Medical Surgical Disorders Flashcards
How does the state of pregnancy affect blood volume?
What sort of offsets the volume change though?
Blood volume will increase 30-50% which increases the workload of the heart
The mom’s vessels will dilate in order to offset increased blood volume
What does state of pregnancy do to HR?
How does this affect CO?
Increase HR which causes increased CO cardiac output
How does pregnancy affect fluid?
How does pregnancy affect weight?
Pregnancy can cause in an increase of edema from fluid but this should be below the knees. If it is higher , than this could be an issue with something else going on.
Well we are expecting there to be weight gain from pregnancy due to the fetus but also fluid and fat stores.
What happens if a mom isn’t able to adapt to her weight gain phsyiolgoically?
Normal woman adapt but if not, secondary issues of the heart can arise. They can have congestive heart failure around the 25-30 week mark. You’ll see the symptoms pop up too.
Diagnosing heart disease steps/progression
History
Physical Exam
Testing
Severity
What is mom’s functional capacity? Depending on the severity of condition, it can be affected.
Degree of disability
More important and dictates her management even more so than her classification.
How many classifications of heart disease are there?
How do they work?
4 classes
The classes of heart disease can progress as pregnancy progresses or symptoms worsen
Class 1 heart disease
No signs or symptoms in majority of pregnancy. - however just so you know , mom's who don't have signs can easily develop them at the 28-30 weeks gestation to where she progresses to a higher class of heart disease
Class 2 heart disease
Sx of heart issues that limit their activity only slightly
- after exertion maybe running up stairs
Class 3 of heart disease
Sx of heart issue but now the limitations of activity are marked
- after just walking across the room
Class 4 of heart disease
Sx of heart issue but now while just resting
What percent of pregnant women are affected by cardiac disorders?
What is surveillance gonna be like for these women when they’re pregnant?
Cardiac only affects 1% of pregnancies
Mom will have more ongoing assessments so you’ll have to warn her she will be coming in a lot
What percent of cardiac issues in pregnant women were from congenital heart lesions or they were born with the heart issue?
Examples?
50% of the cases were from congenital born defects
ASD, VSD etc
If you see a women with pulmonary hypertension, what is a reason this could be?
Weight loss drugs or other drugs that causes her vessels to constrict and cause the hypertension
What is MVP? And how can pregnancy affect it?
Mitral Valve prolapse
Pregnancy sometimes can make the mitral valve prolapse symptoms scale back a bit but others can exacerbations , awareness of heart beating, soa
What is a dropping category of heart disease in pregnancy?
What if happens to the heart if someone gets is and is affected by this?
Rheumatic heart disease because we have antibiotics for Group A Strep and we screen for it aggressively
Mitral valve stenosis occurs due to it
What is Peripartum Cardiomyopathy?
Affects the myocardium (muscle) to the point their left ventricle is dysfunctional despite no previous heart issue
When does Peripartum Cardiomyopathy occur?
In pregnant woman - occurs in last month of pregnancy or up to 5 months after the delivery of the baby
- usually 2-3 weeks within delivery though
Peripartum Cardiomyopathy cause?
Peripartum Cardiomyopathy symptoms?
Unknown
Symptoms of congestive heart failure with cardiomyopathy
- onset of dyspnea
- SOB
- tired
- low edema
- heart enlargement
No heart issue. Gets pregnant. Delivers. 2-3 weeks later you’ll see heart symptoms.
Diagnosis is based off of for Peripartum Cardiomyopathy?
The onset description with symptoms and diagnostic tests like echo or EKG
Medicine Treatment for Peripartum Cardiomyopathy?
Management?
Digoxin
Diuretics
Vasodilators
Anti-coagulant to decrease clots
Reduce sodium and fluid
Put on bedrest
What are the odds Peripartum Cardiomyopathy resolves?
Chance it’ll happen again in another pregnancy?
Chance of death from Peripartum Cardiomyopathy?
50% chance of resolution with 6 months Peripartum Cardiomyopathy
20-50% chance of it happening again
85% chance of death if it doesn’t get resolved from a secondary diagnosis so not a great prognosis
When managing pregnancy in a patient with cardiovascular issues going on, what is the goal?
What tips do we give for this?
(supplementation, health, bathroom)
Minimize the stress for them for their heart’s sake
We want them to take all their vitamins. Fe, prenatal, and folic acid
Avoid infections if they can help it and treat asap if they get on
No straining on toilet so use stool softeners
What diet should you instruct mom’s with heart disease to eat for prenatal management? Activity levels for mom?
Low sodium , High iron, High protein
Activity tolerance may be less so less activity which explain decreased calories
Also make sure she has a consult with dietician to make sure she is eating the right things
- and this prenatal stuff means she should be eating like this anyways !!
Pregnancy is a ________ state so they develop clots easier.
What 3 meds do moms with heart issues receive to address this?
What meds will they avoid?
For moms who are hypercoaguable (any mom with heart disease in pregnancy), what should you mention about their diet in relation to meds?
Hypercoaguable state so more clots
Put mom on heparin or Lovenox to SQ since they are easy and inexpensive and can be self administered
Can be put on Aspirin as well but it is weaned off before delivery
Avoid Warfarin for the first trimester
Eat consistently when it comes to green, leafy foods due to Vit K , so they don’t counter act their medicine
How many hours of do women with heart issues need ?
At least 10 hours of sleep and naps
What to monitor with medication for women with heart disease?
Peak and trough levels
And monitor vit k
When is CHF likely to peak?
What stimulates or causes the heart failure?
treatment for CHF?
24-32 weeks
but infection, severe anemia, or gestational hypertension can stimulate this
Diuretics and digitalis
How does CHF affect the fetal risks?
Fetus can be SGA or premature delivery from impaired placental perfusion and nutrition.
- the s/d ration done may mean they need to be delivered early
How can you minimize physical exertion during labor for women with CHF and therefore help o2 levels?
Will you use stirrups?
Don’t have mom walk around; keep her in bed
HOB elevated
Side lying position
O2 mask 8-10 L (bc we are mouth breathers)
No stirrups! The bending of the knee reduces oxygenation due to compressed popliteal veins
When is regional anesthesia given to women with CHF?
Regional block given early to avoid more stress on heart and increased oxygen consumption due to pain
What should the nurse monitor of a mother who has heart issues rt CHF during the labor?
Monitor blood gases, oxygen sats, vitals, and they can even do an EKG during labor
What are operative options that can be used with the goal to speed up delivery and decrease stress for mom with heart issues rt CHF?
Vacuum or forceps
Which classes of heart disease may be able to labor?
Class 1, 2, 4
Class 4 will probably need c section
What is so important about first 48 hours after delivery?
The fluid shifting occurring due to loss of placenta’s hormones bc blood shifts to ECF to vascular space
Cardiac output increases
Why is it good to have a family member or support person there with women with heart issues rt CHF in postpartum ?
Mom will be exhausted and more so than the average woman. She will need assistance
What med do you anticipate HF mom being on in postpartum ?
Stool softeners so she isn’t straining
Antibiotics but only if she has a possible infection
In postpartum.. will mom with heart failure be able to breastfeed if she is on diuretics?
No she shouldn’t. If there’s any medications she is taking they need to be evaluated though.
If she is set on breastfeeding but the meds at the given time won’t allow for it , she can pump and dump.
Otherwise, she can breast feed as long as she isn’t on any meds. The meds are the issue .
A mom with heart failure asks how long she has to stay in hospital in postpartum. What do you tell her?
What education do you need to give for when she goes home?
She might have to stay longer bc of her condition.
There needs to be somewhere there for her assistance bc she will be so tired.
What type of BC can mom with heart failure use?
Avoid estrogen based and that is it.
- Can use progestin only
- Deprovera shot is ok
With anemia, how does the heart try to compensate?
HR increases tachycardia
In PG why does H&H tend to drop in pregnancy just naturallu?
Due to blood volume increase. BUT, in women who don’t take their iron or prenatal vitamins the anemia is way worse
What labs indicate anemia?
Hemoglobin below 11
Hematocrit below 33%
Most women hover over these levels tho
How does anemia affect your oxygenation?
Anemia decreases oxygen carrying capacity and so the heart has to work harder to make up for it
(hence the tachycardia)
Anemia risks of pregnancy to mom and baby?
Spontaneous abortion ; sab
early Preterm labor risk
small SGA infant
Post partum hemorrhage
Types of Anemia?
Iron deficiency
Folate deficiency
Sickle cell anemia
Thalassemia
How do they diagnosis iron deficiency anemia?
Ferritin levels will be lower than 12 mcg
Low Hematocrit below 33%
Low hemoglobin below 11
What is the main type of treatment for iron deficiency anemia?
It is actually more preventative with nutrition.
- iron supplement beforehand
- iron transfusions later
- blood transfusions later
T/F
If you are iron deficiency anemic, you are more susceptible to infections
iron deficiency Anemic women tend to have plenty of energy
iron deficiency Anemic women will tend to have more painful labors
Women with anemia are more at risk for infections
Anemic women are actually tired most of the time
Anemic women’s labor is more painful bc their uterus becomes more hypoxic
T/F
iron deficiency Anemic women have decreased risk of PPH
iron deficiency Anemic women have increased risk of pre-eclampsia
Anemic woman sure are at risk of PPH and bad outcomes due to lower reserves to begin with
Anemic women have increased change of high bp with protein spilling (pre-eclampsia)
What is a folate deficiency specifically?
Not getting enough vit B(folate) but we do replace it with folic acid
Why do we need folate/folic acid?
RNA and DNA synthesis
without it, you can have neural tube defects or lower extremity issues
List some neural tube defects associated with not enough folate
Lower extremity issues?
Spine bifida
Meningoceal
clubbed foot
How does folate deficiency affect rbcs?
Immature rbcs won’t divide and so they will be large or Macrocytic
(megaloblastic anemia)
List some uncomfortable maternal symptoms mom may experience with low folate
Nausea
Vomiting
Anorexia
How to prevent folate deficiency anemia?
What does mom take to treat her folate deficiency if she already has it?
Take folic acid as instructed! 0.6mg
If mom is already in the anemic stage, 1 mg folic acid daily with iron supplements
What does mom’s diet need to be like if she has folate deficiency?
Water soluble fruits and veggies, Eggs, Legumes, Whole gains
What do we recommend for women in general when it come to preventing folate deficiency?
Take folic acid and iron anyways
What is sickle cell again?
SS
Ss
Abnormal SS hemoglobin that is shaped wrong and causes obstruction
SS= disease
Ss= trait
so you need to have both be SS for it to really affect you in pregnancy
What is the issue with the SS disease in pregnancy?
What is lifespan in rbc SS?
hypoxia
sickle cell crisis leading to clot
Lifespan is shorter . 5-10 days. And that really causes the anemia too
How to treat the sickle cell exacerbation ?
Triggers- dehydration infection hypoxia acidosis
Rehydrate her
Get oxygen
Give antibiotic
Pain analgesics bc the hypoxia can be painful
How to manage sickle cell anemia during labor?
Labor position?
O2 administration
FHR monitoring
Side-lying
Regional block earlier on
Fetal risks from sickle cell anemia?
Preterm
IUGR
but you need to follow up w ultrasound
What is Thalassemia anemia ?
Insufficient amount of hemoglobin to fill the RBC’s from abnormal alpha or beta chains that is hereditary
If they are a heterozygous Thalassemia anemia or one gene - does it effect pregnancy too much?
What if they are homozygous Thalassemia or both genes?
No not really
When both genes are the problem they have the disease and these people have trouble even getting pregnant but sometimes they still do
How does Thalassemia anemia in mom affect the baby?
At birth baby won’t be affected. It is over time as they grow up the issues arise
Why is it that women with Thalassemia anemia don’t get pregnant?
They often die before they are of childbearing years and are often infertile.
The minors are the ones who live
