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Dyspnea and wheezing in a pregnant patient

Case Editor - Judd Flesch

Reviewed By Allergy, Immunology & Inflammation Assembly

Submitted by

Brent P. Riscili, MD

Fellow

Pulmonary and Critical Care Medicine

The Ohio State University Medical Center

Columbus, Ohio

Jennifer W. McCallister, MD

Assistant Professor of Internal Medicine

Division of Pulmonary, Allergy, Critical Care and Sleep Medicine

The Ohio State University Medical Center

Columbus, Ohio

Submit your comments to the author(s).

History

A 30-year-old G2P1 pregnant woman at 15 weeks gestation presents to an outpatient clinic with worsening dyspnea over the preceding two weeks.   Her past medical history is significant for asthma diagnosed in childhood, seasonal allergies, and gastroesophageal reflux disease (GERD) during her previous pregnancy.  She notes that her asthma symptoms had been well-controlled on inhaled fluticasone/salmeterol (250mcg/50mcg), albuterol HFA as needed, and a nasal steroid spray prior to pregnancy.  However, she discontinued all of her medications when she learned that she was pregnant for fear that they might harm her baby.

The patient works in sales and has not used tobacco since college.  She is allergic to cats and dust mites, but currently has no pets in her home.  She has no additional medical history other than that described above. 

At today’s visit she feels that she is unable to take a deep breath.  She also describes one to two episodes of wheezing daily and night time cough two to three times per week.  Warm air, dust, and exposure to cats seem to exacerbate her symptoms.

Physical Exam

On physical exam, the patient is in no acute distress.   There is erythema of the nares bilaterally with clear rhinorrhea and cobble-stoning of the posterior pharynx.  The lungs are clear to auscultation bilaterally.  Heart sounds are normal without audible murmurs, gallops, or rubs.  The abdomen is gravid and consistent with the patient’s current gestational age.  There is trace edema of the lower extremities but no clubbing or cyanosis.

Lab

Spirometry from approximately one year prior to the visit reveals the following:
Pre-bronchodilator forced vital capacity (FVC) 5.11 L (116% predicted), forced expiratory volume in one second (FEV1) 3.12 L (84% predicted), FEV1/FVC 0.61.  Post-bronchodilator FVC 5.16 L (1% change), FEV1 3.99 L (27% change), and FEV1/FVC 0.77.

Figures


Classifying asthma severity

Stepwise approach to therapy for asthma

Question 1

Based on the history and objective data provided, what is the most likely cause of the patient’s symptoms?


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