European Journal of Cardiovascular Medicine

Pregnancy and the postpartum period involve profound physiological changes affecting cardiovascular, respiratory, and hematologic systems. These adaptations, though essential for fetal growth and maternal recovery, can mask or predispose to serious complications. Dyspnea is one of the most frequently reported symptoms during pregnancy, affecting approximately 60–70% of healthy pregnant women.¹ However, acute or worsening dyspnea during pregnancy or postpartum may signal serious cardiac or pulmonary pathology and contributes significantly to maternal morbidity and mortality. The causes are multifactorial- rising metabolic demands, progesterone-induced respiratory stimulation, and diaphragm elevation. Distinguishing physiological from pathological dyspnea is often difficult, making prompt evaluation essential, especially since cardiovascular disease complicates about 0.2–0.4% of pregnancies and remains a leading indirect cause of maternal death worldwide.^2-4

Cardiac output increases by 30–50% during pregnancy due to elevated plasma volume, stroke volume, and heart rate.² In women with pre-existing cardiac conditions, this increased workload may lead to decompensation and acute dyspnea. Furthermore, pregnancy reduces functional residual capacity and expiratory reserve volume, predisposing even healthy women to breathlessness. However, acute exacerbations may signal serious pathologies such as peripartum cardiomyopathy, pulmonary embolism, acute respiratory distress syndrome (ARDS), or severe anemia.⁴

Pathological causes of dyspnea in pregnancy and the postpartum period include cardiac disorders like valvular heart disease, cardiomyopathy, and arrhythmias, as well as non-cardiac conditions such as anemia, postpartum hemorrhage, pneumonia, sepsis, and amniotic fluid embolism.^5,6 The onset can be sudden and rapidly progressive, emphasizing the need for timely recognition and management. Given the limited region-specific data in India, this study was undertaken to evaluate the clinical and laboratory characteristics of pregnant and postpartum women admitted with acute onset dyspnea at a tertiary care center.

After obtaining Institutional Ethical Committee approval and written informed consent from all the patients, this hospital based cross-sectional study was conducted in the Medicine ward and MICU in a tertiary care centre during the time period of 2.5 years from December 2022 to June 2025. A total of 112 pregnant and postpartum women presenting with acute onset dyspnea (grade 2, 3 or 4 NYHA/MMRC grading) were included in the study. Patients with a history of smoking, occupational exposure to lung toxins, or any bone deformity of the thoracic cage, those with known cardiorespiratory diseases presenting with breathlessness or other identifiable non-cardiopulmonary causes of dyspnea, patients diagnosed with post-COVID restrictive lung disease or cardiac illnesses, as well as those unwilling to provide consent or participate in the study, were excluded from the study. The detailed history of the patients was recorded regarding the diagnosis and etiology of acute onset dyspnea performed at first presentation. Socio-demographic variables including age, sex, marital status and personal history were recorded. Chief complaint, history of presenting illness, past medical history was recorded in detail. Along with which Menstrual history, Obstetric history, (timing of presentation like first trimester, second trimester, third trimester or postpartum<48 hours, 3-7 days,>7 days) and mode of delivery were recorded. general and systemic examination findings, radiological and electrocardiographic features, echocardiographic findings, inflammatory and biochemical parameters, obstetric profile, hospital course, and final outcomes. Fetal outcomes such as APGAR score, need for NICU admission, were noted. Duration and course in the hospital, Mortality, and Cause of death in case of mortality were recorded.  Statistical Analysis Data were entered into Microsoft Excel spreadsheets and analyzed using SPSS software (IBM SPSS Statistics, Version 20.0, Armonk, NY: IBM Corp). Descriptive statistics were expressed as means with standard deviations or medians with interquartile ranges (IQRs) for continuous variables, and as frequencies and percentages for categorical variables. Graphical representations such as histograms, box-and-whisker plots, and column charts were used for continuous data, while bar charts and pie charts were employed for categorical data to enhance visualization. The Shapiro–Wilk test was applied to assess the normality of data distribution, and the results indicated that the data were normally distributed. Associations between two categorical variables were analyzed using the Chi-squared test, and a p-value of less than 0.05 was considered statistically significant.

Most patients (56.25%) were aged 25–34 years, with a mean age of 27.18 ± 5.17 years. The mean height, weight, and BMI were 152.4 ± 9.3 cm, 63.0 ± 7.9 kg, and 25.1 ± 4.8 kg/m², respectively. Half of the women belonged to the lower socioeconomic class (50.9%) as shown in table 1. The mean pulse rate, systolic BP, respiratory rate, temperature, and SpO₂ were 87.3 ± 13.8 bpm, 124.3 ± 16.4 mmHg, 24.5 ± 6.9 breaths/min, 99.3 ± 1.2 °F, and 97.5 ± 1.3%, respectively.

Table 1: Sociodemographic Profile of the Study Participants

All patients (100%) presented with breathlessness as the main complaint. Other common symptoms were cough (34.8%), headache (17.9%), fatigue (16.1%), and nausea (14.3%). Less frequent symptoms included vomiting (9.8%), abdominal pain (8.9%), pedal edema (8.9%), and seizures (2.7%). Most symptoms had a short duration (1.6–2.5 days). On examination, edema (27.7%) and pallor (16.1%) were the most common findings, while icterus and cyanosis were rare (0.9% each), (Table 2).

Chest X-ray commonly showed pulmonary edema (53.6%), while 24.1% were normal. Sinus tachycardia (59.8%) was the most frequent ECG finding. Echocardiography revealed LVEF ≥50% in 53.6%, with systolic dysfunction (25%), diastolic dysfunction (21.4%), global hypokinesia (58.9%), and IVC congestion (65.2%). Valvular lesions were seen in 8% of cases (Table 3).

During the first trimester, most participants (17.9%) had normal D-dimer levels (≤0.95 µg/ml), with 7.1% showing elevated values. In the second trimester, 13.4% had normal and 11.6% had raised levels, while in the third trimester, elevated D-dimer (>3 µg/ml) was seen in 21.4% of cases. Postpartum, 13.4% showed raised D-dimer levels (>0.5 µg/ml). Most participants (71.4%) had CPK-MB values between 21–25 U/L, while 8.9% and 19.6% had lower and higher values, respectively. CRP was normal (0–5 mg/L) in 77.7% and elevated in 22.3% of participants. Procalcitonin was below 0.5 ng/mL in 91.1%, mildly elevated in 5.4%, and moderately to severely elevated in 3.6%.

Table 2: Distribution of patients according to symptoms and signs

Table 3: Radiological and Cardiac Findings of the Cases

Most women had a regular 28-day cycle (89; 79.5%), were multigravida (37; 33.0% gravida 2), and 54; 48.2% had live births. Vaginal delivery (64; 57.1%) was more common than cesarean section (48; 42.9%).

The mean hemoglobin, WBC, and platelet counts were 9.7 ± 1.4 g/dL, 8,036 ± 2,401 cells/mm³, and 205.7 ± 116.7 ×10³ cells/mm³, respectively. Mean urea and creatinine levels were 41.4 ± 13.1 mg/dL and 1.7 ± 0.6 mg/dL, with a mean urine output of 872 ± 293 mL/24 hrs. Lipid profile values were within normal limits, and urine analyses showed acidic pH with no RBCs, casts, or crystals, (Table 4).

Table 4: Mean Laboratory Parameters

The electrolyte levels showed that half of the patients (50%) had normal sodium and calcium levels, while the remaining 50% had elevated values. Hyperkalemia (>5 mmol/L) was observed in 59.8%, and high magnesium levels (>2.4 mg/dL) were noted in 45.5% of cases. Liver function parameters were within normal limits in most patients, with 89.3% showing normal bilirubin levels (≤1.0 mg/dL) and all having normal SGPT, SGOT, and albumin levels, indicating preserved hepatic function (Table 5).

Table 5:  Distribution of cases according to electrolyte and LFT parameters

Out of 112 cases, majority (77; 68.8%) were managed in the general ward, whereas nearly one-third (35; 31.3%) required ICU admission. The majority of patients (74.1%) required oxygen support, nearly one-third (27.7%) required endotracheal intubation. Inotropic support was required in 41.9% of cases. Only a small proportion (3.6%) required hemodialysis. In terms of hospital stay, most patients (62.5%) required 7–9 days of admission, while 24.1% stayed ≥10 days and 13.4% were discharged within 4–6 days, (Figure 1).

On clinical examination, most patients showed bilateral fine crepitations (55.4%) in the respiratory system and normal cardiovascular findings (59.8%). The uterine size commonly corresponded to 26–28 weeks (56.3%), and CNS examination was normal in all cases (100%).

The majority of patients had hypertensive disorder of pregnancy with pulmonary edema (48.2%), followed by antepartum eclampsia (14.3%) and LRTI with sepsis and ARDS (8.0%). Other causes included DVT with pulmonary thromboembolism (5.4%), postpartum eclampsia (4.5%), and a few isolated cases of asthma, anemia, congenital heart disease, and other rare conditions as shown in table 6.

Figure 1: Maternal mortality

Table 6: Distribution of patients according to primary diagnosis

The most frequent cause was pulmonary edema and congestive heart failure (CHF), observed in 79.46% of patients, making it the predominant mechanism. Other causes of dyspnea are depicted in figure 2.

Figure 2: Causes of dyspnea

Out of 112 patients, 36 (33.03%) succumbed to the illness, while 76 (66.97%) survived. Pulmonary edema and congestive heart failure were the leading causes of dyspnea, accounting for 79.5% of all cases and the majority of deaths in both antepartum (80%) and postpartum (31.3%) groups. Other causes included ARDS (6.3%), pulmonary thromboembolism (5.4%), infections (4.5%), and bronchial asthma (3.6%). Neuroparalysis was a rare cause, noted in only one antepartum death (Table 7).

Hypertensive disorders and eclampsia with pulmonary edema were the leading causes among survivors and deaths, together accounting for the majority of antepartum cases. Postpartum deaths were mainly seen in postpartum eclampsia (60%) and pulmonary thromboembolism (50%). Other fatal causes included sickle cell crisis, congenital heart disease with sepsis, and peripartum cardiomyopathy. The association between primary diagnosis and outcome was statistically significant (χ² = 288.9, df = 52, p < 0.0001) (Table 7).

Table 7: Association of Cause of Dyspnea and Primary Diagnosis with Mortality (Antepartum vs Postpartum)

In the present study, pulmonary edema and congestive heart failure (CHF) were the most common causes of dyspnea, predominantly associated with hypertensive disorders of pregnancy (54 cases), antepartum eclampsia (16 cases), postpartum eclampsia (5 cases), severe anemia (9 cases), and rheumatic heart disease (4 cases). A few cases were attributed to peripartum cardiomyopathy (1 case). Other causes of dyspnea included lower respiratory tract infections (LRTI) and sepsis leading to ARDS (5 cases), bronchial asthma exacerbation (4 cases), neuroparalytic snake bite (1 case), and pulmonary thromboembolism due to DVT (6 cases). The association between primary diagnosis and cause of dyspnea was found to be highly significant (χ² = 288.9, df = 52, p < 0.0001), (Table 8).

Pulmonary edema/CHF cases mainly showed pulmonary edema on X-ray (64%), LRTI showed consolidation (60%), and ARDS showed bilateral infiltrates (42.9%). The association between cause of dyspnea and X-ray/ECG findings was highly significant (χ² = 89.6, p < 0.001). Sinus tachycardia (59.8%) was the most common ECG finding, mainly in pulmonary edema/CHF, followed by normal sinus rhythm (35.7%). RV strain and S1Q3T3 were seen in pulmonary thromboembolism. The association was statistically significant (χ² = 57.997, p = 0.000196), (Table 8).

Table 8:  Association of Causes of Dyspnea with Chest X-ray and ECG Findings

In the present study, most patients with dyspnea were young women aged 25–34 years, followed by those below 25 years, with few above 35 years. Similar trends were reported in previous Indian studies.^7,8 No significant difference in outcomes across age groups was noted, suggesting dyspnea poses risks irrespective of maternal age, consistent with global obstetric critical care recommendations.⁹ Most participants belonged to lower socioeconomic strata (50.9%), reflecting the typical demographic of government tertiary centers. The majority had normal (41.1%) or overweight (28.6%) BMI, with 21.4% obese indicating that excess body weight is a common comorbidity in dyspneic pregnancies. Over half presented between 26–28 weeks of gestation, the period of maximal hemodynamic stress. On systemic examination, bilateral fine crepitations (55.4%) suggested pulmonary edema, and gallop rhythm (33%) indicated ventricular dysfunction, findings consistent with Nyondo et al.¹⁰, who also reported cardiac dysfunction as a common etiology in dyspneic obstetric patients.

Breathlessness was the universal presenting symptom (100%), confirming it as the hallmark of dyspnea-related admissions during pregnancy and the postpartum period. Associated symptoms included cough (34.8%), headache (17.9%), fatigue (16.1%), and nausea (14.3%), while abdominal pain, pedal edema, vomiting, seizures, and bleeding per vaginum were less common. The mean duration of symptoms (1.6–2.5 days) indicated acute onset and rapid progression. Similar findings were reported by Dahiya et al⁷, Pokhrel et al⁸, Kanbe et al¹¹, and Mishra et al¹². The most common physical findings were edema (27.7%) and pallor (16.1%), while icterus and cyanosis were rare (0.9% each). Notably, over half of the patients had no abnormal general examination findings despite severe dyspnea, emphasizing that early cardiopulmonary compromise may occur without overt physical signs. This observation corresponds with reports by Muzaffar et al¹³ and Barut et al¹⁴.

The chest radiography showed pulmonary edema as the most common abnormality (53.6%), followed by normal findings in 24.1% of cases despite significant dyspnea. Less frequent abnormalities included consolidation (6.3%), cardiomegaly (5.4%), bilateral infiltrates (5.4%), and right ventricular hypertrophy (5.4%). Similar observations were reported by Randhawa et al¹⁵ and Han et al¹⁶. ECG findings revealed sinus tachycardia as the most common abnormality (59.8%), followed by normal sinus rhythm (35.7%), with rare occurrences of LVH, RV strain, S1Q3T3 pattern, and P-mitrale (<2%). These results align with McGourty et al¹⁷ and Agarwal et al¹⁸. Echocardiography revealed preserved LVEF (≥50%) in 53.6%, systolic dysfunction in 25%, and diastolic dysfunction in 21.4%, with global hypokinesia (58.9%) and IVC congestion (65.2%) indicating subclinical cardiac dysfunction. Valvular lesions were less frequent (8%). These findings correspond with studies by Lan et al¹⁹ and Molina et al²⁰.

Laboratory evaluation revealed significant hematologic and biochemical abnormalities. Anemia (Hb ≤11 g/dL) was observed in 82.9% of patients, thrombocytopenia in 44.7%, and leukocytosis in 21.4%, consistent with findings by Mutua et al²¹. D-dimer elevation (21.4%) and raised ferritin (>500 ng/mL in all patients) indicated a hypercoagulable and inflammatory state. CRP was elevated in 22.3%, while procalcitonin increase (8.9%) suggested limited sepsis contribution. These findings are similar to Paixão et al²², and Zhou et al²³. Electrolyte abnormalities were common—hyperkalemia (59.8%), hypokalemia (22.3%), and hypercalcemia (50%)—which may worsen arrhythmias and muscle fatigue, consistent with Griffin et al²⁴. Renal dysfunction was evident in 16.1% (oliguria) and 8% (elevated urea), with 3.6% requiring dialysis, aligning with Xu JH et al²⁵. Proteinuria (46.4%) and pyuria (28.6%) further supported hypertensive and renal etiologies. Mild hepatic dysfunction occurred in 7.1%, less frequent than reported in HELLP or AFLP syndromes.

In terms of etiological profile, hypertensive disorders with pulmonary edema (48.2%) and antepartum eclampsia (14.3%) were the leading causes, followed by severe anemia with CHF (8%) and infections leading to ARDS (4.5%). Rare etiologies included cardiomyopathy, rheumatic heart disease, thromboembolism, and neuroparalytic envenomation. These findings highlight the dominance of hypertensive and eclamptic complications, consistent with global data showing preeclampsia-related pulmonary edema as a major determinant of obstetric ICU admissions (Pramana et al²⁶, Novoa et al²⁷). Infectious and thromboembolic causes, though fewer, remain important differential diagnoses, as reported by Hung et al²⁸ and Vouga et al²⁹. The leading overall causes were ARDS (51.8%) and pulmonary edema/CHF (22.3%), collectively accounting for nearly three-fourths of dyspnea cases. This dual burden of respiratory and cardiovascular etiologies mirrors the findings of Johnson and Paul³⁰ and reinforces the need for integrated cardiopulmonary evaluation.

The most common primary diagnosis among dyspneic obstetric patients was hypertensive disorders of pregnancy with pulmonary edema (48.2%), followed by antepartum eclampsia with pulmonary edema (14.3%). Other causes included severe anemia with congestive heart failure (8%), postpartum eclampsia (4.5%), lower respiratory tract infection with sepsis and ARDS (4.5%), bronchial asthma exacerbation (3.6%), and rheumatic heart disease with pulmonary edema (3.6%).

The hospital course revealed that 74.1% required oxygen support, 27.6% mechanical ventilation, and 42% inotropic support. A small subset (3.6%) required dialysis, reflecting multiorgan involvement. The mean hospital stay was 7–9 days, similar to Padilla et al³¹ and Vasco et al.³² Maternal mortality occurred in 33%, indicating that one in three women presenting with dyspnea succumbed despite interventions, consistent with Hung et al²⁸ and Martin-Arribas et al³³, who also reported high fatality rates in obstetric respiratory failure. Postpartum women exhibited higher mortality (72.7%), emphasizing the need for extended vigilance beyond delivery, a finding echoed by Frise et al.³⁴

This single-center cross-sectional study provides valuable insights into dyspnea in pregnancy but has limitations, including limited generalizability, absence of long-term follow-up, lack of advanced diagnostics (CT pulmonary angiography, cardiac MRI, and biomarker assays (NT-proBNP, troponins, IL-6, procalcitonin), and small subgroup sizes. Future multicenter studies with advanced imaging, biomarkers, and long-term follow-up are needed to validate findings and develop predictive models and evidence-based management strategies to reduce maternal morbidity and mortality.

In conclusion, acute dyspnea in pregnancy and the postpartum period is a critical warning sign often associated with serious underlying conditions such as eclampsia, pulmonary edema, severe anemia, and infections. Postpartum women are particularly vulnerable to adverse outcomes, emphasizing the need for continued monitoring after delivery. Simple bedside parameters (tachypnea, tachycardia, hypoxemia) and laboratory parameters (anemia, proteinuria, thrombocytopenia) can serve as early warning markers in resource-limited settings, while a comprehensive multisystem assessment and timely ICU referral remain vital. Strengthening antenatal screening and maternal critical care systems is essential to reduce preventable maternal morbidity and mortality.

1. Goland S, Perelman S, Asalih N, Shimoni S, Walfish O, Hallak M, et al. Shortness of Breath during Pregnancy: Could a Cardiac Factor Be Involved? Clin Cardiol. 2015 Oct 1;38(10):598–603.
2. Ruys TPE, Cornette J, Roos-Hesselink JW. Pregnancy and delivery in cardiac disease. J Cardiol [Internet]. 2013 Feb 1 [cited 2025 Jul 25];61(2):107–12.
3. Ruys TEP, Roos-Hesselink JW, Hall R, Subirana-Domèlnech MT, Grando-Ting J, Estensen M, et al. Heart failure in pregnant women with cardiac disease: data from the ROPAC. Heart [Internet]. 2014 Feb 1 [cited 2025 Jul 25];100(3):231–8.
4. Choi HS, Han SS, Choi HA, Kim HS, Lee CG, Kim YY, et al. Dyspnea and Palpitation during Pregnancy. Korean J Intern Med [Internet]. 2001 [cited 2025 Jul 25];16(4):247.
5. Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, Blomström-Lundqvist C, Cífková R, De Bonis M, et al. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J. 2018 Sep 7;39(34):3165–241.
6. Maternal mortality rates and statistics - UNICEF DATA [Internet]. [cited 2025 Aug 1]. Available from: https://data.unicef.org/topic/maternal-health/maternal-mortality/
7. Dahiya S, Rani V, Duhan L, Dahiya P, Dahiya S. Clinical profile of respiratory distress in obstetric admissions to intensive care unit at a tertiary care centre in northern India. Heart disease. 2024;5:10-63.
8. Pokhrel S, Ghimire RH, Ghimire A, Shrestha P, Chaudhary AN. Clinical Profile and Outcome of Obstetric Patients Requiring Critical Care Support in a Tertiary Care Centre. Journal of Nobel Medical College. 2020 Dec 11;9(2):18-22.
9. Ashokka B, Loh MH, Tan CH, Su LL, Young BE, Lye DC, Biswas A, Illanes SE, Choolani M. Care of the pregnant woman with coronavirus disease 2019 in labor and delivery: anesthesia, emergency cesarean delivery, differential diagnosis in the acutely ill parturient, care of the newborn, and protection of the healthcare personnel. American journal of obstetrics and gynecology. 2020 Jul 1;223(1):66-74.
10. Nyondo MB. Predictors, Clinical Characteristics and Maternofetal Outcomes of Cardiac Disease Among Pregnant Women Undergoing Emergency Radiological Surveillance at Dodoma Regional Referral Hospital (Master's thesis, University of Dodoma (Tanzania)).
11. Kanbe M, Yatomi M, Wakamatsu I, Uno S, Hanazato C, Aoki-Saito H, Masuda T, Yamaguchi K, Kasahara N, Miura Y, Tsurumaki H. A pregnant woman with severe dyspnoea. Breathe. 2022 Jul 11;18(2).
12. Mishra P, Sharma R, Verma R. Clinical Profile of Patients with Peripartum Cardiomyopathy: A Single-center Experience and Review of Literature. Journal of South Asian Federation of Obstetrics and Gynaecology. 2024 Oct 23;16(5):602-10.
13. Muzaffar T, Fatima S, Akbar H, Shafique N, Riaz T, Shahid R. Assessment of Clinical and Echocardiographic Findings of Pregnant Women with Dyspnea. Pakistan Armed Forces Medical Journal. 2022 Oct 31;72:S659.
14. Barut MU, Güngören F, Kaçmaz C. Assessment of clinical and echocardiographic findings of pregnant women with dyspnea. Medical Science Monitor: International Medical Journal of Experimental and Clinical Research. 2019 Feb 6;25:1032.
15. Randhawa JS, Ashraf H, Colombo JP, Kudla P. Postpartum respiratory distress due to hypertension-related pulmonary edema. Cureus. 2021 Sep 21;13(9).
16. Han Y, Lee JH, Chang JH, Shim SS, Kim Y, Ryu YJ. Clinical features and outcomes in patients with pulmonary complications during pregnancy and peripartum. The Journal of Maternal-Fetal & Neonatal Medicine. 2020 Apr 2;33(7):1191-6.
17. McGourty M, Skaritanov E, Kovell L, Wilkie G. Cardiac evaluation in pregnant patients with dyspnea and palpitations. American Journal of Obstetrics & Gynecology MFM. 2024 May 1;6(5):101359.
18. Agarwal I, Kumar A, Singh S. Maternal tachyarrhythmias in pregnancy and post-partum: Management challenges. Tropical Doctor. 2025:00494755251360305.
19. Lan L, Zhang C, Geng J, Li Q. Echocardiographic Assessment of the Maternal Heart: A Review of the Structural and Functional Changes During Pregnancy. Echocardiography. 2025 Jun;42(6):e70220.
20. Molina OA, Balaguera SB, Campo-Rivera N, Zapata SA, Mendoza MA, Giraldo MB, Escandón AH, Ortiz EM. Normal echocardiographic findings in healthy pregnant women: A narrative review of the literature. Current Problems in Cardiology. 2025 Mar 1;50(3):102969.
21. Mutua DN, Njagi EM, Orinda GO. Hematological profile of normal pregnant women. J Blood Lymph. 2018 Jan;8(2):1-6.
22. Paixão JT, Santos CD, França AP, Lima SS, Laurentino RV, Fonseca RR et al. Association of D-dimer, C-reactive protein, and ferritin with COVID-19 severity in pregnant women: Important findings of a cross-sectional study in Northern Brazil. International Journal of Environmental Research and Public Health. 2023 Jul 20;20(14):6415.
23. Zhou W, Qu C, Liu X, Huang J. Diagnostic value of D-dimer to fibrinogen ratio for pulmonary embolism in postpartum women. BMC Pregnancy and Childbirth. 2024 Jul 16;24(1):482.
24. Griffin KM, Oxford-Horrey C, Bourjeily G. Obstetric disorders and critical illness. Clinics in chest medicine. 2022 Sep 1;43(3):471-88.
25. Xu JH, Czarny HN, Toledo I, Warshak CR, DeFranco EA, Rossi RM. Risk of severe maternal morbidity and mortality among pregnant patients with chronic kidney disease. American Journal of Obstetrics & Gynecology MFM. 2025 Feb 1;7(2):101594.
26. Pramana C, Peranawengrum KB, Juliani V, Laras C, Luxzi NN, Supinganto A, Staryo NA. Maternal characteristics and perinatal outcomes in women with severe preeclampsia. Syst Rev Pharm. 2020 Nov 1;11(11):549-3.
27. Novoa RH, Quintana W, Llancari P, Urbina-Quispe K, Guevara-Rios E, Ventura W. Maternal clinical characteristics and perinatal outcomes among pregnant women with coronavirus disease 2019. A systematic review. Travel medicine and infectious disease. 2021 Jan 1;39:101919.
28. Hung CY, Hu HC, Chiu LC, Chang CH, Li LF, Huang CC, Kao CC, Cheng PJ, Kao KC. Maternal and neonatal outcomes of respiratory failure during pregnancy. Journal of the Formosan Medical Association. 2018 May 1;117(5):413-20.
29. Vouga M, Favre G, Martinez-Perez O, Pomar L, Acebal LF, Abascal-Saiz A, Hernandez MR, Hcini N, Lambert V, Carles G, Sichitiu J. Maternal outcomes and risk factors for COVID-19 severity among pregnant women. Scientific reports. 2021 Jul 6;11(1):13898.
30. Johnson S, Paul J. Breathing for Two: Unraveling the Complex Interplay of Pregnancy and Respiratory Physiology. Indian Journal of Respiratory Care. 2024 Jan;13(1):54-9.
31. Padilla C, Markwei M, Easter SR, Fox KA, Shamshirsaz AA, Foley MR. Critical care in obstetrics: a strategy for addressing maternal mortality. American journal of obstetrics and gynecology. 2021 Jun 1;224(6):567-73.
32. Vasco M, Pandya S, Van Dyk D, Bishop DG, Wise R, Dyer RA. Maternal critical care in resource-limited settings. Narrative review. International journal of obstetric anesthesia. 2019 Feb 1;37:86-95.
33. Martin-Arribas A, Escuriet R, Borràs-Santos A, Vila-Candel R, González-Blázquez C. A comparison between midwifery and obstetric care at birth in Spain: Across-sectional study of perinatal outcomes. International journal of nursing studies. 2022 Feb 1;126:104129.
34. Frise CJ. Management of the critically ill obstetric patient. Obstetrics, Gynaecology & Reproductive Medicine. 2024 Jul 1;34(7):189-96.

35.   Carr AB, Brown DT. McCracken's removable partial prosthodontics-e-book. Elsevier Health Sciences; 2010 Jun 22.

36.   Trulsson U, Engstrand P, Berggren U, Nannmark U, Brånemark PI. Edentulousness and oral rehabilitation: experiences from the patients' perspective. European journal of oral sciences. 2002 Dec;110(6):417-24.

37.   Eitner S, Wichmann M, Schlegel A, Holst S. Clinical study on the correlation between psychogenic dental prosthesis incompatibility, oral stereognosis, and the psychologic diagnostic tools SCL-90-R and CES-D. International Journal of Prosthodontics. 2007 Sep 1;20(5).

38.   Müller F, Schädler M, Wahlmann U, Newton JP. The use of implant-supported prostheses in the functional and psychosocial rehabilitation of tumor patients. International Journal of Prosthodontics. 2004 Sep 1;17(5).

39.   Kawai Y, Murakami H, Takanashi Y, Lund JP, Feine JS. Efficient resource use in simplified complete denture fabrication. Journal of Prosthodontics: Implant, Esthetic and Reconstructive Dentistry. 2010 Oct;19(7):512-6.

40.   Levin B, Richardson GD. Complete denture prosthodontics. A manual for clinical procedures. 2002:54-.

41.   Jang KS, Kim YS. Comparison of oral sensory function in complete denture and implant‐supported prosthesis wearers. Journal of oral rehabilitation. 2001 Mar;28(3):220-5.

42.   Greenland K, Margrain TH. Evaluating the association between anxiety and satisfaction. Optometry and Vision Science. 2009 Mar 1;86(3):216-21.