Objectives

At the end of the session the students should be able to List the different causes of breathlessness Explain the physiological changes in pregnancy

mimic cardiac diseases Plan management of a cases of breathlessness.

A 25 years Primigravida,at34 weeks, came with complain of breathlessness Differential diagnosis

Acute Respiratory tract infections,

such as pneumonia. A severe allergic reaction

(anaphylaxis) Asthma, which often causes

wheezing. A blockage in the respiratory

tract A blood clot or other blockage in

an artery in the lungs. A collapsed lung

(pneumothorax). MI Heart failure Pregnancy changes a woman's

circulatory 

Chronic Asthma. Chronic obstructive

pulmonary disease Interstitial lung

disease Cardiomyopathy Deconditioning Obesity Pulmonary

hypertension

Evaluation

Present History Cough/Fever/chest

pain /Swelling of leg/syncopal attack/Paroxysmal nocturnal dysponea/Orthopnea

Past history Rheumatic

fever/AsthmaDrug history

Examination General

Pallor/Cyanosis/Clubbing/JVP/edema

CVS Pulse/BP/Apex beat/Thrill Murmurs

Systolic – PAN ,LATE, EJECTION with thrill

Diastolic – with thrill RS

Crepitation/Ronchi

Investigations

Parameters JustificationHb% AnaemiaTLC,DC Respiratory infection /

Bacterial endocarditisSputum Gram stain,CultureX-ray Chest (using lead sheild)

PTB

ECG, ECHO Heart diseasePulmonary function test, ABG

Bronchial asthma

Multifetal gestation Polyhydramnios

General• Admission• Propped up position• O2 administration

Anaemia• Blood transfusion• Parenteral Iron• Oral

Cardiac failure/ Pulmonary edema

• Inj. Morphine 15mg IM• Inj.Frusemide 40mg IV• Tab.Digoxin0.5mg—

0.25mgCardiac Asthma• Inhalers• Tab.

Theophyolline100mg TDS

• Tab. Terbutaline 2.5 to 5 mg TDSObstetric Management

• Usually go into spontaneous labour• 1st stage-Intensive monitoring of mother and fetus• 2nd stage - Cut short using outlet forceps of vacuum• 3rd stage – Methylergometrine YES / NO

IE prophylactic regimens

• Inj. Ampicillin 2 gm i.m. / i.v.• Inj. Gentamicin 1.5 mg / kg (max

120mg)With in 30 min of procedureAfter that,

• Inj. Ampicillin 1 gm i.m. / i.v. 6 hours later

Pregnancy changes mimicking Cardiac Disease

Dysponea, decrease exercise tolerance, fatigue , syncope

Tachycardia, Shift of ventricular apex Loud S1

Systolic ejection murmurMammary souffle

Physiological and anatomical changes in CVS

Cardiac output Increases Tachycardia

Heart rate Increases Tachycardia

Stroke volume Increase Tachycardia

Blood volume Increases Tachycardia

Systemic Vascular resistance

Decreases Syncope

Pulmonary Vascular Resistance

Decreases

Elevated diaphragm Shifting of the apex beat

Complications

Maternal CCF IE Embolism Cardiomyopathy

Foetal Foetal distress IUGR Congenital heart diseases (3-5%)

Timings of cardiac failureTimings Reasons

5 weeks following conception Fetal cardiac activity start

5 months Maternal blood volume start increase

5 weeks before EDD Maternal blood volume maximum

5 hours after onset of labour Increase cardiac output

5 minutes after delivery of placenta

Shunting of utero-placental blood

5days after delivery Thromboembolism/Infection

5 weeks after delivery Cardiomyopathy

Causes of death in cardiac disease

Cardiac failurePulmonary oedemaPulmonary emboloismAcute rheumatic carditisSubacute bacterial endocarditisRupture of aneurysm

Clinical Classification (NYHA)• Class I

–Uncompromised–No limitation of physical activity

• Class II– Slight limitation of physical

activity• Class III–Markedly limitation of physical

activity• Class IV– Severely compromised

Predictors of cardiac complications• Prior heart failure, transient ischemic attack,

arrhythmia, or stroke.• Baseline NYHA class III or greater or

cyanosis.• Mitral valve area below 2 cm2

• Aortic valve area below 1.5 cm2

• Peak left ventricular outflow tract gradient above 30 mm Hg by echocardiography.

• Ejection fraction less than 40 percent. • The risk of pulmonary edema, sustained

arrhythmia, stroke, cardiac arrest, or cardiac death was substantively increased with one of these factors and even more so with two or more factors.

Risk• Group 1 0 – 1 %– ASD, VSD, PDA, MS NYHA I & II, Corrected

fallot’s tetralogy• Group 2a 5 – 15 %– MS NYHA III & IV, AS, Aortic coarctation

without valve involovement, uncorrected fallot’s tetralogy, Previous MI

• Group 2b– MS with atrial fibrillation– Artificial valves

• Group 3 25 – 50 %– Pulmonary hypertension, Marfan’s with aortic

involvement

Contraception

• Temporary method– Barrier method– Intrauterine contraceptive device (IUCD)– Progestrones

• Permanent method– Vasectomy– Tubectomy

Summary

Pregnant women with dysponea should undergo through evaluation for underlying cause

Most common heart disease is of Rheumatic originMost common maternal complication is heart failureVaginal delivery should be tried under epidural

analgesic.Caesarean section only for obstetrics indication. 2nd stage should be cut short.Inj. Methylergometrin is contraindicated Contraception- Barrier, Progesterone ,Vasectomy