Chapter 11: Cardiovascular Disease Flashcards
Signs and Symptoms
can be similar to the physiological changes that normally occur during pregnancy
- the pregnant patient may experience heart palpitations associated with the normal increase in blood volume; women with heart disease may experience heart palpitations caused by arrhythmia
- Fatigue, a common complaint during pregnancy, may result from poor cardiac output and myocardial ischemia in patients with heart disease
Categories of Cardiac Disease during pregnancy
-congenital cardiac disease (e.g. atrial septal defect, ventricular septal defect, pulmonic stenosis, congenital aortic stenosis, coarctation of the aorta, tetralogy of Fallot, and Eisenmenger’s syndrome)
-acquired cardiac disease (e.g. lesions that are rheumatic in origin and valvular lesions such as mitral and aortic stenosis)
>Rheumatic mitral stenosis is most common and associated with pulmonary congestion, edema, and atrial arrhythmias during pregnancy and soon after childbirth
Patient Cardiac Function is divided into 4 classes
Class I: patient is asymptomatic and there is no limitation on physical activity
Class II: patient is asymptomatic at rest, symptomatic with heavy physical activity, and requires slight limitation of activity
Class III: asymptomatic at rest, symptomatic with minimal physical activity, and physical activity considerably limited
Class IV: symptomatic at rest, symptomatic with any activity, severe limitations on physical activity
>I and II usually do well during pregnancy, III and IV have increased risk of morbidity and mortality with pregnancy; regardless of classification, any patient with a cardiac hx must be assessed for signs of decompensation
Caring for the pregnant woman with Cardiac Disease
- Antepartally: continuity of care with a single provider, frequent prenatal visits, routine screening for bacteriuria, and prophylaxis against anemia
- Intrapartal: induction of labor when cervical favorability is present and the avoidance of prolonged labor, second stage pushing, and maternal blood loss
- Postpartal: strict management of blood volume and careful but aggressive diuresis
Rapid blood volume changes
labor, birth, and the immediate postpartum period provide a time of increased risk because of the rapid volume changes that occur
-during labor and birth, epidural anesthesia may be used for most patients with cardiac disease, but care must be taken to avoid hypotension
>effective pain control is important in decreasing the cardiac workload
>lateral recumbent position and administration of IV fluids help balance the patient’s blood pressure
-invasive hemodynamic monitoring is beneficial in evaluating rapid changes in heart rate, cardiac output, and pulmonary capillary wedge pressure (an estimation of left atrial pressure) so that fluid, diuretic, vasodilator, and pressor therapy may be guided
Medications for the pregnancy cardiac patient
-diuretics (Lasix) to prevent congestive heart failure
-digitalis
-nitrates (to reduce afterload, the resistance the ventricles must overcome to eject blood during systole)
-antiarrhythmic agents (e.g. lidocaine)
-beta blockers (e.g. labetalol)
-calcium channel blockers (e.g. nifedipine)
-antibiotics
-anticoagulants (heparin-warfarin is contraindicated because it crosses placenta)
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Nursing Interventions
- antenatal assessment of weight gain to ensure proper fetal growth while avoiding excessive weight gain, which causes increased cardiac workload
- nutritional counseling (diet high in iron to prevent anemia and low in sodium to prevent fluid retention)
- education to avoid/reduce stress and anxiety
- encouragement of adequate nighttime sleep and frequent daytime rest periods
- explanation of fetal surveillance testing
- taking medications and keeping prenatal appointments
- education regarding S/S of complications; when to call provider
S/S of decreased cardiac output
- decreased and/or irregular pulse
- increased respiratory rate
- dyspnea
- chest pain
- abnormal breath sounds: crackles at the base of the lungs
- decreased blood pressure
- decreased urinary output (less than 30 mL/hr.)
- edema of the hands, face, and feet
- abnormal heart sounds: diastolic murmur at the hearts apex
- signs of air hunger: anxiety
- decreased oxygen saturation; less than 95%
- cool, clammy, cyanotic skin
- increased capillary refill time: greater than 3 seconds
- EKG changes
- mental changes: disorientation, fatigue; syncope
Intrapartal Interventions
focus on assessing the patient and fetus for decreased cardiac output and oxygenation
- oxygen, if required, should be supplied via a rebreather mask at 10 L/min
- IV fluids administered via a pump
- intake and output monitored throughout labor
- antibiotic prophylaxis may be indicated for selected patients with cardiac disease because of their increased risk for developing endocarditis as a result of invasive procedures (e.g. invasive hemodynamic monitoring, intrauterine pressure catheter, and fetal scalp electrode)
- continuous fetal monitoring
What Happens with Decreased Maternal Cardiac Output
the fetus will show signs of poor placental perfusion, e/b late heart rate decelerations and/or the loss of baseline variability (no nice waves in the wavelength)
>if this develops, improved oxygenation must be delivered to the fetus by giving oxygen to the woman, who should be maintained in lateral position (left side, O2)
>IV fluids should be increased with caution to avoid maternal fluid overload
After Delivery of the Baby and Placenta
large quantities of fluids are rapidly mobilized
- patient with cardiac disease must be continually assessed for decompensation (inability of the heart to maintain sufficient cardiac output) during the puerperium
- ambulation ASAP to prevent DVT
- if receiving cardiovascular meds and chooses to breastfeed, observation of newborn is warranted
Mitral Valve Prolapse (MVP)
does not affect pregnancy
- hemodynamic changes associated with pregnancy may alleviate murmur of MVP and its symptoms
- rarely, experience chest discomfort or rhythm disturbances and should be managed with reassurance
- therapy with beta adrenergic blockers may be initiated in highly symptomatic patients
- if murmur is audible, antibiotic prophylaxis should be administered at time of childbirth
Peripartum Cardiomyopathy
rare syndrome of heart failure that occurs in late pregnancy or within first 5 months postpartum
-has no hx of cardiac disease and presents with dyspnea, fatigue, and peripheral or pulmonary edema
-radiological findings: cardiomegaly
>acute treatment: improving cardiac function; diuretics to decrease preload and relieve pulmonary congestion, digoxin to improve contractility and facilitate rate control when atrial fibrillation is present, beta-adrenergic blockers, anticoagulation with heparin if woman is antepartum and Coumadin if postpartum, and fluid and sodium restriction
