Why fatigue and breathlessness in pregnancy matters
Some tiredness and breathlessness is normal in pregnancy, which is exactly why the abnormal causes get missed. Anaemia is very common in pregnant women in India and affects both mother and baby; a few causes of breathlessness, such as a clot in the lung, are rarer but dangerous.
What to ask in the history
- How the tiredness and breathlessness started, and whether they are worse on exertion or at rest
- Light-headedness, fainting, palpitations, chest pain
- Diet, and whether she takes her iron and folic acid tablets (and any side effects stopping her)
- Previous pregnancies, and the gap since the last one
- Heavy periods before pregnancy, bleeding in this pregnancy
- Craving for non-food items (pica), worm infestation, piles
- Personal or family history of anaemia or thalassaemia
- Leg swelling or pain, headache, visual disturbance
- Fetal movements
Red flags
- Breathlessness at rest, chest pain or fainting
- A fast heart rate at rest or low oxygen saturation
- A swollen, painful calf
- Raised blood pressure, headache or visual disturbance
- Vaginal bleeding
- Reduced fetal movements
- Haemoglobin below 7 g/dL
What to examine
- Pallor, nails (spoon-shaped?), tongue, angles of the mouth
- Pulse, blood pressure, respiratory rate, oxygen saturation
- Heart sounds and murmurs, chest
- Legs: oedema, calf swelling or tenderness
- Abdomen: fundal height for dates, fetal heart
First investigations
- Haemoglobin and full blood count with red cell indices (MCV, MCH)
- Serum ferritin
- Peripheral blood smear
- Haemoglobin electrophoresis or HPLC if the cells are small and iron stores are normal
- Stool for ova and parasites, urine routine
- ECG and further tests if a cardiac or lung cause is suspected
Differential diagnosis of fatigue and breathlessness in pregnancy
Grouped, not ranked. Which one fits this patient is for you to work out in the case.
Anaemia
- Iron deficiency
- Physiological (dilutional) fall in haemoglobin
- Thalassaemia trait
- Folate or vitamin B12 deficiency
- Blood loss, including hookworm
Heart and lung
- Normal breathlessness of pregnancy
- Pulmonary embolism
- Heart disease in pregnancy (rheumatic valve disease, cardiomyopathy)
- Asthma
Other
- Thyroid dysfunction
- Infection
Common mistakes
- Putting all breathlessness down to pregnancy.
- Relying on haemoglobin alone. Ferritin tells you about iron stores; a smear and indices point to the type of anaemia.
- Missing thalassaemia trait, which looks like iron deficiency on a blood count but does not respond to iron.