This presentation describes the common causes of shortness of breath during pregnancy and their approach

1. Dyspnea and palpitation
during pregnancy
PREPARED BY
FARAIDWN MUHAMMAD

2. Contents
• Objective
• Physiological changes
• Differential diagnosis
• What help in history & examination
• Management
• Family planning
• Conclusion

3. Objective
• To evaluate the common causes of dyspnea & palpitation
during pregnancy
• How history, examination & investigation help in diagnosis
• Plan for delivery
• Contraception & family planning

4. Introduction
• Breathlessness ( Dyspnea ) / shortness of breath /difficult,
laboured , consciousness about taking breath is a common
symptom during pregnancy.
• May be related to physiological changes in cardio-
pulmonary, hemopoetic system, increase in weight,
hormonal stimulation, etc.

5. Common differential diagnosis
• Physiological changes occurs in pregnancy
• Heart disease in pregnancy
• Respiratory disease in pregnancy
• Anemia
• Thyroid disorder
• Drug (NSAIDs, Amiodarone)
• Psychological– anxiety, fear

6. Physiological changes in
pregnancy
1. ↑ in plasma volume
2. ↑ Red cell mass
3. Peripheral vasodilation, an ↑in HR, and a fall in systemic &
pulmonary resistance
4. ↑ C.O.P 40% & stroke volume

7. Anatomical changes
• Diaphragm elevation by gravid uterus
• Heart displace upward and to left side .
• CXR show increased C/T ratio (apparent cardiomegaly)

8. Sign & symptom of normal pregnancy
mimic heart disease
• Dizziness
• Dyspnea
• Easy fatigability
• ↑in heart rate
• Edema
• Syncope

9. What in history help in diagnosis
• Duration & Severity of symptoms
• Presence of: fever –cough-sweating -→ resp. disease
• Sweating- lose of appetite –anxiety -→ thyroid disease
• PND –dyspnea on exertion –chest pain -→ heart disease
• History of:-
familial disease like asthma
rheumatic fever in childhood
any cardiac problem and surgery

10. • Medication intake like for thyroid – asthma
Anticoagulants –others
• Obstetrical history
G P A LMP EDD GA
Mode of delivery in previous pregnancy ---
Medications admission to ICU

11. What in examination help
General:
PR & pressure, BP, RR, Temp , edema, cyanosis, exophthalmos
Scar, dilated neck vein
4th heart sound –murmurs
Para sternal thrill
Basal crepitation & scattered rhonchi
Obstetrical examination (Fundal height)
◦

12. Heart disease and pregnancy
Pre conceptional counselling
• Full assessment
• Treatment of any concurrent medical problem
• Discussing the risks for both (mother & fetus)
• Cardiac risk varies among specific forms of heart disease
Some diseases negligible, some prohibitive

13. NYHA (New York Heart Association)
Functional grading of heart disease
Grade I: No limitation of physical activity- asymptomatic
with normal activity
Grade II: Mild limitation of physical activity -Symptoms with
normal physical activity
Grade III: Marked limitation of physical activity -Symptoms
with less than normal activity, comfortable at rest
Grade IV: Severe limitation of physical activity- symptoms
at rest

14. Toronto risk markers of maternal
cardiac complications
Criteria Points
Prior cardiac events 1
NYHA III/IV or cyanosis 1
Valvular and outflow tract obstruction 1
Myocardial dysfunction 1
* Maternal cardiac event rate for 0, 1, and >1 points is 5%, 37%,
and 75%, respectively.

15. Contraindications of pregnancy
• Marfan syndrome with dilated aortic root
• NYHA class 3 & 4 heart failure
• Eisonmenger syndrome (maternal mortality is 40%)
• Peripartum CMP
• Severe uncorrected valvular stenosis
• Primary pulmonary hypertension
• Coarctation of aorta

16. Fetal risks of maternal cardiac disease
• Recurrence (congenital heart disease)
• Fetal hypoxia (Maternal cyanosis)
• Preterm labour
• FGR
• Effects of maternal drugs (teratogenesis, growth
restriction, fetal loss)

17. Case scenario
Sana is 29 years old had history of heart disease, attend
ANC at her 14 weeks of gestation

18. • Need team work management
• The main aims of management are:
early risk assessment, optimization, regular monitoring for
deterioration, planning of delivery, and surveillance for
deterioration in the immediate post-partum period.
Antenatal management

19. Symptoms of heart disease
• Hypertension
• Chest discomfort, hemoptysis & cough
• Progressive dyspnea, orthopnea or dys. at night
• Palpitations & change in heart rate
• Syncope
• Fatigue & exercise intolerance
• Edema
• A past history of congenital or acquired heart disease.
• A family history of congenital heart disease.

20. Clinical findings of heart disease
• Cyanosis
• Clubbing
• Persistent neck vein distention
• Diastolic murmur
• Loud, harsh systolic murmurs
• Persistent split 2nd sound
• Sustained cardiac arrhythmias
• Cardiomegaly
• Pulmonary hypertension

21. What investigations should done
• ECG
• Echocardiography
• Chest X-ray
• Cardiac MRI (dx and px)
• US scan for dating –IUGR

22. Risk factors for developing heart failure
• Anemia
• Hypertension
• Cardiac arrhythmia
• Pre eclampsia
• Infection
• Over work
• Over weight
• Tocolytics

23. • Team approach
• Activity restrictions
• Diet modifications
• Infection control
◦ Immunizations, SBE prophylaxis, prophylaxis against
rheumatic fever
• Use of anticoagulants
Warfarin or heparin from 6-12 weeks of gestation or
throughout pregnancy

24. Case scenario
B is G2 P 0 A1 at 39 week, present to labor room in active
labor she is known case of MVD

25. Management of labour and delivery
• Spontaneous vaginal delivery
• Cesarean section is only indicated for obstetric causes
• Warfarin should be discontinued and substituted with heparin
for 10 days before delivery
• Warfarin is recommenced 2-3 days postpartum

26. Management of labour and delivery
• Sitting position supported with pillow
• Oxygen, diuretic, digoxin, B blocker & antiarrhythmic drugs
• Analgesic (morphine ,epidural anesthesia)
• Prophylactic antibiotics
• Shortening of the 2nd stage by elective forceps & vacuum
• oxytocin
• Anticoagulant

27. Case scenario
Sana is G4 P3 AO she was well up to 34 wk develop CHF
what is your management?

28. Peripartum Cardiomyopathy
Symptoms of CHF that become apparent in last month of
pregnancy or within 5 months postpartum with no pre-
existing disease and no other etiology for heart failure
Tx:
Digoxin and diuretics
Hydralazine
Anticoagulation

29. • 1 in 10 000
• Multiparous, ˃ 35 yr
• Peak incidence in 3rd trimester
• 50% mortality
• Atherosclerosis is infrequent cause (Coronary spasm, in situ
coronary thrombosis, and coronary artery dissection)
• Treatment of MI same as non-pregnant treatment
Ischemic Heart Disease

30. Family planning
• Small family is advised
• Barrier
• POP
• Sterilization by tubal ligation
• IUCD is contraindicated because it may cause infective
endocarditis
• COCP are contraindicated because it contain estrogen that
cause fluid retention

31. Conclusion
• Heart disease is serious condition & it is non obstetrical
causes for maternal mortality
• It need team work
• Close observation throughout pregnancy