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, 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 3

DiagnosisClinical 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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ManagementTreatment 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 careAn 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 pain. It is also advocated for operative delivery as it avoids the potential

complications of ventilating people with asthma -the use of β2-adrenergic antagonists for the treatment of

hypertension and the use of ergometrine or carboprost (prostaglandin F2a) for the management of postpartum haemorrhage. These drugs may cause bronchospasm and should be avoided or used with caution

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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 careBreastfeeding 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 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 careMidwifery, obstetric, dietetic, medical, nursing and

physiotherapy expertise are essential. -Specific assessment includes: pulmonary function testsarterial blood gases sputum culture liver function tests glucose tolerance test chest radiogramelectrocardiogram 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 CF-related diabetes, the risks of which increase with age and are more likely to be problematic in pregnancy

Intrapartum caremonitoring 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

air-borne 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 fevernight sweats, Haemoptysisdyspnoea 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 andan 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 .

ManagementIt 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 careFollowing 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 anti-tuberculous 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 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.