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
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