Pre-gestational

Conditions
NRG 204
Pre-Gestational Conditions
Anatomy of the Heart
 Cardiac Disease
Cardiovascular Diseases complicates only
approximately 1% of all pregnancies
The 2 major categories are Rheumatic and
Congenital heart disease
Early prenatal care should be started for
monitoring
 Cardiovascular Disorders and Pregnancy
• Cardiovascular disease (even with hypertension included), which was once a
major threat to pregnancy, now complicates only approximately 1% of all
pregnancies.
• Cardiovascular disease is still a concern in pregnancy, however, because it can
lead to such serious complications. It is responsible for 5% of maternal
deaths during pregnancy (Cunningham, Leveno, Bloom, et al., 2014).
• The cardiovascular disorders that most commonly cause difficulty during
pregnancy are valve damage concerns caused by rheumatic fever or
Kawasaki disease and congenital anomalies such as atrial septal defect or
uncorrected coarctation of the aorta (Gordon, Jimenez-Fernandez,
Daniels, et al., 2014).
 Cardiovascular disease in Pregnancy
• Pregnancy taxes the circulatory system of every woman, even those without
cardiac disease, because both the blood volume and cardiac output increases
approximately 30% (and up to as much as 50%) during pregnancy. Half of
this increase occurs by 8 weeks; it is maximized by midpregnancy (Ayad,
Hassanein, Mohamed, et al., 2016).
• Because of the increased blood flow past valves, functional (innocent) or
transient murmurs can be heard in many women without heart disease
during pregnancy. Heart palpitations on sudden exertion are also usual.
 Cardiovascular disease
• The estimation of whether a woman with cardiovascular
disease can complete a pregnancy successfully depends on
the type and extent of her disease. As a rule, a woman
with an artificial but well-functioning heart valve, a
woman with a pacemaker implant, and even a woman who
has had a heart transplant can expect to have successful
pregnancies as long as they have effective prenatal and
postnatal care (Abdalla & Mancini, 2014).
Cardiac Class Type:
 Rheumatic Heart Disease
A condition in which permanent
damage to heart valves is caused by
rheumatic fever. The heart valve is
damaged by a disease process that
generally begins with a strep throat
caused by bacteria called
Streptococcus, and may eventually
cause rheumatic fever.
Rheumatic Heart Disease in Pregnancy
RHD is a chronic heart condition caused by rheumatic
fever.
Rheumatic fever is a systemic inflammatory disease
caused by a group A streptococcus (streptococcal)
infection.
• develops after infection with GAS, leads to production
of antibodies that affect the connective tissues.
 Rheumatic Heart Disease
The mitral valve is the most common site for
stenosis.
Mitral stenosis obstructs the free flow of blood
from the left atrium to the left ventricle, the left
atrium becomes dilated.
Pulmonary hypertension, Pulmonary edema or
Congestive heart failure can occur
 Diagnostic findings:

• Lab test: elevated white blood cells count, elevated ESR

• Throat culture: presence of GAS (group A streptococcus)
• echocardiography: valve damage & pericardial effusion
Symptoms:
> Pleuritic chest pain, dyspnea/tachypnea, cough(non-productive).
Congenital Heart Disease
Atrial Septal Defect
Ventricular Septal Defect
Patent Ductus Arteriosus
Atrial Septal Defect

• is a birth defect of the heart in which there is a hole in the wall

(septum) that divides the upper chambers (atria) of the heart.

• Pressure on the left side of the heart is higher than the right side
• Most women can tolerate pregnancy without any problems.
• The hole increases the amount of blood that flows through
the lungs. A large, long-standing atrial septal defect can
damage your heart and lungs.
 Atrial Septal Defect

• No specific treatment is recommended

• Complications like Pulmonary Hypertension
and Eisenmenger Syndrome can increase the
risk of pregnancy
 Ventricular Septal Defect
• is a birth defect of the heart in which there is a
hole in the wall (septum) that separates the two
lower chambers (ventricles) of the heart.
• Asymptomatic, but fatigue or symptoms of
pulmonary congestion occur occasionally
• Pregnancy is well tolerated with small to
moderate VSD
• The hole (defect) occurs in the wall (septum) that separates the heart's lower
chambers (ventricles) and allows blood to pass from the left to the right side of
the heart.
• The oxygen-rich blood then gets pumped back to the lungs instead of out to
the body, causing the heart to work harder.
 Ventricular Septal Defect

• Occasionally precipitates heart failure or

dysrhythmia
• Bacterial endocarditis is common with
unrepaired defects, antibacterial prophylaxis is
recommended.
 Patent Ductus Arteriosus
• is a persistent opening between the two major blood vessels leading from
the heart.
• The opening (ductus arteriosus) is a normal part of a baby's circulatory
system in the womb that usually closes shortly after birth. If it remains
open, it's called a patent ductus arteriosus.
• a large patent ductus arteriosus left untreated can allow poorly oxygenated
blood to flow in the wrong direction, weakening the heart muscle and
causing heart failure and other complications.
• The communicating shunt between the pulmonary artery and aorta is
usually treated in childhood
• Tends to become infected, so antibiotic prophylaxis is recommended
 Eisenmenger Syndrome

• A cyanotic heart condition that develops when pulmonary

resistance equals or exceeds systemic resistance to blood flow .
• Tissue hypoxia occurs as deoxygenated blood that should go to
the lungs is pushed into the systemic circulation.
 Eisenmenger Syndrome

• Operative closure is done ASAP, late

treatment often results to death
• If she survives delayed surgery, pregnancy
may carry 50% maternal mortality risk, usually
from right ventricular failure
 Pathophysiology

The underlying problem depends on the

location and severity of the defect.
Valvular Stenosis – decrease blood flow
through the valve, increasing the workload on
heart chambers located below stenotic valve
 Pathophysiology

Regurgitation – permits blood to leak

through an incompletely closed valve,
increasing the workload on the heart
chambers on either side of the affected valve
 Pathophysiology

The normal heart can compensate for

increased demands, but if myocardial or
valvular disease develops, or if the patient has
congenital heart defect, cardiac
decompensation may occur.
 Assessment Findings

Dyspnea
Tachycardia
Fatigue
Orthopnea
Edema of the hands, face,
and feet
 Assessment Findings
Palpitations
Diastolic murmur at the heart’s apex
Cough
Hemoptysis
Crackles at the bases of the Lungs
 Diagnostic Test
• Chest X-ray
• Electrocardiogram (ECG)- is a medical test that detects
cardiac (heart) abnormalities by measuring the electrical
activity generated by the heart as it contracts. The machine
that records the patient's ECG is called an
electrocardiograph.

• Echocardiogram - is a test that uses ultrasound to show how

your heart muscle and valves are working. The sound waves
make moving pictures of your heart so your doctor can get a
good look at its size and shape.
 Drug Therapy

• Aside from Iron and

Vitamins additional
Drugs are necessary
• Antibiotics, usually
penicillin if not
contraindicated by
allergy
 Drug Therapy

• Heparin if woman develops coagulation

problems
• Thiazide Diuretics and Furosemide (Lasix)
may be used to treat Congestive Heart Failure
 Management:

• Activity Limitation
• Close Medical Supervision with more frequent prenatal visits and
adjustments in pre-pregnancy drug therapy
• Rest
 Management:

• Limit Sodium Intake

• Prophylactic Antibiotics
• Serial Ultrasounds, Non Stress Tests, and
Biophysical Profile to evaluate the fetal status
 Labor and Delivery

Spontaneous natural Labor with adequate

Pain Relief for Class I and II types will be the
best choice with special attention to be given
to prompt recognition and treatment of any
signs of heart failure.
 Labor and Delivery
Use of low forceps or a vacuum
extractor provides safest method of
birth with lumbar epidural anesthesia
to reduce the stress of pushing.
Cesarean birth is used only if fetal or
maternal indications exist, not on the
basis of heart disease alone
Forceps and Vacuum Extraction Delivery
 Nursing Interventions
Assess maternal vital
signs and cardiopulmonary
status for changes
Monitor weight gain
throughout pregnancy
Reinforce use of
prescribed medications to
control heart disease
Reinforce the need for
frequent prenatal visits and
assist follow up testing
 Nursing Interventions

Anticipate the need for increased

doses of maintenance medications
Assess nutritional pattern- meal plans
Encourage frequent rest periods
throughout the day
 Nursing Interventions

Report any signs and symptoms of infection

such as URTI, UTI to prevent overtaxing of the
heart
Advise the woman to rest in side lying position
to prevent supine hypotension syndrome
 Nursing Interventions
• Prepare the woman for labor
anticipating the use of epidural
anesthesia
• Monitor fetal heart rate, uterine
contractions and maternal vital signs
 Nursing Interventions

• Assess vital signs closely after delivery

• Encourage ambulation as ordered, as soon as
possible after delivery
A Woman With Left-Sided Heart Failure
• Left-sided heart failure occurs in conditions such as mitral stenosis, mitral
insufficiency, and aortic coarctation.
• Left ventricle cannot move the large volume of blood forward that it has received
by the left atrium from the pulmonary circulation. This causes back pressure—the
left side of the heart becomes distended, systemic blood pressure decreases in the
face of lowered cardiac output, and pulmonary hypertension occurs.
• Pulmonary edema produces profound shortness of breath as it interferes with
oxygen–carbon dioxide exchange (Brashers & Huether, 2017).
A Woman With Left-Sided Heart Failure
• If pulmonary capillaries rupture under the pressure, small amounts of blood leak
into the alveoli and the woman develops a productive cough with blood-speckled
sputum.
• Because of the limited oxygen exchange, a woman with left-sided heart failure is at
an extremely high risk for spontaneous miscarriage, preterm labor, or even maternal
death.
• As pulmonary edema becomes severe, a woman cannot sleep in any position except
with her chest and head elevated (orthopnea), as elevating her chest this way allows
fluid to settle to the bottom of her lungs and frees space for gas exchange.
A Woman With Left-Sided Heart Failure
• She may also notice paroxysmal nocturnal dyspnea—suddenly waking at
night with shortness of breath. This occurs because heart action is more
effective when she is at rest.
• With the more effective heart action, interstitial fluid returns to the
circulation. This overburdens her circulation, causing increased left-side
failure and increased pulmonary edema.
Management:
• To prevent thrombus formation, a woman may be prescribed an anticoagulant. If
an anticoagulant is required, low–molecular-weight heparin is the drug of choice
for early pregnancy because it does not cross the placenta and so does not have
teratogenic effects.
• To decrease the strain on the aorta, antihypertensives may be prescribed to control
blood pressure, diuretics to reduce blood volume, and β-blockers to improve
ventricular filling.
• A woman will be scheduled for serial ultrasound and nonstress tests after weeks
30 to 32 of pregnancy to monitor fetal health and to rule out poor placental
perfusion (Dennis, 2016).
A Woman With Right-Sided Heart Failure

• Right-sided heart failure occurs when the right ventricle is overwhelmed by

the amount of blood received by the right atrium from the vena cava.
• It can be caused by an unrepaired congenital heart defect such as pulmonary
valve stenosis, but the anomaly most apt to cause right-sided heart failure in
women of reproductive age is Eisenmenger syndrome, a right-to-left atrial or
ventricular septal defect with an accompanying pulmonary valve stenosis
(Bhatt & DeFaria Yeh, 2015).
A Woman With Right-Sided Heart Failure
• Congestion of the systemic venous circulation and decreased cardiac output to the
lungs occurs.
• Blood pressure decreases in the aorta because less blood is able to reach it; in
contrast, pressure is high in the vena cava from back pressure of blood.
• Both jugular venous distention and increased portal circulation are evident. The liver
and spleen both become distended. Extreme liver enlargement can cause dyspnea
and pain in a pregnant woman because the enlarged liver, as it is pressed upward by
the enlarged uterus, puts extreme pressure on the diaphragm.
• Distention of abdominal and lower extremity vessels can lead to exudate of fluid
from the vessels into the peritoneal cavity (i.e., ascites) or peripheral edema.
A Woman With Right-Sided Heart Failure
Management:
• uncorrected anomaly of this type may be advised not to become pregnant.
• Plan a pregnancy: need oxygen administration and frequent arterial blood gas
assessments to ensure fetal growth, expect to be hospitalized for at least some days
during the last part of pregnancy.
• During labor: may need a pulmonary artery catheter inserted to monitor pulmonary
pressure.
• Women with this condition also need extremely close monitoring after epidural
anesthesia to minimize the risk of hypotension.
Related Interventions
• Promote Rest - women with cardiac disease need two rest periods a day, a
full night’s sleep (not tossing and turning) to obtain adequate rest. Rest
should be in the left lateral recumbent position to prevent supine
hypotension syndrome and increased heart effort.
• Women should plan activities so they stop exercising before the point when
cardiac output becomes insufficient to meet systemic body demands causing
peripheral and uterine/placental constriction. Be certain they know exactly
how much they should limit their exercise.
Related Interventions
• Promote Healthy Nutrition – A woman with cardiac disease may need closer supervision
of nutrition during pregnancy than the average woman because she must gain enough
weight to ensure a healthy pregnancy and a healthy baby, but she must not gain so much
weight that her heart and circulatory system become overburdened.
• take her prenatal vitamins (iron supplement –anemia). Anemia is important to prevent
because it places an extra burden on the heart because her circulatory system must circulate
blood more vigorously than usual to distribute oxygen to all body cells.
• a woman’s sodium intake is only limited, not severely restricted, during pregnancy because
it’s important to obtain enough sodium to maintain fluid volume and balance as well as
furnish an adequate supply of blood to the fetus.
Related Interventions
• Educate Regarding Medication
• Women taking cardiac medication, such as digoxin, before pregnancy may
need to increase their maintenance dose because of their expanded blood
volume during pregnancy.
• Digoxin also has a unique use during pregnancy as it can be administered to
the woman to slow the fetal heart if fetal tachycardia is present.
• Antihypertensive and arrhythmia agents such as adenosine,
βblockers, and calcium channel blockers to reduce hypertension are
safe to use during pregnancy and are also frequently prescribed.
Nitroglycerin, a compound often prescribed for angina, although not well
studied during pregnancy (a category C drug), is also considered safe (Karch,
2015).
Related Interventions
• Educate Regarding Medication
• A woman who was taking penicillin prophylactically because she had rheumatic fever as a
child (which is often taken for 10 years after the occurrence of rheumatic fever, or at least
until age 18 years) should continue to take this drug during pregnancy because penicillin is
not known to be a teratogen (a category B drug).
• additional course of ampicillin, amoxicillin (Amoxil), or clindamycin (Cleocin) to
prevent streptococci bacteria from invading the denuded placental site on the uterus and
creating a subacute bacterial endocarditis.
• Help women with heart disease to understand there are valid exceptions to the rule of “no
medicine during pregnancy” so they make out reminders to adhere to their prescribed
regimen.
Related Interventions
• Educate Regarding Avoidance of Infection.
• A systemic infection almost automatically increases body temperature, forcing a woman to
expend more energy and increase her cardiac output as her metabolism increases, an effect
that could be too extreme for a woman with heart disease to withstand.
• Caution women with heart disease, therefore, to avoid visiting or being visited by people
with infections and to alert healthcare personnel at the first indication of an upper
respiratory tract infection or urinary tract infection (UTI) so that, if warranted, antibiotic
therapy can begin early in the course of the infection.
• Monthly screening for bacteriuria with a clean-catch urine test at prenatal visits should help
detect UTIs.
Related Interventions
• Be Prepared for Emergency Actions.
• If women with heart disease overexert during a prenatal visit, they may need
supplemental oxygen or cardiac resuscitation.
Substance Abuse
• Refers to the inability to meet
major role obligations, legal
problems, or an increase in risk
taking behavior or exposure to
hazardous situations because of
addicting substance.
Substance Abuse
• Recreational drugs
commonly abused in
pregnancy are Cocaine,
amphetamines,
marijuana,
phencyclidine
inhalants, opiates and
alcohol.
 Pathophysiology
Substance abuse leads to
fetal harm
It is most detrimental when
used during the first trimester
when fetal organs are being
formed, causes fetal
malformation and preterm
birth
The fetus has 50% drug
concentration that of the
mother
Assessment Findings:
• Most pregnant woman
who abuse substances
don’t seek prenatal care
• Substance abuse may be
compounded by
malnutrition, sexually
transmitted diseases or
poor self image
 Management
• Therapy depends on
substance being used
• Long term counseling
and rehabilitation
(social, mental,
psychiatric, and
vocational) is necessary
 Nursing Intervention:

• Encourage participation in the active treatment

program
• Monitor the woman closely as possible during
pregnancy for adequate progression, fetal growth
and development, and signs and symptoms of
complications
 Nursing Intervention:

• Provide the patient with support and

guidance
• Assist with measures to obtain necessary
support services, such as adequate nutrition
and housing