Breathlessness in pregnancy c

BREATHLESSNESS IN PREGNANCY -C

Prof. M.C. Bansal.

MBBS.MS. MICOG . FICOG .

Founder Principal & Controller.,

Jhalawar Medical College & Hospital ,

Jhalawar ( Raj.)

Ex. P&C .MGMC and hospital,. Sitapura Jaipur

BREATHLESSNESS IN PREGNANCY.

Breathlessness ( Dyspnoea ) / shortness of breath /difficult, laboured , consciousness about taking breath is a common symptom during pregnancy.

May be related to physiological changes in cardio-pulmonary, haemopoetic system , increase in weight etc.

Degree of breathlessness---1. Orthopnoea-breathlessness when lying flat. 2. Paroxysmal Nocturnal Dyspnoea- sudden onset of

dyspnoea at night. 3. Dyspnoea on rest. 4. Dyspnoea-Mild , Moderate Extraneous.

CAUSES OF BREATHLESSNESS Breathlessness of cardiac origin—

Cardio- myopathies and congenital anomalies (surgically corrected or uncorrected ).

Breathlessness of Respiratory origin. Haematological---Anaemia. Drug induced—NFT , NSAIDs, Inhalers ,

Amiodarone . Psychological– anxiety , fear , Minor or

major illness. Metabolic—Acidosis / Alkalosis.

CARDIAC CAUSES OF MATERNAL DEATHS IN UK( TOTAL MATERNAL DEATHS, N=409.,CARDIAC, N =41 )

• Other Congenital ___2 • Unknown heart disease___2• Endocarditis _____3• Myocardiac infarction________5• Aortic Dissection________5• Peri Partum cardiomyopathy ______________7• Pulmonary hypertension_________________8• Myocarditis _____________________9• T0tal______________________________41

CARDIAC CAUSES OF BREATHLESSNESS IN PREGNANCY Cardiao-myopathies— 1. Peripartum cardiomyopathy. 2. Dilated cardiomyopathy. 3. Hypertrophic cardiomyopathy.

Congenital heart Disease. 1. Surgically corrected. 2. non corrected.

CARDIOMYOPATHIES Breathlessness caused by cardiomyopaty in

pregnancy mainly comprises three types---- 1, Peripartum., 2, Dilated 3, hypertrophic. Dilated and hypertrophic can effect any one

and at any time in pregnancy. Peripartum cardiomyopathy occurs mostly in

young women of Afro –Caribbean origin during last trimester or in the 1st 6 weeks of postpartum.

PERIPARTUM CARDIOMYOPATHY - occurring in 1 in 3000-15000 pregnancy. -Some form of viral myocarditis has been

postulated. -Maternal mortality is as high as 20% though

foetal outcome is good. -Management is to correct the impaired

systolic function of ventricles. -There is substantial risk of recurrence in

future pregnancy and permanent impairment of left ventricular function.

DILATED CARDIOMYOPATHY Condition is poorly tolerated in pregnancy. 7% maternal mortality . There is elevated risk of heart failure., to be

managed on same line of treatment as that for non pregnant women.

Angiotensin converting enzyme inhibitors are avoided as they cause renal agenesis in foetus.

HYPERTROPHIC CARDIOMYOPATHY Patient with hypertrophic cardiomyopathy

usually tolerate the increased load in pregnancy ,. as left ventricle adopts in a physiological way.

Women with murmur and increased gradient across the left ventricular flow may present with breathlessness for the 1st time in pregnancy.

There is no risk of sudden death and maternal mortality.

HYPERTROPHIC CARDIOMYOPATHY----- ECG, Ecogardiography trademill, genetic counselling are

done for diagnosis. Women with severe diastolic dysfunction develop

pulmonary congestion---leading to increased breathlessness and even pulmonary edema.

complete bed rest, B-blockers are continued and diuretics are added.

Atrial fibrillation is managed with low-molecular weight heparin and B- blockade . Cardioconversion may

be done after excluding thrombus in atrium by trans oesophagial echocrdigraphy.

prophylactic low forceps – vaginal delivery can be managed in as usual way for other cardiac patients., less chances of prolonged labour and blood loss.

BREATHLESSNESS ___CONGENITAL HEART DISEASE .

Classification of congenital Heart disease---- 1. Low risk lesion. Ventricular septal defect . Atrial septal Defect ( unoperated) coarctation Of aorta Teratology of fallot repaired 2. Moderate Risk lesion Mitral Stenosis Aortic Stenosis Fortan- type circulation 3. High Risk Lesion Marfan Syndrome Eisenmanger Syndrome

PREGNANCY RELATED RISK FOR WOMEN WITH CONGENITAL HEART DISEASE-----

Lesion Exclude before Pregnancy

Potential risk Recomonded Rx in preg & puerperium

Low Risk Lesion

1.Ventrcular septal defe3ct

Pulmonary arterial hypertension

Arrhythmias SABE

Antibiotic Prophylaxis foe SABE

2.Atrial septal defect (un operated )

Pulmonary arterial hypertensionVentricular dysfunction

Arrhythmia Thrombo prophylaxis if pt Is on complete bed rest

PREGNANCY RELATED RISK FOR WOMEN WITH CONGENITAL HEART DISEASE---LOW RISKLesion Exclude

Before pregnancy

Potential hazards

Recomonded Rx in preg., 7 PUERPARIUM

3.Coarctation (reported)

Re-coarctationAneurism formation at the site of operation.Associated Lesions— Aortic bicuspid valve ( with / with out stenosis / regurgitation , ascending atropathy , Systemic BP and Ventricular dysfunction

PIH Aortic dilatation/ dissection

C HF

Endocarditis

Low dose Asprin therapy

B-blockers to control BP

Elective LSCS as soon as foetal lung maturity obtainedAntibiotic prophylaxis.

PREGNANCY RELATED RISKS FOR WOMEN WITH CONGENITAL HEART DISEASE IN ------LOW RISK LESIONLesion Exclude

before pregnancy

Potential Risks

Recommended treatment In prig, puerperium

4.Tetralogy of Fallot

Severe Right Ventricular outflow tract obstruction , severe pulmonary obstruction ,right ventricular dysfunction, DiGeorge Syndrom

Arrhythmias

RVF

Endocarditis

Pre term delivery if RVF develop Antibiotics

PREGNANCY RELATED RISKS FOR WOMEN WITH CONGENITAL HEART DISEASE ------Moderate Risk Lesions

Lesion exclude Before Pregnancy

Potential Hazards

Recomonded Treatment in Preg , puerperium

1. Mitral Stenosis

Severe Stenosis Pulmonary Venous Hypertension

Atrial Fibrillation Thrombi-embolic PhenomenonPulmonary edema

Beta –Blockers

Low dose Aspirin Hospitalization in 3rd trimester .ThrmboprophylaxisAntibiotics

PREGNANCY RELATED RISKS TO WOMEN WITH CONGENITAL HEART DISEASE---MODERATE RISK LESIONSLesion Exclude

before Pregnancy

Potential Hazards

Recommended Treatment during Pregnancy

2. Aortic stenos is

Severe Stenosis ( peak pressure gradient on USG > 80 mmHg, ST segment depression ,symptoms)Left Ventricular dysfunction.

Arrhythmia

Angina

Hospitalization withThromboprophylaxis

Balloon aortic Valvotomy , Pre term LSCS By pass surgery carries 20% risk of foetal death.

Fontan –Type circulation

Ventricular dysfunction, Arrhythmias , Heart failure

Heart Failure Arrhythmia , thromboembolic ,Endocarditis

Low molecular Heparine& aspirin in whole preg, Antibiotics

PREGNANCY RELATED RISKS TO WOMEN WITH CONGENITAL HEART DISEASE -------

High Risk lesions

Lesions Exclude before Pregnancy

Potential Risks Recomonded Treatment in Preg, puerperium

Marfan Syndrome Aortic Root dilatation >4 cm

Type A Dissection of aorta

Beta—blockersElective LSCS at 35 weeks .

Eisenmanger syndrome Pulmonary arterial Hypertension

Ventricular dysfunction

Arrhythmias

30-50 % risk of maternal death

Arrhythmia Heart failure Endocarditis

Therapuetic MTP.

If pregnancy continues , CVs Monitoring, hospitalization , pulmonary vasodilators with O2 supplimentation.Cntnue same in puerperium

INDIVIDUAL CARDIAC LESION ----CAUSING DYSPNYEA 1. Ventricular Septal defect----A small

VSD with normal right sided pressures Puts no added risk to pregnancy .

Prophylactic antibiotics and care full ANC is that all needed. Paradoxical embolism ia not common in VSD with large pressure gradient across the defect . Large VSD with pulmonary HTN & Eisenmenger complex need special cardiac care.

INDIVIDIAL CARDIC LESION --- CAUSING DYSPNOEA 2. Unoperated Atrial Septal Defect---

Unrepaired ASD are well tolerate pregnancy , when pulmonary resistance is normal. Pre existing tendency to atrial fibrillation ---hypercoagulable state of pregnancy and potential right to left shunt increase the chances of paradoxical embolism., more so when intra thorasic pressure increases during active labour. This accident can also occur in cases of patent foramen ovale. There is definite role of prophylactic antilcoaglant therapy.

NDIVIDUAL CARDIAC LESION ---- CAUSING DYSPNOEA 3. Repaired Coarctation of Aorta----As majority of

pt get operated in childhood hence it puts no risk in pregnancy as long as there is no development of aneurism at the site of repair . This can be confirmed by MRI.

4. Repaired Teratology of Fallot ---Most common cynotic congenital heart disease ., once corrected one lives asymptomatic normal life . Pregnancy is well tolerated by such women.

one need not to emphasise to asses such patients thoroughly before planning pregnancy. , torule out and treat any decompensation before hand.

INDIVIDUAL CARDIAC LESION ----CAUSING DYSNOEA- 5. Fontan Type Circulation—These patient are

not cynosed . , but experience long standing low output circulation and risk of ventricular failure and atrial arrhythmias. They need long term ore warferin therapy and arte to be put on low molecular Heparin therapy as soon as pregnancy is planned or diagnosed. There is 30 % twice more risk of abortion as compared to normal pregnant women. Maternal outcome depends on functional capacity of ventricle , it is better when single ventricle is left. Advice to continue the pregnancy is given when there is no decompensation.

INDIVIDUAL CARDIAC LESION ---CAUSING DYSPNOEA- 6. Mitral Stenosis— Commonest rheumatic valvular disease

( corrected / uncorrected –compensated or decompensated )is diagnosed during ANC ,. More common in developing, over populated ,localities with poor sanitation, medical and health services.

it can remain silent till the 3rd decade., symptoms often develop during pregnancy as cardiac load increases . Congenital fusion of the commissures, parchute mitral valve or left atrial mixoma are other causes of mitral stenosis.

INDIVIDUAL CARDIAC LESION ---CAUSING ---DYSPNOEA—MITRAL STENOSIS----- Heamodynamic changes in pregnant women with

mitral stenosis include

Elevated left atrial , pulmonary ( venous and arterial ) pressures which flow across the mitral valve.

Maternal complications include pulmonary edema, pulmonary hypertension and right ventricular failure.

Tachycardia and dyspnoea may be precipitated by exertion , anxiety , anaemia, fever.this may decrease diastolic left ventricular filling time , further elevation of left atrial pressure there by decreased cardiac output.

The end result is biventricular failure., atrial fibrillation ,pulmonary edema and embolic phenomenon

MITRAL STENOSIS---- Clinical Presentation--- pregnant woman with MS may come

in state of failure of both left and right ventricles depending upon the degree of decompensation, duration and severity of valvular disease.

Symptoms of left ventricular failure are more common --- orthopnoea , paroxysmal nocturnal / exertional dyspnoea, hamoptesis.

Symptoms of right ventricular failure develop very late and include ascites and edema feet .

MITRAL STENOSIS---

careful cardiac examination specially for opening snap and a diastolic rumbling murmur with pre systolic accentuation in mitral area.

Elevated jugular venous pressure , hepatomegaly , loud P2 , right ventricular haeve in epigastric region support the diagnosis of MS.

Transthorasic Echocardiography helps in diagnosis as well as severity of cardiac dysfunction ,important to assess the success of percutaneous mitral valvuloplasty by baloon. It can be done safely in such women.

AORTIC STENOSIS--- Symptomatic AS is less common than MS in

pregnancy. Rheumatic AS is more common in developing

countries . Conge4nital AS secondary to membrane on bicuspid valve may also be seen, women is at risk of dissection of aorta related to hormonal changes on connective tissue in pregnancy.

Pressure gradient across aortic valve is responsible for haemodynamic changes in AS.

Increase in left ventricular systolic pressure leads to left ventricular hypertrophy and later on left ventricular failure and diminished coronary flow.

AORTIC STENOSIS---- Increase in stroke volume and fall in peripheral

resistance in pregnancy are responsible for increase in pressure gradient across Aortic valve. Increase demand to increase Cardiac output in late pregnancy and labour ---women with AS develops symptoms of left ventricular failure.

Clinical Presentation depends on degree of stenosis .woman with aortic valve area > 1.0cm tolerate pregnancy well. Women with more severe stenosis will develop left ventricular failure., manifesting as dyspnea and pulmonary edema. Left ventricular impulse is sustained and displaced laterally towards maxilla. A systolic ejection murmur is heard along right boarder of sternum and radiates to neck in carotid area.

AORTIC STENOS IS====

A systolic ejection click may be heard. 4th heart sound may be present indicating abnormal diastolic function too.

Presence of slow rising pulse and narrow pulse pressure (difference between systolic and diastolic pressure indicates significant aortic Stenosis.

Diagnosis can be confirmed by echocardiography and aortic gradient and area of aortic valve can be calculated by dopller flow study. Patient with < 55% ejection flow are at risk of left ventricular failure . fetus of mother with congenital AS is at risk (15%) of developing same cardiac anomaly.

MARFAN SYNDROME ( HIGH RISK LESION )=== Pregnant women carries 1% risk of type

A aortic dissection. But it is ten time more when Aortic root

diameter is > 4cm. Its repair carries 22% maternal mortality., such women should be advise against going for pregnancy.

Women who become pregnant and want to continue it , should be kept on B –blockers and under go elective LSCS on fetal maturity.

Patients should also be aware of the 50% recurrence rate.

.

EISENMENGER SYNDROME ( HIGH RISK LESION )---- Pulmonary hypertension of any reason carries a

high maternal risk. Patient with Eisenmenger complex carries > 50%

mortality. Women should be advised not to become

pregnant. In the event of pregnancy MTP in early weeks (6-

10 ) is indicated . Male partner should be vasectomies / laparoscopic

sterilization can be done with explained risk. The progesterone sub dermal implant

contraceptive is as effective as sterilization and safe also.

CARE IN PREGNANCY ANC Such women once become pregnant or

as soon as heart disease is diagnosed for the 1st time in ANC should be referred to tertiary care centre with 24hrs available facility of cardiologist, high risk pregnancy care , cardiac anesthetist , parental medicine , and well equipped premature NICU.

Patient and her husband should be involved in decision making and let them understand the ‘minimal risk approach’

Generous approach to hospitalization as and when needed and more so in last trimester. Patient confined to bed rest should receive Low molecule Heparin as prophylaxis against risk of thrombi embolism.

ANTI COAGULATION IN PREGNANCY AND LABOUR---- Pregnant women with congenital heart disease ,

Atrial arrhyhmias , prolonged bed rest Are at 6 fold increased risk of thromboembolism in pregnancy and 11fold more in puerperium.Therefore achieving thorough anticoagulation is more important in such cases.

Anti coagulation therapy also carries maternal fetal complications. Warfare crosses the placenta and carries more risk to fetus hence not recommended.

Heparin does not cross the placenta hence safe .

Strict monitoring of dose and regular laboratory test must bed done .