cardiovascular and respiratory disorders Flashcards
attributing factors to heart disease in pregnancy
-congenital heart disease
-lifestyle trends (smoking, alcohol, obesity, DM, HTN)
-chronic medical conditions
-obstetric conditions (twins)
physiologic changes in pregnancy that contribute to cardiac disease (4)
-increased blood volume
-decreased systemic vascular resistance (because of progesterone)
-hypercoagulability
-fluctuations in cardiac output (especially during labor and birth)
when does blood volume reach max during antepartum (highest risk cardiac complications)
32 weeks gestation
3 conditions affected most by increased blood volume during pregnancy
-stenotic heart valves
-impaired ventricular function
-congenital artery disease (marfans; coarctation of aorta)
2 conditions affected most by decreased systemic vascular resistance
-abnormal connection between R and L heart (septal defect)
-shunts (uncorrected patent arteriosus)
2 conditions affected most by hypercoagulability
-artificial valves
-some arrhythmias and cardiac defects
2 conditions affected most by fluctuations in cardiac output
-conditions that require constant blood volume (pulmonary HTN)
-conditions with fixed cardiac output (mitral stenosis)
new york heart association heart failure classification (4 classes)
class 1: no limitation physical activity
class 2: slight limitation physical activity, comfortable at rest
class 3: marked limitation on physical activity
class 4: severe limitation and discomfort with any physical activity, discomfort present at rest
modified WHO classification heart failure (5 groups)
group 1: no increase in mortality, “mild” increase in morbidity
group 2: small increase mortality, moderate increase in morbidity
group 2.5: moderate increase mortality and morbidity
group 3: significant increased risk mortality and severe morbidity, expert counseling needed
group 4: extremely high risk mortality and severe morbidity, pregnancy contraindicated, termination recommended
4 congenital heart diseases that are complicated with pregnancy
-septal defects/patent ductus arteriosus
-eisenmenger’s syndrome
-tetralogy of fallot
-aortic disease (coarctation, marfans)
3 acquired heart diseases that are complicated with pregnancy
-valve disease (stenosis, MVP, rheumatic)
-ischemic disease
-cardiomyopathy
complications of septal defects/intracardiac shunts during pregnancy
-arrhythmias
-paradoxical embolism
-congestive heart failure
-VSD and PDA: pulmonary HTN, aortic regurgitation
complication of uncorrected defect VSD or PDA)
eisenmenger syndrome
complications of eisenmenger syndrome with pregnancy
-pulmonary HTN
-RV hypertrophy
-R to L shunting w cyanosis
(poor pregnancy outcomes)
complications of tetralogy of fallot with pregnancy (corrected v uncorrected)
corrected:
-arrhythmias
-heart failure
uncorrected:
-R to L shunting exacerbated by decreased systemic vascular resistance of pregnancy (could result in eisenmengers)
-risk proportional to degree of shunting
complications of marfans syndrome with pregnancy
-aortic wall weakness
-increased blood volume and CO of pregnancy exacerbates syndrome
-autosomal dominant
-enlarged aortic root/valve involvement = severe risk (surgical correction prn)
complications of coarctation of aorta with pregnancy
-upper extremity HTN
-lower extremity hypoTN
-complicated = high/major risk, aortic dissection, aneurysm, rupture most common
*needs correcting prior to pregnancy
complications of mitral valve prolapse with pregnancy
-(rare) palpitations or arrhythmias
generally tolerate pregnancy and birth well
complications of mitral stenosis (rheumatic) with pregnancy
-peripartum hemodynamic changes lead to ventricular failure and pulmonary edema
-afib
-pulmonary edema
-R sided HF
complications of bioprosthetic valves with pregnancy
-don’t require anticoagulants during pregnancy
-low rate complications during pregnancy
-not as durable, pregnancy accelerates deterioration
are anticoagulants needed for bioprosthetic valves or mechanical
mechanical
problem with heparin during pregnancy
-increased risk fetal/maternal bleeding during pregnancy
-increased risk PPH
-increased risk intraventricular brain hemorrhage in fetus
problem with warfarin during pregnancy
teratogenic
when do you stop anticoagulant (if needed for mechanical valve) when pregnant
2 weeks before labor
what anticoagulants are given during pregnancy if needed for mechanic valves
-LMW heparin (lovenox) during 1st tri
-warfarin during 2nd and 3rd tri
diagnosis ischemic heart disease (2 enzymes)
troponin I and T
(other enzymes not reliable during pregnancy)
management ischemic heart disease during pregnancy
-thrombolytic agents contraindicated
-stents (need for anticoagulants can be issue)
intrapartum:
-lateral positioning
-epidural
-vaginal delivery preferred
-shortened 2nd stage labor (forceps, vacuum)
when is maternal mortality rates highest (due to MI) for pregnant women with ischemic heart disease
within 2 weeks of birth
between what time frame is cardiomyopathy considered peripartum cardiomyopathy
1 month before birth up to 5 months after birth
(congestive heart failure, EF<45%)
management peripartum cardiomyopathy
-diuretics
-b blockers
-inotropic agents
-vasodilators
complication with peripartum cardiomyopathy
recurs and gets worse with subsequent pregnancies (important that ventricle returns to normal before next pregnancy)
3 things used to determine risk for cardiovascular perinatal morbidity and mortality
-specific disease/lesion
-functional abnormality produced
-development of complications
4 categories within predictors of cardiac events risk assessment
-prior cardiac event before pregnancy
-NYHA class 3 or 4 or cyanotic
-left outflow obstruction
-systemic ventricular dysfunction
predictors = risk cardiac event
0 predictors = 5% risk
1 predictor = 27% risk
>1 predictor = 75% risk
other parameters within cardiac risk assessment during pregnancy
-BNP (increased = increased risk HF)
-NT-proBNP
antepartum assessment: red flags (7)
-SOB at rest
-severe orthopnea (4 pillows)
-resting HR>120
-Sbp >160
-RR>30
-O2 sat <94% w/ or w/o h/o CVD
-frequent syncope
interventions during antepartum to decrease cardiac risk
-minimize workload
-teach signs of heart failure to report
-teach signs thromboembolism
-treat infections
-prevent anemia (promote nutrition)
-teach about meds
-continue to assess NYHA functional status
intrapartum interventions to decrease cardiac risk
-O2
-positioning (lateral!)
-prevent hypoTN and HTN (tricky w epidural)
-strict manage fluids
-second stage labor: no valsalva, no pushing
-Abx prn
late intrapartum/postpartum interventions to decrease cardiac risk
-monitor for cardiac decomp with autotransfusion PP
-monitor for infection
-activity as ordered/tolerated
-prevent constipation and valsalva
-discharge planning (cardiac decomp risk for 2 weeks)
4 big resp complications in pregnancy
-asthma
-pneumonia
-pulmonary edema
-cystic fibrosis
complications of asthma during pregnancy
-preterm labor
-SGA/IUGR
-preeclampsia
-C/S
-increased risk fetal death (if not controlled)
management asthma during pregnancy
-prevent hypoxic events:
-monitor lung functions (PEFR)
-avoid/control triggers
-meds (rescue SABA, maintenance inhaled corticosteroids)
preferred rescue med for asthma during pregnancy
preferred maintenance med for asthma during pregnancy
rescue: SABA
maintenance: inhaled corticosteroids
intrapartum interventions for asthma
-continue meds
-position: semi/high fowlers (w hip tilt)
-I&O, avoid fluid overload
contraindicated meds for asthmatic pregnant women
demerol
morphine
(both release histamine)
postpartum interventions for asthma
-continue meds
-anticipate PPH (SABA meds relax uterus)
-avoid methergine and hemabate
-if bleeding: oxytocin and prostaglandin E w resp monitoring
what postpartum meds are contraindicated for asthmatic women (2)
-methergine (vasoconstrictor)
-hemabate
3 types pneumonia
-bacterial
-aspiration (w general anesthesia or seizures)
-viral (most common pregnant women)
complications with pneumonia during pregnancy
-*preterm labor and birth
-bacteremia
-pneumothorax
-afib
-resp failure
-SGA neonate
-neonatal death
pregnancy considerations with pneumonia - chest xray? Abx?
-chest xray is appropriate for Dx
-appropriate choice and dose Abx (least teratogenic effect, esp during 1st tri)
management pneumonia during pregnancy
-prevention with vaccines and clear liquids during labor
-O2 (95%+ O2)
-semi/high fowlers with tilt
-antipyretics
-hydration
-management pain, anxiety, fatigue
-watch for preterm labor
2 types pulmonary edema
-hydrostatic (cardiogenic, CHF) - hypervolemia
-vascular permeability (nonhydrostatic, noncardiogenic) - caused by sepsis, hypovolemia
risks pulmonary edema with pregnancy
-increased blood volume and CO
-decreased plasma COP
-increased risk aspiration
-preeclampsia
-tocolysis
-hemorrhage
management pulmonary edema in pregnancy
-O2 >95%
positioning:
-hydrostatic: upright w wedge
-vascular permeability: lateral
-IV morphine
-monitor I&O
-administer diuretics for hydrostatic
positioning for pulmonary edema during pregnancy
-hydrostatic
-vascular permeability
-hydrostatic: upright w wedge
-vascular permeability: lateral
major contraindication during l&d for IV morphine
about to deliver (resp depression in baby)
preconceptual assessments cystic fibrosis
-lung function
-nutrition (90% ideal body weight)
-autosomal recessive (test dad)
possible complications of cystic fibrosis during pregnancy
-chronic hypoxia
-inadequate nutrition
-frequent pulmonary infections
-fetal/neonatal complications (IUGR, preterm birth, fetal death)
management cystic fibrosis during pregnancy
-aggressive Tx IV Abx for pulmonary infections
-continue chest physio and drainage
-nutrition: enteral/parenteral feedings prn
-pancreatic enzyme replacement prn
-monitor for and treat diabetes (more common)
-antenatal testing start @28-32 weeks
-preterm birth if maternal lung function deteriorates
-epidural
-vaginal birth
-breastfeeding (if sodium content is normal)
