Associate professor of OB&GYN Perinatalogy Department TUMS DYSPNEA IN PREGNANCY DR S khazardoost Associate professor of OB&GYN Perinatalogy Department TUMS

DYSPNEA IN PREGNANCY Underlying cardiac or pulmonary disease or whether dyspnea is due to the pregnancy itself Sudden, persistent, or positional dyspnea requires further evaluation

Physiologic changes Blood volume Cardiac output Elevation of the diaphragm Decreased FRC and stable FEV1 Increased ventilation and respiratory drive Respiratory alkalosis and increased arterial O2 tension

DYSPNEA IN PREGNANCY Sixty to 70 percent Starts during the first or second trimester Stable during the third trimester Worse in the sitting position Not associated with exercise

EVALUATION OF PREGNANT WOMEN WITH DYSPNEA History and physical examination Is dyspnea acute or has gradual onset?  Physiologic dyspnea has a gradual onset pulmonary embolism is characterized by the sudden onset of dyspnea tachypnea, pleuritic chest pain,andhemoptysis in pulmonary embolism heart rate may increase Spontaneous pneumothorax ;sudden onset of dyspnea and pleuritic chest pain Risk factors include smoking, thoracic endometriosis, and previous or family history

EVALUATION OF PREGNANT WOMEN WITH DYSPNEA History and physical examination Acute dyspnea from upper airway obstruction Symptom of anaphylaxis Other symptoms of an acute IgE mediated hypersensitivity reaction (eg, flushing, itching, urticaria, angioedema, tachycardia, hypotension) Acute cardiac tamponade Sudden in onset May be associated with chest pain, tachypnea, and dyspnea, and is life-threatening if not promptly treated The jugular venous pressure is markedly elevated, and may be associated with venous distension in the forehead and scalp. The heart sounds are often muted. Hypotension is common Acute dyspnea can also be a sign of coronary artery ischemia or dissection or an arrhythmia

EVALUATION OF PREGNANT WOMEN WITH DYSPNEA Is cough or wheezing present? Physiological dyspnea of pregnancy is not associated with cough or wheezing Acute cough is most commonly due to an acute respiratory tract infection Acute exacerbation of underlying chronic pulmonary disease, pneumonia, and pulmonary embolism Cough that has been present longer than three weeks is either subacute or chronic Common symptoms of asthma and cardiac diseases with pulmonary venous hypertension Evidence of airflow obstruction on pulmonary function testing supports the diagnosis of asthma

EVALUATION OF PREGNANT WOMEN WITH DYSPNEA Is the chest clear on auscultation? Crackles (rales) are indicative of abnormalities affecting the distal lung parenchyma, such as interstitial pulmonary edema from left ventricular failur Heart failure affecting right ventricular filling pressures is associated with peripheral edema and prominent neck veins

Pulmonary edema Severe preeclampsia/eclampsia Tocolytic-induced pulmonary edema Cardiac disease Focal rales with or without consolidation may also be suggestive of pneumonia

EVALUATION OF PREGNANT WOMEN WITH DYSPNEA Are other symptoms present? Physiologic dyspnea is not accompanied by pain or other symptoms Thoracic tumors and pulmonary emboli may present with dyspnea and chest pain, hemoptysis, cough, or wheezing Dyspnea accompanied by fever and cough suggests an infectious process

EVALUATION OF PREGNANT WOMEN WITH DYSPNEA Is onset early in gestation or near term? Physiologic dyspnea typically begins in the first or second trimester. peripartum cardiomyopathy commonly complain of dyspnea, but onset is rarely before 36 weeks of gestation, and affected patients usually present during the first four to five months postpartum Other frequent symptoms include cough, orthopnea, paroxysmal nocturnal dyspnea, and hemoptysis Nonspecific fatigue, chest discomfort, or abdominal pain may confuse the initial evaluation due to the occurrence of similar symptoms during normal pregnancy.

Laboratory and imaging tests The history and physical examination lead to accurate diagnoses in most patients Chest radiography and pulmonary function testing should be the first tests obtained in the majority of cases in which additional information is required Brain natriuretic peptide ( BNP) levels may be useful in pregnant women with a suspected cardiac cause of dyspnea

Laboratory and imaging tests Spirometry A chest radiograph should be obtained in patients with suspected pneumonia or lung lesions Radionuclide lung scanning is also thought to pose little risk to the fetus B NP levels are not affected by pregnancy, with typical values of < 5 0 pg/mL and median levels of approximately 20 pg/mL throughout pregnancy

PALPITATIONS  Palpitations occur frequently during pregnancy and are a common indication for cardiac evaluation during pregnancy A sensation of palpitations during pregnancy, in the absence of concomitant cardiac arrhythmias, may be related to the high output state, including increased heart rate, decreased peripheral resistance, and increased stroke volumes

PALPITATIONS Palpitations are common during pregnancy and may be caused by a forward and upward shifting of the heart and by increases in cardiac output, heart rate, myocardial contractility, and catecholamine levels. The differential diagnosis includes mild sinus tachycardia, ectopic beats, CHF, arrhythmias, thyrotoxicosis, and pheochromocytom

Cardiac Complaints in Pregnancy Cardiac disease complicates 1% to 4% of all pregnancies A leading cause of maternal mortality Most complications are caused by congenital heart disease Coronary ischemia is becoming increasingly common

Cardiac Complaints in Pregnancy The most common cardiac complaints during pregnancy are dyspnea, palpitations, chest pain, and dizziness or syncope These complaints may be due to the normal physiologic changes that occur during pregnancy or may be presence of an underlying cardiopulmonary disorder

Since cardiac arrhythmias are frequently associated with structural heart disease, any woman who presents with an arrhythmia during pregnancy should undergo clinical evaluation for structural heart disease (including an electrocardiogram and a transthoracic echocardiogram) The most common arrhythmia in women with structurally normal hearts is paroxysmal supraventricular tachycardia

PALPITATIONS In the majority of patients, the cause of palpitations is benign. Attention to characteristics that identify patients at high risk for serious causes of palpitations (eg, structural heart disease) The diagnostic evaluation of all patients with palpitations should include a detailed history, physical examination, and 12-lead ECG. Limited laboratory testing to rule out anemia and hyperthyroidism is also reasonable

PALPITATIONS A 24 hour Holter monitor can be considered in patients who have daily symptoms The management of most sustained supraventricular or ventricular arrhythmias causing palpitations should be managed by a cardiologist trained in the pharmacologic and invasive electrophysiologic management of arrhythmia

Causes of palpitations

Chest pain Chest pain in pregnant women is often caused by gastroesophageal reflux disease (due to progesterone-mediated decreases in esophageal sphincter tone) Other possible causes include pneumonia, PE, and ischemic heart disease

Chest pain in pregnancy: Differential diagnosis

Dizziness Dizziness and even syncope may result from the postural hypotension caused by venous pooling and progesterone- mediated vasodilation during pregnancy The differential diagnosis includes vertigo, anxiety disorders, seizure, hypertrophic cardiomyopathy, cardiac arrhythmias,…

Dizziness/syncope in pregnancy: Differential diagnosis

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