SHORTNESS OF BREATH IN PREGNANCY AFSHAN HAMEED, MD, FACOG, FACC Health Sciences Clinical Professor Maternal Fetal Medicine & Cardiology Director Obstetrical Services & Quality Safety University of California, Irvine SOGH Annual Meeting, September 25 th , New Orleans
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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 Mortality Rate, California and United States; 1999-2013
Mat
erna
l Dea
ths
per 1
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00 L
ive
Birt
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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
• 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
=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