Difficulty in breathing

PROBLEM

• A woman is short of breath during pregnancy, labour or after delivery.

GENERAL MANAGEMENT

• Make a rapid evaluation of the general condition of the woman including vital signs (pulse, blood pressure, respiration, temperature).

• Prop up the woman on her left side.

• Start an IV infusion and infuse IV fluids.

• Give oxygen at 4-6 L per minute by mask or nasal cannulae.

• Obtain haemoglobin estimates using haemoglobinometer or other simple method.

DIAGNOSIS

TABLE S-18   Diagnosis of difficulty in breathing

MANAGEMENT

SEVERE ANAEMIA

• Transfuse as necessary:

- Use packed cells;

- If blood cannot be centrifuged, let it hang until the cells have settled. Infuse the cells slowly and dispose of the remaining serum;

- Give frusemide 40 mg IV with each unit of packed cells.

• If Plasmodium falciparum malaria is suspected, manage as severe malaria.

• Give ferrous sulfate or ferrous fumerate 120 mg by mouth PLUS folic acid 400 μg by mouth once daily for 6 months during pregnancy. Continue for 3 months postpartum.

• Where hookworm is endemic (prevalence of 20% or more), give one of the following anthelmintic treatments:

- albendazole 400 mg by mouth once; 

- OR mebendazole 500 mg by mouth once or 100 mg two times per day for 3 days;

- OR levamisole 2.5 mg/kg body weight by mouth once daily for 3 days;

- OR pyrantel 10 mg/kg body weight by mouth once daily for 3 days.

• If hookworm is highly endemic (prevalence of 50% or more), repeat the anthelmintic treatment 12 weeks after the first dose.

HEART FAILURE

HEART FAILURE DUE TO ANAEMIA

• Transfusion is almost always necessary in heart failure due to anaemia:

- Use packed or sedimented cells as described for severe anaemia (above);

- Give frusemide 40 mg IV with each unit of packed cells.

HEART FAILURE DUE TO HEART DISEASE

• Treat acute heart failure. Drugs used may include:

- morphine 10 mg IM as a single dose; 

- OR frusemide 40 mg IV, repeated as necessary;

- OR digoxin 0.5 mg IM as a single dose;

- OR nitroglycerine 0.3 mg under the tongue, repeated in 15 minutes, if necessary.

• Refer to a higher level if needed.

MANAGEMENT OF HEART FAILURE DURING LABOUR

• Prop up the woman on her left side.

• Limit infusion of IV fluids to decrease the risk of circulatory overload and maintain a strict fluid balance chart.

• Ensure adequate analgesia. 

• If oxytocin infusion is required, use a higher concentration at a slower rate while maintaining a fluid balance chart (e.g. the concentration may be doubled if the drops per minute is decreased by half, Table P-7).

Note: Do not give ergometrine.

• Have the woman avoid sustained bearing down efforts during the expulsive stage, if possible. 

• If necessary to decrease the woman’s workload during delivery, perform an episiotomy and assist delivery by vacuum extraction or forceps.

• Ensure active management of third stage.

Heart failure is not an indication for caesarean section. 

MANAGEMENT OF HEART FAILURE DURING CAESAREAN SECTION

• Use local infiltration anaesthesia with conscious sedation. Avoid spinal anaesthesia.

• Deliver baby and placenta. 

PNEUMONIA

Inflammation in pneumonia affects the lung parenchyma and involves respiratory bronchioles and alveoli. There is loss of lung capacity that is less tolerated by pregnant women. 

• A radiograph of the chest may be required to confirm the diagnosis of pneumonia. 

• Give erythromycin base 500 mg by mouth four times per day for 7 days.

• Give steam inhalation.

• Consider the possibility of tuberculosis in areas where it is prevalent.

BRONCHIAL ASTHMA

Bronchial asthma complicates 3-4% of pregnancies. Pregnancy is associated with worsening of the symptoms in one-third of affected women. 

• If bronchospasm occurs, give bronchodilators (e.g. salbutamol 4 mg by mouth every 4 hours or 250 μg aerosol every 15 minutes for 3 doses).

• If there is no response to bronchodilators, give corticosteroids such as hydrocortisone IV 2 mg/kg body weight every 4 hours as needed.

• If there are signs of infection (bronchitis), give ampicillin 2 g IV every 6 hours.

• Avoid the use of prostaglandins. For prevention and treatment of postpartum haemorrhage, give oxytocin 10 units IM or give ergometrine 0.2 mg IM.

• After acute exacerbation has been managed, continue treatment with inhaled bronchodilators and inhaled corticosteroids to prevent recurrent acute episodes.

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