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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. 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. 2. 36 weeks pregnancy- expectations Mother Obstetrician BabyRelatives Partner
  3. 3. “Doctor, is everything okay?”
  4. 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. 5. Be practical “The rarer the disease you diagnose, the rarer is the possibility that you are correct”
  6. 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. 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. 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. 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
  10. 10. Actions Patient Collapsed?
  11. 11. Actions Patient Collapsed? No
  12. 12. Actions Patient Collapsed? No Prop up position Pulse Oxymetry High flow O2
  13. 13. Actions Patient Collapsed? No Prop up position Pulse Oxymetry High flow O2 Sp O2 ≥92% Complete Assessment
  14. 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. 15. Actions Patient Collapsed? Stimulate Assess Response Yes
  16. 16. Actions Patient Collapsed? Stimulate Assess Response Yes Responsive
  17. 17. Actions Patient Collapsed? No Prop up position Pulse Oxymetry High flow O2 Stimulate Assess Response Yes Responsive
  18. 18. Actions Patient Collapsed? No Prop up position Pulse Oxymetry High flow O2 Stimulate Assess Response Yes Unresponsive (Shock) Responsive
  19. 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. 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. 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. 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. 23. Multidisciplinary Approach • Obstetrician • High Risk Pregnancy Specialist • Internalist • Pulmonologist • Cardiologist • Haematologist • Anaesthetist • Intensivist • Neonatologist
  24. 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. 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. 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. 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. 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
  29. 29. Some Case Scenarios
  30. 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. 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. 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. 33. Severe Pre-eclampsia • Antihypertensives • Diuretics • MgSO4 • PEEP • Delivery
  34. 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. 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. 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. 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. 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. 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. 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. 41. Influenza • Tends to be severe in pregnancy • Consider vaccination • Prophylactic/ therapeutic Oseltamivir/ Zanamivir are safe in pregnancy
  42. 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. 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. 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. 45. Take Home Message • Think about common and life-threatening causes • Diagnosis and management should proceed simultaneously • Involve MDT

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