shortness of breath in pregnancy
TRANSCRIPT
SHORTNESS OF BREATH IN PREGNANCY
AFSHAN HAMEED, MD, FACOG, FACCHealth Sciences Clinical Professor
Maternal Fetal Medicine & CardiologyDirector Obstetrical Services & Quality Safety
University of California, IrvineSOGH Annual Meeting, September 25th, New Orleans
MATERNAL MORTALITYCHILD HEALTH USA 2013
11.1
7.7
10.0
14.6
11.8 11.7
14.0
7.47.3
10.9
9.7
11.6
9.2
6.2
16.9
8.9
15.1
13.1
12.19.99.9
9.8
13.3
12.7
15.5 16.916.6
19.3
19.9
22.0
0.0
3.0
6.0
9.0
12.0
15.0
18.0
21.0
24.0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Year
California Rate
United States Rate
Maternal Mortality Rate, California and United States; 1999-2013
Mat
erna
l Dea
ths
per 1
00,0
00 L
ive
Birt
hs
HP 2020 Objective – 11.4 Deaths per 100,000 Live Births
SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality for California (deaths ≤ 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99). United States data and HP2020 Objective use the same codes. U.S. maternal mortality data is published by the National Center for Health Statistics (NCHS) through 2007 only. U.S. maternal mortality rates from 2008 through-2013 were calculated using CDC Wonder Online Database, accessed at http://wonder.cdc.govonMarch 11, 2015. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, March,
2015.
HOW DID THE WOMEN WHO DIED PRESENT?ONLY 2 WOMEN ENTERED PREGNANCY WITH KNOWN CVD
SYMPTOMSShortness of breathWheezing Palpitations Edema Chest painDizziness Extreme fatigue
• Prenatal period: 43%• Labor and delivery: 51%• Postpartum: 80%
ABNORMAL PHYSICAL EXAMINATION
HTN >140/90 mm Hg (64%)
Tachycardia >120 bpm (59%)
Crackles, S3 or gallop rhythm etc. (44%)
O2 <90% (39%)
Hameed A, Lawton E, McCain C, et al. Am J Obstet Gynecol 2015;213:379
SHORTNESS OF BREATH
• Abnormal or uncomfortable breathing in context of what is normal for a person according to his or her level of fitness and exertional threshold for breathlessness
• 75% women experience breathlessness at some point in pregnancy
Physiologic changesCardiopulmonary system
Hematologic changes
Shortness of breath Signs and Symptoms of Pregnancy that mimic
Cardiopulmonary disease
PLASMA VOLUME IN PREGNANCY
Pitkin RM Clin Obstet Gyn 1976;19:489
Robson et al Am J Physiol 1989;256:H1060
Stroke volume x heart rate = cardiac output
CARDIAC OUTPUT IN PREGNANCY
PREGNANCY -HYPERCOAGULABLE STATE
• Increase in:• Fibrinogen• VII, VIII, IX, X, XII• Von Willebrand factor• Activated protein C
resistance• Plasminogen activator
inhibitor• Decrease in:
• Protein S
Increased thrombin generation
Decreased anticoagulation
Decreased fibrinolysis
TOTA
L LU
NG
CAPA
CITY
=42
00 M
L
RESIDUAL VOLUME=1000ML
RESIDUAL VOLUME=800ML
ELEVATION OF DIAPHRAGM
NONPREGNANT GRAVID AT TERM
FUNCTIONAL RESIDUAL CAPACITY=1700 ML
EXPIRATORY RESERVE VOLUME=700 ML EXPIRATORY RESERVE
VOLUME=550 MLFUNCTIONAL RESIDUAL CAPACITY=1350ML TO
TAL
LUN
G C
APAC
ITY=
4000
ML
TV=450TV=600
VC=3200 VC=3200IRV=2050 IRV=2050
IC=2500 IC=2650
CHANGES IN LUNG VOLUMES
20% increase in oxygen consumption15% increase in the maternal metabolic rate
40% increase in tidal volume40-50% in resting minute ventilation
HYPERVENTILATIONPaO2PaCO2
MILD RESPIRATORY ALKALOSIS
ARTERIAL BLOOD GASESIN PREGNANCY
Lim VS et. al. Am J Physiol 1976;231(6):1764
Pregnant Non-pregnant
pH 7.40-7.45 7.39-7.41
pCO2 28-32 mm Hg 37-43 mm Hg
pO2 95-105 mm Hg <90 mm Hg
HCO3 18-31 mEq/L 20-22 mEq/L
Shortness of Breath in
Pregnancy
Pulmonary Disease
Pregnancy
Cardiac Disease
Others
LUNGSPulmonary embolism
AsthmaCOPD
Pneumonia
HEARTHeart failure
IschemiaValve disease
CardiomyopathyPericarditisArrhythmia
OTHERSAnemia
Acidosis DKAAspirin poisoningMusculoskeletal
PsychogenicTuberculosisSarcoidosis
LymphangiomymatosisCystic fibrosis
TumorTrauma
•PULMONARY ADAPTATONS
•CARDIOVASCULAR ADAPTATIONS
IS IT THE PREGNANCY
?
• PULMONARY• CARDIAC• OTHER
DISEASE STATE
Pulmonary EmbolismPulmonary Edema
SHORTNESS OF BREATH DURING PREGNANCY: COULD A CARDIAC FACTOR BE INVOLVED?
• Pregnancy may induce or unmask myocardial dysfunction• 30 pregnant women with SOB vs. asymptomatic pregnant
controls• 31.8 + 4.9 years• GA 38.2 + 2.8 weeks
Goland S. Clin Cardiol. 2015;38(10):598. Epub2015 Sep 28
SOB NormalSeptum 10.1 + 1.1 mm 8.9 + 0.9 mm P <0.001
Posterior wall 9.1 +1.1 mm 8.9 + 0.9 mm P <0.01
Short E-wave decelerationtime
158 +50 187 +37.6 P <0.01
26.8 + 6.2 mm Hg
19.0 +6.5 mm Hg P <0.01
CASE PRESENTATION
• 28 year old G2P1 @ 28 weeks presents with shortness of breath
CASE PRESENTATION
• 28 year old G2P1 @ 28 weeks presents with shortness of breath
• What immediate information do you need?1. General appearance, vital signs and oxygen
saturations, physical examination?2. Information on rapidity of onset of shortness of
breath ?3. Are there associated symptoms ?4. Detailed history with associated medical
conditions
CASE PRESENTATION
• 28 year old G2P1 @ 28 weeks presents with shortness of breath
• What immediate information do you need?1. General appearance, vital signs and
oxygen saturations, physical examination?
2. Information on rapidity of onset of shortness of breath ?
3. Are there associated symptoms ?4. Detailed history with associated medical
conditions
LUNGSPulmonary embolism
AsthmaCOPD
Pneumonia
HEARTHeart failure
IschemiaValve disease
CardiomyopathyPericarditisArrhythmia
OTHERSAnemia
Acidosis DKAAspirin poisoningMusculoskeletal
PsychogenicTuberculosisSarcoidosis
LymphangiomymatosisCystic fibrosis
TumorTrauma
•PULMONARY ADAPTATONS
•CARDIOVASCULAR ADAPTATIONS
IS IT THE PREGNANCY
?
• PULMONARY• CARDIAC• OTHER
DISEASE STATE
Pulmonary EmbolismPulmonary Edema
CASE PRESENTATION
• 28 year old G2P1 @ 28 weeks presents with shortness of breath
• Vital signs are stable with oxygen saturation >95%
•Next steps?
HISTORY: SHORTNESS OF BREATH
• Sudden vs. insidious• Mild /severe
• Exercise capacity• Ability to perform ADL
• Aggravating and relieving factors• Associated symptoms
• Chest pain• Palpitations• Fevers• Cough• Excessive fatigue
HISTORY: SHORTNESS OF BREATH
• Underlying medical conditions• Asthma• Diabetes• Anemia• Thyroid disease
• Smoking• Recent event ?
• Long travel• Leg trauma
• Recent sick contact/travel exposure
HISTORY
Exertional Cardiac or pulmonary
At rest Cardiac or pulmonaryMetabolic
Orthopnea, paroxysmal nocturnal dyspnea
Congestive heart failureCOPD
Allergies, wheezing Asthma
Hypertension Left ventricular hypertrophyDiastolic heart failure
Anxiety HyperventilationPanic attacks
Medications Beta blockersACE
Other medical conditions Anemia
Smoking Emphysema, chronic bronchitis
DIAGNOSTIC TESTINGSHORTNESS OF BREATH
BNP LEVELS IN NORMAL PREGNANCY
B-TYPE NATRIURETIC PEPTIDE
Increases natriuresisand diuresis
Relaxes vascular smooth muscle
Inhibits renin-angiotensinaldosterone system
BNP LEVELS IN NORMAL PREGNANCY HAMEED ET. AL. 2009
• Median BNP values followed longitudinally in normal healthy pregnancies are:
• 1st trimester: 19.5 pg/mL• 2nd trimester: 18.0 pg/mL• 3rd trimester: 26.5 pg/mL• Postpartum: 18.5 pg/mL
• No statistically significant difference in BNP levels throughout pregnancy and puerperium
• Statistically significant difference in BNP levels between non-pregnant and normal healthy pregnant women overall
RADIATION DURING PREGNANCY
• The majority of the exposure to the fetus from radiation to the mothers chest is due to scattered radiation
• ~ 5% of the radiation absorbed by the tissue directly in the X ray beam
• Radiation to the fetus from nuclear medicine procedures is primarily due to distribution of the radioisotope to the bladder or to the placenta.
RADIATION EXPOSURE TO THE FETUSCARDIAC PROCEDURES
Radiologic Examination Fetal Dose (mGY)Chest X-ray (two views) 0.0005-0.01CT Chest or PulmonaryAngiogram
0.01-0.66
Pulmonary digital subtraction angiography
0.5
Tremblay E et. al. Radiographics 2012;32:897-911
Annual background radiation = 1.1-2.5 mGY
RADIATION & TERATOGENICITY
Gestational Age Effects Estimated Threshold DosePRE IMPLANTATION (0-2 weeks after conception)
Embryonic death(all or none)
50-100 mGy
ORGANOGENESIS (2-8 weeks afterconception)
Congenital anomalies (skeleton, eyes, genitals)Growth restriction
200 mGy
200-250 mGy
8-15 WEEKS Severe intellectual disability (high risk)Microcephaly
60-310 mGy25 IQ points loss/1,000mGy200 mGy
16-25 WEEKS Severe intellectualdisability (low risk)
250-280 mGy
Patel SJ et. al. Radiographics 2007;27:1705-22
COMMON SCENARIOSSHORTNESS OF BREATH
MRS. CARLOS
• 33 year old G3P2002 @ 15 weeks walk in to the OB triage gasping for air
• Moderate respiratory distress• Vital signs
• BP 110/70 HR 104 RR 32 afebrile O2 saturations 89% RA• Physical examination
• Nasal flaring• Heart: RRR tachycardia no murmur• Chest: bilateral expiratory wheezes with decreased breath
sounds
MRS. CARLOS
• History of asthma since childhood on steroid inhaler• PEFR 40% of personal best
PEAK FLOW METER
Normal PEFR >350-400 L/minAbnormal <200 L/min
Mark on the PFM•Personal best•80% lower•50% lower
RESCUE THERAPYTRIAGE OF AN ASTHMA PATIENT
• Symptoms or 20% decrease in PEFR• PEFR <50% = Severe attack• Beta agonist
• 2-6 puffs 20 minutes apart• 2 nebulized treatments every 20 min
PEFR >80% stay homePEFR 50-79% -start oral steroids+office visitPEFR <50% - ER
• Oxygenation - Supplemental O2• Hypoxemia pO2 < 60 mm Hg (<90%)
• Ventilation• Hypercapnia CO2 > 40 mm Hg
• ABG • CXR - individualize
• Fever, CP, WBC, immunosuppressed• EKG - individualize
NHLBI Expert Panel Report 2007
ASTHMA: MANAGEMENT
• Beta agonists• MDI 4 puffs q 20 min x 4• Nebulizer 2.5 - 5 mg q 20 min x 3
• Anticholinergics• MDI 8 inhalations q 20 min• Nebulizer 500 microgram q 20 min x 3
NHLBI Expert Panel Report 2007
ASTHMA: MANAGEMENT
• Glucocorticoids• Severe attack• Methylprednisolone >> prednisone x 10-14 days
• Magnesium sulphate• Severe attack in non-responders 2 gm IV
• Antibiotics +/-• Most infections are viral
NHLBI Expert Panel Report 2007Cochrane database syst rev 2001
ASTHMA: TREATMENT
MRS. SMITH
• 40 year old G1P0 @ 32 weeks presents with sudden onset of shortness of breath when she woke up in the morning. She noticed sharp pains in the chest when she takes a breath
• Mild respiratory distress• Vital signs
• BP 110/70 HR 98 RR 26 afebrile O2 saturations 90% RA• Physical examination
• Heart: RRR no murmur• Chest: bilateral good breath sounds with occasional ronchi• Extremities: Right leg appears a little edematous
§ SYMPTOMS (tachypnea, tachycardia) 80%§ ABG (hypoxia, A-a gradient) 80%
§CXR (70%)
§EKG (non-specific changes 80%, S1Q3T3 15%)§ Spiral CT (sensitivity 85%, specificity 95%)§ VQ scan (sensitivity 67%, specificity 94%)§ Pulmonary angiogram- GOLD STANDARD§ MR angiogram§ Echocardiography
PULMONARY EMBOLISM
PIO2=160mm
PO2=149mm
PAO2=97mmPACO2=42mm
PVO2=40mmPVCO2=46mm
PaO2=90mmPaCO2=40mm
Inspired Oxygen >Alveolar Oxygen >Arterial Oxygen
A (alveolar) – a (arterial) GRADIENT
• ALVEOLAR (PAO2) = 7 x FIO2 (%) – PaCO2 X 1.25
=7 x 21 - (CO2 X 1.25)= 147 – 40 x 1.25=147 – 50 = 97 mm Hg
• ARTERIAL (PaO2) from ABG
• A-a gradient = 20 mm Hg in supine & 15 mm Hg in sitting position
• A-a = 2.5 + 0.21 x age in years
PULMONARY EMBOLISM
EKG CHANGESS1,Q3,T3
TachycardiaRV strain
SPIRAL CT
A. MULTIPLE BILATERAL PERFUSION DEFECTS
B. VENTILATION SCAN IS NORMAL
Pulmonary Embolism
Pulmonary angiogram showing almost total occlusion of the pulmonary arteries to the right middle and lower lobes
INHERITED THROMBOPHILIAS
Thrombophilia %VTE in Pregnancy
RR/OR Probability (-) history
Probability (+) history
FVL (homo) <1 25.4 1.5% 17%
FVL (hetero) 40-44 6.9 0.26% 10%
PGM (homo) <1 na 2.8 >17PGM (hetero) 17 9.5 0.37 >10FVL +PGM <1 84 4.7 na
ATIII def 1-8 119 3-7.2 >40
Protein S def 12.4 2.4 <1 6.6
Protein C def <10 8 0.8-1.7 na
MRS. WILLIAMS
• 28 year old G1 @ 36 weeks presents with shortness of breath for 3 days. She reports subjective fevers and night sweats. She was not able to keep anything down since this am
• Flushed with moderate respiratory distress• Vital signs
• BP 90/50 HR 110 RR 30 T 100.8 F O2 saturations 89% RA• Physical examination
• Heart: RRR tachycardia no murmur• Chest: bilateral ronchi and mild wheezes with decreased
breath sounds
PNEUMONIA• Staphylococcus
• Pleuritis, CP, consolidation without air bronchograms• Mycoplasma, Legionella, Chlamydia
• Gradual onset, less ill, patchy/interstitial infiltrates• Severity of CXR findings out of proportion to the
symptoms• MACROLIDES, FLOUROQUIN
• Listeria• AMP, MACROLIDES, TETRA, SULPHA
• Viral – 40-50% mortality • Influenza – amantadine, ribavirin• Varicella – acylovir• PCP – trimethoprim-sulphamethoxazole
• Fungal - cocci
MANAGEMENT OF PNEUMONIA
• Hospital admission• ABGs, CXR, sputum GS, sputum and blood
cx +/- Cold agglutinins and Legionella titres• Oxygen supplementation• Empiric antibiotics
• Third generation cephalosporins – ceftriaxone or cefotaxime + macrolide
• May change after results available• Continue for 10-14 days
PNEUMONIA
COMPLICATIONS
• Preterm delivery 4 - 40%• IUGR• Perinatal death
• 95% cases are due to inhalation
• TB bacilli multiply in alveolar macrophages>>> to regional lymph nodes>>> lymphohematogenous spread to various organs
• 10% develop TB • first 2 years• HIV + increase risk
Latent Tuberculosis
TUBERCULOSIS
SARCOIDOSIS
LYMPHANGIOMYOMATOSIS
• Disease of young women• Proliferation of smooth muscle in
• Pulmonary/ mediastinal/ retroperitoneal lymphatics• Pulmonary vessels
• Small airways• SYMPTOMS:
• Shortness of breath (pneumothorax, chylothorax)• Rx:
• ? Related to estrogen• Oophorectomy• Lung transplantation
• Bilateral infiltrates on CXR – consider cardiac unless proven otherwise
• New onset asthma in pregnancy-consider cardiac disease
PEARLS
RESTING MINUTE VENTILATION (TIDAL VOLUME X RESPIRATORY RATE)
• MOST STRIKING PULMONARY CHANGE• >50% at term• 40% increase in tidal
volume
• 20% increase in the oxygen consumption