Diagnosis and Management of Shortness of Breath in Pregnancy

Initial Assessment and Stabilization

• Assess severity and timing of symptoms, including persistent excessive shortness of breath that doesn't resolve with rest, which is an emergency warning sign, in patients with suspected cardiac cause, as recommended by the American College of Cardiology 1
• Maintain normal oxygen saturations through oxygen therapy in patients with shortness of breath, as suggested by the European Respiratory Society 2
• Consider physiologic changes of pregnancy, including up to 50% increase in plasma volume, increased cardiac output, and compensatory heart rate increase, which can exacerbate underlying conditions, especially at 24-26 weeks gestation 3

Cardiac Evaluation and Management

• Use echocardiography to evaluate for peripartum cardiomyopathy and structural heart disease in patients with suspected cardiac cause, as recommended by the European Society of Cardiology 4
• Measure NT-proBNP, which can be elevated in heart failure, but also in pre-eclampsia without cardiac abnormality, as suggested by the European Society of Cardiology 4
• Employ a multidisciplinary team approach with cardiology for patients with cardiac cause, as recommended by the European Society of Cardiology 4

Pulmonary Evaluation and Management

• Continue usual asthma medications in patients with asthma, as recommended by the European Respiratory Society 2
• Evaluate and manage signs of right heart failure, including severe chest pain, oxygen saturation <95% on room air, and altered mental status, promptly 1, 4
• Perform chest radiography (CXR) as the first radiation-associated procedure, followed by lung scintigraphy (V/Q scan) if CXR is normal, and CTPA if V/Q scan is nondiagnostic, as recommended by 5
• Consider the following table for radiation exposure of V/Q scan and CTPA:

• Use assessment of clinical probability combined with D-dimer measurement for immediate risk assessment of pulmonary embolism (PE), and validated diagnostic approaches, such as the pregnancy-adapted YEARS algorithm combined with D-dimer levels, to safely exclude PE in pregnancy 6
• Employ the modified Wells score with a cutoff of ≥6 points as the most appropriate scoring system for evaluating suspected PE in pregnancy, especially in patients with a history of deep vein thrombosis (DVT) 7

Anticoagulation and Thrombosis Management

• Initiate anticoagulation while awaiting diagnostic confirmation unless contraindicated, with low molecular weight heparin (LMWH) as the preferred agent in pregnancy, and continue until PE is definitively ruled out, with a high strength of evidence 5, 8
• Administer therapeutic, fixed doses of LMWH based on early pregnancy weight, and avoid using NOACs (non-vitamin K antagonist oral anticoagulants) during pregnancy or lactation 6
• Use unfractionated heparin (UFH) in high-risk PE, especially peri-partum, and reserve thrombolysis for life-threatening PE, according to the European Society of Cardiology 6

Risk Factors and Prevention

• Recognize pulmonary embolism (PE) as a leading cause of pregnancy-related mortality in the developed world, accounting for 20% of maternal deaths in the United States, with a significant risk factor being a history of DVT, and an odds ratio of 9.4 9, 7
• Understand that pregnancy itself increases venous thromboembolism (VTE) risk, which peaks during the post-partum period, and cesarean section increases the risk of PE 20-fold compared to vaginal delivery, as stated by the European Society of Cardiology 10
• Identify women with NYHA class III or IV as being at high risk during pregnancy, and advise those with severe respiratory disorders to avoid moderate-to-vigorous physical activity, according to the British Society of Sports Medicine 11, 12

Patient Education and Management

• Educate patients on the signs and symptoms of PE, including pleuritic chest pain, cough, and sweating, and the importance of seeking immediate medical attention if these symptoms occur, as described by the American Heart Association, and recommend stopping physical activity immediately and consulting a healthcare provider if symptoms occur, with avoidance of activities in excessive heat or high humidity and maintenance of adequate hydration, as recommended by the British Medical Association 13, 14, 1
• Refer women with heart disease to specialized centers with multidisciplinary teams, as recommended by the European Society of Cardiology, and employ a multidisciplinary approach involving maternal-fetal medicine specialists, cardiologists, and emergency physicians for complex cases, as described by the American College of Obstetricians and Gynecologists 14, 5, 13
• Consider caesarean delivery for obstetric indications or severe cardiac/respiratory compromise, as suggested by the European Society of Cardiology, and maintain close monitoring for women with underlying cardiac or respiratory disease, and be alert for new-onset dyspnea postpartum, which may indicate previously undiagnosed cardiac disease, as stated by the European Society of Cardiology 11, 14