CARDIOVASCULAR

DISORDERS AND
PREGNANCY
• Heart disease that occurs specifically with
pregnancy (peripartum heart disease) still rarely
occurs.
• Needs a team approach to care during pregnancy,
combining internist, obstetrician and nurse.
• Should begin prenatal care as soon as she suspect
she is pregnant (1 week after the 1st missed
menstrual period) so that her general condition
can be monitored. *
 LEFT SIDED HEART FAILURE

• Occurs in mitral stenosis,

mitral insufficiency and
aortic coarctation.
• The left ventricle cannot
move the volume of blood
forward that is received by
the left atrium from the
pulmonary circulation.*
• Women with pulmonary hypertension are at an extremely
high risk for spontaneous miscarriage, preterm labor
and maternal death during pregnancy.
• Pulmonary edema becomes severe ,woman cannot sleep in
any position except with her chest and head elevated
(orthopnea).
• She may also experience paroxysmal nocturnal dyspnea-
suddenly waking at night short of breath.
May experience:
 Fatigue
 Weakness
 Dizziness
 Placenta (inadequate blood)
 MANAGEMENT
• Prevent thrombus- anticoagulant (heparin- does
not cross placenta)
• Decrease strain in aorta- antihypertensives
• Diuretics- reduce blood volume (b-blockers)-
improve ventricular filling
• Serial UTZ and nostress test- 30-32 weeks
 RIGHT SIDED HEART FAILURE
• Right ventricle is overwhelmed
by the amount of blood
received by the right atrium
from the vena cava.
• Backpressure from this results
in congestion of the systemic
venous circulation and
decreased cardiac output to the
lungs.
• BP decreases in aorta because
less blood is reaching it,
increase BP in vena cava
Jugular venous distention and increased portal
circulation
Liver and spleen become distended
Liver enlargement can cause extreme pain and dyspnea
in pregnant women it pressed upward by the enlarged
uterus puts extreme pressure in the diaphragm.
Distention of abdominal vessels can lead to exudates
of fluid from vessels into peritoneal cavity ( ascites).
Fluid also moves from systemic circulation into lower
extremity interstitial spaces ( peripheral edema)
Eisenmenger syndrome: right to left atrial or
ventricular septal defect with an accompanying
pulmonary stenosis . Apt to cause right sided heart
failure in women in reproductive age.
• Woman are advised not to get pregnant
• Oxygen, frequent ABG assessment to ensure fetal growth
• Expect hospitalization
• Labor- pulmonary artery catheter, extreme close monitoring after
epidural anesthesia to minimize hypotension
 PERIPARTUM HEART DISEASE

• Peripartal cardiomyopathy- extremely rare condition.

• Originate late in pregnancy with no previous history of heart disease. (5
months postpartum)
• Unknown cause but apparently due to effect of pregnancy on the
circulatory system.
• Occurs often in African- American multiparas in conjuction with
Hypertension of pregnancy.
• Late in pregnancy may develop signs of Myocardial failure: shortness of
breath, chest pain and edema,
• Heart begins to increase in size ( cardiomegaly)- must reduce physical
activity
• Diuretic and digitalis therapy to maintain heart action.
• Low dose heparin may administered-reduced thromboembolism.
• Immunossupresive therapy may improve symptoms.
• Suggested woman may not attempt any further pregnancies because of
recurrence.
• Oral contraceptives are contraindicated because of thromboembolism.
(DVT)
 ASSESSMENT
• Continuous assessment, health education and health promotion are
essential.
• Ask level of exercise , ask about cough, edema.
• Always report coughing during pregnancy (pulmonary edema)
• Normal edema (innocent) must be distinguished from the beginning of
pregnancy-induced hypertension (serious) or edema of heart failure
( serious)
• Normal edema- feet, ankles
• PIH- edema begins after 20 weeks
• Heart failure- begin any time with irregular pulse, rapid, difficult
respiration in sitting/lying position at first prenatal visit.
• At future visit, take the same position for most accurate comparison.
• Comparison: assessment for nail bed filling( less than 5 seconds) and
jugular venous distention
• Right sided heart failure: assessment of liver size is helpful. (more
difficult and probably in accurate) enlarged uterus presses liver upward.
• ECG, CXRAY, echocardiogram
• May use lead apron in xray.
• ECG is less accurate in late pregnancy ( left axis deviation) displaces
heart laterally.
 FETAL ASSESSMENT
• Maternal blood pressure becomes insufficient to provide an
adequate supply of blood and nutrient to the placenta.
• Low birthweights – not enough nutrients, poor perfusion-
acidotic fetal environment ( carbon dioxide exchange)
• Pre-term labor, late deceleration patterns
• Late deceleration patterns on a fetal monitor if cardiac
decompensation has reached a point of placental incompetency.

• Monitor clients BP, pulse, fetal heart rate and uterine

contractions by continuous monitor. Determine if abdominal or
uterine ( placenta) bleeding is present.
• Increased fetal heart rate (tachycardia) is a sign of possible fetal
distress.
• Uterine contractions could mark the beginning of preterm
labor.
 PROMOTE REST
• Promote healthy nutrition.
• Gain enough weight. Prenatal vitamins and Iron supplement to help
prevent anemia.
• Educate regarding medications.
• Educate regarding avoidance of infection.
• Avoid being visited by people with infections, URTI and avoidance of
UTI. Monthly screening for bacteriuria. (clean catch urine) is
recommended.
 NURSING INTERVENTIONS
DURING LABOR AND BIRTH
• Anesthetic of choice during labor is EPIDURAL.
(less taxing)
• should not push with contractions
• Monitor fetal heart rate and uterine contractions
during labor.
• Assess BP, PR and RR frequently.
• If epidural
anesthetic is used,
low forceps or
vacuum extractor
can be used for
birth.
• A rapidly increase heart rate ( more than 100 bpm)
is an indication that a heart is pumping
ineffectively and increased its effort to compensate.
• Advise a woman to assume a side lying position to reduce
possibility of supine hypotension syndrome.
• If with pulmonary edema: have chest, head elevated (semi-
fowlers position- to ease work of breathing.
• Fatigue is a symptom of heart decompensation. - evaluate
the client carefully to determine whether the fatigue is heart
or labor related.
 POST PARTUM INTERVENTIONS
• The period immediately after birth maybe a critical time for a woman
with heart disease.
• With the delivery of placenta, that blood that supplied the placenta is
now released into general circulation, increasing blood volume into 20
to 40%.
• During pregnancy, the increase in blood volume occurred over a 6
month period, so the heart had time to adjust to this change gradually.
After birth, the increase in pressure takes place within 5 minutes, so the
heart must make a rapid and major adjustment
 MANAGEMENT

• decreased activity, possible anticoagulant and digoxin therapy until

circulation stabilizes.
• Antiembolic stockings and ambulation maybe needed to increase
venous return from the legs.
• prophylactic antibiotics -started immediately after birth to
discouraged subacute bacterial endocarditis caused by introduction of
microorganisms through the placental site.
• Point out acrocyanosis is normal in newborn.
• Oxytocin must be used with caution (postpartum) they tend
to increase BP.
• Can be breastfed without difficulty.
• Kegels exercise for perineal strengthening
• Stool softener to prevent straining with BM.
• Before discharge ascertain what help she needs so that she
can continue rest at home.
• Ensure schedule of return appointment both in gynecologic
health and her cardiac status.
ARTIFICIAL VALVE
PROSTHESIS
• Advised not to become pregnant
• One potential problem involve
use of oral anticoagulant to
prevent formation of clots at the
valve site.
• This medication may increase
the risk of congenital anomalies
in infants, woman are usually
placed on heparin therapy
before becoming pregnant to
reduce this risk.
• Heparin does not cross placenta and does not
interfere with fetal development or fetal
coagulation.
• Observe for bleeding/premature separation of the
placenta during pregnancy and labor.
CHRONIC HYPERTENSIVE VASCULAR
DISEASE

• Elevated BP (140/90) or above.

• Usually associated with arteriosclerosis or renal disease, making it a
problem for older pregnant women.
• Compromised by poor placental perfusion during pregnancy .
• Management is the same with PIH.
 THROMBOEMBOLIC DISEASE

• Stasis of blood in lower extremity

from uterine pressure and
hypercoagulability.(increased
estrogen)
• Stasis, vessel damage,
hypercoagulation.
• Thrombus formation on lower
extremites. Deep Vein Thrombosis-
DVT
• Pulmonary emboli
• A woman notice pain, redness in
the calf of the legs.
Can be prevented through:
 avoid constrictive high knee
stockings
 not sitting with leg crossed
 avoid standing in one position for
long period
 Treatment:
bedrest and IV heparin for 24 to 48 hours
 SQ Heparin every 12 to 24 hours for the duration of
pregnancy.
Symptoms of pulmonary embolism:
chest pain, sudden onset of dyspnea, cough with
hemoptysis, tachycardia/ missed beats , severe dizziness or
fainting from lowered BP.
PRACTICE QUESTIONS!
The nurse is caring for a woman with mitral stenosis who
is in the active stage. Which action should the nurse take
to promote cardiac function?

A. Maintain the woman in a side-lying position with the head

and shoulders elevated to facilitate hemodynamics
B. Prepare the woman for delivery by cesarean section since
this is the recommended delivery method to sustain
hemodynamics
C. Encourage the woman to avoid the use of narcotics or
epidural regional analgesia since this alters cardiac function
D. Promote the use of the Valsalva maneuver during pushing
in the second stage to improve diastolic ventricular filling
A. Maintain the woman in a side-lying position with the head and
shoulders elevated to facilitate hemodynamics

The side-lying position with the head and shoulders elevated helps to
facilitate hemodynamics during labor. A vaginal delivery is the preferred
method of delivery for a woman with cardiac disease as it sustains
hemodynamics better than a cesarean section. The use of supportive care,
medication, and narcotics or epidural regional analgesia is not
contraindicated with a woman with heart disease. The use of the Valsalva
maneuver during pushing in the second stage should be avoided because
it reduces diastolic ventricular filling and obstructs left ventricular
outflow.
• During a physical assessment of an at-risk client, the
nurse notes generalized edema, crackles at the base of
the lungs, and some pulse irregularity. These are most
likely signs of:

A. euglycemia.
B. rheumatic fever.
C. pneumonia.
D. cardiac decompensation.
• D. cardiac decompensation.

Euglycemia is a condition of normal glucose levels. These symptoms

indicate cardiac decompensation. Rheumatic fever can cause heart
problems, but it does not present with these symptoms, which indicate
cardiac decompensation. Pneumonia is an inflammation of the lungs
and would not likely generate these symptoms, which indicate cardiac
decompensation. Symptoms of cardiac decompensation may appear
abruptly or gradually.
• A pregnant woman with cardiac disease is informed about
signs of cardiac decompensation. She should be told that
the earliest sign of decompensation is most often:

• A. orthopnea.
• B. decreasing energy levels.
• C. moist frequent cough and frothy sputum.
• D. crackles (rales) at the bases of the lungs on auscultation.
• B. decreasing energy levels.

• Orthopnea is a finding that appears later when a failing heart reduces renal
perfusion and fluid accumulates in the pulmonary interstitial space, leading to
pulmonary edema. Decreasing energy level (fatigue) is an early finding of heart
failure. Care must be taken to recognize it as a warning rather than a typical
change of the third trimester. Cardiac decompensation is most likely to occur
early in the third trimester, during childbirth, and during the first 48 hours
following birth. A moist, frequent cough appears later when a failing heart
reduces renal perfusion and fluid accumulates in the pulmonary interstitial
space, leading to pulmonary edema. Crackles and rales appear later when a
failing heart reduces renal perfusion and fluid accumulates in the pulmonary
interstitial space, leading to pulmonary edema.
• 1. Which of the following physiologic changes are expected during
pregnancy?
• a. decreased plasma volume.
• b. deceased minute ventilation
• c. increase in fibrinogen
• d. increase in glucose utilization.
• C. There is an increase in plasma volume without a proportional
increase in red call mass causing the classic dilutional anemia
associated with pregnancy. There is an increased minute ventilation due
to prostaglandin mediated increase in respiratory drive. There is
decrease in glucose utilization and increased lipolysis leading to
hyperglycemia. There is an increase in fibrinogen as well as factors VII,
VIII, IX, and X adding to stasis in causing a hypercoaguable state.
• Thromboembolic disease in pregnancy
• a. is caused by a combination of increased venous capacitance, venous
stasis by uterine compression and hypercoaguable state due to
increased factors and relative or absolute decreased in proteins C & S.
• b. is treated in the standard way with heparin, followed by coumadin.
• c. should prompt evaluation with d-dimers when suspected.
• d. is a contraindication to thrombolysis.
• A. Treatment is with heparin as it does not cross the placenta; coumadin
is contraindicated because it crosses placenta and is teratogenic. Work-
up is same as non-pregnant, however D-dimers are not useful.
Thrombolysis can be used for massive PE with hemodynamic
compromise. Pathogenesis: Venous stasis - progesterone increased
venous capacitance and caval obstruction by the uterus.
Hypercoaguable - Increase in coagulation factors I, II, VII, VIII, X;
decrease in coagulation inhibition by decrease protein S and increased
resistance to protein C, impaired fibrinolysis and activation of platelets.