Acute Shortness of Breath at 36 weeks of Pregnancy
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lecture delivered by Dr Sujoy Dasgupta at BOGSCON 42, the Annual Conference of Bengal Obstetric and Gynaecological Society, where he was invited as Faculty in a session on "Difficult Clinical Scenario in Pregnancy"
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Acute Shortness of Breath at 36 weeks of Pregnancy
- 1. Acute Shortness of Breath at 36 weeks Dr Sujoy Dasgupta MBBS (Gold Medalist, Hons) MS (Obst & Gynae- Gold Medalist) DNB, FIAOG Assistant Professor: SRIMSH, Durgapur Consultant: •RSV Hospital, Kolkata •Behala Balananda Brahmachary Hospital, Kolkata •Techno India Hospital, Kolkata Secretary, Perinatology Committee: BOGS- 2016-17 Managing Committee Member: BOGS- 2016-17 15 Publications: National and International Journals
- 2. 36 weeks pregnancy- expectations Mother Obstetrician BabyRelatives Partner
- 3. “Doctor, is everything okay?”
- 4. What your mind does not know, eyes cannot see Physiological Haematological Anxiety/ Hyperventilation • Severe Anaemia Respiratory • Pulmonary Embolism • Status Asthmaticus • Acute Chest Syndrome (Sickle Crisis) • Penumonia Metabolic • Interstitial Lung Ds- SLE • Amniotic Fluid Embolism • ARDS • Anaphylaxis • Pneumothorax • Diabetic ketoacidosis Cardio-vascular • Thyrotoxicosis • Severe Preeclampsia • Renal Failure • Mitral Stenosis Drug Induced • Periparum Cardiomyopathy Neurological • Acute Myocardial Infarction • Myasthenic crisis • Arrhythmia • Gullain Burry Syndrome
- 5. Be practical “The rarer the disease you diagnose, the rarer is the possibility that you are correct”
- 6. Categorize the patient Is she known to you? Yes Risk factors known Asthma Heart Disease Hypertension Diabetes Anaemia Anti-Phospholipid Syndrome Age Parity Obesity Family H/O No known risk factors No Needs detailed history
- 7. Categorize the patient Is she known to you? Yes Risk factors known Asthma Heart Disease Hypertension Diabetes Anaemia Anti-Phospholipid Syndrome Age Parity Obesity Family H/O No known risk factors No Needs detailed history
- 8. Categorize the patient Is she known to you? Yes Risk factors known Asthma Heart Disease Hypertension Diabetes Anaemia Anti-Phospholipid Syndrome Age Parity Obesity Family H/O No known risk factors No Needs detailed history
- 9. Categorize the patient Is she known to you? Yes Risk factors known Asthma Heart Disease Hypertension Diabetes Anaemia Anti-Phospholipid Syndrome Age Parity Obesity Family H/O No known risk factors No Needs detailed history
- 12. Actions Patient Collapsed? No Prop up position Pulse Oxymetry High flow O2
- 13. Actions Patient Collapsed? No Prop up position Pulse Oxymetry High flow O2 Sp O2 ≥92% Complete Assessment
- 14. Actions Patient Collapsed? No Prop up position Pulse Oxymetry High flow O2 SpO2 ≥92% SpO2 <92% Laboured breathing Complete Assessment Endotracheal Intubation Mechanical Ventilation Shift to ICU
- 15. Actions Patient Collapsed? Stimulate Assess Response Yes
- 16. Actions Patient Collapsed? Stimulate Assess Response Yes Responsive
- 17. Actions Patient Collapsed? No Prop up position Pulse Oxymetry High flow O2 Stimulate Assess Response Yes Responsive
- 18. Actions Patient Collapsed? No Prop up position Pulse Oxymetry High flow O2 Stimulate Assess Response Yes Unresponsive (Shock) Responsive
- 19. Actions Patient Collapsed? No Prop up position Pulse Oxymetry High flow O2 Stimulate Assess Response Yes Unresponsive (Shock) Responsive Airway- Check for obstruction Breathing- O2, LMA, Intubate Circulation- IV Access Left Lateral Tilt Advanced Life Support
- 20. Complete Assessment Chest • Breath sounds • Ronchi • Crackles • Pleural Rub • Subcostal suction • Respiratory rate Heart • Heart sounds • Murmur • Heart rate Vitals • BP • Temperature • JVP • Pallor • Thyroid
- 21. Investigations • Blood- CBC, LFT, RFT, Electrolytes, Coagulation profile • Arterial blood gas • Troponin-T test • Urinalysis- Proteinuria • 12 lead ECG • Bedside Echocardiography • Duplex Doppler of B/L leg veins • Chest X-ray • Coronary Angiogram • CT Pulmonary angiogram • V/Q Scan
- 22. Investigations to be avoided ? Procedure Fetal exposure Chest radiograph (PA and lateral) <0.01 mGy CT chest 0.3 mGy Coronary angiography 1.5 mGy Percutaneous coronary intervention (PCI) 3 mGy • Maximum tolerable radiation exposure by the fetus- 50 mGy
- 23. Multidisciplinary Approach • Obstetrician • High Risk Pregnancy Specialist • Internalist • Pulmonologist • Cardiologist • Haematologist • Anaesthetist • Intensivist • Neonatologist
- 24. Physiological changes • Bounding/collapsing pulse • Sinus tachcardia • Ejection systolic murmur • Loud first heart sound • Third heart sound • Ectopic beats • Peripheral oedema ECG 15ο left axis deviation ST segment depression T-wave inversion in V1, V2 III Q wave in lead III, AVF Chest Xray ↑cardiac silhoutte D-dimer ↑ Tidal volume ↑ 40% FRC ↓20% Respiratory Rate Unchanged PEFR/ FEV1 Unchanged Vital Capacity Unchanged PaO2 ↑ (105 mm Hg) PaCO2 ↓ (32 mm Hg) pH ↑ (7.42) SpO2 Unchanged
- 25. • ↓ O2-carrying capacity • ↑ CPR circulation demands • ↓Venous Return • Hypoxia develops more quickly • ↓ buffering capacity, acidosis more likely • Difficult intubation and ventilation • ↑ Risk of aspiration Problems in management
- 26. Management in ICU • Fetal oxygenation can be maintained if PaO2 >65 mm Hg and PaCO2 <45 mm Hg • Consider EFM if admitted to ICU
- 27. Definitive Management Obstetric Management • Assess need of delivery • Antenatal steroids for fetal lung maturation • Avoid tocolytics • Decide timing and mode of delivery • Regional Anaesthesia ≥24 hours after last therapeutic dose of LMWH
- 28. Last Ditch Effort • Perimortem CS • Plan- if no response to CPR within 4 minutes • Perform- within 5 minutes of starting CPR • Theatre is not needed
- 30. Case 1 • 25 years, P0+0 • Known asthmatic-well controlled on oral steroid and inhaler • C/O sudden onset dyspnoea, chest pain, haemoptysis • O/E- P-140 bpm, BP 60/40 mm Hg, cyanosis, pleural rub • ECG- S1Q3T3 • ABG- ↓PaO2, ↓PaCO2 • Troponin T test -ve Pulmonary Thromboembolism
- 31. Pulmonary Embolism • LMWH/ UFH, Thrombolytics, IVC Filter • Start anticoagulation and investigate • Duplex Doppler Scan of legs, CTPA, V/Q Scan • D-dimer test not useful in pregnancy
- 32. Case 2 • 25 years P0+0, twin pregnancy • Anaemic, iron-intolerant • C/O sudden onset severe breathlessness • O/E- B/L basal crackles, BP- 180/110 mmHg, P-126 bpm • Urinalysis- 2+ proteinuria Severe pre-eclampsia
- 33. Severe Pre-eclampsia • Antihypertensives • Diuretics • MgSO4 • PEEP • Delivery
- 34. Case 3 • 39 years, P3+0, BMI 35 Kg/m2 • Past Obst H/O- NAD • Chronic hypertensive- controlled on α-methyl dopa • C/O increasing dyspnoea, severe at night and on lying flat • O/E- BP- 130/90 mm Hg, B/L coarse crackles, raised JVP, B/L pedal oedema • Bedside Echo- EF 40%, all 4 chambers dilated Peripartum Cardiomyopathy
- 35. Peripartum Cardiomyopathy • Risk factors- Age >35 years, black race, twin, hypertensive • High chance of recurrence • Form of dilated cardiomyopathy • O2, Vasodilators, Diuretics, Digoxin, LMWH Prophylaxis
- 36. Case 4 • 43 years, P0+0, IVF conception • Overt DM (controlled) • C/O vomiting, epigastric pain f/b chest pain and acute breathlessness • O/E- P- 150 bpm, SBP- 40 mm Hg, cold extremities, quiet S1 • CBG- 106 mg/dl, urine ketone -ve • ECG- ST elevation in most leads • Troponin T+ve Acute Myocardial Infarction
- 37. Acute Myocardial Infarction • Pregnancy- increases risk of AMI • Coronary Dissection- almost peculiar to pregnancy • Troponin-T test in all new chest pain in pregnancy • Antiplatelets, Percutaneous Coronary Interventions, Thrombolytics • Delay delivery by 2 weeks, if possible- to allow myocardium to heal
- 38. Case 5 • Came to you for the first time • C/O severe breathlessness, cough, haemptysis and palpitation • O/E- Pulse- 160 bpm, irregular, B/L crackles, loud S1, soft mid- diastolic murmur • H/O irregular ANC done at PHC- P0+1 • H/O fever and joint pain in childhood Mitral Stenosis
- 39. Mitral Stenosis • Auscultate CVS and chest at 1st ANC visit • Pregnancy worsens stenotic heart disease • Fluid restriction, rest, diuretics, β- blockers • Antiarrhythmics- most are category C
- 40. Case 6 • 22 years, P0+0 • No apparent risk factors • H/O diarrhoea, malaise, running nose, low grade fever, non-productive cough for 2 days • C/O sudden onset dyspnoea • O/E- febrile, tachypnoea, tachycardia, chest exam- unremarkable • Chest X-ray- patchy infiltrates • Serology confirmed H1N1 +ve Viral pneumonia
- 41. Influenza • Tends to be severe in pregnancy • Consider vaccination • Prophylactic/ therapeutic Oseltamivir/ Zanamivir are safe in pregnancy
- 42. Case 7 • 32 years, P0+2 • Known case of sickle cell disease (HbSS) • C/O chest pain and dyspnoea • O/E- Tachypnoea, tachycardia, pallor • Chest X-ray- new infiltrates Acute Chest Syndrome
- 43. Acute Chest Syndrome • More frequent in pregnancy • O2, IV fluid, rest, antibiotics, LMWH prophylaxis • Exchange transfusion • Prophylactic transfusion- not recommended • Analgesics- Do not give Pethidine
- 44. Case 8 • 29 years, P1+0 • No apparent risk factors • C/O abdominal pain • O/E- False labour • Received pain-relief medication • Sudden onset dyspnoea and vomiting • Relieved by O2 and injection ondansetron Tramadol induced respiratory depression
- 45. Take Home Message • Think about common and life-threatening causes • Diagnosis and management should proceed simultaneously • Involve MDT