Differential Diagnosis of Chest Pain/Shock in Pregnancy
| Diagnosis | Key features | Management |
|---|---|---|
| Pulmonary embolism | See breathlessness. | |
Myocardial infarction
| As in non-pregnant (atypical presentations more common in women). | ECG, troponin (not altered by pregnancy). Medical management as in non-pregnant, that is, primary PCI, except avoid IIb/IIIa inhibitors and statins. |
| Stroke CVT/SAH/ICH/infarction | As in non-pregnant. | Appropriate imaging depends on availability and most likely cause of symptoms, but MRI is usually preferred after the 1st trimester Aspirin and other antiplatelet agents can be given in pregnancy as can UFH and LMWH. |
| Aortic dissection | Associated with pregnancy particularly in women with Marfan syndrome, Ehlers-Danlos type IV or coarctation of the aorta. | CXR, CT Combined caesarean section and surgical repair if type A and viable fetus. |
| Amniotic fluid embolism | Shock. Respiratory distress and cyanosis. Early and severe bleeding (DIC). | CXR. FBC, PT, APTT. High flow oxygen and respiratory and circulatory support. |
| Septic shock | Often rapid onset. Temp >38 or <36°C. HR >100/min. RR >20 resps/min. WBC <4 or >17×109/L. Clinical signs – fever, rigors, abdominal pain, vomiting, headache, confusion, offensive vaginal discharge. | Blood cultures, plasma lactate, FBC, U&Es. IV fluids. Antibiotics. HVS/LVS and MSU. Early transfer to level two critical care. Of note – group A strep is increasing in prevalence. |
| Anaphylactic shock | As in non-pregnant. | Need senior anaesthetist early, as intubation in pregnancy is difficult. |