A Case of Chest Pain and Dyspnea During Delivery
- acute coronary syndrome
- coronary artery dissection, spontaneous
- heart failure
- tomography, optical coherence
Information about a real patient is presented in stages (bold-face type) to an expert clinician (Dr Nandita S. Scott), who responds to the information, sharing her reasoning with the reader (regular type). A discussion by the authors follows.
A 35-year-old woman, G2P1, with a history of Hashimoto’s thyroiditis, vitiligo, and gestational diabetes mellitus presented in the 30th week of pregnancy with premature labor. She was admitted to the obstetrics service for monitoring and tocolytic therapy. On hospital day 2, the patient complained of chest heaviness and left arm discomfort, but her assessment was confounded by pain secondary to frequent uterine contractions. On hospital day 3, fetal monitoring disclosed a nonreassuring fetal heart rate pattern, prompting transfer to the operating room for urgent Caesarian section. A viable female infant was delivered, but the immediate postoperative course was complicated by acute dyspnea, coughing, and hypoxia.
Dr Nandita S. Scott: Dyspnea is quite common during pregnancy as a result of physiological changes including weight gain, dilutional anemia of pregnancy, and progesterone-induced hyperventilation. This can make the distinction between pathology and normal dyspnea of pregnancy difficult. In contrast, hypoxia during pregnancy is never normal. The cardiac causes of hypoxia in the peripartum period can be broadly separated into 2 categories: congestive heart failure from preexisting cardiac conditions (eg, cardiomyopathy, valvular disease, or congenital heart disease) or congestive heart failure attributable to pregnancy-induced cardiac conditions (eg, peripartum cardiomyopathy or acute ischemic events). Pulmonary causes such as pulmonary embolism and amniotic fluid embolism also need to be considered.
Pregnancy poses a large hemodynamic burden on the cardiovascular system. A 30% to 50% rise in blood volume and cardiac output, increase in heart rate, reduction in systemic vascular resistance resulting from the low-resistance placental unit, physiological anemia, and positional reduction in cardiac output attributable to compression of …