Shortness of breath during pregnancy usually occurs as a result of physiological changes and less often than other conditions. Due to the lack of appropriate studies, the incidence of these conditions during pregnancy is difficult to estimate. Dyspnea - a feeling of difficulty breathing - should be distinguished from tachypnea - rapid breathing. Respiratory rate plays a critical role in assessing the severity of the disease; clinicians often pay little attention to this indicator. Cyanosis is an unreliable indicator of hypoxia, especially during pregnancy, when anemia is possible.

Causes of shortness of breath

Most probable reasons or known rare complications of pregnancy that cause shortness of breath, such as amniotic fluid embolism. However, most causes are the same, and a pregnant patient with dyspnea should be treated the same as a nonpregnant patient during evaluation. These causes are divided into physiological, related to the upper respiratory tract, respiratory tract, chest, heart (see Shortness of breath in pregnancy: cardiac causes), and metabolic.

Non-cardiac causes of shortness of breath during pregnancy

Localization	States
Physiological	Physiological shortness of breath during pregnancy. Dysfunctional breathing.
Upper respiratory tract	Nasal congestion
Airways	Obstructive airway diseases: asthma, cystic fibrosis, bronchiectasis, chronic obstructive pulmonary disease, bronchiolitis obliterans. Parenchymal and interstitial lung diseases: pneumonia, aspiration pneumonitis, acute lung injury/adult acute respiratory distress syndrome, widespread tuberculosis, pulmonary metastases, sarcoidosis, drug damage, lymphangioleiomyomatosis, cancerous lymphangitis, exogenous allergic alveolitis, fibrosing alveolitis, chronic obstructive pulmonary disease. Vascular pathologies: pulmonary embolism, embolism amniotic fluid,pulmonary hypertension. Pleural diseases: pleural effusion, empyema, pneumothorax
Chest wall	Obesity. Kyphoscoliosis. Ankylosing spondylitis. Neuromuscular disease, e.g. multiple sclerosis, polio
Metabolic	Thyrotoxicosis Acute or chronic renal failure. Metabolic acidosis/diabetic ketoacidosis.

Physiological reasons

Physiological shortness of breath usually begins in the first or second trimester of pregnancy and its frequency increases with increasing pregnancy. Physiological shortness of breath is the norm in 60-70% of pregnant women. The main diagnostic challenge is differential diagnosis with more serious conditions. Physiological shortness of breath during pregnancy is relatively mild, rarely severe and, oddly enough, decreases or at least does not increase by the time of birth. Dyspnea at rest is rare and daily activity and exercise capacity are usually not affected.

Numerous studies aimed at assessing lung function during pregnancy have yielded conflicting results. These changes are an adaptive mechanism to the increasing oxygen needs of the growing fetus. The most significant and well-studied changes are a 20-40% increase in minute ventilation (tidal volume x respiratory rate) due to higher tidal volume. The respiratory rate does not change significantly or increases slightly, so this high tidal volume can be attributed to greater respiratory effort. As a result of activation of proprioceptors in the chest wall, a sensation of shortness of breath occurs, which explains why patients sometimes complain of difficulty breathing.

X-rays and pulmonary function tests are important to rule out other causes of dyspnea, but no specific diagnostic test for physiological dyspnea

There are no pregnant women. Diagnosis is based on clinical signs, a normal chest x-ray, and pulmonary function tests.

Dysfunctional breathing is common in young women and is also common during pregnancy. Patients usually complain of shortness of breath that occurs unrelated to clinical symptoms and daily activities. Dysfunctional breathing occurs at rest, during conversation, and during physical activity. Shortness of breath is often described as “difficulty taking a deep breath” or “a feeling of difficulty breathing in the chest.” As with physiological dyspnea of ​​pregnancy, physical examination findings are normal, except for possible increased respiratory rate.

The term "dysfunctional breathing" covers many clinical manifestations, the best known of which is hyperventilation. These conditions are not at all life-threatening, but they cause significant concern in patients who have psychological problems or mental illness.

Dysfunction of the vocal cords is also classified as dysfunctional breathing; the manifestations of shortness of breath with it are similar. However, the condition often presents with episodes of shortness of breath and can mimic asthma, with which it is often associated. About 10% of acute asthma attacks are actually the result of vocal cord dysfunction. The disease is diagnosed by history, spirometry, demonstrating a decrease in the volume of inhaled air, and laryngoscopy. revealing the closure of the vocal cords during inhalation and sometimes during exhalation. Examination may reveal frank stridor or inspiratory stridor on auscultation of the chest extending from the vocal cords, but is usually normal between attacks.

Upper respiratory tract

Nasal congestion (see Nasal congestion during pregnancy) due to rhinitis due to swelling of the mucous membrane, hyperemia, congestion in the capillaries and hypersecretion of the mucous membrane, which is caused by increased levels of estrogen, occurs in 30% of pregnant women. It occurs mainly in the third trimester, and with severe congestion, a feeling of shortness of breath occurs.

Airways

Obstructive airway diseases

Asthma is the most common obstructive airway disease encountered during pregnancy. It occurs in 0.4-7% of women, but asthma is usually diagnosed before pregnancy. The disease is characterized by attacks of shortness of breath and stridor, aggravated by physical activity and quickly responding to inhaled beta-agonists. When examined in the absence of treatment or during exacerbations, significant expiratory shortness of breath is detected. The diagnosis is confirmed by 2-week peak flowmetry, which reveals a typical overall decrease and significant variability in peaks. Uncontrolled asthma is diagnosed by one of the following: persistent bothersome symptoms, nighttime symptoms, frequent use inhaled beta-agonists, exacerbations and limitation of physical activity.

During pregnancy, asthma symptoms worsen in 1/3 of patients, improve in another 1/3, and remain unchanged in the remaining 1/3. However, during pregnancy, more than 30% of women are known to reduce their use of inhaled corticosteroids, which results in increased visits to the emergency department. The use of nonsteroidal anti-inflammatory drugs (NSAIDs) causes symptoms or worsens asthma.

Cystic fibrosis and bronchiectasis are usually diagnosed before pregnancy and are characterized by frequent respiratory tract infections and increased coughing with thick, colorless sputum. Shortness of breath occurs in moderate or severe cases of the disease. During exacerbations, hemoptysis and chest pain occur, and episodes of pneumothorax become more frequent, especially in cystic fibrosis. In cystic fibrosis, malabsorption and steatorrhea are often observed; sinusitis - in both diseases.

When auscultating over the affected areas, moist inspiratory rales are usually heard. The diagnosis is confirmed by chest x-ray, but sometimes high-resolution computed tomography (HRTC) is necessary for cystic fibrosis - the method of choice is also when bronchiectasis is suspected. During pregnancy, there is sometimes a need for this study. However, if the result does not change the existing treatment, it can be postponed.

Chronic obstructive pulmonary disease develops when there is a history of smoking for at least 20 pack-years - the number of cigarettes smoked per day multiplied by the number of years of smoking divided by 20 (the number of cigarettes in a pack). In this regard, they are more likely to occur in pregnant women over 35 years of age. The main symptom is shortness of breath during physical activity with decreased tolerance. The disease is accompanied by a cough with morning sputum (chronic bronchitis). During exacerbations, a general weakening of breath sounds or shortness of breath is observed. The disease is extremely common, although it occurs in women of the older age group. People often ask about it medical care than with any other respiratory disease. The disease is not diagnosed until there is a significant decline in lung function. The main diagnostic method is spirometry. The chest x-ray shows normal or only excessive airiness of the lungs.

Bronchiolitis obliterans is a relatively rare and difficult to diagnose disease. Clinical and radiological characteristics are indistinguishable from asthma with minor airway obstruction. There may be a history of respiratory tract diseases in childhood.

Parenchymal and interstitial lung diseases

The incidence of pneumonia in pregnant and non-pregnant women is the same. The onset of the disease is acute with a short history of shortness of breath, cough and fever, sputum and pleuritic chest pain. History of sore throat, cold, and flu-like symptoms precedes it. Sometimes, for example with mycoplasma pneumonia, the disease lasts several weeks. On examination, rapid breathing is determined, moist rales and bronchial breathing are heard. The diagnosis is confirmed by chest x-ray, which reveals areas of compaction of the lung tissue. Pneumocystis pneumonia, which complicates human immunodeficiency virus (HIV) infection, usually presents with a dry cough over several weeks and progressive shortness of breath. Chest radiographs usually show bilateral interstitial infiltrates, although this pattern is also observed normally. Bronchoscopy is often necessary to obtain material for cytological examination.

Aspiration pneumonitis is common during pregnancy due to the predisposition to gastroesophageal reflux and may occur during labor or during induction of general anesthesia. The result is a clinical condition indistinguishable from pneumonia, leading to respiratory failure due to acute lung injury or adult acute respiratory distress syndrome (ARDS).

Acute lung injury or acute respiratory distress syndrome occurs in 0.2-0.3% of pregnant women. It is caused by pneumonia, aspiration pneumonitis, eclampsia or amniotic fluid embolism, the symptoms of which appear in the first stage. The diagnosis is confirmed by deterioration of the condition and increased consolidation of all pulmonary fields on radiographs.

In tuberculosis, shortness of breath occurs with extensive bilateral damage to the pulmonary parenchyma. History of cough with sputum, weight loss, hemoptysis and night sweats, often in combination with underlying risk factors such as ethnicity or family history. A sputum test for acid-fast bacteria and a chest x-ray are needed, which will reveal severe shadowing (if the patient is admitted with shortness of breath), often with the formation of cavities. In the absence of sputum, bronchoscopy is necessary to obtain bronchial washings.

Pulmonary metastases, such as choriocarcinoma, are rare and are easily diagnosed by chest x-ray, which reveals one or more nodules various sizes. Symptoms usually appear with extensive metastases - shortness of breath, cough and hemoptysis. However, when auscultating the chest, pathologies are not heard. With metastases of choriocarcinoma in the pleura, pleural effusion is detected.

Sarcoidosis is common in young women, especially those of African-Caribbean ethnicity, in whom it is often more severe. In the presence of pulmonary infiltrates or sometimes with extensive lymphadenopathy of the mediastinum, compressing the main bronchi, shortness of breath appears. In this case, there is a cough, weight loss and damage to other organs - skin or eyes. Auscultation does not detect abnormalities or listen to moist inspiratory rales or wheezing. Sometimes lymphadenopathy and skin lesions are detected. If the clinical picture is appropriate, the diagnosis is confirmed only by chest x-ray. Serum angiotensin-converting enzyme levels are usually increased. Sometimes a biopsy is necessary, for example, of the bronchial mucosa during bronchoscopy.

Drug-induced interstitial lung injury can be caused, for example, by nitrofurantoin or amiodarone. Nitrofurantoin®, used for long-term treatment of recurrent urinary tract infections, causes acute and chronic forms of interstitial lung lesions with severe, life-threatening hypoxia. Amiodarone, used to treat cardiac arrhythmias at a dosage of 200 mg per day, can cause acute pneumonitis (incidence 0.1-0.5%) followed by pulmonary fibrosis (incidence 0.1%). Such phenomena are more common with increasing doses and prolonged treatment. Common manifestations of these conditions. - shortness of breath and dry cough. When auscultating the chest in the lower parts of the lungs, fine bubble inspiratory rales are heard on both sides.

Lymphangioleiomyomatosis is a rare disease that occurs exclusively in young women of reproductive age, and therefore should be included in the differential diagnosis of dyspnea during pregnancy. Clinical manifestations include interstitial lung disease, recurrent pneumothorax, sometimes bilateral, and there is often an obvious connection with tuberous sclerosis. Auscultation of the chest may be normal or may reveal fine inspiratory moist rales. There are some signs that lymphangioleiomatosis may worsen during pregnancy. The disease is suspected based on clinical presentation and chest x-ray, but high-resolution computed tomography (HRTC) is required to confirm the diagnosis.

Cancerous lymphangitis occurs in advanced metastatic breast cancer; it causes severe shortness of breath and a dry cough. As with drug-induced interstitial lung injury, severe hypoxia is observed.

Exogenous allergic alveolitis is a relatively rare disease associated with an identifiable trigger antigen - spores of thermophilic actinomycetes of moldy hay (“farmer's lung”). Progressive shortness of breath, wheezing and cough occur, and X-rays of the lungs reveal infiltrates, often located in the upper lobes.

Fibrosing alveolitis is more common in young women in the second half of life; it is associated with autoimmune diseases - rheumatoid, scleroderma and SLE, and must be taken into account in the differential diagnosis of shortness of breath during pregnancy. It is classified into many conditions, the most common being common interstitial pneumonia and nonspecific interstitial pneumonia. Typical symptoms include progressive shortness of breath, cough, and, on auscultation, bilateral fine-bubbling inspiratory moist rales in the mid-to-late inhalation. Sometimes the terminal phalanges of the fingers thicken, but in the early stages and with a milder course of the disease they do not occur. X-rays of the lower lungs usually show bilateral interstitial opacities, but high-resolution computed tomography (HRTC) is needed to determine the type of disease and possible response to treatment. Lung function tests, as in other interstitial lung diseases, reveal a decrease in transfer factor (diffuse capacity).

In autoimmune diseases, cryptogenic pneumonia occurs, which begins acutely with shortness of breath, cough and hypoxia. Parenchymal opacification is often more focal in nature than in fibrosing alveolitis. During pregnancy, the above-mentioned chronic diseases do not always occur chronically; some of them have a relatively acute onset.

Pleural pathology

Pleural effusion from pneumonia or tuberculosis causes shortness of breath, especially with a moderate or large volume of fluid. Rare causes of pleural effusion during pregnancy are lymphangioleiomyomatosis (chylothorax), choriocarcinoma, breast cancer and other malignant tumors, rupture of the diaphragm during childbirth. Examination of the chest reveals dullness to percussion and absence or muffled breathing over the effusion. A small effusion may be asymptomatic. Whether childbirth predisposes to the accumulation of pleural effusion is controversial. Examination of postpartum chest radiographs revealed an increased number of effusions, but no increase in the frequency of effusions was noted when ultrasound was used.

Empyema and pneumothorax are discussed in another section with reference to noncardiac causes of chest pain.

Chest wall

Obesity (body mass index >30) often leads to shortness of breath and reduced exercise tolerance. All other test results may be normal. Impaired breathing mechanics or paralysis of the diaphragm in kyphoscoliosis, ankylosing spondylitis and neuromuscular diseases leads to respiratory failure. In each patient with one of these diseases who complains of shortness of breath, it is necessary to determine the gas composition of arterial blood to detect hypoxia and hypercapnia.

Rigidity of the diaphragm muscles occurs with ovarian hyperstimulation syndrome and severe polyhydramnios. Treatment depends on the severity of ovarian hyperstimulation syndrome and the length of pregnancy.

Metabolic abnormalities

Anemia is a common condition during pregnancy and usually results in decreased exercise capacity and weakness, but not shortness of breath. The conjunctiva and nail beds should be examined for general pallor, but these signs are unreliable and hemoglobin levels should always be determined.

Sometimes shortness of breath is a manifestation of thyrotoxicosis. Typical symptoms are weight loss, sweating, diarrhea, irritability, tremors, tachycardia and eye symptoms. When examining the neck, a goiter may be detected. The diagnosis is confirmed by thyroid function tests.
Shortness of breath is caused by acute and chronic renal failure, metabolic acidosis and sepsis. However, the diagnosis must correspond to the clinical picture.

The cause of shortness of breath during pregnancy is determined based on history and physical examination, but a chest x-ray is necessary to rule out serious illnesses. Many chronic diseases impair fertility and are therefore rarely first identified during pregnancy. Therefore, a careful history taking is necessary.

Anamnesis

History of complaints

• Onset of symptoms relative to gestational age.
• Duration, chronicity, origin and severity of shortness of breath.
• Exercise tolerance, especially daily activities such as climbing stairs.
• The presence or absence of cough, sputum or hemoptysis.
• Relief when using inhalers.
• Heartbeat.
• Chest pain.
• Weight loss, fever, anorexia, malaise.
• Leg pain.
• Diseases of the nose and paranasal sinuses.
• Sore throat, arthralgia and myalgia.

Previous medical history

Includes the following diseases:

• asthma, hay fever, eczema;
• tuberculosis, BCG (Bacillus Calmette-Guerin), cystic fibrosis, bronchiectasis, other lung diseases;
• sarcoidosis, kyphoscoliosis, neuromuscular diseases, heart disease, recurrent urinary tract infections;
• malignant neoplasms (breast cancer), immunosuppression (HIV+);
• mental illness;
• pulmonary embolism or thrombophilia.

Medicinal history

• Amiodarone, nitrofurantoin, NSAIDs and inhalers.

Psychiatric history

• Symptoms of anxiety or depression. Family history
• Blood clotting disorders, asthma, atopy, tuberculosis, lung cancer and sarcoidosis.

Social history

• Ability to continue normal activities, especially going to work, climbing stairs, doing housework, and shopping.
• Residence or travel to regions with a high prevalence of tuberculosis and contact with patients with tuberculosis.

Physical examination

General appearance: confusion, sweating, tremor, hyperthermia, cyanosis, pallor, obesity, thickening of the terminal phalanges of the fingers, lymphadenopathy, BCG scar, goiter, exophthalmos, eyelid lag. Appearance reflects the severity of the disease or indicates possible causes.

Cardiovascular system: arrhythmia, low or high blood pressure, high blood pressure in the jugular veins, parasternal bulge, gallop rhythm, heart murmur, pericardial friction murmur.

Respiratory system: frequency, use of accessory muscles of aspiration, kyphoscoliosis, tracheal displacement, dullness on chest percussion, wheezing, bronchial breathing, weakened or absent breath sounds, moist rales.

Mammary glands: tumors; if indicated, it is better to perform a mammogram.
Neurological symptoms: muscle weakness, fasciculations, weakness of the upper or lower extremities, sensory loss, cerebellar symptoms.

Research methods

X-ray

Often the patient, her partner, medical or other personnel raise the issue of the risk of exposure to ionizing radiation on the fetus.

The absorbed dose of radiation that can be exposed to a fetus during pregnancy is 5 rad—equivalent to 71,000 chest x-rays, 50 computed tomographic angiographies of the pulmonary artery, or V/Q scans. These numbers must be taken into account when discussing the need for research with a pregnant woman.

However, the risk of developing cancer in the fetus over the next lifetime from exposure to any dose of radiation is unknown. The American College of Radiology states that during pregnancy, X-ray procedures should only be performed if they are necessary to treat the patient. Regarding any side effect on the fetus, the risks of not performing important radiological examinations must be taken into account and the patient informed about this. Most common tests involve minimal radiation exposure. Research plays an important role in accurate diagnosis, which allows an appropriate treatment plan to be developed.

Chest radiography plays a crucial role in the diagnosis of diseases of the respiratory system - pneumonia, pleural effusion, pneumothorax, tuberculosis and sarcoidosis. Without this simple study, it is impossible to adequately treat the patient or correctly assume the causes of shortness of breath. V/Q scanning is necessary to diagnose pulmonary embolism. If the V/Q scan only suggests pulmonary embolism and there is a moderate to high suspicion of pulmonary embolism, computed tomography pulmonary angiography may be helpful. High-resolution computed tomography is used to diagnose bronchiectasis and interstitial lung pathology. If the result is unlikely to change the approach to treatment of the disease, it can be postponed until the postpartum period.

Although the radiation dose from chest CT is acceptable for the fetus, it is believed that there is a high risk of breast cancer in the pregnant woman. In women under 35 years of age, exposure to 1 rad increases the lifetime risk of breast cancer by 14%. With computed tomographic angiography of the pulmonary artery, the dose applied to each mammary gland is 2-3.5 rad.

Lung function

During pregnancy, the most significant indicators of lung function - forced expiratory volume (amount of air) per second (FEV1) and the ratio FEVl/forced vital capacity (FEV1/FVC) - do not change (FVC is the total volume of air that a person can exhale in one breath ). Routine spirometry (FEV1, FVC and FEV1/FVC ratio) on a simple portable spirometer can exclude any obstructive pulmonary disease (asthma, cystic fibrosis, bronchiectasis, chronic obstructive pulmonary disease) of such severity as to cause shortness of breath. With well-controlled asthma, results may be normal. Spirometry in obstructive pulmonary disease is characterized by a low FEV1/FVC ratio (<70%), низкое значение FEV1 (<80%) и типичная выделенная кривая поток-объем, вызванная обструкцией мелких дыхательных путей.

Spirometry should only be performed and interpreted by trained personnel. You cannot draw conclusions from computer printouts. It is necessary to pay attention to the inspiratory flow-volume loop, which can be significantly narrowed with vocal fold dysfunction. Recording peak flow is important for diagnosing asthma, and the greatest benefit will come from measuring it for at least 2 weeks.

More detailed lung function tests, such as diffusion capacity (transfer factor) and static lung volumes, useful for diagnosing and monitoring interstitial lung disease, are performed in a specialized laboratory. For walking oximetry, the patient is asked to walk for 6 minutes with a pocket oximeter placed on the finger. For unexplained shortness of breath, the test is useful for two reasons. First, it demonstrates how far the patient can walk during this time and how many stops he makes; the second - the test detects whether there is a decrease in oxygen saturation during oximetry. In this way, it is possible to objectively determine the distance that the patient can walk and identify significant breathing problems.

Blood tests

When examining a pregnant woman with severe shortness of breath, it is necessary to take blood to determine hemoglobin, white blood cell count, urea, electrolytes, D-dimers and thyroid function tests. The absence of D-dimers eliminates pulmonary embolism and the need for V/Q scanning. D-dimer levels increase progressively before labor and are more suitable for early pregnancy. The presence of D-dimers is relatively non-specific and their levels may be increased, for example during infections.

Arterial blood gases should be determined in any patient who requires further evaluation, and especially if pulmonary embolism or pneumonia is suspected, since severe hypoxia (low Pa02) usually occurs in these diseases.

When does a patient with shortness of breath need to consult a pulmonologist?

Reasons for referring a pregnant woman to a pulmonologist:

• excessive shortness of breath; progression of shortness of breath;
• acute shortness of breath;
• indications for chest CT;
• the need for detailed pulmonary function testing, including diffusion capacity, static lung volumes, or gait oximetry;
• uncertain spirometry results or interpretations;
• uncertain diagnosis.

Shortness of breath during pregnancy is usually physiological in nature. Generally, a thorough history, physical examination, and chest x-ray can rule out serious illness. If necessary, a simple pulmonary function test is performed, which is crucial for diagnosing diseases of the respiratory system.

Shortness of breath during pregnancy: cardiac causes

Pregnant women often complain of shortness of breath, which may be associated with physiological changes. However, shortness of breath in combination with any of the following conditions raises suspicion of the presence of cardiovascular pathology:

• orthopnea - shortness of breath when lying down;
• paroxysmal nocturnal dyspnea - sudden onset of shortness of breath at night;
• arrhythmia is an irregular heart rhythm.

In the list of indirect causes of maternal mortality in the UK, cardiovascular pathology is in second place after suicide. Cardiomyopathy and congenital heart disease are two main conditions that are life-threatening for the mother and fetus.
In the UK, the initial diagnosis of rheumatic heart disease in pregnancy is very rare, but it can be a problem in some ethnic groups. In addition, there are other noncardiac causes of shortness of breath in pregnant women, such as iron deficiency anemia. Exacerbation of pulmonary disease must be ruled out before searching for serious cardiac causes. This chapter discusses cardiac causes of dyspnea, which can be divided into cardiomyopathies and congenital anomalies.

Cardiomyopathies

Cardiomyopathy during pregnancy is divided into 3 types: postpartum, dilated and hypertrophic. Dilated and hypertrophic cardiomyopathy occurs in any woman and manifests itself at any stage of pregnancy. Postpartum cardiomyopathy occurs mainly in young women of African-Caribbean ethnicity during the last trimester of pregnancy or the first 6 weeks after childbirth.

Postpartum cardiomyopathy

Postpartum cardiomyopathy is rare - 1 case in 3000-15,000 pregnancies. Its pathogenesis is unclear; it is assumed that it is some form of myocarditis, possibly viral. Maternal mortality reaches 20%, but the outcome for the fetus is good.

Treatment is similar to that for any form of cardiomyopathy with reduced ventricular systolic function. The main problem is assessing the risk of relapse in future pregnancies. Regular monitoring of the patient with an ECG is necessary to assess left ventricular function, which helps predict the risk of relapse and the outcome of future pregnancies. However, in subsequent pregnancies there is a significant risk of relapse of symptomatic heart failure and persistent impairment of left ventricular function.

Dilated cardiomyopathy

Pregnant women do not tolerate this disease well. If a patient is classified as a New York Heart Association (NYHA) functional group >11, the risk of maternal mortality is 7%. In addition, there is a high risk of heart failure. Differential diagnosis of dyspnea during pregnancy and heart failure is based on a thorough clinical examination. Heart failure is treated in the same way as in non-pregnant women, but before delivery it is necessary to avoid the use of angiotensin-converting enzyme inhibitors, the use of which is associated with renal agenesis in the fetus.

Hypertrophic cardiomyopathy

Women with hypertrophic cardiomyopathy usually tolerate pregnancy well. Adaptation of the left ventricle occurs physiologically. In this case, the disease proceeds favorably, since the cavity of the left ventricle is small. A heart murmur and increased left ventricular outflow gradient may first appear during pregnancy.

Maternal mortality is rare, and there is no evidence of an increased risk of sudden death during pregnancy. Despite this, the diagnosis and the presence of a genetic component are of considerable concern. Diagnosis in pregnant and non-pregnant women includes an echocardiogram, ECG, exercise testing, ambulatory ECG monitoring, and genetic counseling.

Women with severe diastolic dysfunction develop pulmonary congestion and even sudden pulmonary edema. Long-term use of beta blockers is necessary and low-dose diuretics are helpful. To prevent tachycardia, rest in combination with taking beta blockers is recommended.

For atrial fibrillation, women with hypertrophic cardiomyopathy are often prescribed low molecular weight heparin sodium (heparin) and beta blockers. If it is impossible to control the heart rhythm after excluding the presence of a thrombus in the left atrium using transesophageal echocardiography, cardioversion is considered.

Finally, it is necessary to discuss genetic risk, including the phenomenon of anticipation, which determines earlier onset and more severe disease in subsequent generations in some families.

The safest method of delivery for mothers with any form of cardiomyopathy is through the vaginal birth canal with good pain relief and the possible use of forceps. With this delivery, compared to a cesarean section, the volume of blood loss is less, and hemodynamic changes occur more slowly.

Congenital heart defect

Congenital heart disease is the most common birth defect in the world. Approximately 1% of newborns worldwide have a heart defect. In the UK, approximately 250,000 adults have congenital heart disease, and men and women are affected equally often. Some people have simple defects, such as small atrial or ventricular septal defects, which may remain clinically asymptomatic until diagnosed by routine testing. Others have complex anomalies that require surgery for survival.

50 years ago, 90% of patients would not have survived to adulthood. Advances in cardiology and cardiac surgery have meant that 85% of these babies survive to childbearing age. The number of new cases increases by approximately 1,600 each year.

Pregnancy in such women carries an increased risk of complications for the mother and fetus. Therefore, doctors must know the clinical manifestations, diagnosis and treatment of these diseases.

Based on the relative risk for the pregnant woman, congenital heart defects during pregnancy are divided into low, moderate and high risk defects.

The following discussion focuses on the clinical presentation and diagnosis of congenital heart defects. Tactics during pregnancy and childbirth depend on the risk category for the patient.

Low risk conditions

Unoperated atrial septal defect

With normal pulmonary vascular resistance, unoperated atrial septal defects are well tolerated. During pregnancy, as cardiac output increases, the tendency for atrial arrhythmia increases. The combination of potential right-to-left shunting and hypercoagulability during pregnancy increases the risk of paradoxical embolism, especially as intrathoracic pressure increases during labor. The same situation occurs when the foramen ovale is not closed. In unrepaired atrial septal defects, thromboembolic prophylaxis rather than antibiotic prophylaxis plays a major role, but potential benefits and risks must be weighed.

Operated coarctation of the aorta

Currently, almost all patients with aortic coarctation are operated on in early childhood. As long as there is no aneurysm at the surgical site, pregnancy poses little risk. The absence of an aneurysm must be confirmed before conception with an MRI or CT scan.

Operated tetralogy of Fallot

Tetralogy of Fallot is the most common congenital defect of the “blue” type. This is one of the first complex congenital defects to be successfully corrected surgically. Most patients with tetralogy of Fallot who live into adulthood have already had surgery, lead almost normal lives, and have no symptoms. They tolerate pregnancy well. However, severe pulmonary insufficiency may occur, and decompensation occurs during pregnancy. This emphasizes the need for regular evaluation of women with congenital heart disease, even after successful surgery, in order to correct any heart defects that could limit its reserve capacity and complicate the course of pregnancy before conception.

Moderate risk conditions

Fontan circulation

Various forms of the Fontan procedure create two separate blood flow systems with a single functioning ventricle of the heart. These patients do not have cyanosis, but they have long-term low cardiac output and are at risk for ventricular failure and atrial arrhythmia. Patients receive anticoagulant therapy with warfarin, which during pregnancy must be replaced with an adequate dose of low molecular weight heparin sodium (heparin*). The outcome of pregnancy for the mother depends on the functional capacity and function of the ventricle. If the only ventricle is the left one, there is a high probability that its function is sufficient. If these conditions are met and the woman knows that the miscarriage rate in the first trimester is 30%, which is 2 times higher than in the general population, there is no reason to discourage the woman from pregnancy, as was done in the past.

Mitral stenosis

Mitral stenosis is the most common chronic rheumatic valve disease in pregnancy in the UK, particularly in Indian, Chinese, Eastern European and East African populations. Rheumatic mitral stenosis may remain asymptomatic until the third decade of life, and symptoms often first appear during pregnancy. Other causes of mitral stenosis during pregnancy include congenital commissural fusion or parachute mitral valve and left atrial myxoma.

Hemodynamic disturbances in pregnant women with mitral stenosis - increased pressure in the left atrium, pulmonary veins and arteries - arise as a result of the valve and blood flow through it. Maternal complications include pulmonary edema, pulmonary hypertension, and right ventricular failure. Tachycardia precipitated by exercise, fever, or emotional stress decreases left ventricular diastolic filling time, and the subsequent increase in left atrial pressure decreases cardiac output. The outcome is failure of both ventricles. In pregnant women, increased left atrial pressure also predisposes to the development of atrial arrhythmias, in which loss of atrial contractility combined with rapid ventricular response can have an adverse effect with subsequent pulmonary edema.

Clinical picture. Depending on the severity and duration of valve damage, pregnant women with mitral stenosis develop symptoms of left and right ventricular failure. Symptoms of left-sided heart failure are more often observed - orthopnea, paroxysmal nocturnal dyspnea and dyspnea on exercise. In the absence of long-term valve damage, symptoms of right ventricular failure occur less frequently - peripheral edema and ascites, which is difficult to diagnose during pregnancy.

A thorough examination is aimed at looking for typical auscultatory signs of mitral stenosis - a click of the mitral valve opening and a rumbling diastolic murmur with presystolic amplification. Increased jugular venous pressure, hepatomegaly, a loud pulmonary component of the second heart sound, and right ventricular bulge found during examination confirm the diagnosis of mitral stenosis. Most pregnant women with mitral stenosis present with atrial fibrillation with or without heart failure.

Examination and diagnosis. When examining pregnant women with mitral stenosis, the method of choice is transthoracic echocardiography. It confirms the diagnosis and determines the severity of the stenosis. In addition, echocardiography determines pulmonary artery pressure, right ventricular function, mitral regurgitation, the status of other valves and the configuration of the subvalvular apparatus, which plays an important role in determining the success of percutaneous balloon valvuloplasty of the mitral valve. Invasive diagnostic testing - right heart catheterization is rarely warranted.

Aortic stenosis

Symptomatic disease of the aortic valves in pregnant women is less common than the mitral valve. In the UK, the predominant cause is congenital stenosis due to a membrane on the bicuspid aortic valve. In contrast, in developing countries and ethnic populations in the UK, the most common cause is rheumatic heart disease. During pregnancy, women with bicuspid aortic valves are at risk of aortic dissection due to hormonal influences on connective tissue.

Hemodynamic changes in aortic stenosis depend on the pressure gradient across the aortic valve. The increase in systolic pressure in the left ventricle, necessary to maintain sufficient pressure in the arterial system, leads to an increase in stress on the ventricular wall. Compensatory left ventricular hypertrophy develops, which can result in diastolic dysfunction, fibrosis, decreased coronary blood flow reserve, and late systolic failure.

The increase in stroke volume and fall in peripheral resistance are largely responsible for the increase in gradient across the aortic valve. The clinical consequences of an increased aortic gradient depend on the degree of preexisting left ventricular hypertrophy and systolic function. With inadequate compensatory changes in the left ventricle, which do not satisfy the need for increased cardiac output in late pregnancy, clinical signs appear. This situation usually occurs with moderate to severe aortic stenosis.

Clinical picture. The clinical picture and symptoms depend on the degree of aortic stenosis. Women with an aortic valve area >1 cm 2 tolerate pregnancy well and have no clinical signs. Women with more severe aortic stenosis may have symptoms of left-sided heart failure, which initially manifest as shortness of breath on exertion. Loss of consciousness or lightheadedness is rare, and pulmonary edema is even rarer.

Because the symptoms of aortic stenosis resemble those of normal pregnancy, this may mislead doctors. Physical findings vary depending on the severity of the disease. The left ventricular impulse is long and displaced laterally. The systolic ejection murmur is heard along the right edge of the sternum, it extends to the carotid arteries, and a systolic click can be heard. During diastolic function, a IV heart sound may appear. A slowly rising pulse and narrow pulse pressure amplitude are characteristic of hemodynamically significant aortic stenosis.

Examination and diagnosis. The diagnosis is confirmed by echocardiography. Aortic gradient and valve area are calculated from Doppler flow studies. In addition, echocardiography reveals left ventricular hypertrophy. Assessment of ejection fraction and left ventricular volume is useful for prognosis of pregnancy and childbirth. In women with ejection fraction<55% риск сердечной недостаточности во время беременности высокий. При клинической картине тяжелого аортального стеноза, если данные неинвазивных обследований неубедительны и необходима чрескожная вальвуло-пластика, показана катетеризация сердца. Если у матери имеется врожденный стеноз аорты, показана эхокардиография плода, поскольку риск подобной аномалии плода составляет приблизительно 15%.

High risk lesions

Marfan syndrome

In pregnant women with Marfan syndrome and a normal aortic root, the risk of dissection is approximately 1%. With an aortic root diameter >4 cm, the risk of dissection increases 10-fold; the main risk for the mother in Marfan syndrome is type A aortic dissection, with surgical treatment of which maternal mortality is 22%. Patients with a poor family history, cardiac involvement, and aortic root diameter >4 cm or rapid aortic dilatation are at high risk for dissection. In these cases, pregnancy is not recommended. For those who choose to continue the pregnancy, beta blockers are prescribed and an elective caesarean section is performed. Patients should be aware of the 50% risk of relapse.

During pregnancy, aortic dissection can occur without preexisting disease, likely as a result of hormonal changes and increased stress on the cardiovascular system. A risk factor for aortic dissection during pregnancy is a bicuspid aortic valve with a dilated aortic root. The histological picture is similar to Marfan syndrome.

Eisenmenger syndrome

With pulmonary hypertension of any etiology, there is a high risk of maternal mortality. The risk of death in patients with Eisenmenger syndrome is 40-50%. Women should be discouraged from becoming pregnant. Laparoscopic sterilization is possible, but not without significant risks. Subcutaneous progesterone implantation is as effective as sterilization but does not carry additional cardiovascular risks. During pregnancy, the woman must be offered an abortion. Women wishing to continue their pregnancy are referred to specialized center.

Observation during pregnancy

Prenatal care

The level of prenatal care is determined before conception or immediately after pregnancy is confirmed.

Obstetricians and gynecologists at the main district hospital in the UK see few patients with moderate to severe congenital heart disease, so such patients need to be referred to a specialist center for advice. Ideally, moderate-to-high-risk patients should be treated by a tertiary multidisciplinary team with a cardiologist, anesthesiologist, obstetrician-gynecologist, and neonatologist on call 24 hours a day. Low-risk patients can be observed at the place of residence, taking into account the recommendations of a specialist.

Prenatal care and delivery should be carefully planned. The patient must participate in the decision-making process and understand the “minimal risk approach.” Some patients benefit from hospitalization in the third trimester for bed rest, close monitoring of cardiovascular function, and oxygen therapy. Patients admitted to bed rest should receive adequate thromboprophylaxis with low molecular weight heparin sodium (heparin).

Patients with Eisenmenger syndrome (or other forms of pulmonary artery hypertension), Marfan syndrome with an aortic root diameter >4 cm, or severe left-sided obstructive lesions should be advised of the high maternal morbidity and mortality associated with pregnancy. In case of unplanned pregnancy, early abortion is performed. If the patient still wishes to continue the pregnancy, the need for monitoring by a third-level multidisciplinary team should not be emphasized too much.

Anticoagulant therapy during pregnancy and childbirth

Because of chronic or recurrent arrhythmias, slow blood flow, or the presence of metallic valve prostheses, women with congenital heart disease have an increased risk of thromboembolic complications. During pregnancy, the risk of thromboembolism increases 6 times, in the postpartum period - 11 times, so it is important to achieve adequate anticoagulation. However, this treatment is associated with risks and significant complications for the mother and fetus. Warfarin is an effective oral anticoagulant that crosses the placenta and poses a major risk to the fetus. In contrast, sodium heparin (heparin) does not cross the placenta and is therefore safe. It is reportedly less effective in preventing blood clots, especially in women with metal valve prostheses. Therefore, when giving any advice on anticoagulant treatment during pregnancy, the risks and benefits to the mother and fetus must be weighed. Treatment must take into account the needs of the mother and fetus.

Dyspnea is a violation of the frequency and depth of breathing. Very often this phenomenon accompanies pregnant women during pregnancy. different dates. It is accompanied by an acute lack of air and causes a lot of inconvenience. At first the woman has difficulty climbing stairs, then she cannot breathe full breasts, then, one might say, attacks appear when it is difficult to breathe and the heartbeat increases greatly.

Why does this alarming phenomenon occur in pregnant women, what does it indicate and how to deal with it?

Reasons for appearance in the first trimester

A fairly large number of factors can provoke this condition. It also matters in what month of the child’s development it occurred, and what diseases the expectant mother suffers from.

For example, shortness of breath that suddenly appeared early stages, most often indicates an incorrect lifestyle, but sometimes it is a sign of some internal pathology.

In the first trimester, the following factors may make breathing difficult:

• Severe emotional stress;
• Significant physical activity;
• Smoking;
• Alcohol consumption;
• The hormonal surge is too sharp;
• Increasing the volume of blood circulating throughout the body;
• Anemia;
• Lung diseases, for example, asthma, tuberculosis;
• Wearing synthetic, tight clothing.

Appears in the second trimester

It is worth noting that in the early stages this phenomenon is very rare. Expectant mothers at this time can fully enjoy their position. In the vast majority of cases, shortness of breath begins to make itself felt at the beginning of the second trimester.

It is during this period that serious changes occur in a woman’s body:

1. The child is getting bigger, so he needs additional space;
2. In order for the fetus to develop normally, the uterus stretches and puts pressure on nearby organs;
3. The pressure of the uterus affects the diaphragm more than others, so it is at this time that the first, as yet subtle, symptoms of shortness of breath occur;
4. Smoking, alcohol, anemia, and improperly selected clothing increase the unpleasant symptoms. Diseases that the expectant mother has also play a role. internal organs and systems, especially the lungs;
5. The degree of difficulty breathing depends on how high the uterus rises every day.

Occurrence late in life

• Shortness of breath during pregnancy in the third trimester is especially pronounced. At this stage, the uterus is so enlarged that it is difficult for it to fit into the body, and it begins to put more pressure on the diaphragm. In this case, nothing can be done and you will have to endure.
• A few weeks before birth, the fetus descends into the pelvis, which reduces pressure. This moment is characterized by the fact that breathing becomes much easier. But this does not happen to everyone, so some will have to endure until the birth itself.

Almost all of the above reasons help expectant mothers understand that everything that happens is completely natural and natural. The only question that remains open is how this unpleasant condition can be alleviated in any trimester.

Warning signs

In some cases, a woman needs to see a doctor as soon as possible or call ambulance. This is done when shortness of breath is accompanied by other phenomena:

• chest pain;
• rapid heartbeat;
• pulse fluctuations;
• wet feet and palms.

If the doctor suspects anemia, he will definitely give a referral for a blood test to confirm or refute the diagnosis.

Methods for eliminating shortness of breath

If a woman has experienced this unpleasant phenomenon at the very beginning of pregnancy, it means that she needs to reconsider her lifestyle and eliminate the factors that led to such consequences.

1. First of all, you need to visit a doctor and undergo examination for the presence of pathologies of internal organs and systems, paying special attention to the lungs. Of course, heavy physical activity is excluded, but this does not mean that you need to lie on the couch for the entire 9 months.
2. A pregnant woman should be active at all stages, but in moderation. Stress, emotional shock, psychological pressure - all these factors must be excluded. If necessary, the doctor will prescribe sedatives, for example, tincture of valerian or motherwort.
3. Such bad habits, like smoking and drinking alcohol, should be eliminated immediately after a woman learns about her situation, or better yet, at the planning stage. The last reason is uncomfortable clothes, so you need to reconsider your wardrobe, giving preference to loose items made from natural fabrics.

If the cause is only a child growing in the uterus, then you can resort to well-known methods that can eliminate shortness of breath altogether or at least alleviate its attacks:

• Do breathing exercises regularly;
• Be in the fresh air more often;
• Try to sleep in a reclining position;
• When sitting at the computer, TV, or at work, change positions more often;
• Ventilate the room where the woman stays for a long time;
• Give preference to fractional meals. You need to eat food often, but in small portions. This will avoid overloading your stomach and keep it relaxed. He, in turn, will take on some of the pressure, since he is close to the uterus;
• Perhaps the doctor will prescribe sedatives from medicinal plants;
• When symptoms appear, you need to pull yourself together and under no circumstances give in to panic.

If you take these tips into account, shortness of breath during pregnancy will stop bothering you and your well-being and mood will improve. A woman must understand that there is no need to suffer from attacks and endure them. Although they are almost always the result of natural processes, they negatively affect the emotional state, causing anxiety.

It evokes a double feeling in women: on the one hand, it is a pleasant expectation of their future baby, and on the other, there are many problems, difficulties and sensations that cause discomfort during such a long nine months.

And all this happens because the body undergoes a complete restructuring associated with the growth of the fetus.

Moreover During this time, a woman may experience a lot of unpleasant deviations: rashes on the stomach, nasal congestion, pressure surges, the appearance of venous “stars”, pain in the lumbar region, perineum, back, legs, stomach and legs and much more.

Some people endure pregnancy easily, not knowing at all what toxicosis and other difficulties are, while others go through it in full and count every minute when all the torment will end.

Each stage of pregnancy has its own difficulties. Thus, in the seventh month of pregnancy it most often manifests itself dyspnea, the woman has the feeling that there is less and less air in her lungs.

And the logical question arises, why is it difficult to breathe during pregnancy?

Causes of difficulty breathing

Shortness of breath has quite logical explanation– every week the fetus gains weight and needs more space, so the uterus begins to stretch and put pressure on nearby organs.

First to enter the pressure zone stomach(because of this, a woman may suffer from heartburn), bladder(the number of urinations increases noticeably) and intestines(this manifests itself in the appearance of constipation).

To the diaphragm the uterus rises only in the third trimester of pregnancy, which is undoubtedly a big plus. It’s too hard to endure constant shortness of breath for nine months.

And because how high the uterus rises, the degree of difficulty breathing depends.

In most cases this phenomenon occurs two to three weeks before birth– the baby prepares to be born, descends into the pelvic area and the pressure goes away.

However, for some women, the lowering of the abdomen does not occur at all and they have to endure it until the last moment.

Most often, shortness of breath occurs when excessive stress, both physically and emotionally - walking on floors, quarrels, unnecessary excitement, etc.

If difficulty breathing makes itself felt at a time when you are emotionally calm and not doing anything, you need to consult a doctor. He will send you for a blood test and an ECG, since shortness of breath may be a consequence or disease of the cardiovascular system.

Many pregnant women mistakenly assume that the appearance of shortness of breath during pregnancy causes a lack of oxygen in the baby. It's completely unrelated, so don't worry.

What to do when shortness of breath appears?

Firstly, you need consult your gynecologist. Good doctor is obliged to warn the woman about the possible occurrence of shortness of breath and advise how to cope with this problem without the use of medications.

But since you are not always lucky with a doctor, you can read some useful tips on our page.

1. Breathing exercises.

Try to use the technique used during childbirth during difficult breathing. If you have not yet started learning different types of breathing, now is the time to do so.

Proper breathing will help you feel better and the necessary amount of oxygen will reach the fetus. And before the moment of birth, you will master breathing techniques perfectly.

Here's one way correct breathing : get down on your knees and lean on your hands, try to relax as much as possible, breathe deeply and slowly - inhale, exhale. Repeat the exercise until shortness of breath subsides.

2. If you experience difficulty breathing, try to find a place to sit and the best option, lie down. If there is no such place, squat for a while.

If you have difficulty breathing at night, try to sleep in a reclining position. Do not sleep on your back under any circumstances, this can also cause shortness of breath, plus the baby is not very comfortable in this position.

3. If you still work or often sit in front of the TV, try to get up and walk around the room more often, change positions. Walking in the fresh air helps improve your breathing, so take half an hour every day and take a walk in the park, by the sea, or just near your house.
4. Learn to control your food intake, do not eat at one time a large number of. It is better to eat a little 5-6 times than to eat a full plate three times - after all, your stomach is compressed on all sides by the uterus, and a large amount of food eaten will make your breathing even more difficult.
5. Take a comfortable position in a chair, completely relax your upper body. Place your right hand on your stomach and your left hand on your chest. Inhale for three seconds, exhale for the fourth second.
6. An infusion of motherwort and herbs helps well. However, before using it, you should consult your doctor to see if you can drink it.
7. Aromatherapy relieves shortness of breath - take a bath, adding a couple of drops essential oil rosemary or lemon balm. You can also use an aroma lamp.

AND Finally: do not panic if shortness of breath suddenly appears, remember everything you read above, try to calm down and put your breathing in order with the help of our tips.

Have a successful and quick birth!

During pregnancy, especially in the last trimester, the expectant mother may experience increased shortness of breath as the uterus expands, limiting lung capacity. Pregnancy hormones (primarily progesterone) also stimulate rapid breathing to help compensate for limited breathing space. abdominal cavity. As a result, you breathe more quickly to ensure you and your baby get enough oxygen.

Is it normal to experience shortness of breath during pregnancy?

Shortness of breath is very common during pregnancy. About 70% of expectant mothers who have never experienced breathing difficulties before face this problem already from the first trimester.

Shortness of breath may begin in the first or second trimester. Most often it affects women who have gained excess weight or carrying more than one child.

In addition, a low level of physical fitness contributes to shortness of breath. But even those who previously kept themselves in good shape may notice that during pregnancy they begin to lose their breath.

At first, the lack of air scares most expectant mothers. And although difficulty breathing often causes discomfort, in most cases during pregnancy it is harmless.

Why do pregnant women experience shortness of breath?

Estrogen levels rise during pregnancy, either before or in parallel with progesterone levels. This hormone increases the number and sensitivity of progesterone receptors in the respiratory center of the central nervous system (hypothalamus and medulla oblongata).

Also, the appearance of shortness of breath may be associated with active substances such as prostaglandins, which stimulate the smooth muscles of the uterus during childbirth and are present in all three trimesters of pregnancy. Some of them increase airway resistance by contracting bronchial smooth muscle, while others may have a bronchodilator effect (dilate the bronchi).

This describes only part of the hormonal influence on the respiratory system.

Physical changes

Hormones stimulate the body to accumulate fluid, and blood volume also increases. Deeper breathing helps the heart cope with increased blood flow. Thanks to this, the unborn child is provided with a full metabolism. The breathing rate does not change due to this reason, but the breaths become deeper so that the process of absorbing oxygen and releasing carbon dioxide is more efficient. This is why expectant mothers sometimes experience shortness of breath even before the belly begins to round.

The gradual size of the growing fetus also leads to a lack of air. As the uterus expands after the 4th month, it increasingly begins to push against the muscle located under the rib cage (diaphragm), which as a result compresses the lungs. It also leads to a change in the shape of the chest - its height becomes shorter, but other chest dimensions increase to maintain a constant total lung capacity.

Do not worry. Although anatomical changes during pregnancy reduce the so-called expiratory reserve volume and functional residual capacity of the lungs, vital capacity, airway patency and gas exchange are still preserved in a healthy pregnancy. Simply put, you still have the ability to breathe adequately despite your shortness of breath symptoms.

How long will the breathing difficulties last?

Shortness of breath can be observed almost until the very birth, namely until the moment when the baby’s head drops into the pelvis and is fixed. As a result, the pressure on the diaphragm will decrease.

In the first pregnancy, this will happen around 36 weeks, when the baby descends into the pelvis. In a multiparous woman, it may not drop to the last level.

Immediately after childbirth, the level of the hormone progesterone drops, pressure on the diaphragm and uterus decreases, and breathing returns to normal.

But in some cases, it may take up to six months for the chest to return to its previous volume. However, even after this it will be slightly wider than before pregnancy.

Does shortness of breath affect the unborn child?

In the absence of other alarming symptoms, feeling short of breath is completely normal during pregnancy and does not harm the baby. In fact, you are breathing deeply enough to provide the fetus with the necessary amount of oxygen, even if it seems to you that this is not the case.

How to relieve shortness of breath?

MEASURES	DESCRIPTION
Strive to keep your back straight	This will help you not only reduce the feeling of shortness of breath, but also cope with it, so the effort is worth it. Give your lungs plenty of room to expand by sitting up straight with your shoulders back. When you sleep, you can support your body with pillows for relief.
Pay attention easy time physicalactivity	Simple exercises such as walking or swimming may cause slight shortness of breath while doing them, but they generally help make breathing easier. To understand, gentle loads are different in that when performing them, you can talk without making much effort. Proper physical activity during pregnancy is not only safe, but also beneficial. But if you experience shortness of breath at rest or after minimal exertion, tell your gynecologist.
Do breathing exercises	Breathing exercises can help with this problem if done 10 minutes daily. They help open the lungs to their maximum, which will also be useful after childbirth. For example, to increase the volume of your chest and give more room to your lungs, stand as straight as possible and raise your arms above your head while taking deep breaths.
Try this breathing technique	Do this while standing, which can also relieve pressure from the diaphragm and improve breathing: Inhale deeply, raising your arms to the sides and up. Then exhale slowly as you lower your arms down. Remember to raise and lower your head while breathing. You can place your hands on your chest to make sure you are breathing in through your chest and not your stomach. The ribs should be pushed out when you inhale, and it is recommended to focus on deep breathing so that you can practice it whenever you feel short of breath.

How to prevent shortness of breath?

MEASURES	DESCRIPTION
Eat right	Eating healthy foods can prevent shortness of breath. Healthy eating helps maintain normal weight, and this usually makes breathing easier. Avoid unhealthy foods high in sugar, salt and fat.
Maintain good hydration levels	Drink enough water and avoid drinks that increase urination, such as tea or soda. They can dehydrate the body. Polyphenols present in tea and coffee also interfere with absorption.
Eat foods rich in iron	Eat iron-rich foods such as dark green leafy vegetables, red meat and dark berries. Also increase your intake of vitamin C, as it helps the body absorb this micronutrient.
Consume dark beans with caution	Although beans are an excellent source of protein, they should be consumed in moderation. Too many legumes, especially dark legumes, can hinder the efficiency of iron absorption due to the so-called phytates they contain.
Avoid overexertion	Don't overwork yourself. Learn to ask for help when you need to lift heavy objects, such as grocery bags. You can also talk to your manager to free you from stressful tasks at work.

When should you worry?

Difficulty breathing, fatigue, and a fast heartbeat may be signs of low iron levels in the blood (anemia).

Shortness of breath during pregnancy most often occurs in the second and third trimesters, when the growing uterus begins to shift the diaphragm towards the lungs. In most cases, this symptom is of a physiological nature, but there are also pathological causes its appearance, which must be detected in time for treatment.

The causes of shortness of breath during pregnancy can be divided into:

• physiological: caused by physiological changes that occur during pregnancy;
• non-cardiac: caused by pathological and physiological changes in the respiratory tract, chest wall or metabolic disorders;
• cardiac: caused by pathologies of the cardiovascular system.

To determine the cause of shortness of breath, a pregnant woman should undergo timely examinations and consult a doctor if difficulty breathing occurs that is not caused by physiological reasons. In our article we will introduce you to the reasons for the appearance of this symptom and the necessary measures to eliminate them.

During pregnancy, a healthy woman may experience shortness of breath during exercise.

Physiological shortness of breath is observed in almost 70% of pregnant women. It is mild, rarely severe and does not have a significant impact on daily activities.

The causes of physiological shortness of breath during pregnancy are the following changes in a woman’s body:

• the fetus grows and gains weight, stretching the uterus, which begins to shift the organs located next to it;
• changes in the location of internal organs, starting from the second trimester, begin to put pressure on the diaphragm and lungs.

As the fetus and uterus grow, shortness of breath gradually increases, and the woman experiences it more acutely during physical or emotional stress. Also, physiological shortness of breath can be aggravated by wearing clothing that restricts the chest, in a stuffy room, or by the pregnant woman’s addiction to smoking or drinking alcoholic beverages. In the last weeks before birth, the fetus descends into the pelvis and difficulty breathing usually subsides.

Physiological shortness of breath should not bother a pregnant woman if it does not occur at rest and goes away within a few minutes after rest. To facilitate or eliminate it, you must follow a number of simple rules:

1. Visit your doctor regularly and undergo all necessary diagnostic examinations.
2. Reduce physical and psycho-emotional stress.
3. Stop drinking alcoholic beverages and smoking.
4. Wear comfortable clothes.
5. To walk outside.
6. Ventilate the room regularly.
7. Sleep in a comfortable position (preferably reclining).
8. Eat food in small portions.
9. Avoid staying in one position for a long time.

Non-cardiac dyspnea

Often the cause of shortness of breath in pregnant women is airway obstruction.

The causes of non-cardiac dyspnea can be some physiological causes caused by pregnancy and affecting the upper respiratory tract, as well as pathologies of the respiratory system or metabolic disorders.

Nasal congestion

During pregnancy, large-scale hormonal changes occur in a woman's body. An increase in estrogen levels in 30% of women can cause swelling of the mucous membranes of the nose. This leads to congestion, a feeling of lack of air and shortness of breath. As a rule, such changes are observed in the third trimester.

Respiratory diseases

The cause of shortness of breath during pregnancy can be various pathologies of the respiratory system, which are present in the woman’s medical history or develop already during gestation. Such pathologies include:

• bronchial asthma;
• cystic fibrosis;
• bronchiectasis;
• bronchiolitis obliterans;
• pneumonia;
• adult distress syndrome;
• aspiration pneumonitis;
• tuberculosis;
• metastases in the lungs;
• cancerous lymphangitis;
• sarcoidosis;
• fibrosing alveolitis;
• exogenous allergic alveolitis;
• lymphagioleiomyomatosis;
• pneumothorax;
• empyema;
• chronic obstructive pulmonary disease;
• pulmonary embolism;
• pulmonary hypertension;
• amniotic fluid embolism.

The following indications may be reasons for referring a pregnant woman to a pulmonologist:

• acute shortness of breath;
• progression or exaggeration of shortness of breath;
• uncertain diagnosis;
• indeterminate spirometry results;
• indications for CT scan of the lungs;
• the need for oximetry while walking and pulmonary function testing.

Depending on the causes of shortness of breath, the doctor will be able to prescribe treatment, which can be carried out in a hospital setting or on an outpatient basis.

Chest wall

Some pathologies of the chest wall can also contribute to the appearance of shortness of breath during pregnancy:

• obesity;
• polio;
• multiple sclerosis;
• kyphoscoliosis.

If these pathologies are detected, the pregnant woman must undergo an examination to determine the blood gas composition, which will help to identify hypoxia and hypercapnia in a timely manner.

Abnormal functioning of the diaphragm and chest can be caused by polyhydramnios or ovarian hyperstimulation syndrome. Treatment in such cases is determined depending on the severity of the syndrome and the duration of pregnancy.

Metabolic disorders

Metabolic disorders caused by various diseases can cause shortness of breath at different stages of pregnancy. Such pathologies include:

• anemia;
• thyrotoxicosis;
• chronic or acute renal failure;
• metabolic acidosis;
• sepsis.

The diagnosis in such cases is made on the basis of other clinical symptoms, test results and instrumental studies. After this, the woman is prescribed the main course of treatment.

Cardiac dyspnea

Shortness of breath of varying severity can occur in a pregnant woman against the background of cardiac pathology.

You can suspect the appearance of cardiac disease during pregnancy if this symptom is combined with the following factors:

• the appearance of shortness of breath at rest;
• shortness of breath when lying down;
• the appearance of shortness of breath at night;
• Availability .

The main causes of cardiac dyspnea are congenital heart defects and cardiomyopathies. Difficulty breathing can also be caused by other pathologies of the cardiovascular system: ischemic heart disease, hypertension, Morphan's syndrome, acquired heart defects, myocarditis, pericarditis, Eisenmenger syndrome, etc.

Cardiomyopathies

May cause shortness of breath and other pregnancy complications. During gestation, three forms of this cardiac pathology are distinguished:

• postpartum: rarely observed and in most cases goes away on its own, but with repeated pregnancy it can get worse;
• dilated: difficult to tolerate by pregnant women and often leads to the development of heart failure; the risk of maternal mortality with this pathology reaches 7%;
• hypertrophic: more easily tolerated by pregnant women and has a good prognosis.

For cardiomyopathies, women are recommended natural childbirth with adequate anesthesia, which can be supplemented by the application of obstetric forceps. Unlike caesarean section, such delivery causes fewer hemodynamic complications and ensures less blood loss during childbirth.

Heart defects

Depending on the severity of shortness of breath, high, medium and low risks of these pathologies for pregnancy are distinguished. They determine the tactics of pregnancy and delivery.

High risk includes:

• Marfan syndrome: the risk of aortic root dissection increases significantly when its diameter is more than 4 cm; in such cases, conception and continuation of pregnancy is not recommended;
• Eisenmenger syndrome: pulmonary hypertension, which accompanies this syndrome, in 40-50% of cases threatens the death of the mother; pregnancy with this pathology is recommended to be terminated.

If a woman with such pathologies decides to continue the pregnancy, she is recommended to be hospitalized in a specialized center, where she can receive all the necessary cardiac and obstetric care.

Average risk includes:

• : may manifest itself as nocturnal shortness of breath, with rapid progression it can lead to the development of pulmonary hypertension, the decision to manage pregnancy is made individually depending on diagnostic indicators;
• blood circulation according to Fontan: the prognosis of pregnancy depends on the functional capacity and function of the ventricle; with a single left ventricle, the chance of maintaining pregnancy increases, but in 30% of cases miscarriages are possible;
• : The prognosis of pregnancy depends on the degree of stenosis; with moderate or severe stenosis, aortic dissection, left ventricular diastolic dysfunction, systolic failure, fibrosis and decreased coronary blood flow reserve are possible.

Low risk includes:

• operated tetralogy of Fallot: in most cases, pregnancy is well tolerated, but sometimes severe pulmonary insufficiency and decompensation may develop;
• unoperated atrial septal defect: pregnancy can cause atrial arrhythmia, and when this defect is combined with hypercoagulation, the risk of paradoxical embolism during labor increases; to ensure the normal course of pregnancy, drug prophylaxis of thromboembolism and antibiotic prophylaxis are recommended;
• operated coarctation of the aorta: in the absence of an aneurysm in the surgical area, pregnancy does not pose a significant risk, to prevent possible complications For this condition, CT or MRI before conception is recommended.

The degree of risk for pregnancy in other pathologies of the heart and blood vessels that cause shortness of breath is assessed based on data on age, gestational age, concomitant diseases and the severity of the underlying disease. That is why all women with pathologies of the cardiovascular system are recommended to plan and prepare for conception.

Shortness of breath during pregnancy, which occurs as a result of physiological changes occurring in the body during gestation, should not cause worry or concern. It can be easily eliminated or alleviated by following some simple recommendations.

To prevent and timely detect diseases that can cause pathological shortness of breath during pregnancy, a woman should healthy image life, plan to conceive a child and consult a doctor in time if symptoms of diseases appear. If breathing difficulty that causes concern has already appeared during pregnancy, then it may be necessary to conduct a detailed examination to identify the pathology. Such measures will help prevent not only the progression of the disease that caused shortness of breath, but will also help doctors determine further tactics for managing pregnancy and childbirth, which would prevent the development of more severe complications.

Series of video programs “Questions about pregnancy”, issue 14 “Shortness of breath in pregnant women”: