. P. Fat embolism. In: Caplan, L. M. & 157. Cohen, L. F., di Santâ€™Agnese, P. A. & Friedlander, J. Cystic fibrosis and
Miller, S. M. (eds.), Anesthesiology Clinics of North America, Embolism II. pregnancy. A national survey. Lancet 1980; 2: 842â€“4.
Volume II, Number I. New York: W. B. Saunders Co., 1993; pp. 25â€“54. 158. McMullen, D. H., Pasta, D. J., Frederick, P. D. et al. Impact of pregnancy on
132. Dauphin-McKenzie, M., Gilles, J. M., Jacques, E. & Harrington, T. Sickle women with cystic fibrosis. Chest 2006; 129: 706â€“11.
cell anemia in the female patient. Obstet. Gynecol. Surv. 2006; 61: 343â€“52. 159. Geddes, D. M. Cystic fibrosis and pregnancy. J. R. Soc. Med. 1992; 85:
133. Esseltine, D. W., Baxter, M. R. N. & Bevan, J. C. Sickle cell states and the S36â€“7.
anaesthetist. Can. J. Anaesth. 1988; 35: 385â€“403. 160. Odegaard, I., Stray-Pedersen, B., Hallberg, K. et al. Maternal and fetal
134. Dunn, A., Davies, A., Eckert, G. et al. Intraoperative death during morbidity in pregnancies of Norwegian and Swedish women with cystic
Caesarean section in a patient with a sickle-cell trait. Can. J. Anaesth. fibrosis. Acta Obstet. Gynecol. Scand. 2002; 81: 698â€“705.
1987; 34: 67â€“70. 161. Gillet, D., De Braekeleer, M., Bellis, G. & Durieu, L. Cystic fibrosis and
135. American College of Obstetricians and Gynecologists. Preconception and pregnancy. Report from French data (1980â€“1999). Br. J. Obstet. Gynaecol.
prenatal carrier screening for cystic fibrosis. Clinical and laboratory guide- 2002; 109: 912â€“18.
lines. Washington, DC, 2001. 162. Gilljam, M., Antoniou, M., Shin, J. et al. Pregnancy in cystic fibrosis. Fetal
136. Kotloff, R. M., FitzSimmons, S. C. & Fiel, S. B. Fertility and pregnancy in and maternal outcome. Chest 2000; 118: 85â€“91.
patients with cystic fibrosis. Clin. Chest Med. 1992; 13: 623â€“35. 163. Edenborough, F. P., Mackenzie, W. E. & Stableforth, D. E. The outcome of 72
137. Riordan, J. R., Rommens, J. M., Kerem, B. S. et al. Identification of the cystic pregnancies in 55 women with cystic fibrosis in the United Kingdom
fibrosis gene: cloning and characterization of complementary DNA. 1977â€“1996. Br. J. Obstet. Gynaecol. 2000; 107: 254â€“61.
Science 1989; 245: 1066â€“73. 164. Edenborough, F. P., Stableforth, D. E., Webb, A. K., Mackenzie, W. E. &
138. Rommens, J. M., Iannuzzi, M. C., Kerem, B. S. et al. Identification of the Smith, D. L. Outcome of pregnancy in cystic fibrosis. Thorax 1995; 50:
cystic fibrosis gene: chromosome walking and jumping. Science 1989; 245: 170â€“4.
1059â€“65. 165. Hardin, D. S., Rice, J., Cohen, R. C., Ellis, K. J. & Nick, J. A. The metabolic
139. Ratjen, F. & Doring, G. Cystic fibrosis. Lancet 2003; 361: 681â€“9. effects of pregnancy in cystic fibrosis. Obstet. Gynecol. 2005; 106; 367â€“75.
140. Anonymous. Correlation between genotype and phenotype in patients 166. Hyde, N. H. & Harrison, D. M. Intrathecal morphine in a parturient with
with cystic fibrosis. The Cystic Fibrosis Genotypeâ€“Phenotype Consortium. cystic fibrosis. Anesth. Analg. 1986; 65: 1357â€“8.
N. Engl. J. Med. 1993; 329: 1308â€“13. 167. Howell, P. R., Kent, N. & Douglas, M. J. Anaesthesia for the parturient with
141. McKone, E. F., Emerson, S. S., Edwards, K. L. & Aitken, M. L. Effect of cystic fibrosis. Int. J. Obstet. Anesth. 1993; 2: 152â€“8.
genotype on phenotype and mortality in cystic fibrosis: a retrospective 168. Novy, M. J., Tyler, J. M., Shwachman, H., Easterday, C. L. & Reid D. E. Cystic
cohort study. Lancet 2003; 361: 1671â€“6. fibrosis and pregnancy. Report of a case with a study of pulmonary function
142. Mickle, J. E. & Cutting, G. R. Genotypeâ€“phenotype relationships in cystic and arterial blood gases. Obstet. Gynecol. 1967; 30: 530â€“6.
fibrosis. Med. Clin. North Am. 2000; 84: 597â€“607. 169. Deshpande, S. Epidural analgesia for vaginal delivery in a patient with
143. Chaun, H. Colonic disorders in adult cystic fibrosis. Can. J. Gastroenterol. cystic fibrosis following double lung transplantation. Int. J. Obstet. Anesth.
2001; 15: 586â€“90. 1998; 7: 42â€“5.