Experience Summary

These two 360-degree videos are designed to be watched together and the differences in at the antenatal appointment reflected upon. Observe a patient attending an antenatal appointment with increased shortness of breath.

Clinical Context

Heart failure in pregnancy is a serious condition that poses significant risks to both maternal and fetal health. Pregnancy induces substantial physiological changes, including increased blood volume, cardiac output, and heart rate, which can unmask previously undiagnosed cardiac disease or exacerbate existing heart conditions. The peripartum period, especially the third trimester and the first few weeks postpartum, is when women are most vulnerable.

Several risk factors increase the likelihood of developing heart failure during pregnancy, including:

• Pre-existing cardiac conditions (e.g., congenital heart disease, cardiomyopathy, valvular disease).
• Hypertensive disorders of pregnancy (e.g., pre-eclampsia, eclampsia).
• Advanced maternal age (>35 years).
• Obesity.
• Multiple pregnancy.
• Family history of cardiomyopathy.
• Lifestyle factors such as smoking or substance misuse.

Peripartum cardiomyopathy is a specific form of heart failure that develops in previously healthy women, usually in the last month of pregnancy or within five months postpartum, and is characterised by left ventricular systolic dysfunction.

Complications

Heart failure in pregnancy can lead to severe maternal and fetal complications, including:

• Pulmonary oedema.
• Arrhythmias.
• Thromboembolic events.
• Preterm labour.
• Intrauterine growth restriction.
• Fetal hypoxia or death.
• Maternal cardiac arrest.

Assessment

Prompt recognition and assessment are essential to improve outcomes. Symptoms may overlap with normal pregnancy changes, but concerning signs include:

• Severe breathlessness, particularly at rest or when lying flat.
• Fatigue disproportionate to pregnancy stage.
• Palpitations or syncope.
• Peripheral oedema beyond typical pregnancy swelling.
• Cyanosis or chest pain.

Clinical examination may reveal tachycardia, elevated jugular venous pressure, pulmonary crackles, and peripheral oedema. An echocardiogram is the primary diagnostic tool for assessing cardiac structure and function. Additional investigations may include ECG, chest X-ray (with abdominal shielding if pregnant), and blood tests including BNP or NT-proBNP levels, although interpretation requires caution in pregnancy.

Management

Management requires a multidisciplinary team, including obstetrics, cardiology, anaesthetics, and critical care. Treatment focuses on optimising cardiac function while minimising fetal risk.

• Oxygen therapy and diuretics (e.g., furosemide) for symptom control.
• Beta-blockers or vasodilators as appropriate.
• Anticoagulation if there is significant ventricular dysfunction or arrhythmia risk.
• Early delivery may be considered if maternal or fetal status deteriorates.

Ongoing monitoring and postpartum follow-up are essential, as heart failure may persist or worsen after delivery.

Learning Outcomes

1. Understand the causes of shortness of breath in pregnancy.
2. Observe and reflect upon the clinical assessment of the patient in this case.
3. Understand the investigations required for shortness of breath in pregnancy.
4. Understand the investigation and management of heart failure in pregnancy.
5. Observe effective multidisciplinary team communication in the context of maternal medicine.

External Resources

• ESC Guidelines on the management of cardiovascular diseases during pregnancy
• Intrapartum care for women with existing medical conditions or obstetric complications and their babies