Exam 3 Flashcards
Changes in cardio physiology
CARDIAC OUTPUT
- increased 40 percent in pregnancy, almost half is increased by 8 weeks, maximal at mid pregnancy. It is because of augmented stroke volume that results from decreased vascular resistance
PULSE AND STROKE VOUME
- increase more later in pregnancy because of increased end-diastolic ventricular volume, results from pregnancy hypervolemia
Increase SV Increase HR Increase CO increase preload decrease systemic vascular resistance decrease afterload
CO up 40%
HR up 17
vascular resistance- DECREASED
heart rate changes in pregnancy
HR rises in first trimester and slowly rises throughout pregnancy
by the middle of the third trimester, pulse is 15-20 beats above baseline
mild resting tachycardia is normal
systemic vascular resistance changes in pregnancy
fall in peripheral vascular resistance
decreased afterload
DROP in arterial BP (starting in 7th week)
normal cardiac exam findings in pregnant women
mammary souffle jugular venous distension venous hum S2P increased; S2 split S1M increased and widely split occasional s3 aortic or pulmonary flow murmurs
Symptoms heart disease in pregnancy
progressive dyspnea or orthopnea nocturnal cough hemoptysis syncope chest pain
Clinical Findings heart disease pregnancy
cyanosis clubbing of flingers persistent neck vein distension systolic murmur grade 3/6 or greater diastolic murmur cardiomegaly persistant arrhythmia persistant split second sound criteria for pulmonary hypertension
Heart changes in pregnancy
diaphram elevation benign pericardial effusion exagerated splitting of first sound no changes in aortic/pulm elements in second sound loud, easily heard third sound systolic murmur
EKG changes
-Mean QRS can shift leftward due to elevation of the diaphragm
-Can return to the right as the fetus descends at pregnancy end
-Minor ST-segment and T-wave changes may be observed
–Less often, T-wave inversions may appear transiently in the left precordial leads.
- These changes are seldom of sufficient magnitude to raise the question of ischemic heart disease
normal echocardiography changes
- Small, silent pericardial effusion = common
- Slightly but significantly increased tricuspid regurgitation
- Left atrial end-diastolic dimension
- Left ventricular mass
effects of fetus
worsening heart function
decreased oxygenation to tissues (including placenta)
decreased oxygen to fetus
IUGR, NRFHT
Palpitations in Pregnancy
occur frequently during pregnancy
common indication for cardiac eval
look for arrhythmia with EKG
if abnormal EKG, do echo to look for structural heart disease as underlying cause
physical exam for heart disease
HR
weight gain
SPO2
How many flights of stairs can you walk up with ease? Two? One? None?
Can you walk a level block?
Can you sleep flat in bed? How many pillows do you use?
Does your heart race?
Do you have chest pain?
• Does this occur with exercise?
• Do you have pain when your heart races?
Mitral Valve Prolapse (williams)
left atrium and left ventricle
blood backed up from left atrium into lungs
mitral insufficiency
mostly asymptomatic
sometimes experience anxiety, palpitations, atypical chest pain, dyspnea with exertion, and syncope
rare complications in pregnancy
hypervolemia may improve alignment of the mitral valve
NOT considered an indication for infective endocarditis prophylaxis
symptomatic women receive beta blockers to decrease sympathetic tone, relieve chest pain and palpitations and reduce the risk of life-threatening arrhythmias
headache etiology in pregnancy
hormonal changes, increase in blood volume, tension, postural changes, muscle strain, preeclampsia (3rd trimester)
common headache triggers
inadequate sleep, smoke, change in caffeine, stress, hormones, eyestrain, sensory overload, very cold food/drinks, MSG, chocolate, tyramine containing foods, alcohol
Migrane patho
without aura: unilateral, throbbing, N/V, photophobia
with aura: hallucinations, acrotoma, aphasia, numbness/weakness, can happen without a headache, reversible in 5-60minutes
chronic: 15 days/month for greater than 3 months
often decrease in pregnancy (2nd and 3rd)
increase risk of preeclampsia
Migraine pharm
- acetaminophen when symptoms start
- acetinophen + metoclopramide (reglan) or compazine
- aceta + codeine= watch for rebound headache with overuse NAS
- aceta + caffeine
- Fioricet = rebound headache with overuse
- compazine (antiemetic)
- triptans NOT first line
- opioids AVOID can worsen
- severe= IV hydration, IV antiemetics, IV mag, benadryl, compazine, botox
patient education migraine pharm
- tylenol 4g max per day
- NO NSAIDS, NO ergots
- tylenol with caffeine (how much extra caffeine)
- if they take fioricet- already HAS tylenol.. dont take more
- tylenol given at early onset
- NO ergots NO Ibuprofen
Tension headaches patho
- most in pregnancy infrequent episode - less than 1/month - last 30 minutes- 7 days - bilateral, non-pulsing, not worse with activity frequent episode - >10 per month - both N/V - photophobia or phonophobia Chronic - >15 days
tension pharm
aceta.
aceta + caffeine
aceta + codeine
Fioricet
non-pharm cluster treatments
relaxation, breathing, meditation, visual/guided imagery, progressive relaxation, cognitive behavioral therapy, physical therpay (massage, TENS, chiropractic, heat/cold) biofeedback, regular and adequate sleep patterns, dietary modifications; some cheese, salty foods
cluster headaches
pre-existing= neurology
presentation: Unilateral, severe, explosive, 15 minutes to 3 hours, watery eyes, stuffy nose, sweating
