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