Overview

Pleurisy is when the lungs become inflamed, which then causes a sharp pain in the chest.¹ It is important to address pleurisy in pregnancy as it can lead to other complications for pregnant women such as difficulty in breathing, increased risk in preterm labour, reduced foetal growth and an increase in infection.² Therefore this article aims to outline the considerations and management of pleurisy during pregnancy and how it can be prevented. 

Aetiology and pathophysiology

Causes of pleurisy 

Infections 

One of the main causes of pleurisy can be viral infections (flu) or bacterial infections (pneumonia). A type of bacteria called MRSA (methicillin-resistant Staphylococcus aureus) often affects hospital patients as it is resistant to many antibiotics, leading to pleurisy.³

Autoimmune conditions (e.g., lupus)

Autoimmune diseases such as lupus and rheumatoid arthritis can also cause pleurisy. Since rheumatoid arthritis causes swelling and inflammation around the body.⁴ Hence why it can lead to pleurisy. Lupus also affects the immune system as it attacks the healthy tissue and causes inflammation in the lungs leading to pleurisy.⁵

Pulmonary embolism

This is when a blood clot has been formed and ends up transported to the bloodstream and gets lodged into the lungs. This leads to pleurisy when the pulmonary embolism is small and lodged in a part of the lungs near the pleura.⁶

Trauma or injury 

Chest injury such as bruised or fractured ribs can cause the lungs to become inflamed which then leads to pleurisy.⁷

Other infections like pneumonia are also major causes of pleurisy. 

Pathophysiology of pleurisy 

Inflammation of the pleura

Pleurisy occurs when a large thin sheet that wraps around the outside of the lungs and lines the inside of the chest cavity called the pleura becomes inflamed. In Between the layer of the pleura and the chest cavity is the pleural space. The pleural space consists of a small amount of fluid which enables the two layers of the pleura to slide past smoothly as the lungs breathe in and out. But when pleurisy occurs the layers of pleura become inflamed and rub against each other every time the lungs breathe in air. ⁸

Accumulation of pleural fluid

When there is an accumulation of pleural fluid in the pleural space it is known as pleural effusion. This can be very serious as it can cause severe shortness of breath. Some other symptoms of pleural effusion are chest pain, dry coughs and trouble breathing while lying down.⁹

Common symptoms 

• Sharp, stabbing chest pain 
• Pain that worsens with breathing or coughing 
• Shortness of breath 
• Possible fever or chills

Considerations during pregnancy

Physiological changes in pregnancy 

Respiratory changes

During pregnancy, women often experience a change in their respiratory system, some of which includes an increase in metabolic rate which then increases the consumption of oxygen. There is also an increase in minute ventilation where there is an increase in tidal volume. Furthermore, in late pregnancy, diaphragm elevation occurs where one portion of the diaphragm is higher than the other. This causes a decrease in functional residual capacity. Hypoxia may also occur during pregnancy which usually occurs during the third trimester, breathlessness is present at rest or whilst talking.¹⁰ These are some of the most common changes the respiratory system goes through in normal pregnancy, whereas when pleurisy develops, these changes may seem more severe.

Impact of pleurisy on pregnancy 

Risks to the mother (e.g., respiratory distress) 

Being affected by pleurisy can lead to pneumonia in pregnant women. This poses a risk to both the mother and foetus. Pneumonia occurs due to respiratory changes and immune changes that occur during pregnancy. Influenza pneumonia causes the risk of preterm delivery, abortion, caesarean section, maternal respiratory failure and even death.¹¹ In maternal pneumonia it can cause oxygen levels to decrease as the lungs fail to receive and transport enough oxygen out to the rest of the body therefore less oxygen can get to the uterus to support the baby. Furthermore, the rate of pneumonia increases as the body puts most of its energy into supporting the foetus which then suppresses the immune system. The foetus and uterus also reduce a woman’s lung capacity which then decreases the function of the lungs and makes it more prone to infection within the lungs.¹²

Potential effects on the foetus (e.g., hypoxia) 

Pleurisy can cause foetal pleural effusion where there is an excess amount of fluid in the chest cavity of the foetus and this compresses the developing lungs and heart. A high amount of fluid can lead to foetal heart failure and pulmonary hypoplasia (underdeveloped lungs).¹³ When the foetus receives low amounts of oxygen it can then lead to hypoxia, which can lead to difficulty breathing, rapid heart rate and bluish skin, which all pose a risk to the foetus's survival.¹⁴

Management strategies

General principles 

Safety for both mother and foetus 

When it comes to managing pleurisy and treating it in pregnant women the main goal is to make sure the treatment is safe for both the mother and the foetus. Some of the common treatment options for pregnant women include a combination of medications, lifestyle changes and close monitoring.¹⁵

Multidisciplinary approach involving obstetricians, pulmonologists

Another precaution to be made with pregnant women with a high-risk pulmonary embolism is to include a multidisciplinary team that involves obstetricians, pulmonologists, radiologists, cardiologists, oncologists and cardiovascular surgeons.¹⁶ These people need to come up with a tailored management option that follows the guidelines properly in order to avoid further complications for the mother and the foetus. 

Pharmacological treatments 

Some of the main medications used to relieve symptoms of pleurisy are NSAIDs. They are non-steroidal anti-inflammatory drugs that reduce pain and inflammation. Some examples of NSAIDs include aspirin, ibuprofen and naproxen sodium.¹⁷ Other medications taken for pain include corticosteroids which help treat rheumatologic diseases such as rheumatoid arthritis and lupus. Some examples of corticosteroids include cortisone and prednisone.¹⁸

Furthermore, respiratory issues caused by pleurisy can be dealt with using antiviral agents. They inhibit DNA synthesis and viral replication by competing with deoxyguanosine triphosphate for viral DNA polymerase. Some examples of these antiviral agents include amantadine, rimantadine and acyclovir.¹⁹ 

Non-pharmacological treatments 

Other possible treatments for pleurisy other than medication include lifestyle and home remedies. One of the key things to do is to take a lot of rest and stay in a position that causes the least discomfort and not overdo it when you begin to feel better. 

Breathing exercises and physiotherapy

Going to see a physiotherapist may be helpful as it will help pregnant women get detailed consolidation as to what specific symptoms they are experiencing and how the condition is affecting their lifestyle. A physiotherapist session may involve breathing technique retraining such as controlling respiratory rate, diaphragmatic breathing and relaxation breathing exercises.²⁰

Thoracentesis for significant pleural effusion

Thoracentesis treats pleural effusion by figuring out what causes the fluid. During a thoracentesis, the person will be plugged into machines where the heart rate is monitored and oxygen is given through a tube in the nose. The area is numbed with a needle and local anaesthesia then a small cut is made in the skin and another needle is inserted between the ribs to take out the fluid. Then the needle is removed and will heal on its own.²¹

Monitoring and follow-up

Regular monitoring 

After a thoracentesis, an X-ray or ultrasound of the lungs may be taken. They will continue to take vital signs until it is okay for them to leave. The recovery time for a thoracentesis is only 48 hours and they will be provided with instructions for post-op care for a smooth recovery. 

Furthermore, foetal monitoring can also be done via ultrasounds and non-stress tests. Ultrasound is a non-invasive imaging technique that can be used during pregnancy to monitor fetal movement and heart rate. It can also help check for any congenital defects in the spinal cord, heart and other parts of the body.²²

Special considerations

Labour and delivery planning

During labour, there are physiological changes within the respiratory and cardiovascular systems. There is a dramatic change in tidal volume and minute ventilation during labour and delivery. There is also an increase in pain during labour, the pain is managed by the use of narcotic analgesics which decrease hyperventilation. Furthermore, women with pleurisy often experience a higher heart rate during labour increasing chances of cardiovascular complications. However, the right planning in collaboration with the obstetric and anesthesiology team about how to adapt delivery and pain management strategies will ensure safe delivery and protect both the mother and fetus.²³

Conclusion

Overall pleurisy is when the lungs become inflamed and can cause respiratory distress which can often lead to pneumonia. If pleurisy occurs in a pregnant woman and it is more severe than normal levels and affects the foetus and mother’s breathing levels it should not go unrecognised. Pleurisy in pregnant women can be managed by various treatments such as taking pharmacological medications such as NSAIDs and corticosteroids that help reduce pain and inflammation or it can be managed via making lifestyle changes and attending physiotherapy. Overall, more pregnant women should be educated about pleurisy and its complications and how it can be managed and treated.