Cardiac issues in pregnancy

Question 1

What are the normal cardiac changes in pregnancy?

Answer 1

• 40% increase in cardiac output
• 20% increase in stroke volume
• 40% increased blood volume (all peak 20-24/40)
• increased heart rate (peaks in 3rd trimester)
• decreased total peripheral resistance due to vasodilation (throughout)
• decreased blood pressure in first and second trimester

Question 2

What are 9 signs/symptoms of cardiac compromise in pregnancy?

Answer 2

• fatigue
• shortness of breath (dyspnoea)
• difficulty breathing when lying down (orthopnoea)
• dysrhythmias
• tachycardia or bradycardia
• chest pain with activity
• peripheral oedema
• abnormal heart sounds
• thromboembolism

Question 3

What are the riskiest times for women with heart disease in pregnancy?

Answer 3

• 28-32 weeks gestation
• labour (particularly 3rd stage)
• 12-24 hours postpartum

Question 4

What is the responsibility of the midwife where a woman presents with a history of cardiovascular disease at commencement of care?

Answer 4

• C refer

Question 5

What antepartum considerations are important in the care of a woman with cardiac disease in pregnancy?

Answer 5

• multidisciplinary collaborative care
• preconception counselling
• early referral to tertiary centre
• baseline evaluation (ECG)
• ultrasounds for screening for fetal cardiac abnormalities
• increased frequency of antenatal care
• birth planning
• importance of rest (esp in T3)
• prevent anaemia
• screening for asymptomatic bacteriuria (increased risk of pyelonephritis)

Question 6

What intrapartum considerations are important in the care of a woman with cardiac disease in pregnancy?

Answer 6

• notify appropriate personell
• collaborative care
• vaginal birth has lowest risks
• pain relief often recommended (esp epidural, timing with thromboprophylaxis)
• additional observations
• management of fluid balance
• oxygen if required
• position in labour (left lateral, sitting)
• fetal monitoring
• antibiotic prophylaxis (at higher risk of infections)
• length and managment of second stage
• active management of third stage (not ergometrine)

Question 7

What postpartum considerations are important in the care of a woman with cardiac disease in pregnancy?

Answer 7

• increased observations, high risk for several days
• thromboprophylaxis (stockings & early ambulation)
• length of postpartum stay
• encourage breastfeeding, rest, signs of mastitis, bottle feeding may be indicated in some women
• contraception, guidance on future pregnancies
• health follow up (6 weeks, 6 months if concerns and then usual care)