Care of the Mother, Child and Family at Risk or With Problems

CARE OF THE MOTHER, CHILD AND FAMILY AT RISK OR WITH PROBLEMS Lesson 1 Cardiovascular Diseases: What Are the Risks in Pregnancy? CARDIOVASCULAR DISEASE AND HEMATOLOGIC DISORDERS IN PREGNANCY “Your body undergoes a lot of cardiovascular changes in drugs during pregnancy” RISK FACTORS FOR DEVELOPING HEART DISEASE DURING PREGNANCY INCLUDE: 1. Age 2. Multiple pregnancies 3. History of complications 4. Alcohol/drug abuse 5. Poor nutrition during/before pregnancy 6. High blood pressure Non-Modifiable cardiovascular risk factors :  age, sex, and genetic inheritance Modifiable cardiovascular risk factors:  lifestyle, such as obesity,cholesterol, tobacco, stress, HEART DISEASE AND PREGNANCY       Blood volume and cardiac output increase approximately by 30% (up to 50%). Half of this increase occurs by 8 weeks; it is maximized by mid pregnancy.   The most dangerous time for a patient is in weeks 28 to 32, just after the blood volume peaks. *  A patient’s heart may become so overwhelmed by the increase in blood volume toward the end of pregnancy that her cardiac output falls to the point that vital organs (including the placenta) are no longer perfused adequately. The World Health Organization (WHO) classification of cardiovascular diseases according to the maternal risk they pose TYPE 1 RISK- Mildest in relation to pregnancy, as they do not cause a detectable increased risk of maternal mortality or morbidity: 1. 2. 3. 4. 5. Pulmonary Stenosis Permeable ductus arteriosus Mitral Valve Prolapse Simple lesions repaired successfully Isolated atrial or ventricular extrasystoles Type II risk- Slightly increase risk of maternal mortality or moderate increase in morbidity: 1. Unexplained atrial or ventricular septal defect 2. Repair of tetralogy of fallot 3. Most of the arrythmias Complicates 1% to 4% of pregnancies Leading cause of pregnancy-related death May worsen with pregnancy Pregnancy symptoms may be more severe You will be closely monitored by your cardiologist, doctor, and OB-GYN THE IMPACT OF CD IN FETAL 1. Premature birth 2. Low birth weight 3. Respiratory distress 4. Fetal death 5. Neonatal death 6. Genetic heart disease Cardiac Changes in Pregnancy 1. 2. 3. 4. 5. BLOOD VOLUME- Increases between 30-50% Cardiac rhythm increases- 10-15 beats per minutes Increased blood volume Increased heart rate Increased cardiac output Decrease in peripheral resistances Decreased blood pressure Type 3 risk- More serious cardiovascular diseases with an increased risk of maternal mortality or serious morbidity, so medical advice is required before attempting a pregnancy. -If the woman decides to become pregnant, intensive cardiac and obstetric monitoring throughout gestation, delivery and puerperium will be necessary. 1. Mechanical valve prosthesis 2. Systemic right ventricle cases ( Atrial exchange, transposition of great vessels 3. Circulation of Fontan 4. Unrepaired cyanotic heart disease 5. Marfan syndrome with 40-45mm aortic dilation 6. Aortic pathology associated with bicuspid aortic valve with aortic dilatation of 45-50mm 7. Other complex congenital heart diseases, such as 8. hypertrophic cardiomyopathy, congenital valvular heart disease, etc. Type IV risk- Extremely high risk of maternal mortality or serious morbidity, so pregnancy is completely contraindicated. In the event that any of these women becomes pregnant, it would be advisable to assess a voluntary interruption of pregnancy or, if continued, to carry out strict monitoring. 1. Pulmonary Hypertension 2. Severe systemic ventricular dysfunction 3. Previous peripartum cardiomyopathy with any residual impairment of the left ventricle 4. Severe mitral stenosis 5. Severe symptomatic aortic stenosis 6. Marfan syndrome with >45mm aortic dilation 7. Aortic pathology associated with bicuspid aortic valve with aortic dilatation of >50mm 8. Coarctation of severe congenital aorta 9. Eisenmenger syndrome FOUR CATEGORIES based on criteria established by the New York State Heart Association : Class I or II heart disease: can expect to experience a normal pregnancy and birth. Class III: can complete a pregnancy by maintaining almost complete bed rest. Class IV: heart disease are poor candidates for pregnancy because they are in cardiac failure even at rest and when they are not pregnant. -They are usually advised to avoid pregnancy. III- Markedly compromised. During less than ordinary activity, patient experiences excessive fatigue, palpitations, dyspnea, or anginal pain. IV- Severely compromised. Patient is unable to carry out any physical activity without experiencing discomfort. Even at rest symptoms of cardiac insufficiency or anginal pain are present. Can I continue to take drugs for my cardiovascular disease in pregnancy?  Some medications have teratogenic effects for the fetus, so the medical specialist will have to assess the riskbenefit of each of the drugs for both the mother and the baby. Management  Before pregnancy: - detailed examination to determine whether she is suitable to pregnant access to counselling  - specialized  - multidisciplinary  - preconception • In order to empower them to make choices about pregnancy  CLASSIFICATION OF HEART DISEASE I- Uncompromised. Ordinary physical activity causes no discomfort. No symptoms of cardiac insufficiency and no anginal pain. II- Slightly compromised. Ordinary physical activity causes excessive fatigue, palpitation, and dyspnea or anginal pain. The main aims of management • To optimize the mother's condition during the pregnancy 1. - considering B-blockers 2. - Thromboprophylaxis 3. - pulmonary arterial vasodilators • To monitor for deterioration • Minimize any additional load on the cardiovascular system Pregnant women with CD 1. 2. 3. 4. Should be assessed clinically as soon as possible A multidisciplinary team and appropriate investigations undertaken The core members of the team should include: • Suitably experienced obstetricians 5. 6. 7. 8. 9. Cardiologists Anaesthetists Midwives Neonatologists Intensivists Management of gestation period  Regular prenatal care  Early prevention of heart failure - adequate rest - appropriate weight limit - treatment the motivation of heart failure: infection, anemia, PIH  The treatment of heart failure - as same as those who are not pregnant What screening tests will I have during pregnancy if I have cardiovascular disease? 1. Echocardiogram: This is a type of ultrasound in which the heart and its structures are observed. 2. Electrocardiogram-This is used to record the electrical activity of the heart What to Expect During an Echocardiogram 1. Gel is placed on chest 2. Transducer sends soundwaves through chest to heart 3. Sound waves bounce back from heart to transducer 4. Computerprocesses sound waves to make visual of beating heart LEFT SIDED HEART FAILURE VS. RIGHT SIDED HEART FAILURE LSDH 1. Paroxysmal Nocturnal Dyspnea E 2. Elevated Pulmonary Capillary Wedge Pressure 3. Pulmonary Congestion -Cough - Crackle - Wheezee -Blood-Tinged Sputum - Tachypnea 4. Restlessness 5. Confusion 6. Orthopnea 7. Tachycardia 8. Exertional Dyspnea 9. Fatigue 10. Cyanosis RSDH- (COR PULMONALE) 1. Fatigue 2. Increased PeripheralVenous Pressure 3. Ascites 4. Enlarged Liver & Spleen 5. May be secondary to chronic pulmonary problems 6. Distended Jugular Veins 7. Anorexia & Complaints of GI Distress 8. Weight Gain 9. Dependent Edema Cardiac disease: Left-sided Heart Failure  Left-sided heart failure happens when the left ventricle cannot shunt the blood forward that is received by the left atrium from the pulmonary circulation.  Failure mostly occurs at the level of the mitral valve.  When the mitral valve could not push the blood forward, it causes back pressure on thepulmonary circulation which results in pulmonary hypertension.  Pulmonary hypertension in pregnant patient could precipitate a high-risk pregnancy for  spontaneous miscarriage, preterm labor, or maternal death.  The placenta may not receive adequate blood because of the decreased peripheralcirculation.  The patient would have difficulty in sleeping due to the worsening pulmonary edema. MANAGEMENT  Advise the patient with left-sided heart failure to sleep with her chest and head elevated.  Heart action is more effective at rest, so the interstitial  fluid returns to the circulation and overburdens it,  distention and causing increased left-sided failure and pulmonary  increased portal circulation. edema.  Liver is enlarged, and this could cause extreme dyspnea When complications of left-sided failure occur, these and pain in a pregnant patient because the enlarged may result in impaired blood flow to the uterus, poor liver is pressed upward by the enlarged uterus, and placental perfusion, intrauterine growth restriction, extreme pressure is placed on the diaphragm. and fetal mortality.  Pressure is high in the vena cava, leading to jugular vein  Eisenmenger syndrome is the congenital anomaly that The patient needs to have a serial ultrasound and would most likely cause right-sided heart failure in nonstress tests on the 30th to 32nd week of her patient of reproductive age. pregnancy to monitor fetal health.  It is a right to left atrial or ventricular septal defect with pulmonary stenosis. What to Know About a Non-Stress Test  A prenatal non-stress test assesses fetal heart rate and movement    Patient with this anomaly are advised to avoid getting pregnant.  Oxygen administration and frequent assessment of the It provides useful information about the oxygen supply arterial blood gas is needed to ensure fetal growth once to the fetus the patient gets pregnant. The noninvasive procedure has no risk for the pregnant  hypotension after epidural anesthesia. person or child  It takes 20 to 30 minutes, but can take up to an hour  A nonreactive non-stress test indicates the fetus needs more monitoring and testin Ways to Reduce Risk of Developing Heart Failure Lifestyle factors 1. Regular physicalactivity 2. Healthy Weight 3. No Smoking 4. Healthy eating Medical conditions 1. Treat high blood pressure 2. Control diabetes 3. Maintain healthy cholesterol levels 4. Take heart protective medications as prescribed The nurse’s role during labor is to closely monitor for EISENMENGER SYNDROME PATHOPHYSIO • Systemic to pulmonary circulation connection • Left to right shunting of blood • Increased pulmonary blood flow • Irreversible pulmonary vascular injury • Irreversible pulmonary vascular resistance • Right to left shunting of blood • Hypoxia and erythrocytosis Rx: Heart-lung Congestive Heart Failure Nursing Diagnoses  Activity intolerance r/t fatigue secondary to cardiac insufficiency  Excess fluid volume r/t cardiac failure  Disturbed sleep pattern r/t nocturnal dyspnea  Impaired gas exchange r/t increased preload and afterload  Anxiety r/t dyspnea / fear of death  Knowledge deficit r/t disease process Cardiac disease: Right-sided Heart Failure  Right-sided heart failure happens when the output of the right ventricle is less than the blood volume received by the right atrium from the vena cava.  Back-pressure from this results in congestion of the systemic venous circulation and also decrease in cardiac output. Table 2: Initial Nursing Assessment in the Emergency Department.  objective measurement of dyspnoea severity: Respiratory rate, dyspnoea severity scale, tolerance of lying prone, effort of breathing, oxygen saturation  Haemodynamic status: Systolic and diastolic blood pressure monitoring  Heart rhythm: Heart rate and rhythm, 12-lead electrocardiogram  Cardiac output: Body temperature, peripheral perfusion, urine output, mental status   Clinical examination for signs of congestion: Pulmonary rales, peripheral oedema, jugular venous pressure   Laboratory blood tests: Full blood count, urea, creatinine, electrolytes, glucose, troponin, natriuretic peptide level  Patient already diagnosed with chronic hypertensive vascular disease already has an elevated blood pressure (140/90 mmHg and above) in pregnancy.  Both the mother and the fetus are compromised because of the poor placental perfusion which places the fetal well-being in jeopardy.  The primary care provider could prescribe beta-blockers and ACE inhibitors to decrease the blood pressure by peripheral dilation, but not to reduce it below the threshold that allows for good placental circulation. Anxiety levels: Using objective assessment tool 12 leads resting Electrode placement 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Chronic Hypertensive Vascular Disease RA right forearm or wrist LA- left forearm or wrist LL-left lower leg, proximal to ankle RL right lower leg, proximal to ankle V1-4-th intercostal space, right sternal edge V2-4-th intercostal space, left sternal edge V3 - midway between V2 and V4 V4-5-th intercostal space, mid-clavicular line V5 - anterior axillary line in straight line with V4 V6-mid-axillary line in straight line with V4 and V5 Beta Blocker Trick "LOL" A-N  Beta 1 Selective (Cardioselective) Atenolol, Metoprolol, Esmolol 0-Z  Beta 1 and Beta 2 (Non-selective) Propranolol, Timolol  Different than "olol" ending Alpha and Beta Blocker Labetalol, Carvedilol NURSING CONSIDERATIONS BETA-BLOCKERS ⚫ Teach patients that they shouldn't suddenly stop therapy because of the risk of rebound tachycardia and hypertension. ⚫ Beta blockers can cause transient increases in serum lipid and glucose levels.  Monitor for symptoms of hypoglycemia in patients with diabetes who use insulin.  Some older beta blockers such as propranolol can cause bronchoconstriction and asthma symptoms. ⚫ Check for common adverse effects of beta blockers, such as dizziness, slowing of the pulse, fatigue, and hypotension. Venous Thromboembolic Disease Venous thromboembolic disease happens more likely in pregnant patient because of the stasis of blood in the lower extremities due to uterine pressure and the effect of elevated estrogen on the hypercoagulability of the patient.  The triad of stasis, vessel damage, and hypercoagulation results in: thrombus formation in the lower extremities. NORMAL PREGNANCY INDICATORS OF ISCHEMIC HEART DISEASE MILD DYSPNEA SEVERE OR DYSPNEA FATUGUABILITY DECREASED TOLERANCE PROGRESS SYNOCOPE WITH EXERTION EXERCISE CHEST PAIN WITH EXERTION  ASSESSMENT OF A PATIENT WITH CARDIAC DISEASE Signs & symptoms of Cardiac Disease 1. 2. 3. 4. 5. 6. CHEST PAIN AT REST    Patient who are 30 years and older have an increased risk of developing deep vein thrombosis leading to pulmonary emboli.  Pain and redness in the calf of the leg usually signal thrombus formation.  Thrombus formation can be prevented by avoiding the use of constrictive knee-high stockings.  Advise the patient not to sit with her legs crossed at the knee and to avoid standing in one position for a long time.   A thrombus that occurred during pregnancy is diagnosed by Doppler ultrasonography and a patient’s history.  The patient will be placed on bed rest and intravenous heparin administration for 24 to 48 hours.   Patient who are taking heparin during pregnancy are not candidates for routine episiotomy or epidural anesthesia to prevent hemorrhage.  PTT determination should be continued during labor.  A breastfeeding patient cannot take heparin or Coumadin, or Coumadin should be used cautiously.     The main danger of thrombophlebitis is pulmonary embolism or a clot that lodges in the pulmonary artery, blocking the circulation to the lungs and heart. Symptoms of pulmonary embolism include chest pain, sudden onset of dyspnea, cough with hemoptysis, tachycardia, and severe dizziness or fainting. Pulmonary embolism is recognized as an immediate emergency. Fatigue Cough Tachycardia Increased respiratory rate Poor fetal heart tone (FHT) variability from poor tissue perfusion Decreased amniotic fluid from intrauterine growth restriction Normal and adverse cardiovascular clinical symptoms and signs during pregnancy Usual symptoms/ signs of pregnancy 1. Breathlessness on exertion 2. Intermittent palpitations 3. Mild fluid retention 4. Mildly elevated jugular venous 5. pressure 6. 3rd heart sound 7. Soft systolic murmur 8. Resting tachycardia Signs and symtoms suggestive of cardiac pathology 1. • Extreme breathlessness 2. • Chest pain 3. Orthopnoea, paroxysmal nocturnal dyspnoea, nocturnal cough 4. Tachycardia>100 bpm 5. 4th heart sound 6. • Harsh systolic or diastolicmurmurs 7. • Pulmonary oedema 8. • Pleural effusion 3. 4. 5. Educate regarding medications  Patient taking cardiac medication before pregnancy may need to increase their maintenance dose because of their expanded blood volume during pregnancy.  Educate regarding avoidance of infection A systemic infection almost automatically increases body temperature, causing a patient to have to expend more energy and increase her cardiac output as her metabolism increases, an insult that could be too extreme for a patient with heart disease to withstand. Be prepared for emergency actions  Patient with heart disease may need supplemental oxygen if they overexert as could happen during a prenatal visit. Nursing Interventions during labor & birth Nursing Interventions 1. Promote rest  A pregnant patient needs two rest period a day  Rest should be in the left lateral recumbent position to prevent supine hypotension syndrome and increased heart effort 2. Promote healthy nutrition  Must not gain so much weight that could overburden her heart andcirculatory system. 1. Advise a patient to assume a side-lying position to reduce the possibility of supine hypotension syn- drome. 2. Semi-fowlers position to ease the work of the breathing 3. Oxygen administered during labor to compensate for the added oxygen required because of the increased exertion needed for labor 4. If an epidural anesthetic is used, low forceps or a vacuum extractor can be used for birth.