Dyspnea in Pregnancy: Outcome

Category: Pregnancy | Tags: dyspnea, postpartum, Pregnancy, pulmonary, respiratory

Are there any contraindications to physical activity during pregnancy? Several have been outlined by the American College of Obstetricians and Gynecologists and divided into relative and absolute contraindications. Relative refers to those which, under controlled conditions, allow a woman to maintain a moderate program of physical activity. Medical conditions such as hypertension, anemia or blood disorder, thyroid disease, diabetes, and cardiac arrhythmias fall into this category. Others are related to the pregnancy itself, such as a history of precipitous labor in a prior pregnancy, history of intrauterine growth retardation, bleeding during the present pregnancy, or a breech presentation in the last trimester. Other constitutional problems such as excessive obesity or anorexia or a history of an extremely sedentary lifestyle could all be considered relative contraindications for increasing activity level during pregnancy. Each patient must be evaluated on an individual basis when any of these relative factors is present alone or in combination with others.

The absolute contraindications to physical activity include: more than three spontaneous abortions or ruptured membranes; a history of premature labor, especially in the current pregnancy; diagnosed multiple gestation; and the presence of an incompetent cervix, even if the woman has a cerclage in place. The presence of bleeding or a diagnosed placenta previa that has not bled and diagnosed unmanaged cardiac disease greater than New York Heart Association class 2 also prohibit participation in exercise programs. So what advice can we give the mother who asks, “I want to feel better. How can I do it?” Specific program guidelines can be recommended for her. The manner of exercise and the mode in which she performs physical activity should be outlined. The frequency should be at least three times per week. The duration should be no greater than 30 minutes. The intensity should be such that she can maintain a conversation while she is participating in her activity. If her breathlessness is such that she cannot comfortably say at least three words in a row, the woman is exercising to excess.

We must encourage the woman to use a warm-up and a cool-down period to minimize dizziness and syncope after any activity. The woman should also limit exercise in the heat, use low^intensity programs, especially the nonathlete, and avoid exercising to exhaustion or chronic fatigue. Once the woman has been delivered, she can resume her level of activity anywhere from 2 to 6 weeks postpartum. Breast feeding is not a contraindication to exercise. With these guidelines, a woman can participate in activity, whether organized in a supervised program or on her own, can participate on a regular basis, and can maintain almost all exercises that she enjoyed prior to conception. These women should benefit from an overall sense of well being and a decrease in their sensation of dyspnea.
Question, Dr. Thomas DiUard: What are the most common causes of respiratory failure during pregnancy?
Answer: Dr. Tknholder: Acute respiratory distress syndrome or respiratory failure postpartum can be caused by all of the diseases that we mentioned that mimic amniotic fluid embolism in this setting. The incidence of pulmonary edema after pregnancy is rare and its occurrence should be viewed as a serious development that mandates a search for all of these possibilities. We should also emphasize that patients with underlying pulmonary disease can often go unrecognized. We have recently consulted on a patient whose pregnancy was complicated by pulmonary alveolar proteinosis. Since most patients have not had a chest film during pregnancy, we should carefully review the medical history for a missed pulmonary disorder whenever an ARDS or interstitial pattern appears postpartum.