A 26-year-old woman, gravida 1 para 0, at 20 weeks gestation comes to the office due to a nonproductive cough, chest tightness, and shortness of breath for a month. The symptoms occur a few times a week, mostly at night, and have occasionally awakened the patient. They have recently been bothersome during the day. They are not worse during meals or while lying down. The patient is asymptomatic during her visit. Medical history is significant for asthma in middle school, but she has not experienced symptoms or needed an inhaler since her late teenage years. The patient has no known environmental or drug allergies. She has never used tobacco and has not been exposed to secondhand smoke. Blood pressure is 118/70 mm Hg and pulse is 74/min. Fetal heart rate is 152/min. The oropharynx is clear. Chest auscultation reveals normal breath sounds. The uterine fundus is palpable at the umbilicus, consistent with 20 weeks gestation. Which of the following is the most likely diagnosis in this patient?

Question

A 26-year-old woman, gravida 1 para 0, at 20 weeks gestation comes to the office due to a nonproductive cough, chest tightness, and shortness of breath for a month.  The symptoms occur a few times a week, mostly at night, and have occasionally awakened the patient.  They have recently been bothersome during the day.  They are not worse during meals or while lying down.  The patient is asymptomatic during her visit.  Medical history is significant for asthma in middle school, but she has not experienced symptoms or needed an inhaler since her late teenage years.  The patient has no known environmental or drug allergies.  She has never used tobacco and has not been exposed to secondhand smoke.  Blood pressure is 118/70 mm Hg and pulse is 74/min.  Fetal heart rate is 152/min.  The oropharynx is clear.  Chest auscultation reveals normal breath sounds.  The uterine fundus is palpable at the umbilicus, consistent with 20 weeks gestation.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_da98_da94_bc81_57c49853b8d3_MD0003_00 This patient's intermittent cough, chest tightness, and shortness of breath, worse at night, are hallmark symptoms of asthma. Asthma is the most common pulmonary disorder encountered during pregnancy; roughly one-third of cases improve, one-third are stable, and one-third worsen. Patients with a history of severe or poorly controlled asthma are prone to developing unstable disease during pregnancy, typically worsening in the second trimester. The immunologic and endocrine changes during pregnancy can also rekindle previously resolved childhood asthma. Asthma presents similarly in pregnant and nonpregnant patients (eg, cough, wheezing, dyspnea, chest tightness). Symptoms are typically intermittent and may be exacerbated by weather changes (especially cold), allergens, infections, or exercise. They usually worsen at night, potentially due to circadian hormonal variation (eg, low epinephrine and glucocorticoid signaling causing reduced anti-inflammatory effects) or to environmental factors (eg, dust mites or pet hair in mattress). Wheezing may be absent outside of acute attacks. Asthma control is essential for avoiding maternal and fetal complications (eg, preterm delivery, low birth weight, antenatal hypoxia). Most therapies are safe and generally involve inhaled, short-acting beta agonists (eg, albuterol) for acute symptoms. Inhaled corticosteroids are required daily for persistent asthma. Oral corticosteroids (eg, prednisone) may be required for acute exacerbations. Gestational asthma can be confused with dyspnea of pregnancy, a common physiologic cause of shortness of breath (air hunger) likely due to progesterone-induced stimulation of the medullary respiratory center. Although it worsens during the second trimester, dyspnea of pregnancy is persistent, rather than intermittent, and not associated with diurnal variation. It would not explain this patient's cough and chest tightness (Choice C). (Choice A) Acute bronchitis, a self-limiting (eg, <2 wk) illness, presents with cough and chest tightness both day and night and rhonchi on examination. (Choice D) Gastroesophageal reflux disease, which may mimic or exacerbate asthma, usually causes chest discomfort/burning, and symptoms are typically associated with eating and are worse while lying down. (Choice E) Pregnancy increases the risk for pulmonary embolism (eg, chest tightness, dyspnea), but an acute and a persistent, rather than a chronic and an intermittent, presentation of respiratory symptoms is expected. Educational objective: Presentation of asthma, similar in pregnant and nonpregnant patients, includes intermittent cough, wheezing, shortness of breath, and chest tightness that all worsen with physical activity. Adequate control (eg, inhaled corticosteroid) is recommended to prevent maternal and fetal complications. References: Asthma outcomes and management during pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/28867295)

A 26-Year-Old Woman, Gravida 1 Para 0, at 20 Weeks