From the Guidelines
Dyspnea in pregnancy is a concerning symptom that requires a thorough diagnostic workup, and the initial step should be to assess the patient's clinical presentation, including symptoms such as shortness of breath, pleuritic chest pain, hypoxemia, tachycardia, and tachypnea 1.
Diagnostic Approach
The diagnostic approach for dyspnea in pregnancy involves:
- Plasma D-dimer measurement: This should be the initial test in suspected pulmonary embolism (PE), but it is essential to note that D-dimer levels increase physiologically throughout pregnancy, reducing the proportion of pregnant patients in whom a normal D-dimer level can rule out PE 1.
- Leg vein imaging: Compression ultrasonography (CUS) of the lower extremities should be performed in patients with an abnormal D-dimer level 1.
- Chest radiograph: A chest X-ray can be useful in the diagnostic assessment of suspected PE in a pregnant woman, with a low radiation dose to the fetus 1.
- Lung scintigraphy: Perfusion lung scintigraphy is a reasonable option, with a high diagnostic yield in pregnant women and lower radiation exposure to the breast tissue compared to CT 1.
- Computed Tomographic Pulmonary Angiogram (CTPA): CTPA can be performed safely in pregnant women, with a lower radiation dose to the fetus compared to pulmonary angiography, but it is essential to optimize the protocol to minimize radiation exposure 1.
Key Considerations
- Radiation exposure: The risks of radiation exposure to the fetus should be carefully considered, and the benefits of diagnostic testing should be weighed against the potential risks 1.
- Patient-specific factors: The decision to perform diagnostic testing should take into account patient-specific factors, such as the clinical suspicion of PE, the risk of bleeding, and the patient's preferences 1.
- Local expertise and resources: The choice of diagnostic test should also consider local expertise and resources, as well as the availability of testing modalities 1.
From the Research
Diagnostic Workup for Dyspnea in Pregnancy
The diagnostic workup for dyspnea in pregnancy involves a comprehensive approach to rule out underlying cardiac or extra-cardiac etiologies. Some key points to consider include:
- A thorough physical examination and routine lab tests should be performed to identify any potential causes of dyspnea 2
- Echocardiography is a feasible screening tool to rule out previous cardiac and lung diseases, anemia, and thyroid disorders 2
- Imaging studies, such as chest X-rays or CT scans, may be necessary to evaluate for mediastinal masses or other thoracic abnormalities 3
- A multidisciplinary approach, involving obstetricians, cardiologists, and other specialists, may be necessary to diagnose and manage underlying conditions contributing to dyspnea 4, 3
Cardiac Evaluation
Cardiac evaluation is an essential component of the diagnostic workup for dyspnea in pregnancy. Some key findings include:
- Pregnant women with dyspnea may have thicker hearts, shorter E-wave deceleration time, and higher pulmonary artery pressure compared to those without dyspnea 5
- Echocardiography may reveal valvular diseases, pulmonary hypertension, or other cardiac abnormalities in pregnant women with dyspnea 2
- A significant association has been found between NYHA class and valvular disease, as well as between NYHA class and systolic pulmonary artery pressure 2
Differential Diagnosis
A broad differential diagnosis is essential when evaluating dyspnea in pregnancy. Some potential causes of dyspnea include: