cardiovascular and respiratory disorders

Question 1

attributing factors to heart disease in pregnancy

Answer 1

-congenital heart disease
-lifestyle trends (smoking, alcohol, obesity, DM, HTN)
-chronic medical conditions
-obstetric conditions (twins)

Question 2

physiologic changes in pregnancy that contribute to cardiac disease (4)

Answer 2

-increased blood volume
-decreased systemic vascular resistance (because of progesterone)
-hypercoagulability
-fluctuations in cardiac output (especially during labor and birth)

Question 3

when does blood volume reach max during antepartum (highest risk cardiac complications)

Answer 3

32 weeks gestation

Question 4

3 conditions affected most by increased blood volume during pregnancy

Answer 4

-stenotic heart valves
-impaired ventricular function
-congenital artery disease (marfans; coarctation of aorta)

Question 5

2 conditions affected most by decreased systemic vascular resistance

Answer 5

-abnormal connection between R and L heart (septal defect)
-shunts (uncorrected patent arteriosus)

Question 6

2 conditions affected most by hypercoagulability

Answer 6

-artificial valves
-some arrhythmias and cardiac defects

Question 7

2 conditions affected most by fluctuations in cardiac output

Answer 7

-conditions that require constant blood volume (pulmonary HTN)
-conditions with fixed cardiac output (mitral stenosis)

Question 8

new york heart association heart failure classification (4 classes)

Answer 8

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

Question 9

modified WHO classification heart failure (5 groups)

Answer 9

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

Question 10

4 congenital heart diseases that are complicated with pregnancy

Answer 10

-septal defects/patent ductus arteriosus
-eisenmenger’s syndrome
-tetralogy of fallot
-aortic disease (coarctation, marfans)

Question 11

3 acquired heart diseases that are complicated with pregnancy

Answer 11

-valve disease (stenosis, MVP, rheumatic)
-ischemic disease
-cardiomyopathy

Question 12

complications of septal defects/intracardiac shunts during pregnancy

Answer 12

-arrhythmias
-paradoxical embolism
-congestive heart failure
-VSD and PDA: pulmonary HTN, aortic regurgitation

Question 13

complication of uncorrected defect VSD or PDA)

Answer 13

eisenmenger syndrome

Question 14

complications of eisenmenger syndrome with pregnancy

Answer 14

-pulmonary HTN
-RV hypertrophy
-R to L shunting w cyanosis
(poor pregnancy outcomes)

Question 15

complications of tetralogy of fallot with pregnancy (corrected v uncorrected)

Answer 15

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

Question 16

complications of marfans syndrome with pregnancy

Answer 16

-aortic wall weakness
-increased blood volume and CO of pregnancy exacerbates syndrome
-autosomal dominant
-enlarged aortic root/valve involvement = severe risk (surgical correction prn)

Question 17

complications of coarctation of aorta with pregnancy

Answer 17

-upper extremity HTN
-lower extremity hypoTN
-complicated = high/major risk, aortic dissection, aneurysm, rupture most common
*needs correcting prior to pregnancy

Question 18

complications of mitral valve prolapse with pregnancy

Answer 18

-(rare) palpitations or arrhythmias
generally tolerate pregnancy and birth well

Question 19

complications of mitral stenosis (rheumatic) with pregnancy

Answer 19

-peripartum hemodynamic changes lead to ventricular failure and pulmonary edema
-afib
-pulmonary edema
-R sided HF

Question 20

complications of bioprosthetic valves with pregnancy

Answer 20

-don’t require anticoagulants during pregnancy
-low rate complications during pregnancy
-not as durable, pregnancy accelerates deterioration

Question 21

are anticoagulants needed for bioprosthetic valves or mechanical

Answer 21

mechanical

Question 22

problem with heparin during pregnancy

Answer 22

-increased risk fetal/maternal bleeding during pregnancy
-increased risk PPH
-increased risk intraventricular brain hemorrhage in fetus

Question 23

problem with warfarin during pregnancy

Answer 23

teratogenic

Question 24

when do you stop anticoagulant (if needed for mechanical valve) when pregnant

Answer 24

2 weeks before labor

Question 25

what anticoagulants are given during pregnancy if needed for mechanic valves

Answer 25

-LMW heparin (lovenox) during 1st tri
-warfarin during 2nd and 3rd tri

Question 26

diagnosis ischemic heart disease (2 enzymes)

Answer 26

troponin I and T
(other enzymes not reliable during pregnancy)

Question 27

management ischemic heart disease during pregnancy

Answer 27

-thrombolytic agents contraindicated
-stents (need for anticoagulants can be issue)

intrapartum:
-lateral positioning
-epidural
-vaginal delivery preferred
-shortened 2nd stage labor (forceps, vacuum)

Question 28

when is maternal mortality rates highest (due to MI) for pregnant women with ischemic heart disease

Answer 28

within 2 weeks of birth

Question 29

between what time frame is cardiomyopathy considered peripartum cardiomyopathy

Answer 29

1 month before birth up to 5 months after birth
(congestive heart failure, EF<45%)

Question 30

management peripartum cardiomyopathy

Answer 30

-diuretics
-b blockers
-inotropic agents
-vasodilators

Question 31

complication with peripartum cardiomyopathy

Answer 31

recurs and gets worse with subsequent pregnancies (important that ventricle returns to normal before next pregnancy)

Question 32

3 things used to determine risk for cardiovascular perinatal morbidity and mortality

Answer 32

-specific disease/lesion
-functional abnormality produced
-development of complications

Question 33

4 categories within predictors of cardiac events risk assessment

Answer 33

-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

Question 34

other parameters within cardiac risk assessment during pregnancy

Answer 34

-BNP (increased = increased risk HF)
-NT-proBNP

Question 35

antepartum assessment: red flags (7)

Answer 35

-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

Question 36

interventions during antepartum to decrease cardiac risk

Answer 36

-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

Question 37

intrapartum interventions to decrease cardiac risk

Answer 37

-O2
-positioning (lateral!)
-prevent hypoTN and HTN (tricky w epidural)
-strict manage fluids
-second stage labor: no valsalva, no pushing
-Abx prn

Question 38

late intrapartum/postpartum interventions to decrease cardiac risk

Answer 38

-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)

Question 39

4 big resp complications in pregnancy

Answer 39

-asthma
-pneumonia
-pulmonary edema
-cystic fibrosis

Question 40

complications of asthma during pregnancy

Answer 40

-preterm labor
-SGA/IUGR
-preeclampsia
-C/S
-increased risk fetal death (if not controlled)

Question 41

management asthma during pregnancy

Answer 41

-prevent hypoxic events:
-monitor lung functions (PEFR)
-avoid/control triggers
-meds (rescue SABA, maintenance inhaled corticosteroids)

Question 42

preferred rescue med for asthma during pregnancy
preferred maintenance med for asthma during pregnancy

Answer 42

rescue: SABA
maintenance: inhaled corticosteroids

Question 43

intrapartum interventions for asthma

Answer 43

-continue meds
-position: semi/high fowlers (w hip tilt)
-I&O, avoid fluid overload

Question 44

contraindicated meds for asthmatic pregnant women

Answer 44

demerol
morphine
(both release histamine)

Question 45

postpartum interventions for asthma

Answer 45

-continue meds
-anticipate PPH (SABA meds relax uterus)
-avoid methergine and hemabate
-if bleeding: oxytocin and prostaglandin E w resp monitoring

Question 46

what postpartum meds are contraindicated for asthmatic women (2)

Answer 46

-methergine (vasoconstrictor)
-hemabate

Question 47

3 types pneumonia

Answer 47

-bacterial
-aspiration (w general anesthesia or seizures)
-viral (most common pregnant women)

Question 48

complications with pneumonia during pregnancy

Answer 48

-*preterm labor and birth
-bacteremia
-pneumothorax
-afib
-resp failure
-SGA neonate
-neonatal death

Question 49

pregnancy considerations with pneumonia - chest xray? Abx?

Answer 49

-chest xray is appropriate for Dx
-appropriate choice and dose Abx (least teratogenic effect, esp during 1st tri)

Question 50

management pneumonia during pregnancy

Answer 50

-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

Question 51

2 types pulmonary edema

Answer 51

-hydrostatic (cardiogenic, CHF) - hypervolemia
-vascular permeability (nonhydrostatic, noncardiogenic) - caused by sepsis, hypovolemia

Question 52

risks pulmonary edema with pregnancy

Answer 52

-increased blood volume and CO
-decreased plasma COP
-increased risk aspiration
-preeclampsia
-tocolysis
-hemorrhage

Question 53

management pulmonary edema in pregnancy

Answer 53

-O2 >95%

positioning:
-hydrostatic: upright w wedge
-vascular permeability: lateral

-IV morphine
-monitor I&O
-administer diuretics for hydrostatic

Question 54

positioning for pulmonary edema during pregnancy
-hydrostatic
-vascular permeability

Answer 54

-hydrostatic: upright w wedge
-vascular permeability: lateral

Question 55

major contraindication during l&d for IV morphine

Answer 55

about to deliver (resp depression in baby)

Question 56

preconceptual assessments cystic fibrosis

Answer 56

-lung function
-nutrition (90% ideal body weight)
-autosomal recessive (test dad)

Question 57

possible complications of cystic fibrosis during pregnancy

Answer 57

-chronic hypoxia
-inadequate nutrition
-frequent pulmonary infections
-fetal/neonatal complications (IUGR, preterm birth, fetal death)

Question 58

management cystic fibrosis during pregnancy

Answer 58

-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)