The Pregnant Woman with Cardiac Disease 5/21/2018 Chapter 26 The Pregnant Woman with Cardiac Disease Khulod Barqawi

5/21/2018 New York Heart Association Functional Classification of Heart Disease: Class I: uncompromised. No limitation of physical activity. Asymptomatic with ordinary activity. Class II: slightly compromised, requiring slight limitation of physical activity. Comfortable at rest but ordinary physical activity causes fatigue, dyspnea, palpitations, or anginal pain. Khulod Barqawi

5/21/2018 Class III: marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes excessive fatigue palpitation dyspnea, or anginal pain. Markedly compromised. Class IV: inability to perform any physical activity without discomfort. Symptoms of cardiac insufficiency even at rest. In general, maternal and fetal risks with classes I and II diseases are small but are greatly increased with classes III and IV. Khulod Barqawi

Diagnostic Evaluation 5/21/2018 Early recognition and careful assessment of specific S/S include: Dyspnea Syncope with exertion Hemoptysis Paroxysmal nocturnal dyspnea Chest pain with exertion Diastolic presystolic or continuous heart murmur Cardiac enlargement Loud harsh systolic murmur with thrill Serious dysrythmias Khulod Barqawi

clinical signs and symptoms and physical examination. 5/21/2018 Diagnosis Depend on clinical signs and symptoms and physical examination. Chest radiography Electrocardiography Echocardiography Khulod Barqawi

Therapeutic Management: 5/21/2018 Therapeutic Management: Class I and II heart disease - Limit physical activity, the woman should remain free of symptoms of cardiac stress such as dyspnea ,and chest pain - Avoid excessive weight gain, Diet: adequate in protein ,calories and sodium, but a low sodium diet might be advised to prevent congestive heart failure - Prevent anemia, adequate Iron and folic acid in diet - Prevent infection: immunization for influenza and pneumonia may be taken and a prophylactic antibiotics - Careful assessment for the development of congestive heart failure, pulmonary edema, and cardiac dysrhythemias. Khulod Barqawi

Signs and Symptoms of Congestive Heart Failure 5/21/2018 Nur 234 , second semestre 2010 Cough (frequent, productive, hemoptysis) Progressive dyspnea with exertion Orthopnea Pitting edema of legs and feet or generalized edema of face, hands, or sacral area Heart palpitations Progressive fatigue or syncope with exertion Moist rales (Crackles)in lower lobes, indicating pulmonary edema Moist rales: a bubbling rale caused by air mixing with a fluid exudate in the bronchial tubes or cavity. Khulod barqawi, Course coordinator

Therapeutic Management for Class III and IV: 5/21/2018 Nur 234 , second semestre 2010 Therapeutic Management for Class III and IV: Primary goal for management is to prevent: cardiac decomposition (a condition of congestive heart failure in which heart is unable to ensure adequate cellular perfusion in all parts of the body without assistance.) (causes: include myocardial infarction, increased workload, infection, toxins, or defective heart valves). development of congestive heart failure. Precaution listed for Class I and II heart disease in addition the following Khulod barqawi, Course coordinator

Bed rest, especially during the last trimester 5/21/2018 Bed rest, especially during the last trimester Prophylaxis such as elastic compression stockings. Prophylactic anticoagulation may be needed Protect fetus from hypoxia and IUGR. Khulod Barqawi

Drug Therapy Anticoagulants(Heparin or Enoxaparin) 5/21/2018 Drug Therapy Anticoagulants(Heparin or Enoxaparin) Warfarin is associated with fetal malformation so it should be avoided Enoxaparine need less frequent monitoring of bleeding complications than heparin When giving heparin the nurse should frequently monitor Pt,PTT and platelets count Antidysrhythmics(Digoxin) is safe Khulod Barqawi

Fetal growth restriction is associated with furosemide 5/21/2018 Anti-infective prophylactic for endocarditis, if infection developed it should be chosen according to the causative agent Drug for Heart Failure when given the drugs the physician should weighs the benefits and risks of it Fetal growth restriction is associated with furosemide Neonatal juindice,thrombocytopenia,anemia and hypoglycemia are associated with thiazide diuretics Khulod Barqawi

Intra-Partum Management -Minimize effect of labor on CVS 5/21/2018 Intra-Partum Management -Minimize effect of labor on CVS  - prevent fluid overload. - Woman should be positioned on her side( head and shoulder elevated - Oxygen is administered - Discomfort should be reduced to a minimum. Khulod Barqawi

The fetus is monitored electronically. 5/21/2018 The environment is kept as quite and calm as possible to decrease anxiety which leads to tachycardia The fetus is monitored electronically. Monitor signs of fetal compromise and maternal cardiac decompensation(tach cardia,rapid resp.,moist rales and exhaustion) these signs should be reported immediately to the physician Vaginal delivery is recommended unless there is specific indications for CS Khulod Barqawi

Uterus should not be massaged to expedite separation of the placenta. 5/21/2018 Vacuum extraction or outlet forceps are often use in delivery to minimize the using of valsalva maneuver during second stage valsalva maneuver (moderately forceful attempted exhalation against a closed airway(mouth, nose, closed glottis)not recommended because it decrease cardiac output) Abrupt positional changes should be avoided during fourth stage of labor to minimize the risk of overloading the heart after the placenta is removed Uterus should not be massaged to expedite separation of the placenta. Careful assessment for signs of circulatory overload. Such as bounding pulse, distended neck and peripheral veins and moist rales Khulod Barqawi

Post Partum Management 5/21/2018 Post Partum Management . Women who have shown no evidence of cardiac distress during pregnancy, labor or childbirth may still decompensate during the post partum. . They must be observed closely for signs of infection, hemorrhage, or thromboembolism. Khulod Barqawi

Nursing Consideration: 5/21/2018 Nursing Consideration: The nurse determine what functional classification the physician has assigned the woman. Assess for changes in Vital Signs Note increase fatigue or other signs of congestive heart failure at each visit Identify factors that can increase the woman’s cardiac workload (anemia, infection, anxeity, inadequate support) helping the woman and family to understand factors that increase the workload of heart. Khulod Barqawi

Well balanced diet of 2200/day calories and high quality protein 5/21/2018 Well balanced diet of 2200/day calories and high quality protein Emphasis importance of folic acid and iron supplement Make necessary modification in life style Take rest period during day and an hour after meals sit rather than stand when performing activity Stop activity if experiencing dyspnea chest pain and tachycardia Khulod Barqawi

avoid extremes of temperature when possible. 5/21/2018 avoid extremes of temperature when possible. Discuss methods for stress management. Teach the mother that smoking and drugs such as cocaine increase the stress on the heart and associated with hypertension Khulod Barqawi

In post partum continue to observe signs of congestive heart failure. 5/21/2018 In post partum continue to observe signs of congestive heart failure. Observe urine output. Breast feeding impose extra demands on the mother’s heart, and whether it is advised is individualized. Maintain mother infant contact Consult physician and make any needed referrals for follow up care. Before discharge, review the signs and symptoms of cardiac complications.   Khulod Barqawi