Dyspnea during pregnancy
- Steven E Weinberger, MD
Steven E Weinberger, MD
- Adjunct Professor of Medicine
- University of Pennsylvania School of Medicine
- Executive Vice President and CEO
- American College of Physicians
- Section Editors
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
- Peter J Barnes, DM, DSc, FRCP, FRS
Peter J Barnes, DM, DSc, FRCP, FRS
- Editor-in-Chief — Pulmonary and Critical Care Medicine
- Section Editor — Asthma
- Professor of Medicine
- National Heart and Lung Institute, Imperial College, London
Dyspnea is common during pregnancy. The development of dyspnea in the pregnant woman raises the question as to whether she has some form of underlying cardiac or pulmonary disease or whether her dyspnea is due to the pregnancy itself. Making this assessment requires an understanding of the cardiopulmonary changes that occur during normal pregnancy, as well as recognition of the syndrome of dyspnea during normal pregnancy [1-4].
PHYSIOLOGICAL CHANGES IN PREGNANCY POTENTIALLY AFFECTING RESPIRATION
Cardiovascular changes — The most striking cardiovascular changes during pregnancy are increases in blood volume and cardiac output [5-7].
●Blood volume — Blood volume starts to rise during the first trimester and eventually reaches a maximum that is 40 to 50 percent above the baseline, nonpregnant blood volume. Because plasma volume increases more than red cell mass, the hematocrit generally falls, resulting in the physiologic "anemia of pregnancy" (figure 1). (See "Hematologic changes in pregnancy".)
●Cardiac output — Cardiac output also starts to rise in the first trimester, reaching a peak at 20 to 32 weeks of gestation that is 30 to 50 percent above baseline (figure 2) [7,8]. Although the increase in cardiac output is initially due to a rise in stroke volume, the increase is maintained later in pregnancy by an increase in heart rate, as stroke volume falls during the third trimester. A decrease in systemic vascular resistance accompanies the increase in cardiac output. Blood pressure during pregnancy is often notable for a rise in pulse pressure due to an unchanged systolic pressure accompanied by a decrease in diastolic pressure. (See "Maternal cardiovascular and hemodynamic adaptations to pregnancy".)
Respiratory changes — The normal respiratory tract changes during pregnancy result in a compensated respiratory alkalosis, with a higher PO2 and a lower PCO2 than in the nonpregnant state. The lower PCO2 is thought to provide a diffusion gradient that may facilitate the fetus' ability to eliminate waste from aerobic metabolism. (See "Respiratory tract changes during pregnancy".)
- Pereira A, Krieger BP. Pulmonary complications of pregnancy. Clin Chest Med 2004; 25:299.
- Graves CR. Acute pulmonary complications during pregnancy. Clin Obstet Gynecol 2002; 45:369.
- Ie S, Rubio ER, Alper B, Szerlip HM. Respiratory complications of pregnancy. Obstet Gynecol Surv 2002; 57:39.
- Burdon J. Breathlessness and pregnancy. Aust Fam Physician 2000; 29:451.
- Zeldis SM. Dyspnea during pregnancy. Distinguishing cardiac from pulmonary causes. Clin Chest Med 1992; 13:567.
- Longo LD. Maternal blood volume and cardiac output during pregnancy: a hypothesis of endocrinologic control. Am J Physiol 1983; 245:R720.
- McAnulty, JH, Metcalfe, J, Ueland, K. Cardiovascular disease. In: Medical Complications During Pregnancy, 4th ed, Burrow, GN, Ferris, TF (Eds), Saunders, Philadelphia, 1995.
- Robson SC, Hunter S, Boys RJ, Dunlop W. Serial study of factors influencing changes in cardiac output during human pregnancy. Am J Physiol 1989; 256:H1060.
- Weinberger, SE, Weiss, ST. Pulmonary diseases. In: Medical Complications During Pregnancy, 4th ed, Burrow, GN, Ferris, TF (Eds), Saunders, Philadelphia, 1995.
- CUGELL DW, FRANK NR, GAENSLER EA, BADGER TL. Pulmonary function in pregnancy. I. Serial observations in normal women. Am Rev Tuberc 1953; 67:568.
- PROWSE CM, GAENSLER EA. RESPIRATORY AND ACID-BASE CHANGES DURING PREGNANCY. Anesthesiology 1965; 26:381.
- Milne JA, Mills RJ, Coutts JR, et al. The effect of human pregnancy on the pulmonary transfer factor for carbon monoxide as measured by the single-breath method. Clin Sci Mol Med 1977; 53:271.
- Elkus R, Popovich J Jr. Respiratory physiology in pregnancy. Clin Chest Med 1992; 13:555.
- Yannone ME, McCurdy JR, Goldfien A. Plasma progesterone levels in normal pregnancy, labor, and the puerperium. II. Clinical data. Am J Obstet Gynecol 1968; 101:1058.
- Lim VS, Katz AI, Lindheimer MD. Acid-base regulation in pregnancy. Am J Physiol 1976; 231:1764.
- Andersen GJ, James GB, Mathers NP, et al. The maternal oxygen tension and acid-base status during pregnancy. J Obstet Gynaecol Br Commonw 1969; 76:16.
- Templeton A, Kelman GR. Maternal blood-gases, PAo2--Pao2), hysiological shunt and VD/VT in normal pregnancy. Br J Anaesth 1976; 48:1001.
- Simon PM, Schwartzstein RM, Weiss JW, et al. Distinguishable types of dyspnea in patients with shortness of breath. Am Rev Respir Dis 1990; 142:1009.
- Hytten, FE, Leitch, I. Respiration. In: The Physiology of Human Pregnancy. Oxford, Blackwell Scientific Publications, 1971.
- Dieter RA Jr, Kuzycz GB, Dieter RA 3rd. Malignant and benign thoracic tumors during pregnancy. Int Surg 2006; 91:S103.
- Bonebrake CR, Noller KL, Loehnen CP, et al. Routine chest roentgenography in pregnancy. JAMA 1978; 240:2747.
- Resnik JL, Hong C, Resnik R, et al. Evaluation of B-type natriuretic peptide (BNP) levels in normal and preeclamptic women. Am J Obstet Gynecol 2005; 193:450.
- PHYSIOLOGICAL CHANGES IN PREGNANCY POTENTIALLY AFFECTING RESPIRATION
- Cardiovascular changes
- Respiratory changes
- DYSPNEA OF PREGNANCY
- EVALUATION OF PREGNANT WOMEN WITH DYSPNEA
- History and physical examination
- - Is dyspnea of acute or gradual onset?
- - Is cough or wheezing present?
- - Is the chest clear on auscultation?
- - Are other symptoms present?
- - Is onset early in gestation or near term?
- Laboratory and imaging tests
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS