Dyspnoea in pregnancy SEMINAR undergrad.pptx

Undergraduate Medical Knowledge

1. Dyspnoea in pregnancy Presented by cadets: Aung Khaing Moe Aung Htoo Set Aung Bhone Myint Myat Aung Myin Tun 27/5/2024 (Monday) 1 Supervisor: Major Thaung Tan Soe

2. Contents Introduction Diagnostic Approach to Dyspnoea Respiratory Causes Cardiac Causes Haematological Causes Dyspnoea in Pregnancy 2

3. 3 Introduction Presented by: 5719 Aung Bhone Myint Myat

4. Introduction 4 Dyspnoea is a common complaint in pregnant women. O ccur due to the physiological changes or cardio-respiratory disease s. P regnant women may experience dyspnoea during their pregnancy becoming symptomatic before 20 weeks’ gestation and the incidence increased until about 30 weeks’ gestation. Awareness on complications of pregnancy producing dyspnoea in the previously well patient. 

5. 5 Diagnostic Approach to Dyspnoea

6. 6 Acute/Subacute Breathlessness Sudden Insidious Hours/Days Pleuritic pain Crushing central pain Fever, cough, green sputum Tightness, atopy/pets Weight loss, cough Dry cough Haemoptysis, swollen leg Unilateral absent breath sounds Crackles in chest Normal breath sounds, ↑JVP Signs of consolidation, rigors Wheeze Wheeze Unilateral dullness, clubbing Crackles, night sweats Fine inspiratory crackles Pulmonary embolus/ infarct Pneumothorax MI with pulmonary oedema Large pulmonary embolus Pneumonia Acute bronchitis New onset of asthma Malignant pleural effusion Tuberculosis Interstitial lung disease Time course Other history Examination and other findings Diagnosis Duration

7. 7 Chronic Breathlessness Occurs at rest/night Exertional Angina, frothy sputum Tightness, atopy/pets Paraesthesia, ‘can’t get enough air’ Smoker Dry cough Crackles, peripheral oedema Wheeze Carpopedal spasm, anxiety Hyperinflation Fine inspiratory crackles Congestive cardiac failure Asthma Hyperventilation COPD Interstitial lung disease Time course Other history Examination and other findings Diagnosis Duration

8. Causes of Dyspnoea in Pregnancy 8 Physiological Dyspnoea Respiratory Causes Cardiac causes Haematological Causes

9. Respiratory Causes 9 Presented by: 5718 Aung Htoo Set

10. Physiological Dyspnoea 10 Reduced total lung capacity by 5% due to elevation of enlargement of uterus Reduced total pulmonary resistance due to progesterone effect Pregnancy is in a state of respiratory alkalosis

11. Causes of Dyspnoea in Pregnancy 11 Common Respiratory Causes in Pregnancy Asthma Pneumonia Pulmonary embolism

12. Asthma 12 Increasing with 2-4% of pregnant women affected worldwide Exacerbations mostly occur in women with severe asthma than mild asthma and most episodes occur between 24 and 34 weeks of pregnancy Systematic reviews report FGR is more common in women with symptomatic asthma than in non-asthmatic women Prolong maternal hypoxia can lead to FGR and fetal brain injury

13. Asthma 13 Parenteral steroid cover maybe needed for those who are on regular steroid , regular medication should be continued throughout labour Bronchoconstrictor such as ergometrine or Prostaglandin F2alpha should be avoided in women with severe asthma Life threatening complications include pneumothorax, cor -pulmonale, respiratory failure

14. Features of life threatening asthma 14 Peak expiratory flow rate<35% of predicted Po2<8kpa Pco2>4.6kpa Silent chest Bradycardia Arrhythmia Hypotension Exhaustion confusion

15. Management 15 Fetal growth scan Consultation with physician or chest physician Continuous asthma treatments (beta agonists, steroids)

16. Pneumonia 16 Pneumonia that occurs during pregnancy is called maternal pneumonia Begins with common cold or flu, which then spread to the lungs Can be life threatening if untreated Community acquired pneumonia is the most common form of pneumonia in pregnancy, with Streptococcus pneumoniae, H-influenzae, Mycoplasma pneumoniae Neonatal effects of pneumonia in pregnancy include low birth weight and increased risk of preterm birth

17. Pneumonia Warning Signs 17 Respiratory rate >30/min Hypoxaemia;pO2<7.9kPa on room air (10.5-13.5) Acidosis; pH<7.3 Hypotension Disseminated intravascular coagulation Elevated blood urea Evidence of multiple organ failure

18. Management 18 FBC, Sputum C&S Chest X-ray, ECG Appropriate antibiotics (penicillin and cephalosporin is the first choice)

19. Pulmonary Embolism 19 Leading cause of maternal death in developing countries DVT in the leg or in the pelvic is most likely the cause of Pulmonary embolism Clinical features depend on the size of the embolus and preceding health status of the patient Classical symptoms of massive pulmonary embolism are sudden collapse with acute chest pain and air hunger Death usually occur in short time from shock and vagal inhibition

20. Signs and symptoms of pulmonary embolism 20 Tachypnoea (>20 breaths/min) Dyspnoea Pleuritic chest pain Tachycardia(>100bpm) Haemoptysis Rise in temperature

21. Management 21 Chest x-ray ECG Arterial blood gas D-dimer Doppler Ultrasound Lung scan (ventilation and perfusion scan or V/Q scan) Treatment with unfractionated heparin

22. Tuberculosis 22 It is uncommon in pregnancy If it is diagnosed and treated appropriately in the first 20 th week, there is no adverse effect on pregnancy. If treatment is inadequate or delay, there is increased risk of prematurity and IUGR.

23. Clinical Features 23 Cough Fever Haemoptysis Weight loss Chest pain Night sweat

24. Management of TB in pregnancy 24 Respiratory physician and microbiologist involvement is essential. A minimum of 6 months course of treatment is required. A typical treatment regime of pulmonary TB Initial phase of therapy with isoniazaide , rifampicin, ethambutol,+/- pyrazinamide for 2 months Continuous phase of 4 months of isoniazaide and rifampicin

25. Cardiac Causes 25 Presented by: 5716 Aung Khaing Moe

26. Contents 26 Haemodynamic changes during pregnancy Classification of heart disease in pregnancy Effects of heart disease on pregnancy and pregnancy on heart disease NYHA classifications and Toronto risk markers for maternal cardiac events Pre-pregnancy preparations Management outlines of heart disease in pregnancy

27. Haemodynamic Changes during Pregnancy 27 Parameters Nonpregnant Pregnancy near term Change Cardiac output (L/min) 4.5 6.26 +40% Stroke volume 65 75 +27% Heart rate (per minute) 70 85 +17% Blood pressure Unaffected or mid-pregnancy drop of diastolic pressure by 5-10 mm Hg Venous pressure 10 cm (femoral) 20-25 cm (water) +100% Colloid oncotic pressure (mm Hg) 20 18 -14% System vascular resistance (SVR) _ _ -21% Pulmonary vascular resistance (PVR) _ _ -34% Normal pregnancy is associated with significant haemodynamic changes. These may not be tolerated in women with heart disease.

28. Classification of Heart Diseases in Pregnancy 28 Rheumatic valvular heart disease Bacterial endocarditis Cardiomyopathy (Peripartum cardiomyopathy) Cardiac arrhythmia Ischaemic heart disease Congenital heart disease

29. Effects of Heart Diseases on Pregnancy 29 Severe heart disease is associated with preterm labour and with IUGR. Cyanosis and poor functional capacity are indicators of significant maternal and fetal risk.

30. Effects of Pregnancy on Heart Diseases 30 The physiological changes During labour, cardiac output rises even higher during contractions but falls again between contractions. There is also a significant rise after delivery. In cases of heart disease, may result in considerable myocardial compromise

31. Effects of Pregnancy on Heart Diseases 31 Left heart failure, as pulmonary oedema, may present early in pregnancy in those with moderate or severe disease. In mitral valve disease, third stage and puerperium are particularly dangerous due to the increasing circulatory volume. Infective endocarditis is a significant risk indicating the need for antibiotic prophylaxis during labour.

32. NYHA Classification of Heart Disease 32 (Depending upon the Cardiac Response to Physical Activity) Grade-I Uncompromised and no limitation of physical activity Grade-II Slightly compromised with slight limitation of physical activity. The patients are comfortable at rest but ordinary physical activity causes discomfort. Grade-III Markedly compromised with marked limitation of activity. The patients are comfortable at rest, but discomfort occurs with less than ordinary activity. Grade-IV Severely compromised with discomfort even at rest. Limitation: This classification has considered the symptoms only but not the anatomical type and severity of pathology. It does not predict pregnancy outcome.

33. Toronto Risk Markers for maternal cardiac events 33 Markers 1 Prior episode of heart failure, arrhythmia, or stroke 2 NYHA Class >II or cyanosis 3 Left heart obstruction 4 Reduced left ventricular function (EF <40%) 0 predictor: risk of cardiac event is 5% 1 predictor: risk of cardiac event is 37% >1 predictors: risk of cardiac event is 75%

34. Pre-pregnancy preparations 34 Consultation with obstetrician and cardiologist Blood Pressure management Medication review Lifestyle adjustments Specialized care Risk factor identification Comprehensive care plan

35. Management outline 35 Antenatal Intrapartum Postpartum

36. Antenatal Management 36 Diagnosis of heart disease may be made during antenatal visit Advise to book for AN care as early as possible Take detailed booking history Access cardiac status according to NYHA grading Review all available documents including investigation results/ Physician’s note Arrange/ organize to have joint care Prescribe iron and vitamins Lifestyle modifications Treat dental sepsis effectively (if present)

37. Antenatal Management 37 AN care visit schedule should be in accordance with patient’s condition rather than routine schedule (may need more frequent visit) Arrange to have serial growth scan Arrange paediatrics visit for counseling Consider hospital admission if any symptoms develop or any deterioration Advise admission for antenatal rest if she has NYHA class III and IV Counseling regarding sterilization based on medical ground and/or obstetric indication Wait for spontaneous onset of labour (rather than induction)

38. Antenatal Management 38 Aiming for easy vaginal delivery Consider CS if obstetric indications present Cardiac indications of cesarean delivery Coarctation of aorta Aortic dissection or aneurysm Aortopathy with aortic root >4cm Warfarin treatment within two weeks

39. Intrapartum Management 39 The aim should be to make the labour as easy and non-stressful as possible. Prolonged labour is physically and emotionally draining and increases the risk of infection. The patient should labour in a propped-up, comfortable position. (lithotomy position should be avoided)

40. Intrapartum Management 40 Good analgesia is essential in order to avoid the tachycardia associated with labour pain. It is now standard practice to give antibiotic prophylaxis to protect against the dangers of bacterial endocarditis in women with structural cardiac lesions. (IM Ampicillin and Gentamicin is recommended.) Shorten second stage Avoid ergometrine in third stage

41. Postpartum Management 41 Postnatal follow up Postnatal check by obstetrician Contraception – IUCD is contraindicated for Valvular heart disease Low dose COC and barrier methods can be used Progesterone inj , progestogen only pills, implants can be given Sterilization Refer back to Cardiologist

42. Summary of Common Cardiac Diseases in Pregnancy 42 Signs and Symptoms Provisional Diagnosis Management Third trimester of pregnancy Physiological Diagnosis of exclusion ECG: sinus tachycardia DOE (NYHA 3,4) Orthopnoea, PND, palpitation, chest pain Past history of cardiac diseases Pulse: tachycardia, abnormal rhythms Enlarged heart Heart murmur Basal crepitation Oedema Heart Failure due to: Congenital Heart Diseases Peripartum cardiomyopathy Rheumatic Valvular Heart Diseases ECG Echocardiogram CXR (only if indicated) Oxygen 4 5° position IV Morphine IV Laxis Seek senior review Consultation with cardiac team

43. Haematological Causes 43 Presented by: 5720 Aung Myin Tun

44. Haematological causes 44 Physiological Anaemia Hereditary causes (Thalassaemia, Sickle cell Haemoglobinopathy, Haemolytic anaemia) Acquired causes (Nutritional-Iron Deficiency Anaemia, Folate deficiency, Vit B12) Anaemia due to bone marrow failure Anaemia secondary to inflammation, chronic disease, malignancy Due to blood loss Acquired haemolytic anaemia

45. Physiological anaemia 45 Maternal plasma volume increase by about 40-50% RBC volume increases by 20% Relative fall in haemoglobin and haematocrit Marked demand of extra iron during pregnancy especially in second half Adequate diet cannot provide extra demand of iron There is also associated low serum iron, increased iron binding capacity and increased rate of iron absorption. Thus pregnancy is “Iron deficiency state”.

46. Anaemia in pregnancy 46 During pregnancy(factors which lead to development of anaemia) Increased demand of iron Diminished intake of iron Diminished absorption Disturbed metabolism Pregnant health status Excess demand

47. Anaemia in pregnancy 47 The global problem, 2011 WHO estimated the prevalence of anaemia in pregnant women to be 38% and 29% in all women of reproductive age. Defined by low haemoglobin level of less than 110 g/L Iron deficiency anaemia is the commonest cause leading to 50% of cases of anaemia Other causes include deficiency of macronutrients such as folate and vitamin B12, malaria, tuberculosis, and HIV, malignancies

48. Effects of anemia on pregnancy 48 Maternal High incidence of pregnancy complications (PIH, Abruptio placentae, Preterm labour) Predisposed to infections like (UTI, puerperal sepsis) Increased risk to PPH Subinvolution of uterus Lactation failure Maternal mortality due to CHF Cerebral anoxia Sepsis Thrombo-embolism

49. Effects of anemia on pregnancy 49 Fetal Miscarriage Preterm birth IUGR IUFD Low APGAR at birth More susceptible for anemia and infections Higher perinatal morbidity and mortality

50. Iron deficiency anemia 50 Symptoms Lassitude and fatigue or weakness may be the earliest manifestations Anorexia and indigestion; palpitation caused by ectopic beats, dyspnoea Examination Pallor of varying degrees; evidences of atrophic glossitis, stomatitis and angular cheilitis Edema of legs Soft systolic murmur may be heard in the mitral area Koilonychia

51. Iron deficiency anaemia 51 Causes Nutritional anaemia Repeated pregnancy and short interval between successive pregnancies to replenish the iron tore Previous history of APH, PPH Malaria Hookworm infestation

52. Management 52 Degree of anemia Hemoglobin, total red cell count, packed cell volume Type of anemia Peripheral blood smear, Hematological indices(MCHC) Grading of Anaemia based on hemoglobin level (WHO 2011) Normal level in pregnancy >11gm/dL Anaemia Mild: 10 to 10.9 gm/dL Moderate: 7 to 9.9 gm/dL Severe: <7 gm/dL

53. Management 53 Cause of anemia Examination of stool (should be done as routine especially in Tropics, particularly hookworm) Examination of urine (protein, sugar and pus cells, clean catch midstream specimen of urine is subjected to culture and colony count, if the counts are over 10⋀5ml, indicates infection)

54. Management 54 Treatment Oral iron therapy (Ferrous sulphate 300mg) Parenteral iron therapy (IM iron dextran 50mg/ml x 2ml) Blood transfusion (preferably packed cell transfusion) Treatment of underlying cause (Antimalarial drugs, Deworming in 2 nd trimester, Antibiotics)

55. Thalassemia syndromes 55 Heterogonous group of autosomal recessive haemolytic anemias with decreased synthesis of one or more globin chains Two main types classified alpha and beta thalassaemias Commonest monogenetic disease worldwide High prevalence of alpha thalassemia (10%) and beta thalassemia (0.54%) in Myanmar (2011 Anaemia Research Project)

56. Alpha thalassemia 56 Produced by four alpha globin genes on each copy of chromosome 16 Caused by decreased in synthesis of these alpha chains; the severity of the conditions depend on how many genes are affected Heterozygous form, alpha thalassemia minor, asymptomatic, mild anaemia If three genes mutated, HbH disease, patient will have chronic anaemia and may require repeated blood tranfusions Homozygous form, alpha thalassemia major, Bart’s Hb, there is complete absence of the gene, is incompatible of life and results in death in utero(Bart’s hydrops)

57. Beta thalassemia 57 Two beta genes, one on each chromosome 11 Caused by decrease in synthesis of these beta chains, severity depends on how many genes are affected Heterozygous, beta thalassemia minor, asymptomatic, mild anaemia Homozygous, beta thalassemia major, hypochromic microcytic anaemia from a few months after birth and the patient is blood transfusion dependent Beta thalassemia intermedia, moderate impairment, non transfusion dependent thalassemia

58. Diagnosis 58 Full blood count (hypochromic microcytic anaemia with MCH cut off of 27pg for thalassaemia carriers and 25pg in the homozygous forms) Iron studies (differentiate from IDA) Haemoglobin electrophoresis ( HbH -alpha thalassemia, HbA2 and HbF are elevated in beta thalassemia) Partner screening (important to enable genetic analysis and counselling about the risk of an affected child)

59. Diagnosis in fetus 59 Non invasive prenatal tests for beta thalassemia Free fetal DNA Preimplantation genetic diagnosis Invasive tests Chronic villous sampling Amniocentesis Ultrasound surveillance for alpha thalassaemia (fetuses will have major abnormalities; increased cardio-thoracic ratio, thickened placenta, abnormal middle cerebral artery Doppler and finally hydrops fetalis in second or third trimester)

60. Treatments 60 Regular life long transfusions to keep Hb>90g/L (2-4 weekly) Oral folic acid supplementation (5mg once daily for 4months until term in pregnancy, doses up to 15mg per day may be required in malabsorption state) Oral iron therapy is contraindicated in major thalassemia (iron overload affects liver, thyroid and parathyroid functions) Oral iron therapy in thalassemia minor is given only when the laboratory diagnosis of iron-deficiency is established

61. Take home message 61 Awareness of symptoms of dyspnoea Respiratory, Cardiovascular and haematological causes Awareness of life-threatening conditions of asthma and infections in Respiratory causes Awareness of effects of heart diseases on pregnancy Awareness of IDA and its importance during the pregnancy Life style changes and follow-up

62. References 62 DC- Duttas Textbook of Obstetrics Including Perinatology and Contraception Epidemiology and current status of case management of thalassaemia in Myanmar Country Report by Associate Professor/Senior consultant Haematologist , Dr. Sein Win, Yangon General Hospital, UM-1, Yangon Obstetrics by Ten Teachers by Kenny, Louie C Obstetrics Illustrated by Kevin P. Hanretty Obstetrics and Gynaecology management guidelines by Myanmar Medical Association Oxford Textbook of Obstetrics and Gynaecology Oxford Handbook of Obstetrics and Gynaecology

63. THANK YOU Group-3