What are the appropriate steps to manage chest pain and shortness of breath (dyspnea) in a pregnant patient?

Management of Chest Pain and Shortness of Breath in Pregnancy

Chest pain and shortness of breath in pregnancy require immediate systematic evaluation for life-threatening cardiovascular emergencies—including acute coronary syndrome, pulmonary embolism, and aortic dissection—with diagnostic imaging and interventions that should not be withheld due to pregnancy status, as maternal mortality far outweighs fetal radiation risks. 1

Immediate Risk Stratification

The first priority is distinguishing between physiologic symptoms of normal pregnancy versus life-threatening emergencies. This determination hinges on specific clinical features rather than symptom presence alone.

Red Flag Symptoms Requiring Emergency Evaluation

Stop and immediately evaluate for cardiovascular emergencies if any of the following are present:

• Severe chest pain, particularly pleuritic chest pain 2, 1
• Severe dyspnea at rest (not just exertional) 2, 3
• Syncope or presyncope 3
• Hemoptysis 3
• Palpitations with unexplained hypotension 3

Critical Physical Examination Findings

The following examination findings mandate immediate workup:

• Oxygen desaturation (SpO2 <95%) 3
• Tachypnea at rest (>20 breaths/min) 3
• Persistent tachycardia (>130 bpm) 2, 3
• Abnormal lung auscultation 3
• Unilateral leg swelling (suggests DVT) 3
• Systolic BP >160 mmHg or diastolic BP >100 mmHg 2, 3

Life-Threatening Diagnoses to Exclude

Pulmonary Embolism

PE is the leading cause of pregnancy-related maternal death in developed countries, accounting for 20% of maternal deaths, with an incidence of 1 per 1000 to 1 per 3000 deliveries. 3, 1 Pregnancy creates a hypercoagulable state due to increased coagulation factors and decreased venous flow from uterine compression. 3

Diagnostic approach for suspected PE:

• Begin with bilateral lower extremity compression ultrasound to look for DVT 3
• If DVT ultrasound is negative or not indicated, proceed with either CT pulmonary angiography or ventilation-perfusion scintigraphy 1
• Chest X-ray and arterial blood gas can help risk-stratify but normal results do not exclude PE 3

Critical caveat: The absence of pleuritic chest pain has a negative predictive value of 97.8% for PE, but clinical features like tachycardia and leg swelling do not provide significant diagnostic value. 4 D-dimer and arterial blood gas are statistically different between those with and without PE but not to a clinically useful degree. 4

Acute Coronary Syndrome

ACS occurs in 1.5-10 per 100,000 deliveries with 5-10% maternal mortality. 1 Spontaneous coronary artery dissection is the most common cause of pregnancy-associated ACS, occurring predominantly peripartum due to progesterone-induced collagen changes in vessel walls. 1

Diagnostic approach for suspected ACS:

• Obtain ECG and cardiac biomarkers (troponin) immediately 1
• Perform diagnostic coronary angiography without delay, as this directly visualizes coronary artery dissection and significantly improves survival 1, 5
• Do not withhold coronary angiography due to fetal radiation concerns—maternal mortality risk far exceeds fetal radiation risk, especially outside the first trimester 1, 5

Treatment for confirmed ACS:

• Proceed immediately to primary PCI for STEMI 1, 5
• If stenting is required, use bare metal stents only—drug-eluting stents should be avoided due to unknown safety profile and requirement for prolonged dual antiplatelet therapy 1, 5
• Initiate β-blockers and low-dose aspirin (75-100 mg daily), which are considered relatively safe 1, 5
• Use clopidogrel only when strictly necessary (e.g., after stenting) and for the shortest duration possible due to limited safety data 1, 5
• Absolutely avoid ACE inhibitors, ARBs, and renin inhibitors 1, 5
• Avoid ergometrine for postpartum bleeding, as it can cause coronary vasospasm and worsen ischemia 5

Aortic Dissection

Aortic dissection must be considered in the differential diagnosis of chest pain in pregnancy, particularly with hypertensive emergencies. 2 Echocardiography should be performed to evaluate for this and other structural cardiac abnormalities. 2, 5

Management of Mild Exertional Dyspnea with Normal Examination

If the physical examination is completely normal and symptoms are limited to mild exertional dyspnea without red flags, reassurance is the appropriate initial approach, as this is a common physiological adaptation to pregnancy. 3

When Reassurance is Appropriate

A normal physical examination effectively rules out the need for invasive testing in the absence of:

• Oxygen desaturation 3
• Tachypnea 3
• Abnormal lung sounds 3
• Signs of cardiopulmonary compromise 3

Chest X-ray is not appropriate as first-line management when the physical examination is normal and there are no concerning features. 3 However, pregnant patients are significantly less likely to undergo radiography compared to non-pregnant patients, which could place them at increased risk for delayed diagnosis. 6

Patient Counseling for Mild Symptoms

• Encourage maintenance of moderate-vigorous physical activity—patients with well-controlled mild-moderate respiratory symptoms should not restrict activity 3
• Instruct to seek immediate care if they develop chest pain, severe dyspnea at rest, palpitations, syncope, or signs of fluid overload 3
• Maintain adequate nutrition and hydration 2
• Avoid physical activity in excessive heat with high humidity 2

Safety Precautions for Physical Activity

Pregnant women should be counseled to stop activity and seek medical attention if they experience:

• Persistent excessive shortness of breath that does not resolve on rest 2
• Severe chest pain 2
• Regular and painful uterine contractions 2
• Vaginal bleeding 2
• Persistent loss of fluid from the vagina 2
• Persistent dizziness or faintness that does not resolve on rest 2

Common Pitfalls to Avoid

The most dangerous pitfall is attributing chest pain or dyspnea to normal pregnancy without proper evaluation. Pregnancy may induce or unmask myocardial dysfunction that causes shortness of breath. 7 Research shows that significant SOB during otherwise normal pregnancy is associated with echocardiographic findings suggesting subtle cardiac involvement, including thicker hearts, shorter E-wave deceleration time, and higher pulmonary artery pressure. 7

Do not delay imaging due to radiation concerns. ACOG Committee Opinion 656 clearly states that, with few exceptions, radiography should not be withheld from pregnant patients. 6 The risk of delayed diagnosis and treatment far exceeds radiation risk to the fetus.

Do not rely solely on D-dimer or clinical prediction rules developed for non-pregnant populations. Symptoms of normal pregnancy including shortness of breath, tachycardia, and leg swelling are included in clinical tools for risk stratification for PE in the non-pregnant population, resulting in poor specificity. 4