pulmonary function, and increases the risk of re- current attacks. The choice of medications is based on both the severity and persistence of symptoms.
The main categories of asthma drugs for long-term maintenance include (1) inhaled or systemic corti- costeroids (e.g., Vanceril, Flovent, prednisone), (2) cromolyn sodium (Intal) and nedocromil (Tilade), (3) long-acting beta2-agonists (e.g., Serevent), (4) methylxanthines such as theophylline, and leukotriene modifiers (e.g., Singulair). In addition to short-acting inhaled beta2-agonists, anticholiner- gics such as ipratropium bromide, or short courses of oral corticosteroids may offer relief [40]. The National Heart, Lung, and Blood Institute Web site (www.nhlbi.nih.gov) provides access to the most current guidelines on asthma management. In gen- eral, newly diagnosed asthma should be evaluated in consultation with or by referral to a physician ex- perienced in respiratory care.
During pregnancy, asthma symptoms may worsen as the lung space is compressed by the growing fetus. Women with moderate to severe asthma and recent exacerbations should be referred to a physician for evaluation. Liu and colleagues re- ported an increase in adverse pregnancy outcomes related to maternal asthma, including preterm labor and birth, preterm premature rupture of mem- branes (PPROM), and hypertensive disorders of pregnancy [42]. However, they could not identify severity of disease or level of asthma control in their retrospective cohort. Thus it is not clear that well- managed asthma with minimal exacerbations would have the same effect on pregnancy outcome.
If a woman’s condition is stable and she is not ex- periencing any limitations in physical activity, there is no reason why she should not receive prenatal care and give birth with a midwife.
Gastrointestinal Disorders and Abdominal
major contributing organisms, diagnostic criteria, and management [44]. E. coliis the most common cause of traveler’s diarrhea. These bacteria may cause symptoms either as a result of toxin release or by directly attacking the bowel wall. With mild bac- terial gastrointestinal infections, fever is less likely to be present than with viral diseases. As with the viral causes of diarrhea, symptomatic measures will usually suffice when the cause is bacterial. The use of antibiotics in the treatment of diarrhea should be reserved for culture-proven or severe disease that is clearly bacterial in nature.
Constipation
Straining to produce hard stools, infrequent bowel movements (fewer than once in three days), and painful defecation are characteristic of constipa- tion. Initial questioning of women with these com- plaints should include an assessment of their
“usual” bowel function. Among healthy women, inadequate dietary fiber, possibly decreased fluid in- take, and iron therapy for anemia (whether real or simply suspected by the woman) are common causes. Other medications, such as tricyclic antide- pressants (e.g., Elavil), anticholinergics (e.g., Atrovent), and calcium channel blockers (e.g., Cardizem and Verapamil), may slow peristalsis and increase stool transit time, leading to constipation.
Misuse of laxatives, leading to decreased natural stimulation of the bowel, is also common, more so among the elderly. More serious causes range from neurological dysfunction to abuse of opiates. Stress, anxiety, and depression may lead to changes in bowel habits, as would abnormalities of the bowel and functional problems such as irritable bowel syndrome. A careful history and physical assess- ment of women with any chronic bowel changes is necessary to rule out serious underlying disease that would require a medical referral [45].
Management of chronic constipation in healthy women includes counseling about diet and exercise, and an increase in fluid intake. Avoidance of strain- ing, and recognizing the physical cues that indicate the need to defecate, are included in teaching.
Women should also be counseled to stop the over- use of laxatives, cathartics, and enemas. If any med- ication is necessary during early treatment, a bulk-forming over-the-counter drug such as Metamucil should be used; however, adding fiber to the diet is a better strategy since it promotes a pat- tern of healthy eating to maintain normal function.
If symptom relief is not obtained with the above
measures, a trial of laxatives such as docusate sodium (Colace) is in order before referring the woman to a physician.
Irritable Bowel Syndrome
Irritable bowel syndrome (IBS) consists of lower gastrointestinal tract complaints of increased bloat- ing, diarrhea, and/or constipation in the absence of any structural or biochemical cause. It is chronic in nature, and one of the most common presenting complaints in primary care practice. The current definition (Rome II) includes onset associated with changes in the frequency or composition of the stool and pain relief with defecation, persisting over 12 weeks within the last year. To meet the diagnos- tic criteria, the symptoms need not be continuous.
Intermittent symptoms totaling 12 weeks are con- sidered significant. Increased or decreased stool fre- quency, abnormal stool formation (either hard or watery), bloating, difficulty in the passage of stool (straining, urgency, or failure to completely empty the bowel), and mucus in the stool are further con- firmation of the diagnosis [46]. The onset of IBS usually occurs during the young adult years; be- cause organic causes of bowel changes are more common with increasing age, a new diagnosis should be made with care in adults over 40.
Assessment includes evaluation for bowel obstruc- tion, including malignancies, and for gastrointesti- nal bleeding. Irritable bowel syndrome should not be confused with inflammatory bowel diseases such as Crohn’s disease and ulcerative colitis, which are chronic, recurrent inflammations of the bowel. The relationship of symptom relief to having a bowel movement is strongly suggestive of IBS.
Care plans may include short-term use of ther- apy for diarrhea or constipation, but their chronic use should be avoided. Some women will complain of food allergies or conditions such as lactose intol- erance. Most food allergies present as acute upset, not as chronic bowel changes. If a patient has se- verely restricted her dietary intake, adding foods back into the diet may improve general health and nutrition as well as symptoms.
There is a strong psychosocial component to seeking care for IBS, although the symptoms are common among adults who do not seek care. Thus, an important step in managing care for individuals with this complaint is building a trusting relation- ship. Education about IBS, reassurance about the course and management possibilities, and dietary modification are important in helping women man-
age their symptoms effectively [47]. Because of the strong likelihood of underlying psychological dis- tress among patients with IBS, a careful assessment for anxiety disorders and depression is warranted.
Considerations in managing this aspect of the dis- ease include the use of antidepressants, particularly the selective serotonin reuptake inhibitors (SSRIs) such as Prozac or Zoloft, psychotherapy, and sup- portive behavioral therapy [48].
Gastroesophageal Reflux Disease
Gastroesophageal reflux disease (GERD), a condi- tion affecting up to one in five adults, produces symptoms of heartburn that worsen with meals, bending over, and lying down. Other less easily rec- ognizable symptoms include an asthmalike wheeze, cough, laryngitis, and chest pain. Persistent severe disease may produce complications such as injury to the epithelium of the esophagus (Barrett’s esoph- agus) and stricture formation [49].
Therapy for GERD includes weight reduction, maintaining a diet high in protein and low in fat, and the avoidance of triggers such as caffeine, tobacco, and spicy or acidic foods. Remaining upright after meals will help prevent symptoms. If reflux is occur- ring primarily at night, elevating the head while in bed will also help avoid discomfort. If these measures do not relieve symptoms, the use of antacids will bring short-term relief, while H2 receptor antago- nists such as cimetidine (Tagamet), famotidine (Pepcid), ranitidine (Zantac), and nizatidine (Axid) will relieve symptoms for longer periods. Proton pump inhibitors can be used for persistent problems.
They include prescription drugs such as omeprazole (Prilosec), esomeprazole (Nexium), and lansoprazole (Prevacid). (See Table 7-12 for common regimens.)
Midwives whose patients fail a trial of H2 re- ceptor antagonists should obtain consultation from a physician, to assess the need for endoscopy or possible fundoplication of the stomach [49].
Comparison of surgical outcomes with medical management has been shown to improve quality of life in severe cases, or when the patient is not satis- fied with the results of medication therapy [50].
Treatment to eliminate Helicobacter pylorihas also been demonstrated to have a beneficial effect on the course of GERD [51]. GERD is a common cause of chronic cough, due to reflux into the esophagus or larynx triggering a cough reflex, or to aspiration of refluxed stomach contents into the respiratory tract. Cough may be the only symptom of GERD, in which case treatment for GERD will relieve a cough not otherwise responsive to therapy [52].
Ulcers
Peptic ulcers are open lesions of the stomach or duodenum, penetrating through the mucosa into muscle. Common causes are excessive use of non- steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or aspirin, and H. pyloriinfection, a condition responsible for 80 to 90 percent of all gastric and duodenal ulceration. It is more common among the elderly, persons of lower socioeconomic status, and Black and Hispanic ethnic groups; how- ever, most persons who are colonized with H. pylori do not suffer from ulcers [53].
Endoscopy with collection of biopsy samples for histology is the most accurate technique for di- agnosis as well as assessment of lesions for cancer risk. Culture for H. pylori is an additional useful tool in areas where antibiotic resistance is becoming a serious problem, in order to utilize the most ef- Medications for the Management of Gastroesophageal Reflux Disease (GERD)
TABLE 7-12
Medication Dose Duration of Therapy FDA Pregnancy Category
H2 Receptor Antagonists
Cimetidine (Tagamet) 400 mg po QID or 12 weeks B
800 mg po BID
Famotidine (Pepcid) 20 mg po BID 6 weeks B
Nizatidine (Axid) 150 mg po BID 12 weeks B
Ranitidine (Zantac) 150 mg po BID 12 weeks B
Proton Pump Inhibitors
Esomeprazole (Nexium) 20 mg po QD 4 weeks B
20 mg po QD maintenance
Iansoprazole (Prevacid) 15 mg po QD 8 weeks B
Omeprazole (Prilosec) 20 mg po QD 4-8 weeks C
fective therapy first. Noninvasive testing methods such as serology and urea breath tests are most ap- propriate in symptomatic, healthy adults at low risk for stomach cancer. However, urea breath tests are more expensive and less widely available, and thus are more commonly used only to confirm the erad- ication of infection [54, 55].
Counseling about avoiding aspirin and NSAIDs, stress reduction, and smoking cessation are all useful interventions in conjunction with medication for the management of ulcers. Alone, they will not resolve the disease. Midwives should consult with or refer to a physician if considering the management of peptic ulcers. First-line drug therapy for peptic ulcer disease begins with re- moval of the H. pylorifrom the stomach and duo- denum with aggressive antibiotic therapy, usually with more than one antibiotic, for two weeks.
One example of this sort of therapy would be omeprazole (Prilosec) 20 mg po bid, plus clar- ithromycin (Biaxin) 500 mg po bid, plus metron- idazole (Flagyl) 500 mg po bid for 14 days. Unless the ulceration has been caused solely by use of NSAIDs, no other therapy will provide lasting re- sults. Drugs to reduce the acid content of the stomach—including antacids, H2 receptor antag- onists, and proton pump inhibitors—are useful in promoting the healing of tissue [56]. Following the eradication of H. pylori, recurrence rates are low; maintenance doses of a proton pump in- hibitor or sucralfate (Carafate) may be used when refractory or severe ulcers are resolved [57].
Gastric ulcers which remain unresolved need to be evaluated to exclude cancerous lesions of the stomach [58].