Cardiac Disorders and Pregnancy Outcomes

Medical Conditions Affecting Pregnancy Outcomes: Pregestational Conditions

• Cardiac physiology changes induced by pregnancy can profoundly affect underlying heart disease.
• Cardiac output rises by ~40% during pregnancy, occurring by 8 weeks gestation and peaking in mid-pregnancy.
• This early rise comes from augmented stroke volume, due to lowered vascular resistance.
• Pregnancy hypervolemia increases end-diastolic ventricular volume, leading to elevated resting pulse and stroke volume.
• Normal left ventricular function is maintained during pregnancy.
• Pregnancy lacks hyperdynamic function or a high cardiac output state.

Cardiac Disorders

• Includes a number of congenital and acquired heart diseases/defects.
• Better care, screening, and surgical correction of defects mean more pregnant women with heart disease are identified.
• Pregnancy alters heart rate, blood pressure, and cardiac output.
• Incidence is 0.5%-2% of all pregnancies.
• Predisposing factors include syphilis, arteriosclerosis, lung/kidney disease, rheumatic fever, congenital defects, surgical repair of defects.

Prognosis Factors

• Functional capacity of the heart.
• Complications increasing cardiac load.
• Quality of healthcare provided.
• Maternal and fetal risk (increases from Classes 1 to 4; Classes 3 and 4 have serious problems).

Functional Heart Disease Classification (NYHA)

• Class I: Uncompromised, no activity limitation, no cardiac insufficiency symptoms or anginal pain.
• Class II: Slight activity limitation, comfortable at rest, discomfort with ordinary activity.
• Class III: Marked activity limitation, comfortable at rest, less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain.
• Class IV: Severely compromised, inability to perform any activity; cardiac insufficiency or angina symptoms even at rest.

WHO Classification of Maternal Cardiovascular Risk

• Class I: No detectable increase of maternal mortality and no/mild increase in morbidity.
• Class II: Small increased risk of maternal mortality or moderate increase in morbidity.
• Class III: Significantly increased risk of maternal mortality or severe morbidity; expert counseling and intensive monitoring are needed through pregnancy, childbirth, and the puerperium if pregnancy is decided upon.
• Class IV: Extremely high risk of maternal mortality or severe morbidity; pregnancy contraindicated; if pregnancy occurs, termination should be discussed as care as for class III.
• The danger of pregnancy in a woman with cardiac disease primarily comes about from increases in circulatory volume.
• The riskiest period for a woman is weeks 28 to 32, following peak blood volume
• If heart disease is severe, symptoms can manifest beginning in pregnancy
• Ventricular volumes and mass increase in pregnancy to accommodate hypervolemia.
• All adaptations return within months postpartum.

Diagnosis of Heart Disease

• Symptoms include progressive dyspnea, orthopnea, nocturnal cough, hemoptysis, syncope, chest pain.
• Signs include cyanosis, clubbing of fingers, persistent neck vein distention, systolic murmur grade 3/6 or greater, diastolic murmur.
• Additional signs are cardiomegaly, persistent tachycardia/arrhythmia, persistent split-second sound, fourth heart sound, pulmonary hypertension.

Systolic Murmur Grading

• Grade I indicates very faint, only heard by an expert, not heard in all positions, no thrill.
• Grade II Indicates soft, heard in all positions, no thrill.
• Grade III indicates a moderately loud, no thrill.
• Grade IV Indicates loud, and associated with a palpable thrill.
• Grade V indicates a very loud, with thrill, heard with the stethoscope partly off the chest.
• Grade VI indicates more loud with thrill, heard with the stethoscope entirely off the chest (just above the precordium, not touching the skin)

Labor and Delivery

• Vaginal delivery is preferred, and labor induction is usually safe.
• Cesarean recommended for dilated aortic root (>4 cm) or aortic aneurysm, acute congestive heart failure, recent myocardial infarction, symptomatic aortic stenosis.
• Further C-section recommendations include warfarin use within 2 weeks of delivery, or emergency valve replacement immediately after delivery.
• During labor, the mother should be in a semi-recumbent position with lateral tilt.
• PR >100 bpm and RR >24 bpm + dyspnea might indicate ventricular failure.
• Delivery might not improve the maternal condition.
• Emergency cesarean delivery can be particularly hazardous.

Analgesia and Anesthesia

• Pain and apprehension relief is important; continuous epidural analgesia is recommended.
• Maternal hypotension is a major problem.
• Narcotics regional analgesia or general is preferable
• Subarachnoid blockade (spinal anesthesia) not recommended due to hypotension.
• Epidural analgesia is favored for cesarean delivery (spinal anesthesia may cause respiratory depression).

Recommendations for Anticoagulation

• Discontinue heparin just before delivery.
• Protamine sulfate is given intravenously if extensive bleeding occurs during heparin administration.
• Warfarin/heparin anticoagulant therapy may be restarted 6 hours after vaginal delivery if there are no complications.
• ACOG (2017) advises resuming unfractionated or low-molecular-weight heparin 6 - 12 hours after cesarean.
• These anticoagulants are compatible with breastfeeding.

Prognosis

• Pregnancy is contraindicated with severe disease, especially pulmonary arterial changes.
• Prognosis is better with milder disease from other causes, and pregnancy is tolerated reasonably well.
• Right heart failure and death is the final common pathway of pulmonary hypertension, regardless of etiology.
• Average survival after diagnosis is <4 years.

Management

• Treatment for symptomatic pregnant women includes activity limitation, avoiding the supine position, diuretics, supplemental oxygen, and pulmonary vasodilator drugs.
• Some experts recommend anticoagulation -- Heparin, the drug of choice, does not cross the placenta.
• Relief from pain and apprehension is important.
• The risks increase during labor & delivery with diminished venous return and right ventricular filling.
• Assiduous attention given to epidural analgesia and blood loss to avoid hypotension.

Maternal and Fetal Assessment

• Continuous assessment needed for health status, health education, and health promotion activities.
• Assess respiratory rate (sitting or lying position), nail bed filling, jugular venous distention, liver size, ECG, chest x-ray (with abdominal protection), and echocardiogram.
• Cardiac failure affects fetal growth if maternal blood pressure cannot provide nutrients to the placenta.
• Possible outcomes are low birth weights and preterm labor due to acidotic fetal environment.
• C-section delivery may be needed if cardiac decompensation causes placental incompetency.

Nursing Diagnoses and Interventions

• Nursing Diagnosis: Deficient knowledge regarding steps to reduce the effects of maternal cardiovascular disease on the pregnancy and fetus
• Outcome Evaluation: Client identifies danger signs and steps to take when they occur; maternal blood pressure is maintained above 100/60 mm Hg and fetal heart rate at 120 to 160 beats per minute. Set realistic goals and outcomes. Considerations should be given to note that not all women with heart disease will be able to complete pregnancy successfully; infants of severely affected women may be born with the effects of placental insufficiency, such as neurologic involvement or cognitive challenge.

Nursing Considerations

• Promote Rest. need two rest periods a day (fully resting and a full night's sleep) to obtain adequate rest. Should be in the left lateral recumbent position to prevent supine hypotension syndrome and increased heart effort.
• Promote Healthy Nutrition. Close supervision of nutrition- must gain enough weight to ensure a healthy pregnancy and a healthy baby, but must not gain so much weight that could overburden the heart. Avoid anemia, too much sodium intake.
• Educate Regarding Medication. Take medication as prescribed and avoid OTC drug
• Educate Regarding Avoidance of Infection. To avoid visiting or being visited by people with infections. Advise to continue frequent follow up visit to HC privider
• Be Prepared for Emergency Actions. Prepare for any adverse events

Nursing Interventions During Labor and Birth

• Constant monitoring of fetal heart rate and contraction.
• Assume side-lying position to prevent supine hypotension syndrome.
• Semi-Fowler's position to ease breathing is acceptable during pulmonary edema.
• Check for signs of fatigue, as symptom of heart decompensation.
• Administer oxygen.
• Avoid pushing; consider forceps, vacuum delivery, or CS.
• Epidural anesthesia is recommended to avoid respiratory depression.

Postpartum Nursing Interventions

• Monitor vitals, especially heart rate.
• Bed rest is appropriate for CHF.
• Provide anti-embolic stocking.
• Administer Rx antibiotic.
• Breast feeding aids uterine involution, but take caution with Pitocin (increases HR).
• Prevent straining with stool softener.

Pregestational Diabetes (Definition and Incidence)

• Also called preexisting diabetes.
• Condition when a person has diabetes (typically Type 1 or 2) before pregnancy.
• Incidence: 1-2% of all pregnancies; one in nine women.

Predisposing Factors

• Obesity
• Age over 25 years
• History of large babies (10 lb or more)
• History of unexplained fetal or perinatal loss
• History of congenital anomalies in previous pregnancies
• History of polycystic ovary syndrome
• Family history of diabetes (one close relative or two distant ones)
• Being of Native American, Hispanic, or Asian descent

Effects of Diabetes on the Mother

• Common occurrence of uteroplacental insufficiency.
• Increased incidence of dystocia
• Higher susceptibility to infections
• Insulin resistance progressively increases from hormones released by the placenta, such as human placental lactogen, cortisol, estrogen, progesterone, and catecholamines.
• Unstable blood glucose levels.
• Insulin shock is common.

Types of Diabetes

• Gestational Diabetes: Onset during pregnancy, due to insulin resistance and impaired glucose metabolism, is managed by diet, exercise, and medication in some cases.
• Type 1 Diabetes Mellitus: Onset before pregnancy, caused by autoimmune destruction of insulin-producing pancreas cells.
• Managed via insulin, blood glucose and carbohydrate monitoring, and exercise.
• Type 2 Diabetes Mellitus: Onset before pregnancy, caused by lifestyle and genetics; managed with oral meds and insulin, plus diet and exercise.

Diabetes Risk Factors

• Ethnicity
• Family history, especially Type 1
• Obesity
• Smoking during pregnancy
• Western diet
• Excess weight gain during pregnancy
• High BMI
• Multiparity
• Maternal age >35
• Personal history of previous GDM
• polycystic ovary syndrome or metabolic syndrome

Diabetes Maternal Consequences

• Glycosuria during the second or third trimester
• Gestational hypertension
• Cardiovascular disease
• Preterm delivery
• Perineal industry
• Postpartum hemorrhage
• Prolonged hospitalization

Diabetes Fetal Consequences Short term

• Macrosomia
• Low Apgar score
• Shoulder dystocia
• Brachial plexus injury
• Birth injuries
• Respiratory distress
• Neonatal hypoglycemia
• Neonatal ICU Admission
• Perinatal mortality
• Hyperbilirubinemia

Diabetes Fetal Consequences Long Term

• Increased adiposity/obesity
• Type 1 or 2 Diabetes
• Metabolic syndrome
• Increased cardiometabolic risk
• Various cancers (breast, colorectal, ovarian, etc.)

Diabetes Management Obstetrics

• Nuchal Translucency Scan
• Detailed Ultrasound (US) for fetal anomalies
• Fetal Echocardiography
• Serial growth scan
• Monitor fetal well-being via Doppler US & CTG
• Aim for vaginal delivery between 38–40 weeks
• 50% C-section rate expected (macrosomia, pre- eclampsia, or failed induction)

Management Preterm Labor & Polyhydramnios

• Difficult labor
• Tocolytics (e.g., ritodrine, salbutamol) are diabetogenic.
• I/M steroid is used for fetal lung maturation.
• I/V insulin/glucose infusion might be required.

Management Intrapartum

• Induced/Spontaneous labor: sliding scale insulin to maintain normoglycemia
• Hourly maternal glucose testing is needed
• Continuous fetal monitoring is a must
• Fetal scalp blood sampling if CTG is abnormal

Management Post-Delivery

• Insulin needs return to pre-pregnancy needs
• In cases of GDM, stop insulin
• 6/52 post-delivery OGTT to ensure diabetes has resolved

Substance Abuse

• A majority of pregnant women are reluctant to reveal any form of substance abuse
• Usage of drugs greatly increases the risk of medical complications in mother & baby
• The placenta becomes act as an active transport that carries mechanisms
• Teratogenic effects stem from numerous drugs
• Critical determinants for the effect of the drug include: drug dosage, administration route, the timing of exposure

Common Substances Abused During Pregnancy

Common substances abused during pregnancy are:

• Alcohol
• Caffeine
• Nicotine
• Cocaine
• Marijuana
• Narcotics
• Sedatives
• Chemical dependence (to alcohol, tobacco legal and illicit substances)

Substances

• Alcohol
• Marijuana
• Cocaine
• Amphetamines and methamphetamines
• Opioids
• Antidepressants

Alcohol-Related Effects

• No amount of alcohol during pregnancy
• Fetal Alcohol Spectrum Disorder
• Craniofacial Dysmorphia, IUGR Microcephaly, Limb/Cardiac anomalies.

Cognitive & Behavioral Problems

• Attention Deficit/hyperactivity Disorder
• Inability to foresee consequences
• Inability to learn from previous experiences
• Lack of Organization
• Learning difficulties
• Poor abstract thinking.
• Poor Impulse control
• Speech and Language problems

Management of Nursing

• Emphasize screening & prevention to reduce the high incidence of the following complications: obstetric & medical complications among users and passively addicted infants
• Assessment
• History
• Screening Questionnaires

HIV in Pregnancy

• HIV stands for human immunodeficiency virus, which attacks the immune system by destroying white blood cells.
• AIDS stands for the acquired immunodeficiency syndrome, which is the advanced stage of the disease.
• HIV in Pregnancy is simply the presence of an existing HIV/AIDS in pregnant women.

Factors Affecting Mother to Child Transmission

• Viral: Viral genotype and phenotype, Viral resistance and Viral load
• Maternal: Maternal immunological status, Maternal nutritional status, Maternal clinical status, Behavioural factors and Antiretroviral treatment.
• Obstetrical: Prolonged rupture of membranes (> 4 hours), Mode of delivery, Intrapartum haemorrhage, Obstetrical procedures and Invasive fetal monitoring.
• Fetal: Prematurity, Genetic and Multiple pregnancy.
• Infant: Breastfeeding, Gastrointestinal tract factors and Immature immune system.

Transmission and Preventive Measures

• Active infection is marked by Fever, Skin Rash, Muscle Aches, Diarrhea and Fatigue.
• AIDS-related complex: Weight Loss, Oral candidiasis, Oral Ulcers, Genital ulcers, Pelvic Inflammatory Disease ("PID") and Thrombocytopenia.
• Effect of HIV in Pregnancy may be the result of its interaction with related social and medical conditions in the pregnant woman.

Complications

Complications include:

• Infections.
• Preterm Labour
• Abruptio Placentae
• Rupture of membranes
• Stillbirth.
• Low Birth Weight.
• Spontaneous Abortion.
• Ectopic Pregnancy.

Effects on fetus

• HIV can easily cross the placenta
• Fetal infection is possible via transplacental transmission, contact with infected secretions through breastfeeding
• Adverse effects include -Intrauterine fetal infection, Repeated abortions, Prematurity, Intrauterine growth retardation, Stillbirth, Congenital deformities and AIDS.
• Most HIV-Positive women can be asymptomatic.
• They should receive similar care to women that are HIV-negative.
• Antenatal care is needed based on risk of experiencing an adverse perinatal outcome.
• Assess fetal growth.
• Avoid procedures that can result in a risk of further infection.
• Be extremely cautious of considering external cephalic version of breech fetus due to its potential maternal-fetal leaks.

Examinations and Investigations

• Monitor the weight of the mother as well as advise her on any nutritional supplements. At each visit be certain to examine oropharynx.
• Syphilis testing should be preformed as well as a repeat check in late pregnancy may be recommended.
• Hemoglobin needs o be checked as well complete blood count as T cell subset investigations. Anemia is much more common when affected with HIV and repeats may be required.
• Measure viral lod to provide a prognostic indicator and take cervical smear as preformed in the past. Use of the the Colposcopy can be reserved for abnormal cervical smear analysis.
• Treat Positive Pregnant Women.
• Recommend the following medical and obstetrical management with family and peer counseling or social support.

Treatment

• No cure is available for HIV. Antiretroviral drugs help prevent spread of the virus and limit the damage to the body(Nucleoside/nucleotide reverse transcriptase, such as abacavir, emtricitabine, and tenofovir).
• Adherence is key and important to make certain ART regimens need to be taken for the the person's the rest of their life.
• Multifaceted Management must include with regular antenatal care, preform routine obstetrical measures, under take and exam, follow any medical treatment as care must also be considered for delivery.

Care During Labor and Delivery

• Prolonged rupture may need consideration if it is determined or suspected as it may promote greater mother-child contraction.
• Episiotomy should not be performed, unless in indication for this to occur.
• If an assisted delivery Is indicated take use of the preferable instrument to prevent to scalp(Risk of laceratoins).
• There should be increased and prevent during a cesarean-section(elective). The risks must outweigh.
• Recommend antibiotics if needing an elective procedure or cesarean in case of emergency.
• Conclude with knowing to prevent and what to do if exposed and make sure that the importance is not disregarded and the that the knowledge is known and understood.

Rh incompatibility

• Rh factors genetically determine. a baby may have the blood type and Rh factor from either parent or a combination of both parents

• The positive gene is more dominant than the counterpart one when coupled a positive gene take over

• The other the hand if the factor occurs the outcome is negative and the the offspring ends with a positive state

• Another disease or condition is when the antibodies are attacking the blood cells in the new baby's and is known as hemolytic to the newborn as well

• In scenario that negative and the baby is positive the pregnancy and the especially during labor and delivery the RH-positive red or positive can enter the mother's stream

SENSITIZATION

• Process on the other trying to fight against antibodies against the positive stream.
• Rh Follow these steps genetic transmission baby may inherit what blood type is and what faction factor from which parent they receive for either some. positive again is strong more strength is exhibited from that state.
• In circumstance it and will positive.

Pathophysiology involved

• Diagnostics and what and what steps to take during and or with treatment

Anemia and Pregnancy

• hematocrit blood red cell blood to carry to all areas to where its needed. Normal values may variety but what steps may be taken. There is Anemia based on level of blood percentage when there is more the issue as well. Iron is needed for blood in a lot scenario which is recommend to increase these levels.

• Is there any underlying infection or disease that may be the primary cause to the issue. Is there loss is blood. What ever the causes be, be certain to always recommend steps in order to correct. Iron or Fe supplement. Can cause issues with with mothers and delivery.

• B(B9)is for baby to recommend supplements and to make certain things work Vitamin.

• Folate or B(3)is for babies nervous system and health.