Breathlessness in Pregnancy (28 Sept 2026)

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00:00:00

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00:00:33 Dr Heather Kennedy

Hello and welcome to this episode of Clinical Conversations brought to you by the Trainees and Members Committee of the Royal College of Physicians of Edinburgh.

00:00:41 Dr Heather Kennedy

I'm Dr Heather Kennedy, I'm an ST4 in acute medicine and a member of the Trainee and Members Committee.

00:00:48 Dr Heather Kennedy

I'm joined today by Dr Ailie Young who is a consultant in acute medicine in NHS Fife and she has a special skill in obstetric medicine.

00:00:57 Dr Heather Kennedy

Welcome, Ailie, and thank you so much for joining me today.

00:01:00 Dr Ailie Young

Thank you for having me, Ellie.

00:01:02 Dr Heather Kennedy

And before we dive into our topic today, which is breathlessness in pregnancy in the AMU, I was wondering if you could tell me a bit about your role and how you became interested and involved in obstetric medicine.

00:01:17 Dr Ailie Young

Of course.

00:01:18 Dr Ailie Young

So way back when I was much, much younger, I used to think I wanted to be an obs and gynae consultant.

00:01:26 Dr Ailie Young

I was very interested in the formation of the fetus and the embryology and the really complicated surgeries that came with being pregnant and what went wrong in pregnancy.

00:01:37 Dr Ailie Young

And I'd always loved it and I'd done a lot of my intercalate was in women's health and I just thought it was the job for me.

00:01:45 Dr Ailie Young

I then did a rotation in FY2 and actually realised that I was much more interested in the medical side of obstetrics rather than the operations or gynecology.

00:01:56 Dr Ailie Young

And it wasn't until there was a pregnant woman who had an MI on the ward I thought this is the niche that I want to do.

00:02:03 Dr Ailie Young

I knew that I didn't really want to be a surgeon deep down and I thought actually I'm going to become a better clinician and more confident in treating these medical problems in pregnancy, which is how I ended up doing core medical training and then ultimately decided to do acute medicine for the thrill and the diagnostics and knowing that I could CTT with a specialist skill in obstetric medicine.

00:02:26 Dr Ailie Young

And that's how I've got to where I am today.

00:02:29 Dr Heather Kennedy

Amazing.

00:02:29 Dr Heather Kennedy

So that's combined several different interests that you had and allowed you to pursue something within acute medicine as a special skill.

00:02:37 Dr Heather Kennedy

And I think that's something that I didn't really know about acute internal medicine as a training program that you have time that you can develop a skill in a different area.

00:02:46 Dr Heather Kennedy

So thanks for sharing that.

00:02:48 Dr Heather Kennedy

And I wonder, are there many people in Scotland or in the UK that are trained as acute physicians with this special skill?

00:02:56 Dr Ailie Young

So it's fairly new.

00:02:57 Dr Ailie Young

So acute medicine is a young specialty.

00:03:00 Dr Ailie Young

I keep saying that, but it's about 26 years old now.

00:03:03 Dr Ailie Young

And yes, as you said, everyone has to pick a specialist skill, but there are many to pick from.

00:03:09 Dr Ailie Young

So not everybody is going to specialise in obstetric medicine.

00:03:12 Dr Ailie Young

There are some absolutely amazing physicians and surgeons in England who have pioneered the way for looking after medical problems in pregnancy.

00:03:22 Dr Ailie Young

And they have very much supported me in my journey.

00:03:25 Dr Ailie Young

Scotland is

00:03:26 Dr Ailie Young

a smaller country.

00:03:27 Dr Ailie Young

There are not as many acute physicians in Scotland and therefore there are not very many people that are doing this as a specialist skill.

00:03:35 Dr Ailie Young

So me and another colleague, we are the only two in Scotland at the moment, but I do think this is something that is going to become more popular.

00:03:43 Dr Ailie Young

It's unfortunately very, very needed.

00:03:46 Dr Ailie Young

You know, we're all having babies later in life and we're not as healthy as we once were and we've all got a wee bit of a higher BMI.

00:03:54 Dr Ailie Young

So this is something that is

00:03:56 Dr Ailie Young

So there's not many of us now, but I expect there to be more in the future.

00:04:01 Dr Ailie Young

Great.

00:04:01 Dr Heather Kennedy

And today we're going to be discussing breathlessness in pregnancy in the AMU.

00:04:08 Dr Heather Kennedy

And I think I speak for many of my fellow resident doctors when I see that encountering a pregnant patient in this setting can cause quite a bit of anxiety, a bit of feeling uncertain and unfamiliar.

00:04:22 Dr Heather Kennedy

I wondered in the acute medicine setting, what do you think are the most common presentations and complaints that we were asked to deal with in an obstetric patient?

00:04:32 Dr Ailie Young

So I think if there is a pregnant woman, and when I say pregnant woman, I really do mean anybody who has the ability to carry a fetus through to term, but I will continue to use the word women, but I just want to acknowledge that.

00:04:45 Dr Ailie Young

When people come to the AMU,

00:04:47 Dr Ailie Young

The most common thing they're going to present with is going to be headaches or breathlessness or palpitations.

00:04:55 Dr Ailie Young

But the big question really is actually do we know that they are pregnant?

00:04:59 Dr Ailie Young

And are we thinking about that when we see anyone of a childbearing age coming into the AMU?

00:05:04 Dr Ailie Young

And obviously, there's a massive disparity across the whole of the UK as to whether or not your acute admissions unit accepts pregnant women to acute admissions.

00:05:12 Dr Ailie Young

Some people will take them right up to 36 weeks just before they're coming to the end of their pregnancy.

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And some places only take them up to booking, which is 12 weeks.

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So there's a lot of variation across the UK.

00:05:25 Dr Ailie Young

But yet, I think it will be headaches, palpitations, and breathlessness.

00:05:30 Dr Heather Kennedy

And obviously those are too many things for us to discuss today.

00:05:34 Dr Heather Kennedy

And I know if people are interested, we do have headaches in pregnancy that was put out on our podcast in February of this year, so check that out.

00:05:42 Dr Heather Kennedy

And today we're going to be focusing in on breathlessness.

00:05:45 Dr Heather Kennedy

And can I start by asking, is it normal to be breathless in pregnancy?

00:05:52 Dr Ailie Young

So I think anyone who's listening to this who's ever been through a pregnancy may have had a bit of a chuckle and a knowing sort of, oh yes, it's really common.

00:06:00 Dr Ailie Young

So sort of about 75% of women will have said they're breathless at some point in their pregnancy.

00:06:07 Dr Ailie Young

And it's not just at the last trimester, this can come on very early on.

00:06:12 Dr Ailie Young

And there are many different factors that can contribute to it.

00:06:16 Dr Ailie Young

There's the fact that you're growing a baby, so there's physically something pushing up

00:06:21 Dr Ailie Young

on your diaphragm the further through the pregnancy that you get.

00:06:25 Dr Ailie Young

But there's obviously the physiological change that comes with that too.

00:06:29 Dr Ailie Young

In pregnancy, you develop an increase in progesterone.

00:06:33 Dr Ailie Young

And progesterone is a bronchodilator.

00:06:35 Dr Ailie Young

Your vessels and your airway system is naturally a little bit more dilated, which in turn is going to increase your tidal volume, so you're breathing deeper, you're sighing a little bit more.

00:06:46 Dr Ailie Young

And with that,

00:06:48 Dr Ailie Young

It can give you a relative respiratory alkalosis.

00:06:50 Dr Ailie Young

Now, everyone says when you do an exam question, it always comes up, look at this, alkalotic pregnant woman.

00:06:56 Dr Ailie Young

That can be normal.

00:06:57 Dr Ailie Young

It's not always normal.

00:06:58 Dr Ailie Young

But physiologically, there is this sort of, you know, you're breathing deeper, your diaphragm's higher, your lungs are squashed, but you're breathing more.

00:07:06 Dr Ailie Young

And it's a case of actually all of that together can make you feel breathless.

00:07:12 Dr Ailie Young

But that doesn't mean that everybody is breathless.

00:07:16 Dr Ailie Young

I know that's very paradoxical.

00:07:18 Dr Ailie Young

Sometimes pregnant women will say I'm sitting on the sofa and I can feel it and I'm gasping, but as soon as I get up for a cup of tea, it gets better.

00:07:26 Dr Ailie Young

What shouldn't change though is oxygenation in pregnancy.

00:07:30 Dr Ailie Young

So if you were to put a SATS probe on these women, that oxygen saturation shouldn't change.

00:07:35 Dr Ailie Young

The respiratory rate can go up for lots of different reasons, but if you had an asthmatic, their peak flow shouldn't change as normal physiology in pregnancy.

00:07:45 Dr Ailie Young

So people do get breathless, but there is a big difference between pathological breathlessness, which we're obviously going to have a wee chat about today.

00:07:53 Dr Ailie Young

But if a pregnant woman came into the AMU and just said off the cuff, I'm breathless, that might be totally normal for her.

00:08:02 Dr Heather Kennedy

That's really helpful to think in the context of what is a normal physiological adaptation of the body during pregnancy and then

00:08:10 Dr Heather Kennedy

What indicates things might be abnormal?

00:08:13 Dr Heather Kennedy

And if we're seeing someone in the EMU or perhaps in obstetric triage that we've been referred, what would go through your head when assessing a patient who's breathless and how would you approach your assessments?

00:08:26 Dr Ailie Young

So I think the most important thing is to not panic.

00:08:30 Dr Ailie Young

And definitely the most important thing to do is to not sneakily put her to the bottom of the pile and pick someone else.

00:08:37 Dr Ailie Young

To begin with,

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treat her as if she is a young man or treat her as if she is an old man.

00:08:43 Dr Ailie Young

Forget the pregnancy.

00:08:45 Dr Ailie Young

The most important thing that you can do for this woman is give her a proper history and an examination and then think about your basic tests.

00:08:53 Dr Ailie Young

So when you have your breathless patient, you're coming in, you're asking about what are you doing when you're breathless?

00:08:59 Dr Ailie Young

How long has it been going on for?

00:09:01 Dr Ailie Young

Have you talked about coughs and colds and fevers and is there any pain associated with it?

00:09:07 Dr Ailie Young

In your examination, you should again examine them as you would examine A breathless man.

00:09:12 Dr Ailie Young

There's no point poking and prodding at our tummy.

00:09:15 Dr Ailie Young

You're not trained to do that.

00:09:17 Dr Ailie Young

You're trained to listen to our lungs and have a think about, can I hear breath sounds in all six zones?

00:09:22 Dr Ailie Young

Is it quieter on one side?

00:09:24 Dr Ailie Young

And having a think about other pathologies, we're going to specifically talk about lungs today, but anaemia is really common in pregnancy.

00:09:31 Dr Ailie Young

is she looking paler than normal?

00:09:33 Dr Ailie Young

Like actually does her breath smell like pear drops and she's ketotic and that's why she's breathing fast.

00:09:39 Dr Ailie Young

So a really thorough history and an examination is helpful.

00:09:44 Dr Ailie Young

Sometimes women have been pregnant before, they're not necessarily a prima gravida.

00:09:48 Dr Ailie Young

And you can ask, what was your last pregnancy like?

00:09:52 Dr Ailie Young

That's often a helpful question, but it's only really useful if something went wrong in the last pregnancy or they have a medical condition, so for instance, asthma.

00:10:02 Dr Ailie Young

It's really, really important to ask these women about smoking and vaping and cannabis.

00:10:07 Dr Ailie Young

Just because people are pregnant doesn't mean that they stop all of their habits before pregnancy.

00:10:13 Dr Ailie Young

And it's just it's a really good public health moment to suggest actually, you know, stopping is a good idea.

00:10:20 Dr Ailie Young

There's not a lot of evidence on vaping at the moment that will come, but we can suggest that vaping in pregnancy is also not a good idea, as is cannabis.

00:10:30 Dr Ailie Young

So that would be our history and our examination.

00:10:33 Dr Ailie Young

And then thinking about actually what are the other things we're going to do at the bedside.

00:10:36 Dr Ailie Young

So if you have a pregnant woman in the first trimester, we should really confirm that she is pregnant.

00:10:41 Dr Ailie Young

You're not going to feel a bump or even see a bump at that point.

00:10:44 Dr Ailie Young

So doing a urinary pregnancy test is a sensible idea and confirm that there's a pregnancy there.

00:10:50 Dr Ailie Young

You can obviously also do a blood pregnancy test if urine isn't available for whatever reason.

00:10:55 Dr Ailie Young

Or you're specifically looking, you know, if your lady has said, I miscarried last week

00:11:00 Dr Ailie Young

week, sadly, and you want to see if that beta HCG is coming up or down.

00:11:05 Dr Ailie Young

So confirming the pregnancy is a good idea.

00:11:07 Dr Ailie Young

If it's before 12 weeks, she might not have booked with obstetrics yet or obstetrics and gynaecology.

00:11:13 Dr Ailie Young

And it's worth remembering that if you do have a pregnant woman at that gestation, you might want to give them a heads up that she's being admitted just because they don't know about her yet.

00:11:23 Dr Ailie Young

Now we need to think about all of our very basic investigations that we're going to do.

00:11:27 Dr Ailie Young

So like I said before, if you have a breathless asthmatic, you're going to do that peak flow.

00:11:32 Dr Ailie Young

And I think that's something we're not all that great with doing in the non-pregnant patient.

00:11:37 Dr Ailie Young

So I think getting it done straight away in your pregnant patient's a good idea.

00:11:42 Dr Ailie Young

And then we need to have a wee think about what other imaging we can do.

00:11:47 Dr Ailie Young

Now there is obviously a lot of fear about exposing women to radiation, but I promise that doing a chest x-ray is fine.

00:11:54 Dr Ailie Young

If you think this woman's got a cracking pneumonia and her chest is all horrible and can't quite differentiate what's going on, a chest x-ray is absolutely safe and important to do.

00:12:06 Dr Ailie Young

The worst thing you can do is omit any important investigation from these patients.

00:12:13 Dr Heather Kennedy

So what I'm hearing is

00:12:15 Dr Heather Kennedy

Some of us might get intimidated by seeing that there is a pregnant patient coming in, but we treat this person exactly the same as any other patient we're assessing in the AMU who's coming in with breathlessness.

00:12:26 Dr Heather Kennedy

We all know how to do that in terms of our history, examination, and like you say, booking those initial tests, including a chest x-ray, and just keeping our usual differentials and our usual thinking processes going on in the back of our mind.

00:12:42 Dr Heather Kennedy

And in terms of investigations,

00:12:45 Dr Heather Kennedy

You mentioned a chest X-ray.

00:12:47 Dr Heather Kennedy

We might think about doing bloods, ECG.

00:12:51 Dr Heather Kennedy

In our initial tests, are there anything there that would be what initially we might think is abnormal but is actually normal in pregnancy?

00:13:00 Dr Ailie Young

Yeah, so ECG, for whatever reason, is often omitted at the front door.

00:13:07 Dr Ailie Young

And this is obviously a very, very useful test.

00:13:11 Dr Ailie Young

Sometimes really basic things can get in the way.

00:13:14 Dr Ailie Young

For instance, people are often uncomfortable.

00:13:16 Dr Ailie Young

Where do you stick the stickers when there are large breasts?

00:13:20 Dr Ailie Young

Do you stick the stickers on top of the breast tissue?

00:13:22 Dr Ailie Young

Do you stick the stickers right up underneath on the ribs?

00:13:26 Dr Ailie Young

And sometimes just having the confidence of knowing where to do your basic tests can sometimes change the outcome.

00:13:32 Dr Ailie Young

So if you are doing an ECG or your colleagues are doing an ECG, make sure you're putting them on the closest bony part that you can get to.

00:13:40 Dr Ailie Young

Now, I would just recommend looking this up every time, but there are some ECG changes in pregnancy.

00:13:46 Dr Ailie Young

But the important thing is that they do not happen to everybody.

00:13:51 Dr Ailie Young

And they very much depend on, you know, your transthoracic impedance and the gestation.

00:13:56 Dr Ailie Young

So sometimes we can get little Q waves, we can get small Q waves and inverted T waves, but only in lead three.

00:14:03 Dr Ailie Young

If I was seeing progressive Q wave changes or while

00:14:07 Dr Ailie Young

spread T wave changes.

00:14:08 Dr Ailie Young

That is abnormal.

00:14:10 Dr Ailie Young

You can sometimes get inferior ST depression but it is subtle and very small and clinically if it isn't in keeping I would be a little bit retitent to do anything about that.

00:14:22 Dr Ailie Young

And then again, with advancing pregnancy, your uterus is bigger, your ribs are splayed, you can get a bit of left axis deviation.

00:14:29 Dr Ailie Young

But these are all small and subtle and are not necessarily always present.

00:14:34 Dr Ailie Young

So your ECG really needs to be correlated, as it always is, with your clinical presentation.

00:14:41 Dr Ailie Young

Now, blood tests in pregnancy, the only one we ever really get caught up on is D-dimer.

00:14:47 Dr Ailie Young

Now, in my admissions unit, all my bloods are done before I've

00:14:51 Dr Ailie Young

even had an opportunity to think about it.

00:14:53 Dr Ailie Young

So you need to be doing your basic for your full blood count, your liver tests, your urea and your electrolytes.

00:14:58 Dr Ailie Young

You know, a CRP is great.

00:15:00 Dr Ailie Young

If you need a troponin, you get the troponin done.

00:15:02 Dr Ailie Young

Clotting, you know, actually do a group and save if you've got a pregnant woman, but D-dimer is the one where people get caught up on.

00:15:09 Dr Ailie Young

Now, everybody listening to this podcast, no matter what grade you are or job you hold, we know that we should not do D-dimer in pregnancy just because we've got a

00:15:21 Dr Ailie Young

a lot of fibre and turnover and it is naturally going to be high.

00:15:25 Dr Ailie Young

But the problems going to come is what we're going to do when we've got a breathless pregnant patient and our amazing colleagues have done that D-dimer.

00:15:33 Dr Ailie Young

Now it's really important that we acknowledge it.

00:15:37 Dr Ailie Young

If I had a D-dimer that was just above the cutoff, I would be a lot more confident to leave it alone.

00:15:44 Dr Ailie Young

But if you have a D-dimer that is in the several thousands and you've got a woman with a big swollen leg and a productive hemoptysis and right-sided chest pain, then that isn't something I can ignore.

00:15:56 Dr Ailie Young

But going back to what I said earlier, the most important thing is getting a good history and examination off of these patients.

00:16:02 Dr Ailie Young

So D-dimer can muddy the waters if you have the power to not do the blood test.

00:16:07 Dr Ailie Young

then please choose not to do it.

00:16:10 Dr Ailie Young

But if you do end up getting a D dimer in there, then please correlate it to the clinical picture.

00:16:17 Dr Ailie Young

The other thing to think about is what do you do if you have a patient, a young patient,

00:16:22 Dr Ailie Young

with a D-dimer.

00:16:23 Dr Ailie Young

And this is just something to think about.

00:16:25 Dr Ailie Young

How often do we make sure we've done a pregnancy test in these patients?

00:16:29 Dr Ailie Young

You know, your non-pregnant patient that comes in at the front door query PE and you've got a D-dimer of a couple of thousand.

00:16:35 Dr Ailie Young

Please make sure you do a pregnancy test in these patients because it could be a pregnancy indicator for you.

00:16:41 Dr Heather Kennedy

Thank you.

00:16:42 Dr Heather Kennedy

I would not have thought of that, but yeah, a really good thing to think about.

00:16:45 Dr Heather Kennedy

We often get kind of funnelled into thinking about presenting complaint, but in a young woman with breathlessness or anything else, like

00:16:51 Dr Heather Kennedy

abdominal pain, nausea and vomiting, we should be thinking of doing that pregnancy test.

00:16:56 Dr Heather Kennedy

So you've spoken about doing our history examination as we would with any other patient in the AMU, the initial investigations which may or may not have given us a D-dimer.

00:17:07 Dr Heather Kennedy

And I wondered what would be the initial differential diagnoses going through your head that might be general or more specific to pregnant women?

00:17:18 Dr Ailie Young

So if I knew this lady was pregnant, the first thing that comes through my head, especially if she doesn't have a past medical history, is actually if she got the cold or an infection.

00:17:29 Dr Ailie Young

That is the most common cause of breathlessness that we see.

00:17:33 Dr Ailie Young

If she has a background of asthma, then actually does she have an asthma exacerbation?

00:17:39 Dr Ailie Young

I would think about anemia.

00:17:40 Dr Ailie Young

Anemia is very, very common.

00:17:42 Dr Ailie Young

I would make sure that, has she started her iron tablets that all pregnant women are advised to take during pregnancy?

00:17:50 Dr Ailie Young

Have we thought about if she's not necessarily from Scotland, but actually does she have ancestral history that might suggest she's got a thalassemia or a different type of haemoglobinopathy?

00:18:00 Dr Ailie Young

Have we thought about that?

00:18:02 Dr Ailie Young

But from a lung perspective, I would be thinking, is there actually a pathology here?

00:18:07 Dr Ailie Young

Why is she turned up to the AMU?

00:18:09 Dr Ailie Young

Would she have turned up to the AMU if she wasn't pregnant?

00:18:13 Dr Ailie Young

Am I looking at an anxiety in someone who's in their first pregnancy and has never had the cold or is worried about antibiotics, etc?

00:18:21 Dr Ailie Young

Obviously we're not going to talk about any cardiac condition in this podcast and that might be something for the future, but we need to be having a think about is she breathless because she's running at a heart rate of 180 and she's actually an SVT that we've not looked at?

00:18:34 Dr Ailie Young

Has she developed a cardiomyopathy or has this pregnancy unveiled a new cardiomyopathy that hadn't been picked up before?

00:18:42 Dr Ailie Young

So there are lots of things to think about.

00:18:45 Dr Ailie Young

PE in pregnancy is what we are drilled to recognise, but the most common things are not PE.

00:18:53 Dr Ailie Young

And it is really important that in our differential, we don't blind ourselves to the fact she's pregnant, but think about everything.

00:18:59 Dr Ailie Young

The other thing I've not necessarily talked about is pneumothorax.

00:19:03 Dr Ailie Young

Now pneumothorax is common.

00:19:05 Dr Ailie Young

it's as common as it is in the non-pregnant population, but if you got called as a medical emergency to say labour ward or after a patient had been admitted with hyperemesis and she was suddenly breathless, then please think about pneumothorax.

00:19:22 Dr Ailie Young

It is

00:19:23 Dr Ailie Young

Unfortunate, but it is well known that when you push, push, push, push, push, have a baby, and you've popped an alveoli.

00:19:29 Dr Ailie Young

So if a woman says, you know, my neck feels funny and there's crackling up the sides of her neck, has she got a pneumothorax?

00:19:35 Dr Ailie Young

Has she got bilateral pneumothorax?

00:19:37 Dr Ailie Young

I've seen that.

00:19:38 Dr Ailie Young

Please make sure you get a chest x-ray.

00:19:40 Dr Ailie Young

And your woman who's got hyperemesis, who's vomit and vomit and vomit and not keeping anything down, have we thought about a Bohovs?

00:19:48 Dr Ailie Young

Have we looked at that pneumomediastinum?

00:19:50 Dr Ailie Young

And the management's the same.

00:19:52 Dr Ailie Young

but it's really important not to forget about these very common conditions.

00:19:58 Dr Ailie Young

If you have a pregnant woman coming into the AMU, don't use a news chart.

00:20:04 Dr Ailie Young

A lot of our scoring systems are now electronic.

00:20:08 Dr Ailie Young

Certainly the departments I work in, it's all online, but we need to be using a maternal early warning score for these patients.

00:20:16 Dr Ailie Young

So anyone that's pregnant at any gestation.

00:20:19 Dr Ailie Young

So if you are pregnant one day, you should be going on to a Muse chart.

00:20:24 Dr Ailie Young

The reason being, as I said earlier, the physiology in pregnancy is different to the non-pregnant patient.

00:20:29 Dr Ailie Young

So our markers of worry need to be different in pregnancy.

00:20:33 Dr Ailie Young

So if you're

00:20:34 Dr Ailie Young

department doesn't have some paper forms or the ability to put electronic muse charts on for these patients, please make sure you've had a think about it.

00:20:43 Dr Ailie Young

You don't want to end up missing something that's very important.

00:20:46 Dr Ailie Young

So please use a muse chart if you can.

00:20:50 Dr Heather Kennedy

Great.

00:20:51 Dr Heather Kennedy

So in a differential diagnosis, we're wanting to keep a broad view, thinking about not just PE, not getting blinkered by that like you say,

00:21:00 Dr Heather Kennedy

But then also having those specific pregnancy related queries such as thalassemia, anemia, and like you say, whether there's an anxiety elements going on.

00:21:09 Dr Heather Kennedy

And as you said, we don't have time to discuss all of the potential differentials, particularly important cardiac ones.

00:21:15 Dr Heather Kennedy

And we're going to focus in on more of the lung related ones that are probably quite common for us to see in AMU.

00:21:22 Dr Heather Kennedy

And I think maybe asthma would be a good place to go over in more detail.

00:21:27 Dr Heather Kennedy

And I wondered,

00:21:29 Dr Heather Kennedy

Asthma, does it tend to be kind of better or worse in pregnancy?

00:21:32 Dr Heather Kennedy

Is there any trend?

00:21:35 Dr Ailie Young

So pregnancy itself doesn't change the severity of your asthma.

00:21:41 Dr Ailie Young

If you have a mild or well controlled asthma, then you're likely to sail through pregnancy.

00:21:47 Dr Ailie Young

The most important thing really is, and almost for any

00:21:52 Dr Ailie Young

I was gonna say condition, but really anything that you have before you are pregnant, the better controlled the thing that you have, which includes high BMI, blood pressure, asthma, chronic long-term autoimmune conditions.

00:22:07 Dr Ailie Young

If they are controlled before pregnancy, you are likely to have a better pregnancy.

00:22:14 Dr Ailie Young

A healthy mum creates a healthy baby and a healthy pregnancy.

00:22:17 Dr Ailie Young

So in asthma, if your asthma is well controlled,

00:22:20 Dr Ailie Young

then you're likely to be fine throughout pregnancy.

00:22:23 Dr Ailie Young

Now, sadly, what I've seen, and I've seen this firsthand, is women get pregnant and then they stop taking all their inhalers.

00:22:31 Dr Ailie Young

I don't know why, but they assume, oh, it's a medication.

00:22:35 Dr Ailie Young

You know, I've not had any flares for several years.

00:22:37 Dr Ailie Young

I'm gonna stop taking my preventer and my reliever.

00:22:40 Dr Ailie Young

And it's at that point, these women start having asthma exacerbations.

00:22:45 Dr Ailie Young

Please don't ever tell any pregnant woman to stop taking inhalers.

00:22:50 Dr Ailie Young

not just their inhalers, but their Monty Lucast and all of this, they need to speak to our respect.

00:22:55 Dr Ailie Young

Respiratory physician, and they should be reassured that the medications that they take in pregnancy for their asthma are safe if someone comes into the AMU.

00:23:05 Dr Ailie Young

she's in her second trimester and she's been running around the fields, at harvest time and suddenly has a very acute asthma exacerbation.

00:23:14 Dr Ailie Young

We should be treating them as if she was not pregnant.

00:23:17 Dr Ailie Young

So please go ahead and use all your nebulized medications.

00:23:21 Dr Ailie Young

Please give her steroids.

00:23:22 Dr Ailie Young

Don't forget to do that chest x-ray.

00:23:24 Dr Ailie Young

But steroids are safe in pregnancy.

00:23:27 Dr Ailie Young

Make sure you do your peak flow, get your chest x-ray, but think about doing your ABG.

00:23:33 Dr Ailie Young

Think about is this woman sick enough that this is a severe asthma and I need to be looking at magnesium and aminophylline.

00:23:40 Dr Ailie Young

If you are thinking that, you need to be contacting critical care or anaesthetics.

00:23:46 Dr Ailie Young

When you're pregnant, there is a lot more fluid going around your body.

00:23:51 Dr Ailie Young

By the third trimester, there's about 50% more fluid.

00:23:54 Dr Ailie Young

That in itself, it means that if you suddenly have an airway crisis, these women can be harder to intubate than your non-pregnant patient.

00:24:03 Dr Ailie Young

Just because of the increased mucosa and the larynx can be a little bit more floppy, it's important that if you think I have a severe asthmatic pregnant patient in front of me, ITU, critical care, anaesthetics are going to want to know sooner.

00:24:16 Dr Ailie Young

Obviously, if you have a non-pregnant patient and you're at that stage, you should be phoning them anyway.

00:24:21 Dr Ailie Young

But intubation in these patients can be more challenging.

00:24:26 Dr Ailie Young

Now, if you have a patient who turns up and you diagnose a pregnancy on the AMU, but they say, oh, I'm on a biologic for my asthma, then it's very important to make sure that their named respiratory physician is aware of it, but I would not stop it.

00:24:40 Dr Ailie Young

There is a lot of evidence of biologics in asthma in pregnancy, and we know that they are safe, they are

00:24:46 Dr Ailie Young

big molecules, but it's going to be an individual patient prescription that's going to need discussed.

00:24:53 Dr Ailie Young

But asthma is something that I think will be common.

00:24:56 Dr Ailie Young

It is a common presentation in pregnancy.

00:24:58 Dr Ailie Young

I think if you look at the cohort of people who are pregnant at one time, about 7% of them will have an asthma diagnosis.

00:25:04 Dr Ailie Young

So once again, it is important to treat them as if they are a non-pregnant patient, but with the caveat of knowing they are difficult to intubate, so get critical care involved early.

00:25:16 Dr Heather Kennedy

So bearing in mind that some patients who are pregnant may have stopped taking the regular inhalers, encourage them to continue them because they're safe.

00:25:25 Dr Heather Kennedy

And like you say, when they're in the AMU with an acute exacerbation, treat them as usual, give the nebs, give the steroids, but bear in mind if this is a more severe exacerbation, early discussion with critical care.

00:25:36 Dr Heather Kennedy

That's really helpful.

00:25:37 Dr Heather Kennedy

Thank you.

00:25:38 Dr Heather Kennedy

And can we move on to the one that everyone will probably have been thinking we would discuss is PE.

00:25:45 Dr Heather Kennedy

And I think that's what most people would think of first in a breathless pregnant patient.

00:25:49 Dr Heather Kennedy

But like we've already discussed, keep in mind other possibilities.

00:25:54 Dr Heather Kennedy

And do you know, is there a time during pregnancy when women are at a higher risk of PE or is it just throughout the whole pregnancy or postpartum?

00:26:03 Dr Heather Kennedy

What do we know about that?

00:26:05 Dr Ailie Young

So you are at greatest risk of having a pulmonary emboli in your third trimester.

00:26:12 Dr Ailie Young

or postpartum.

00:26:14 Dr Ailie Young

So that is the point where people are most likely to get a PE.

00:26:19 Dr Ailie Young

But sadly, the highest time where people are going to have a death or an adverse outcome is in the first trimester.

00:26:29 Dr Ailie Young

Scary, I think that is something that is frightening.

00:26:32 Dr Ailie Young

And we know that when you look at the MBRACE report, so that is a big triennial report that looks at all the morbidity and mortality of pregnant patients up to a year postpartum, we know that thromboembolic disease is the leading cause of death and it has been up there for a good while.

00:26:51 Dr Ailie Young

Now these are the patients that are coming to our AMU.

00:26:55 Dr Ailie Young

These are the patients that are being seen not by obstetricians or gynaecologists, but are being seen by acute physicians or the med reg on call.

00:27:04 Dr Ailie Young

Sometimes these patients haven't been diagnosed with a pregnancy, but sometimes they have and we are frightened about treating them or investigating them.

00:27:13 Dr Ailie Young

Now I know that we are a Scottish podcast, but there's some very good English guidelines that have just been published in January this year.

00:27:20 Dr Ailie Young

So it's the maternity care bundle, it's very good, I would recommend a read of it.

00:27:25 Dr Ailie Young

But in there it suggests that at the first point of presentation to any medical personnel, we should be doing an antenatal thromboembolic risk assessment.

00:27:36 Dr Ailie Young

And what that guideline means, so for those of you that are listening from out with Scotland,

00:27:41 Dr Ailie Young

is that when this pregnant patient turns up to your AMU, you need to be doing the scoring for them to make sure, should I be giving this woman doltaparin or an oxaparin or whatever prophylaxis they need?

00:27:53 Dr Ailie Young

And I suspect that Scotland will follow in that very soon.

00:27:56 Dr Ailie Young

So if there is a woman who's, you know, a high BMI, she's had a PE before and her mum had a PE and her sister had a PE and her granny had a DVT, then actually should this woman be on DVT prophylaxis throughout pregnancy?

00:28:11 Dr Ailie Young

That is where the highest mortality is.

00:28:13 Dr Ailie Young

But again, you need to be thinking about postpartum.

00:28:16 Dr Ailie Young

So when your woman's had her baby and she turns up to your AMU and you panic because there's a newborn on the floor and a postpartum patient, that actually this is where we need to be thinking about could there be a PE there?

00:28:29 Dr Ailie Young

The D-dimer is going to be high.

00:28:30 Dr Ailie Young

She's just had a baby and also there's a lot of trauma if it's a vaginal birth and it's a big operation if it's a C-section.

00:28:36 Dr Ailie Young

So once again, your D-dimer is useless.

00:28:40 Dr Ailie Young

in this moment.

00:28:42 Dr Ailie Young

We probably need to think about how are we actually going to investigate it, aren't we?

00:28:46 Dr Ailie Young

That's going to be the next thing.

00:28:48 Dr Heather Kennedy

Yeah, exactly.

00:28:49 Dr Heather Kennedy

So we have discussed there that the highest risk in terms of timing would be in the third trimester or postpartum, but high risk of mortality early on.

00:28:59 Dr Heather Kennedy

And this is when we're going to be seeing these patients in the AMU.

00:29:02 Dr Heather Kennedy

So the big question is, how do we diagnose PE in pregnant women?

00:29:09 Dr Ailie Young

First things first, we're going to convince ourselves that there is no other cause and we think, right, this is going to be a PE.

00:29:17 Dr Ailie Young

Please look at their legs.

00:29:18 Dr Ailie Young

I know that sounds very silly, but if we think it's a PE, if we can confirm a DVT, then we feel a lot better about it.

00:29:26 Dr Ailie Young

In pregnancy, you're going to get a blood clot in your left leg.

00:29:30 Dr Ailie Young

That is well studied and it's just because of with your increasing blood volume,

00:29:35 Dr Ailie Young

you've got compression of your common iliac vein from the common iliac artery.

00:29:40 Dr Ailie Young

In these patients, though, you might get a negative Doppler.

00:29:44 Dr Ailie Young

We're going to move to PE in a sec, but if we're thinking about DVT and you scan a leg and it's negative, but you think, I'm pretty convinced there's a blood clot in there, then please anticoagulate them and scan them in a fortnight.

00:29:57 Dr Ailie Young

The reason being is that DVTs in pregnancy are more proximal.

00:30:03 Dr Ailie Young

You can't reach them with your Doppler scan.

00:30:06 Dr Ailie Young

Out with pregnancy, they're more likely to be distal, but it's just worth remembering that if you have a negative Doppler in pregnancy, then anticoagulate if you've got a high enough index of suspicion and then see them in two weeks.

00:30:22 Dr Ailie Young

Now, the big conversation is, as always, the VQ scan versus CTPA.

00:30:27 Dr Ailie Young

Before we get into that, and I know I've said this lots already, please do a chest x-ray.

00:30:34 Dr Ailie Young

Because even though you might have a woman that has right-sided pain, it's come on very acutely and they've coughed up blood, actually you still don't know if she's got TB or unusual atypical pneumonia, or sadly, maybe there's a cancer there.

00:30:50 Dr Ailie Young

And what you don't want to do is diagnose something on a VQ scan or a CTPA that you could have diagnosed off of a chest x-ray.

00:30:57 Dr Ailie Young

Now, everybody will have very different opinions on what scan to do, and that is absolutely fine.

00:31:04 Dr Ailie Young

The important thing is whether or not you are confident in your decision making.

00:31:08 Dr Ailie Young

And I'll talk you through how I decide whether or not a VQ scan or a CTPA is more helpful.

00:31:14 Dr Ailie Young

The most helpful thing is your availability.

00:31:16 Dr Ailie Young

Now I can't remember the last time I requested a VQ scan.

00:31:20 Dr Ailie Young

I actually don't think I can get one in the hospital that I'm working in at the moment.

00:31:25 Dr Ailie Young

On the flip side, I know that I have many colleagues in London that can get a VQ scan any time of the day in hours.

00:31:32 Dr Ailie Young

The important thing to remember is that a VQ scan will diagnose PE.

00:31:38 Dr Ailie Young

but it is not very good at diagnosing other lung pathology.

00:31:43 Dr Ailie Young

So if you think, well, I'm in a bit of a toss up whether or not this is a very apical or behind the diaphragm pneumonia or it's a PE, then you want to be thinking about doing a CTPA because the CTPA is going to look at the lung parenchyma.

00:31:56 Dr Ailie Young

I know that I can get a CTPA any time of the day, like including out of hours, and it is readily available.

00:32:04 Dr Ailie Young

But what comes up is the radiation exposure.

00:32:08 Dr Ailie Young

Now just to take a breath and have a think about our own practice, when was the last time we consented a young patient, a young man or young woman, about the radiation risk even when they're not pregnant?

00:32:23 Dr Ailie Young

And sometimes we do CT chest, abdomen, pelvis, or we do a looking for that pyelonephritis, or we sort of willy-nilly do these scans.

00:32:32 Dr Ailie Young

When was the last time we talked about radiation to our non-pregnant patients?

00:32:37 Dr Ailie Young

And I think this is why we feel very frightened or anxious about discussing radiation risk with our pregnant patients.

00:32:44 Dr Ailie Young

The reassuring thing is that for a VQ scan and a CTPA, the radiation risk is very, very small.

00:32:50 Dr Ailie Young

The guideline, the green top guideline, will say that actually the worst thing you can do is 1, omit a scan from someone that you think has a PE.

00:33:00 Dr Ailie Young

or pick the wrong scan and then have to do a VQ and a CTPA.

00:33:04 Dr Ailie Young

So if I'm talking to a patient that I am worried that there is a PE there, then what I'm saying to her or to them is actually, I am worried that you have a blood clot and I need to exclude it.

00:33:18 Dr Ailie Young

The way that I can do that is either in this hospital I'm going to do a VQ scan or in that hospital I'm going to do a CTPA.

00:33:25 Dr Ailie Young

These scans are in the recommended guidelines and they are safe for pregnancy.

00:33:31 Dr Ailie Young

Now if I worked in my dream hospital and I had immediate access to a VQ scan and to a CTPA, then I might decide which scan I'm going to do based on my woman's personal history of breast cancer risk.

00:33:45 Dr Ailie Young

So if I had a young woman that has

00:33:48 Dr Ailie Young

never smoked, never had breast trauma, has a normal BMI, has no family history, then I would feel more confident with her having a CTPA versus my older pregnant patient who has smoked all her life, whose mum and gran and sisters have had breast cancer and she herself has the BRCA gene and her risk of having breast cancer is much, much higher.

00:34:12 Dr Ailie Young

So a CTPA, even though the radiation is small,

00:34:17 Dr Ailie Young

The worry is with the granular breast tissue turnover, it's that change with radiation can increase the individual's background risk.

00:34:26 Dr Ailie Young

So it is not the same risk to everybody.

00:34:29 Dr Ailie Young

But as I've said earlier, VQ scans have a limited availability based on where you are and if the radioisotope is available.

00:34:36 Dr Ailie Young

And a CTPA can be done almost at any time.

00:34:39 Dr Ailie Young

What you don't want to do is omit doing a scan.

00:34:44 Dr Ailie Young

or having to do both scans because that's double the amount of radiation.

00:34:48 Dr Ailie Young

So the important thing from this is that if you are convinced the woman in front of me has had normal chest X-ray and has a PE, then I am going to pick one or the other to get an outcome and get a positive diagnosis for this patient.

00:35:04 Dr Heather Kennedy

Absolutely, because as you said earlier, the risk of mortality, particularly in early pregnancy, is

00:35:11 Dr Heather Kennedy

significant and we don't want to be missing a PE or avoiding investigating because we're worried about the radiation risk.

00:35:17 Dr Heather Kennedy

So like you say, taking a pragmatic approach with a very person-centered view of what's the right scan for this person in this place that we're working in to get the answers that we need.

00:35:28 Dr Heather Kennedy

And so if we do get a scan, whether that's the VQ or the CTPA and it proves there is a PE,

00:35:33 Dr Heather Kennedy

I imagine we won't be deciding ourselves as a junior resident doctor in the AMU about treatment, but can you give us an idea of how we would manage a woman's anticoagulation at diagnosis and perhaps around the time of delivery?

00:35:50 Dr Ailie Young

So we have diagnosed a PE.

00:35:52 Dr Ailie Young

We're feeling good on ourselves because we've been brave and we've got the scan.

00:35:56 Dr Ailie Young

And you're right, now we need to think about anticoagulation.

00:35:59 Dr Ailie Young

So the easiest thing to do is to look at your local guidelines and obviously need to speak to your obstetric colleagues.

00:36:05 Dr Ailie Young

And you are definitely going to make a plan with the women and that around about the time of birth.

00:36:11 Dr Ailie Young

But it's not a different conversation.

00:36:13 Dr Ailie Young

It's an earlier conversation if you've diagnosed it early in pregnancy.

00:36:17 Dr Ailie Young

At the moment, there's no definitive guidelines whether or not you use a booking weight or you use a current weight for giving your treatment dose.

00:36:27 Dr Ailie Young

And it might be dolparin, it might be enoxaparin, you need to look at what your local guidelines are.

00:36:31 Dr Ailie Young

At the moment, the majority of places will base it on booking weight.

00:36:35 Dr Ailie Young

However, you know, there might be different caveats.

00:36:37 Dr Ailie Young

So for instance, you might have a high increase in body weight over your pregnancy, so the dosing might change.

00:36:44 Dr Ailie Young

What is often a little bit different with treatment

00:36:47 Dr Ailie Young

of your dolparin or your oxaparin is sometimes we use split dosing.

00:36:52 Dr Ailie Young

The guidelines again are not super clear on this, but a lot of departments, just in case you see it, different departments will give a morning and an evening dose rather than one big dose at the beginning of the day.

00:37:02 Dr Ailie Young

The theory being again that you've got this increased volume of fluid going around so it feels better or safer to split it.

00:37:09 Dr Ailie Young

Now you're asking a woman to one, self-inject twice a day.

00:37:13 Dr Ailie Young

Some people might be very used to that with their diabetes or they

00:37:17 Dr Ailie Young

have had a pregnancy before where they've had to use Dotaparin.

00:37:20 Dr Ailie Young

But for those of you that are listening and have never had a Dotaparin injection, it's really nippy, it's really sore, and there is a lot of mental...

00:37:29 Dr Ailie Young

you have to really get over yourself to jab yourself in the bottom with a jaggy needle that then stings.

00:37:36 Dr Ailie Young

The worry is that you need to make sure that they are getting this drug.

00:37:40 Dr Ailie Young

You do not want anything happening to these women.

00:37:44 Dr Ailie Young

And I would always spend a little bit of time making sure that we have talked about it is going to sting, there are ways around it with ice or you could even think about numbing creams, it's unusual, but you could think about it.

00:37:56 Dr Ailie Young

And driving home the importance of please make sure you take this medicine.

00:38:00 Dr Ailie Young

We don't use a DOAC in pregnancy, we don't use apixaban, that might come one day, but for now the treatment is very much daltaparin and oxaparin.

00:38:08 Dr Ailie Young

Warfarin is teratogenic.

00:38:10 Dr Ailie Young

There are very, very minimal cases that we would use that in pregnancy.

00:38:14 Dr Ailie Young

We're definitely not using it for PE.

00:38:16 Dr Ailie Young

So it's important to drive that home.

00:38:19 Dr Ailie Young

Now the worry or the case that always is a bit worrisome is whether when you have your big PE diagnosed either a couple of days before this woman's going to give birth or after she's had a big C-section.

00:38:33 Dr Ailie Young

These are decisions that you're not going to be making alone.

00:38:36 Dr Ailie Young

You're never going to make these alone.

00:38:38 Dr Ailie Young

Please don't ever make big decisions alone.

00:38:40 Dr Ailie Young

Medicine in itself is a team working game.

00:38:43 Dr Ailie Young

What you need to think about is, should we be considering putting this woman onto a low molecular weight infusion?

00:38:50 Dr Ailie Young

At the time, IV unfractionated heparin is absolutely safe in pregnancy.

00:38:55 Dr Ailie Young

Should we be thinking about maybe catheter directed thrombolysis?

00:38:58 Dr Ailie Young

Would that be something that our hospitals can offer, you know, to just get rid of that clot?

00:39:03 Dr Ailie Young

If we are thinking about a PE that is a massive PE and it is so big that the patient arrests, and I know that might be really triggering for some people to listen to, but if this ever happens, you are going to treat the PE.

00:39:20 Dr Ailie Young

You are going to go into automatic mode of thrombolysis.

00:39:24 Dr Ailie Young

You have to tell obstetrics they need to get there because this woman is going to bleed.

00:39:29 Dr Ailie Young

But right now, when that patient has died,

00:39:33 Dr Ailie Young

Your priority is to the mother and the priority is to fix the PE and get ROSC, get life back and then think about the bleeding afterwards.

00:39:44 Dr Ailie Young

And I know that sounds really harrowing and I hope that nobody is ever, ever in that circumstance.

00:39:50 Dr Ailie Young

But it is important to remember that if someone has a clot or any reason for the mother to suddenly arrest, then your duty of care is to the mother and then think about the baby afterwards.

00:40:02 Dr Ailie Young

Please always put out, some of you may have been in that maternal cardiac arrest or maternal medical emergency.

00:40:09 Dr Ailie Young

Make sure that there has been a call to neonates.

00:40:12 Dr Ailie Young

Make sure that there has been a call to obstetrics.

00:40:16 Dr Ailie Young

The worry is that you might not be on a site that has these people nearby.

00:40:20 Dr Ailie Young

You might work somewhere that there isn't paediatrics or obstetrics.

00:40:24 Dr Ailie Young

And you need to have a think about what am I going to do if a pregnant woman arrests on my site?

00:40:28 Dr Ailie Young

Are you going to phone the general surgeons?

00:40:30 Dr Ailie Young

Or is the med reg or the medical consultant going to have to think about these things?

00:40:33 Dr Ailie Young

And I know that is a horrible thing to think about, but take a moment and reflect on actually, what would I do in that circumstance?

00:40:41 Dr Ailie Young

So if someone does arrest because they've got a massive PE, then yes, thrombolyse them.

00:40:46 Dr Ailie Young

But this is a decision that should be made with critical care, obstetrics.

00:40:50 Dr Ailie Young

If the baby is still in, then phone neonates because there is a chance that baby's coming out.

00:40:55 Dr Ailie Young

And I guess if we are talking about, if we're thinking about our ALS with these patients, there are medical patients, the difference is please don't forget a manual uterine displacement.

00:41:05 Dr Ailie Young

So if you think about the weight of that baby or babies on the IVC, you need to be prioritizing blood flow.

00:41:13 Dr Ailie Young

So when you're thinking about your resus, you allocate the role of one person to hold on to that uterus and either pull it towards you or push it away from you.

00:41:22 Dr Ailie Young

And that is one job and it should be tiring.

00:41:25 Dr Ailie Young

You should be tired if you're doing that job to make sure for that cycle of CPR, there is weight off of the IVC to maintain blood flow back to the heart.

00:41:35 Dr Ailie Young

We're probably not going to talk about whose job it's going to be to do any sort of resuscitative hysterotomy.

00:41:40 Dr Ailie Young

but have a think about that if it comes up and it's something we maybe don't talk about enough.

00:41:45 Dr Ailie Young

Obviously, if anyone is ever in a harrowing situation with a pregnant patient, please make sure you debrief and talk to someone about it repeatedly because that's a circumstance that nobody ever wants to be in.

00:41:59 Dr Heather Kennedy

I think that's been really useful and interesting to think about how we treat PE in a stable patient who we've diagnosed in the EMU.

00:42:07 Dr Heather Kennedy

And like you said, we wouldn't be doing this alone.

00:42:08 Dr Heather Kennedy

We would be discussing with the obstetric team, probably with our pharmacists as well and looking at our local guidelines in terms of the doses and weights.

00:42:17 Dr Heather Kennedy

And then also that other scenario, which is a very scary thought, like you acknowledged, of a pregnant patient arresting probably from PE and how we manage that.

00:42:25 Dr Heather Kennedy

So that's been really useful for us all to kind of think over how we would approach that situation, particularly where we work locally.

00:42:32 Dr Heather Kennedy

So I think that's probably all we've got time to discuss in terms of specific scenarios, but I think that's been a really helpful overview.

00:42:39 Dr Heather Kennedy

Thank you so much, Ailey.

00:42:40 Dr Heather Kennedy

And I think my main learning points have been, like you said, when you are

00:42:45 Dr Heather Kennedy

Seeing a pregnant woman who's breathless, your initial approach should be the same as with any other patient in the AMU in terms of history and examination and do a chest x-ray.

00:42:54 Dr Heather Kennedy

That's really important initially.

00:42:57 Dr Heather Kennedy

Thinking about our differential diagnosis, which is not just PE, thinking about common things like chest infections, whether this patient is asthmatic, considering anaemia, cardiac causes, and in the AMU, not using the news charts, but using MUSE.

00:43:14 Dr Heather Kennedy

because that's really specific for women in this situation.

00:43:17 Dr Heather Kennedy

We've discussed asthma and how it's really important to carry on with usual medications in the background.

00:43:23 Dr Heather Kennedy

If someone's presenting to the EMU, treat them as we usually would with NEBs and steroids, escalate early to critical care if we're worried.

00:43:31 Dr Heather Kennedy

And then we've just gone over PE, how we diagnosed that and using either a VQ or CTPA and not shying away from

00:43:41 Dr Heather Kennedy

doing the investigation that is needed to diagnose this condition and how we treat it.

00:43:45 Dr Heather Kennedy

And I wondered if you had any other final thoughts or advice for our listeners.

00:43:52 Dr Ailie Young

So no, I think that's a really lovely summary.

00:43:54 Dr Ailie Young

I think a nugget of helpful information that I've not quite covered is prescribing.

00:44:01 Dr Ailie Young

The BNF is useless.

00:44:03 Dr Ailie Young

because it says refer to a medical professional and sadly that is us.

00:44:09 Dr Ailie Young

The place you want to look for any prescribing is a website called UKTIS, the UK Teratology Information Service.

00:44:18 Dr Ailie Young

That will give you, yes you can use this in pregnancy, no don't use it in pregnancy.

00:44:22 Dr Ailie Young

There is a sister site called Best Use of Medications in Pregnancy or Bumps that will give you patient information leaflets for when you want to give your pregnant patient amoxicillin for their chest

00:44:33 Dr Ailie Young

infection.

00:44:34 Dr Ailie Young

And then finally, which we've not discussed at all today, is breastfeeding.

00:44:38 Dr Ailie Young

Your breastfeeding unwell patient is LactMed is the site to use for that.

00:44:44 Dr Ailie Young

So those three sites will give you the confidence in prescribing in your medically unwell pregnant patient.

00:44:50 Dr Ailie Young

But all in all, the most important thing, as Heather said, is to remember that this is a team sport.

00:44:55 Dr Ailie Young

You are not alone.

00:44:57 Dr Ailie Young

And it is very much a please do a good history examination as if they were an old man and then think.

00:45:05 Dr Heather Kennedy

Great.

00:45:05 Dr Heather Kennedy

And we can put links in our show notes to those websites for medication advice and also the maternity care bundle guideline that you mentioned earlier and green top guidelines just as a reference point for our listeners.

00:45:19 Dr Heather Kennedy

I think I'm going to definitely feel a lot more confident now approaching a pregnant patient who is breathless in the AMU.

00:45:25 Dr Heather Kennedy

So thank you so much Ailey for joining us today.

00:45:27 Dr Heather Kennedy

And thanks to all of our listeners.