1. Prof. M.C.Bansal MBBS.,MS. FICOG. MICOG. Founder Principal & Controller ,Jhalawar Medical College And Hospital Jhalawar.Ex Principal & controller MGMC and Hospital , Sitapura Jaipur.

2. Physiological causes ofBreathlessness in Pregnancy Physiological breathlessness starts as early as 1stor second trimester and increases in incidence asgestation progress. It occurs in 60 -70 % women and thus is the commonphenomenon , it is usually mild and seldomincapacitate , the women to perform routine activity. Breathlessness at rest is uncommon and tolerance tolight exercise and daily activity are usually not affected. 3. Physiological breathlessness---- Changes in lung function occur as result ofhomeostasis owing to increasing demand of O 2 ofthe growing fetus . , increased maternal BMR . Minute ventilation is increased by 20-40 % ( tidalvolume x Respiratory rate ) Tidal volume is increasedbut respiratory rate is not increased significantly. 4. Respiratory Causes. Respiratory centre becomes more sensitive to CO2. respiratory rate increases at rest even , Vertical diameter of thoracic cavity decreases due to up pushing of diaphragm by enlarging uterus, Respiration becomes more thoracic as abdominal movements with respiration are restricted , In later period of pregnancy there is flaring out of ribs there by anterio lateral diameter of thoracic cage increase , vital capacity decrease more so in lying down position , supine hypotension due to caval compression by enlarged uterus also cause cardio respiratory distress. 5. Breathlessness due to RespiratoryDysfunction Dysfunctional breathing is common in young women hence while pregnant ,it may continue. Patient typically complains of breathlessness which is out of proportion to clinical findings and able to perform daily activity . It may occur even at bed rest . Pt describes it as difficulty in taking full breath or felling a blockage in the chesty . Pt may have psychological problem or psychiatric illness. Vocal Cord Dysfunction---Presents as attacks of breathlessness similar to asthma., with which it often co exist.10 % of acute asthma cases may infect be due to vocal cord dysfunction. It can be diagnosed simply by clinical history and spirometry., narrowed inspiratory flow volume loop laryngoscopy will reveal adduction of voal cord on inspiration and some time on expiration.Frank strider / aspiratory wheeze on chest auscultation may be present., Which is absent between attacks of breathlessness. . 6. Breathlessness Causes, Reasonsand Solutions www.normalbreathing.com/d/labored-breathlessness.php#.UPs2GSc73dk 3/5 The main causes of breathlessness and labored breathing (why it is hard to breathe): - constriction of airways due to hypocapnia in the airways - reduced oxygen levels in the diaphragm and chest muscles due to reduced oxygen transport - tense states in the diaphragmatic and chest muscles due to arterial hypocapnia. Exacerbating reasons in the pathophysiology of labored breathing and breathlessness are: - mouth breathing (due to reduction in nitric oxide absorption and alveolar CO2) - chest breathing (due to reduction in arterial oxygenation) - presence of inflammation and mucus in airways, causing further narrowing or an obstruction of air flow (as in COPD). Exertion, mouth breathing, physical exercise with mouth breathing, chest breathing, meals (eatingand especially overeating), overheating, anxiety, stress, attempts to inhale deeply, deep breathingexercises with CO2 losses, poor posture, night sleep and many other factors are known causes of hyperventilation. Hence, they worsen breathlessness and labored breathing. 7. Non cardiac causes ofBreathlessness Physiological ,dysfunctional , vocal cord dysfunction. Upper Airways Nasal obstruction Respiratory --- 1.Obstructive airways diseases like br. Asthma , cystic fibrosis ,COPD , bronhiectesis , obliterative bronchiolitis.2, Paranchymal and interstitial lung diseasepneumonia ,aspiration pneumonitis , ARDS , Acute lung injury , extensivetuberculosis , pulmonary metastasis ,sarcoidosis , drug induced, Extrinsic allergic alveolitis , Emphysema.3. Vascular --- pulmonary embolism , amniotic fluid embolism, Pulmonary HTN ( pri .sec.)4. Pleural effusion, pneumothorax , empyema , Chest wall----obesity , kyphoscoliosis , Ankylosing spondilitis ,neuromuscular disease (polio , multiple sclerosis.) Metabolic ---Anaemia , thyrotoxicosis , Acute or chronic Renalfailure , Acidosis diabetic /metabolic . Systemic sepsis . 8. Individual disorders-------- Upper Air Ways Nasal Obstruction------- Due to rhinitis can occur in 30 % pregnant women . As a result of mucosal edema , hyperaemia ,capillary congestion and mucosal hyper secretion which is caused by increased oestrogen level in pregnancy . This occurs mostly in 3rd trimester and may lead to breathlessness , particularly if severe. 9. Respiratory causes------- Obstructive Air Ways Disease Asthma is by far most obstructive air ways disease likely to encounterin pregnancy. , occurring in 0.4 -7 % cases and patient are alreadyknown to have it.Patient develops intermittent breathlessness with wide spreadExpiratory wheeze , bronchial secretion and precipitated by exertionand change in weather / temperature . Peak flow monitoringwillreve3al reduced peak flow with variability. Symptoms worse at latenight and early morning. Patient respond well to inhaled Beta agonist( broncho dilators ) Uncontrolled asthma----persistent troublesome symptoms , nocturnalsymptoms , frequent use of Beta agonist inhalation with little relief ,limitation of physical activity. They need hospitalization. Asthma in pregnancy worsen in 1/2rd cases , remain unchanged in 1/3rdand rest have improvement in their symptoms there by requiring lessdose of corticosteroids. NSAIDS use may trigger or worsen asthma. 10. Respiratory Causes----- 2. Cystic Fibrosis and Bronchiectasis Usually pre existing and characterized by frequent chest infection , increased cough with viscous discolored expectoration. Breathlessness develops in moderate to severe forms. Haemoptysis and chest pain develop in the phase of exacerbations. Sinusitis is common in both conditions while pneumothorax and steatorrhoea----malabsorption are common in cystic fibrosis . pregnancy carries risk of exacerbations and fetal IUGR / prematurity. 11. Cystic Fibrosis And Bronchectasis--- Auscultation reveals crackles over affected area.Diagnosis confirmed by X ray chest . High resolutionCT scanning will confirm . , but this investigation isdeferred in pregnancy. 12. Chronic Obstructive pulmonarydisease (COPD ) It is seen in pregnant women > 35 years of age with H/O smoking minimum 20 packs per year For 20 years.main symptom is breathlessness on exertion and reduced exercise tolerance. , may be accompanied by morning cough and expectoration . Reduced breath sounds in all fields with wheeze during exacerbations. 13. Obliterative Bronchiolitis ---- Relatively uncommon and difficult to diagnose. Clinical and X ray findings are indistinguishable with those of Asthma. , with small air ways obstruction , There may be H/O childhood respiratory illness. 14. Parenchymal and Interstitial lungdiseases 1, Pneumonia---Pneumococcal--- An acute febrile illnesswith Chills and rigors ,a short history of breathlessness ,cough , sticky blood stained sputum , chest pain precedingcommon cold .Respond well to high dose penicillintherapy.Clinical examination---- Increased respiratory rate,Bronchial breathing, crepitations , and consolidationConfirmed by X ray . Mycoplasm pneumonia complicatesHIV disease and its course run for several weeks, x Rayreveals bilateral interstitial infiltration. Bronchoscopy forCytological analysis is some time necessary. 15. Acute Lung Injury Or ARDS ----- Occurs in 0.2-0.3 % cases in pregnancy and may be secondary to pneumonia , aspiration pneumonitis, eclampsia ,amniotic fluid embolism . Its diagnosed by deteriorating condition of patient and worsening X ray consolidation findings through out both the lung 16. Tuberculosis (TB)----- TB can cause breathlessness when extensive bilateral involvement of lung paranchyma is present. H/O cough , low grade evening rise fever , night sweats, weight loss, loss of appetite , haemoptysis. Three samples on consecutive days for AFB , Xray chest showing consolidation often with cavitations. ATT is to be continued as in case of non pregnant women. Breast feeding is allowed if pt is not an open case / newborn is immunized with Isonex resistance BCG and prophylactic isonex therapy to child. 17. Pulmonary Metastases Are rare , can easily be diagnosed by X ray chest ----cannonball metastatic infiltration Symptoms usually develop when multiple lesions arepresent . Breathlessness ,cough , haemoptysis . Chest auscultation may be normal . Chorio carcinoma is common tumor with lung metastasesduring pregnancy or following evacuation of malignantvesicular mole / invasive mole. Pleural effusion is common . , when pulmonary metastasesare present. The metastases disappear with Chemotherapy followingmanagement of primary lesion. 18. Sarcoidosis-------- It is common in young women of Afro caribbean originand is often severe. Breathlessness is common when pulmonary infiltration iswide / enlarged mediastinal lymph nodes press thebronchus. Patient also develops cough , weight loss and involvementof other organs like skin and eyes. Auscultation of chest may be normal or crackles along withwheeze may be present.X ray chest in conjunction with clinical picture , raisedserum angiotensin conversion enzyme . Bronchial mucosa biopsy with bronchoscope will confirmthe diagnosis. 19. Drug induced Interstitial LungDisease NFT used for long term treatment of resistant /persistent UTI, can cause severe acute or chronic formof interstitial lung disease with hypoxia . Amioderone used in cardiac arrhythmia can causeacute pneumonitis ( incidence 0.1-0.5 % with dose of200mg / day ) and subsequent pulmonary fibrosis. Patient develops breathlessness and cough . Chest auscultation reveals bilateral basal fine crepts. 20. Lymphangio leiomyomatosis Rare but occurs in young women of reproductive age. Clinical manifestation includes interstitial lungdisease , recurrent pneumothoraces . May be bilateral with tuberous sclerosis. Chest auscultation may reveal bilateral crackles . Once suspected , it can be confirmed by X ray and highresonance CT . 21. Lymphangitis carcimatosa Occurs in advance metastatic breast carcinoma. Patient develops profound hypoxia. Like drug induced interstitial lung disease patient develops breathlessness and dry cough . 22. Extrinsic Allergic Alveolitis Relatively uncommon . Associated with an identifiable trigger antigen , suchas inhalation of Thermophylic Actinomycocetes sporesin mouldy hay( farmers lung ) Progressive breathlessness , wheeze and cough occurswith pulmonary infiltrates on X ray chest . , often theupper lobes . 23. Fibrosing Alveolitis Associated with auto immune diseases , which occurfrequently in young women . Auto immune diseases like rheumatoid disease, SLE ,scleroderma may be associates. Progressive breathlessness and cough are typical withfine , late aspiratory crackles on auscultation . Finger clubbing may be present . X ray shows bilateral , peripheral , basal interstitialshadows . HR CT helps in confirmation . Lung function studies reveal reduced diffusioncapacity. 24. Cryptogenic Organizing Pneumonia Also associated with auto immune disease. Patient develops Acute breathlessness . Cough andhypoxia. Parenchyma shadowing is more patchy than fibro singalveoli is .Note --- Chronic nature of some of these interstitial lungdisease may not be compatible with pregnancy . 25. Vascular diseases causingBreathlessness in Pregnancy Pulmonary embolism( PE ) is an important cause ofbreathlessness, its risk increases as gravidity , maternal age , BMIincreases and LSCS , Family h/o thrombi embolism , DVT , PIH ,Thrombophyllia , previous thromboembolism , prolong bed rest, varicose veins, Valvular heart disease etc. Pregnancy itself is also a major risk factor for Peas it is a state ofhyper coagulation. It is most common cause of maternal death indeveloped countries where other causes of MMR are wellcontrolled. Patient suddenly develops breathlessness and chest pain . Theremay be tachycardia, hypotension , blood stained frothy sputumand cyanosis in severe cases. Auscultation may be normal exce3pt increased respiratory rate.Ventilation /Perfusion (V/Q ) Scanning, X ray chest will help indiagnosis. Computerized tomographic pulmonary angiography (CTPA) may be needed when V/Q is in conclusive . 26. Vascular causes of Breathlessness--- Amniotic Fluid Embolism Amniotic fluid embolism is rare occurring in 1in 100-1000of deliveries. Presents with sudden onset of breathlessnessduring labor or with in 30 minutes of delivery . There is cardiovascular shock and DIC. Mortality is 60 -90% . , a major cause of maternaldeath during labor. 27. Vascular Causes--- Primary Pulmonary Hypertension A rare condition usually occurring in young women . Presenting With breathlessness on exertion. There may be ankle edema and other signs of right sided heart failure. Onset and progression is often insidious anddiagnosis is frequently missed early in course of earlydisease. Ecocardiography will help in diagnostic confirmation. 28. Vascular causes----- Secondary Pulmonary HypertensionOccurs as a consequent of chronic lung diseases or pulmonary embolism.Present with similar symptoms and signs.There can be significant hypoxia with both types of pulmonary hypertension. 29. Pleural Causes---- Pleural EffusionSecondary to pneumonia or tuberculosis may cause breathlessness.Rare cause of pleural effusion in pregnancy is chylothorax ( Lymphangomyomatosis ), chorio - carcinoma , breast carcinoma and other metastatic malignancies and rupture of diaphragm in labor. Chest examination will reveal shifting of trachea to opposite side , dull on percussion, absent breath sounds . X ray chest will show collapsed lung and pleural effusion on affected side. 30. Pleural Causes------ Empyema Findings are same as that of pleural effusion , butpatient will be toxic. Fluid drained will be frank pus instead of ecxudate.Pneumothorax Rupture of Emphysematous bullae is the commoncause .Often acute in onset , leading to progressivebreathlessness as more and more air is trapped inpleural cavity more and more lung is compressed. Onchest examination affected side is resonant ., X rayshows collapsed lung an d air in pleural cavity. 31. Chest wall causes of Breathlessness Obesity (Body Mass Index > 30 ) frequently leads tobreathlessness and reduced exercise tolerance.Examination otherwise will be normal. Kyphoscoliosis, Ankylosing spondilitis andneuromuscular disorders may cause breathlessnessdue to abnormal lung mechanism or paralysis ofdiaphragm . Such patients should be investigated forPartial pressure of arterial blood for evidence ofhypoxia and hypercapnoea Splinting of diaphragm may occur in pregnancycomplicated by OHSS, Massive acute Polyhydramniosor plural pregnancy leading to too much distension ofuterus leading to Breathlessness. 32. Metabolic causes--- Anaemia Moderate to severe in pregnancy usuallycause tiredness and decreased exercise tolerance ,Breathlessness is less common. Thyrotoxicosis may be present with breathlessnessin pregnancy . Typical features include tachycardia,weight loss inspite of good diet and appetite, diarrhea,tremors, insomnia and eye signs .There may be goiterin neck. Thyroid function test will confirm thediagnosis. Acute / chronic renal failure / acidosis and systemicsepsis can develop breathlessness. 33. Clinical Approach-------- History of Present Illness 1.Onset of symptoms in relation in to timing of pregnancy2.Duration, chronicity , nature and severity of breathlessness.3. Exercise tolerance specially in relation to day to day activity .4. Presence / absence of cough , sputum , haemoptysis .5 . Relief with inhaler.6. Palpitation.7. Chest pain.8. Weight loss, fever, anorexia , malaise .9. Leg pain.1o. Nasal and sinus problem .11. Sore throat , arthrelgia and myelgia. 34. Past Medical history Asthma, allergy , hay fever , eczema. Nasal block. TB, previous BCG vaccination , Cystic Fibrosis ,Brochiectasis , other lung disease. Sarcoidosis , Kyphoscoliosis ,Neuromuscular disease,Ankylosing Spondolitis , Herat Disease , RecurrentUTI. Malignancy ( breast ), immunosuppresion (HIV +ve.) Psychiatric illness. Previous history of Pulmonary embolism , DVT ,Thrombophillia . Thyrotoxicosis. 35. Other contributory history------ Drug History NFT , Amioderone , NSAIDs andinhalers. Psychology Anxiety or depression . Rx continuing orstopped ? Family History Clotting disorder , Asthma , Atopy ,Lung cancer , TB , sarcoidosis. Social History Ability to lead normal routine life ,specially going to work , climbing stairs , doing household work and shopping. Living in travel to high prevalence and contact TB. 36. Physical Examination General appearance- Confusion ,Sweating , tremors,pyrexia , pallor , obesity/ reduced weight , clubbing ,cyanosis , lymphadenopathy , BCG vaccination scar ,goiter , exophthalmos , lid legging ,edema leg, DVT. Cardiovascular Low / high Bp, Raise3d Jugular veinpressure , parasternal heave , gallop rhythm , murmurs, pericardial rub ,hepatomegaly , cardiomegaly , basalcrepts . Respiratory Tachypnoea , accessory muscle use tobreath , Kyphoscoliosis , tracheal shift , dullness /resonance to percussion ,Bronchial breathing ,Wheeze , crepts , reduced / absent breath sounds atbase of lungs . 37. Physical Examination----- Breast any lump / mammography is better. Neurological muscle wasting , fasciculations , limb weakness, sensory loss ,cerebral signs if any . 38. Investigations RadiologyThe accepted cumulative dose of X ray radiation to which fetus can be exposed safely is estimated, ---5 rads.This is equivalent to n71 thousand X rays , 50 CTPAs , or 3o V/Q scan. It can be concluded that , for most of the common tests , exposure to radiation is minimal and lease likely to effect the fetus. In the first instance Xray chest is crucial to reach the diagnosis like pneumonia , pleural effusion , hydro /pneumothorax, tuberculosis and sarcoidosis . 39. Radiological Investigations---- V/Q scanning is essential to diagnose pulmonaryembolism , an acute life threatening condition. CTPA is still more important in PE when V/Q isshowing only an intermediate probability of PE , andthe clinical findings are in favor of PE. HR CT is needed to diagnose bronchiectasis andinterstitial lung diseases., could be avoided tillpuerperium , if the clinical outcome is not affected. . Although ct is l-safe for fetus but mother also carryan increased risk of carcinoma breast in pregnancy. Aradiation of 1 red can increase life time risk of breastcancer as high as 14 % in exposed women at 35 years ofage. CPTA Delivers 2-3.5 reds to each breast . 40. Investigations---- Lung Function Tests Forced Expiratory Volume in one Second (FEV1-)---egg, volume of air blown out in one second .Forced Vital Capacity ( FVC ),e.g. Total volume air thesubject is able to blow out in one effort ( man oeuvre)FEV1 / FVC ratio remain unchanged in pregnancy. Normal SpirometryFEV1, FVCand FVC1 / FVC ratio performed with simplehand held spirometry, if normal will exclude anyobstructive lung disease like asthma , cystic fibrosis ,bronchiectasis and COPD . 41. Lung Function Tests ------ Low FEV1 /FVC ratio < 70% low FEV1