Creating Waves of Awareness
Chest Pain or discomfort in a gravida is quite a common clinical problem that physicians and obstetricians encounter. In majority of cases, it is due to esophagitis (Kent’s Repertory: Chest, Pain, Burning; Page 852) or gastritis (Kent’s Repertory: Chest, Pain, Sternum; eating after, behind; Page 859) especially in the earlier months of gestation. In few others, pectoral myalgia (Kent’s Repertory: Chest, Pain, Pectoral muscles; Page 846) and functional (Kent’s Repertory: Chest, Pain, Parturition; Page 850) causes do play a major role. Still, there are a myriad reasons and the causes determine the methodology of management. Let us elaborate some of the uncommon reasons.
Uncomplicated Pregnancy Case
Consider the case of Ms K, aged 32 years, a multigravida who had an uneventful pregnancy recently. Her labor was uncomplicated and she delivered a female at 40 weeks gestation. After about 12 hours of delivery she suddenly developed breathlessness with oppression in the middle of the chest. Her pulse rate was 160 /min and Blood Pressure fell down to 80 mm systolic. She also developed mild bruising over the back. She was resuscitated and put on Carbo Veg 0/1 every hourly. But unfortunately she deteriorated and had to be intubated. After 4 days she stabilized and it took nearly a fortnight for her to recover fully.
In this case, the most probable diagnosis was Amniotic fluid embolism which is, basically, a rare complication of pregnancy. Typically the clinical presentation is sudden collapse. The patient needs to be resuscitated or else mortality rate is high. If the patient develops Disseminated Intravascular Coagulation (DIC) then one can notice bruising (as in the above case) or bleeding from oral, nasal and anal cavities. If fetal squames are found in the central blood or maternal sputum, it supports the diagnosis.
Mrs. N, a 42 years old Primi who was a known case of Systemic Hypertension since 5 years, presented to us during 27 weeks ANC with complaints of retrosternal chest pain & dyspnoea (Kent’s Repertory: Respiration, Difficult, Heart during pain in; Page 769 & Respiration, Difficult, perspiration; page 770) with perspiration since 1 hour. She had a history of recurrent chest discomfort since 5 years but was uninvestigated & was taking analgesics for the same. Even in the earlier trimesters she had transient episodes of chest pain. On examination she had tachycardia, B.P 140/90mm Hg, Respiratory Rate 20/minute, No S3 gallop; ECG showed ST depression in leads V2-V4 and her CPK MB was normal. She was shifted in the ICCU and kept for observation. On the basis of ESRA Protocol of NAHI for Chest Pain we administered Arsenic Alb 0/1 every 30 minutes till symptomatic relief. This was a case of anterior wall ischemia.
But had it evolved into a Myocardial Infarction it would have been quite a rare cause of chest pain during pregnancy. Nowadays with the rising incidence of Ischemic Heart disease in young Indians, this diagnosis of chest pain needs to be entertained seriously particularly in elderly Primi. During pregnancy, the heart has to work extra especially in first & third trimester & during labor. In known hypertensive patients or in those who already have recurrent episodes of chest discomfort, one can expect Myocardial Infarction during pregnancy. Ladner et al reviewed hospital discharge records for deliveries in California between 1991 and 2000 and reported an incidence of 1 AMI in 35,700 deliveries. James et al published a nationwide inpatient sample for all pregnancy-related discharges in 2000 to 2002 and found a total of 859 cases of AMI, giving an incidence of 1 in 16,129 deliveries. Echocardiogram is safe during pregnancy and is used to evaluate wall-motion abnormalities. Interpretation of biochemical markers is somewhat complicated by changes that may occur during normal labor. Creatine kinase MB can increase by nearly 2-fold within 30 minutes after delivery and is related to the uterus and placenta, which have substantial amounts of this enzyme. In contrast, there is only a marginal rise of Troponin I levels after delivery. The safety and efficacy of Thrombolytic Therapy for Acute Myocardial Infarction is a double-edged sword and may increase the risk of maternal hemorrhage, preterm delivery, fetal loss, spontaneous abortion, minor vaginal bleeding, massive subchorionic hematomas, abruptio placenta and post-partum hemorrhage. Hence primary PTCA would be advisable if such an eventuality ever occurs.
Severe Central Chest Pain
Mrs Z, a 29 years business executive in a multinational company was pregnant soon after a miscarriage (2 months duration). Her pregnancy was uneventful and she delivered a healthy male at 39 weeks. Just as the placenta was out, she complained of severe central chest pain (Kent’s Repertory: Chest, Pain, cutting; Page 855) difficulty in breathing and cough (Kent’s Repertory: Respiration, Difficult, Cough with; Page 768). On examination she had tachycardia, mild cyanosis and ECG – S in I, Q wave + inverted T in III. Oxygen saturation had dropped to 88% (Kent’s Repertory: Respiration, Asphyxia; Page 763). If such is the clinical presentation, then the diagnosis is pulmonary embolism.
Mrs. U aged 18 years, a lean girl got pregnant soon after marriage. Hardly a week after her Urine tested positive for pregnancy, she developed body ache and dry cough. Even after 2 weeks of antibiotics administered by the local doctor, the symptoms remained constant. Initially, cough was dry but then became loose yellowish green colored (Kent’s Repertory: Cough, Loose, fever during; Page 796). She also started having Left sided chest pain (Kent’s Repertory: Chest, Pain; Sides, Left, cough during; Pages 846, 847). She was referred to us in the 11th week of gestation. On examination, the trachea was central, no asymmetry of chest wall expansion and dullness on percussion in the Left infra-axillary region. Her Leucocyte Counts were 13,200/cu mm; Neutrophils 80%, ESR 24mm, normocytic normochromic RBC and HB - 10gm/dl. Blood sugar, Liver and Kidney profiles were normal. Sputum was negative for Tubercle Bacilli. So this was a case of Left Lobar pneumonia in pregnancy. Pulsatilla 30 TDS for a week along with good nutrition made her well. The patient delivered a full term female and could breast feed her for 8 months.
Polycystic Ovarian Disease
Mrs. J, aged 28 years and married since 8 years was an obese house-wife. She was diagnosed to have Polycystic Ovarian disease. With difficulty and after therapy she conceived. During the 30th week, she had to travel to Kolkata due to a crisis in her family. Just after landing, she experienced a sharp stabbing right sided chest pain (Kent’s Repertory: Chest, Pain, Sides, right, inspiration; Page 847) and breathlessness. Thinking it may be a muscle pull, she massaged that area but the symptoms worsened and she was hospitalized. On examination, the trachea was deviated to the left, reduced air entry on the right with hyper-resonance on percussion (discharge notes). She was diagnosed to have Right pneumothorax. A chest X-Ray with an abdominal shield confirmed the pathology. Basic laboratory tests were normal. The patient was treated with oxygen and observed. After a week she recovered and lung re-expansion was achieved without chest tube placement. A follow-up chest X-Ray showed no evidence of residual pneumothorax or any pulmonary pathology.
Multigravida With Constant Dull Pain
Ms F, a multigravida aged 33 years reported during 24 weeks of pregnancy with complaints of a constant dull pain in the right chest. There were no particular modalities and neither did she have accompanying cough, breathlessness, fever or a history of injury or features suggestive of a rib fracture. On examination there was marked tenderness over the area of pain (Kent’s Repertory: Chest, Pain, Aching, Costal cartilages; Page 851). This was clearly Costo-chondritis or Tietze’s syndrome. A few doses of Staphysagria 30 relieved her symptom.
Infine - Thus it is quite clear from our case studies that while dealing with chest pain during pregnancy, a proper evaluation of the patient is mandatory to assess the future approach. Repertory is a great tool for managing this symptom. But, finally, it is the eye and skill of the homoeopath that gets the job done.