Question

How will you evaluate and manage a woman with 34 weeks pregnancy with dyspnoea at rest? [3+3]

Hint:

In a pregnant woman with dyspnoea at rest, careful assessment of the cause is critical. Timely intervention and monitoring can prevent maternal and fetal complications.

Answer 1

Step 1: Evaluation of Dyspnoea at Rest in a 34-Week Pregnancy.
In a pregnant woman at 34 weeks with dyspnoea at rest, the evaluation should aim to differentiate between physiological and pathological causes of dyspnoea. Key steps include:
(1) Detailed History: - Onset and duration of symptoms: Is the dyspnoea recent or long-standing? Is it associated with exertion or present at rest? Any history of pre-eclampsia, heart disease, or pulmonary disease?
- Associated symptoms: Ask about chest pain, palpitations, cough, hemoptysis, or edema, which can indicate a more serious underlying condition such as pulmonary embolism, cardiac failure, or pneumonia.
(2) Physical Examination: - Vitals: Check pulse oximetry for oxygen saturation, blood pressure, heart rate, and respiratory rate. - Auscultation of the chest: Listen for wheezing (asthm, crackles (pulmonary edem, or absent breath sounds (pneumothorax, large pleural effusion).
- Peripheral edema: Look for signs of peripheral edema, which may suggest heart failure or pre-eclampsia.
- Cardiac examination: Check for signs of heart failure such as jugular venous distension (JV, S3 gallop, or hepatomegaly.
(3) Investigations: - Chest X-ray: Rule out lung pathology (e.g., pneumonia, pulmonary edema, pleural effusion). - Arterial Blood Gas (ABG): To assess oxygenation and pH, particularly if there are concerns of respiratory failure.
- Electrocardiogram (ECG): To evaluate for any cardiac arrhythmias or evidence of myocardial ischemia. - Echocardiography: If there is a suspicion of heart failure or pulmonary hypertension.
- D-dimer and CT Pulmonary Angiogram (CTP: If pulmonary embolism is suspected based on clinical signs or risk factors.
Step 2: Management of Dyspnoea in a 34-Week Pregnant Woman.
The management of a woman with dyspnoea at rest at 34 weeks of pregnancy depends on the underlying cause. The general approach includes:
(1) Oxygen Therapy: - If oxygen saturation is low, provide supplemental oxygen to maintain saturation levels above 95%.
(2) Manage Underlying Cause: - If asthma is diagnosed, use bronchodilators (e.g., albuterol) and consider steroids if necessary.
- If heart failure is suspected, administer diuretics (e.g., furosemide) and inotropes (e.g., dobutamine) if required. Consider antihypertensive agents if hypertension is a concern.
- If pulmonary embolism is diagnosed, start anticoagulation therapy and initiate supportive care.
- For pre-eclampsia, manage blood pressure with labetalol, administer magnesium sulfate for seizure prophylaxis, and prepare for delivery if maternal or fetal compromise is imminent.
(3) Positioning and Comfort Measures: - Encourage the patient to sit up in a semi-upright position (to reduce diaphragmatic pressure) and provide comfort measures to reduce anxiety.
(4) Monitor Fetal Well-being: - Fetal heart rate monitoring and non-stress tests (NST) should be performed to evaluate fetal health.
(5) Delivery Planning: - If the underlying cause of dyspnoea is related to pre-eclampsia or cardiac decompensation, consider early delivery (vaginal or cesarean) depending on maternal and fetal stability.