Cardiovascular Changes in Pregnancy

Nursing Care of a Family Experiencing a Pregnancy Complication

• A pregnancy complication can arise from a preexisting or newly acquired illness.

Definition of a High-Risk Pregnancy

• A high-risk pregnancy is one in which a concurrent disorder, pregnancy-related complication, or external factor jeopardizes the health of the woman, fetus, or both.

Nursing Process Related to Care of a Woman With a High-Risk Pregnancy

• Assessment:
  • Objective data (vital signs)
  • Subjective data (edema, exhaustion)
• Nursing diagnoses:
  • Impaired tissue perfusion related to poor heart function (secondary to conditions like mitral valve prolapse during pregnancy)
  • Pain related to pyelonephritis (secondary to uterine pressure on ureters)
  • Fear regarding pregnancy outcomes and related chronic illnesses
• Outcome identification and planning: Based on the pattern of life.
• Implementation and Outcome Evaluation: Methods for implementing care and evaluating outcomes.

Establishing a Baseline for High-Risk Pregnancy

• Essential for evaluating, monitoring and planning care.

2020 National Health Goals Related to Complications of Pregnancy

• Goal 1: Reduce the rate of fetal deaths
• Goal 2: Reduce the rate of maternal deaths
• Goal 3: Reduce the rate of maternal illness and complications

High-Risk Pregnancy: Cardiovascular System

• Cardiovascular disease complicates approximately 1% of pregnancies, but accounts for 5% of maternal deaths.
• Blood volume and cardiac output increase significantly during pregnancy (peaks at 28-32 weeks), putting stress on a compromised heart.
• The New York Heart Association (NYHA) criteria are used to categorize cardiac disease severity.
• Common cardiac issues: valve damage (rheumatic fever or Kawasaki disease), congenital anomalies (aortic coarctation, atrial septal defect).
• Most dangerous time: 28-32 weeks post conception.
• Whether a woman with a preexisting cardiovascular condition can successfully complete pregnancy depends on the type and extent of the disease.

High-Risk Pregnancy: Common Cardiovascular Clinical Findings

• Left-sided heart failure: Occurs in conditions like mitral stenosis, insufficiency, and aortic coarctation. Symptoms may include orthopnea, pulmonary edema, and paroxysmal nocturnal dyspnea. Interventions include low-molecular-weight heparin, antidiuretics, antihypertensives, and beta/blockers. NST and serial UTZ are useful for assessing placental perfusion.
• Right-sided heart failure: Caused by unrepaired congenital heart defects like pulmonary valve stenosis. Symptoms can include distended liver and spleen, ascites, and peripheral edema,
• Pregnancy is typically contraindicated for patients with uncorrected right-sided heart failure. Close monitoring is crucial after epidural anesthesia to prevent hypotension.

High-Risk Pregnancy: Cardiovascular System Assessment

• Level of exercise
• Presence of cough or edema
• Baseline vital signs comparison
• Liver size (right-sided heart failure involvement)
• ECG/echocardiogram
• Fetal size and response to labor (including FHR decelerations)

High-Risk Pregnancy: Cardiovascular System Nursing Diagnoses

• Example: Deficient knowledge regarding steps to take to reduce the effects of maternal cardiovascular disease on the pregnancy and fetus

High-Risk Pregnancy: Cardiovascular System Nursing Interventions in the Antepartal Phase

• Promoting rest
• Promoting healthy nutrition
• Educating patients about medications
• Educating patients about infection avoidance

High-Risk Pregnancy: Cardiovascular System Nursing Interventions in the Intrapartum and Postpartum Phase

• Intrapartum: Positioning during labor, epidural anesthesia, assisted vaginal delivery.
• Postpartum: Assessing for heart failure, use of anticoagulants, digoxin therapy, and intermittent pneumatic compression boots.

Quality & Safety Education for Nurses (QSEN)

• Patient-Centered Care
• Teamwork & Collaboration
• Evidence-Based Practice
• Quality Improvement
• Safety
• Informatics

Reducing Risk of Thromboembolic Disease Through QSEN Competencies

• Assessment:
  • Pulmonary embolus may occur.
  • Increased estrogen levels increase blood coagulation.
  • Increased blood congestion in pelvis leads to stasis.
  • Thrombophlebitis may occur.
• Risk Factors:
  • More than 30 years old
  • Signs:
    • chest pain,
    • sudden onset of dyspnea,
    • cough with hemoptysis,
    • tachycardia or missed beats,
    • dizziness or fainting.
• Interventions:
  • Avoiding constrictive knee-high stockings
  • Avoiding sitting with legs crossed at the knee
  • Avoiding standing in one position for a long period.
  • Heparin administration.

Anemia and Pregnancy

• Pseudoanemia: Complicates 15-25% of pregnancies.
• Causes:
  • Diet low in iron
  • Heavy menstrual periods
  • Unwise weight-loss programs
• Antenatal effects:
  • Poor weight gain,
  • pre-term labour,
  • pre-eclampsia.
• Intranantal effects:
  • dysfunctional labour,
  • haemorrhage,
  • shock,
  • cardiac failure.
• Postnatal effects:
  • puerperal sepsis,
  • sub-involution,
  • embolism.
• Fetal effects:
  • Risk of pre-maturity,
  • Intrauterine growth restriction (IUGR),
  • low birth weight (LBW),
  • poor Apgar score,
  • anaemia in infancy,
  • poor growth and intellectual development

High-Risk Pregnancy: Endocrine System #1

• Diabetes mellitus: Pathophysiology, clinical manifestations and classification of diabetes mellitus.
• Gestational diabetes: Complications during diabetes during pregnancy.
• Diabetes during pregnancy: Decreased control of glucose regulation, impact on fetal size, infant hypoglycemia.

A Pregnant Patient with Malaria

• Malaria: Protozoan infection transmitted by Anopheles mosquitos.
• Incubation period: 12-14 days.
• Symptoms: Elevated liver enzymes, fever, malaise, headache, thrombocytopenia, renal failure.

Prevention/Treatment for Malaria

• Wearing protective clothing
• Using insect repellent
• Sleeping under mosquito nets
• Keeping windows closed
• Delay travel to endemic areas
• Combination of anti-malarial drugs for prevention and treatment to reduce LBW and preterm birth.

A Pregnant Patient with UTI

• Progesterone dilates ureters during pregnancy, causing urine stasis, increasing risk of UTIs.
• The minimal amount of glucose (glycosuria) creates an environment for bacteria growth.
• UTIs are associated with preterm labor and PROM (premature rupture of membranes).
• UTIs are frequently caused by E. coli.
• Treatment(safe): Use of amoxicillin, ampicillins, cephalosporins, and sulfonamides.

A Pregnant Patient with COVID-19

• Symptoms: Common COVID-19 symptoms such as fever, cough, fatigue, diarrhea, and myalgia.
• Respiratory Droplets: The mode of transmission of COVID-19, which can infect newborns through breastfeeding.
• Precautions: Importance of hand washing, covering nose and mouth, avoiding touching face, and maintaining a safe distance (1 meter) from others.
• Impact on newborns can cause shortness of breath, fever, thrombocytopenia and other symptoms.

High-Risk Pregnancy: Endocrine System #2

• Diabetes in pregnancy (cont.): Screening and monitoring during pregnancy.

High-Risk Pregnancy: Endocrine System #3

• Diabetes in pregnancy (cont.):
• Nursing diagnosis ("Deficient knowledge related to therapeutic regimen necessary during pregnancy").
• Interventions:
  • Education regarding nutrition during pregnancy.
  • Education regarding exercise during pregnancy.

High-Risk Pregnancy: Endocrine System #4

• Diabetes in pregnancy (cont.):
• Therapeutic management:
  • Insulin needs and dosage adjustments
  • Education about blood glucose monitoring.
  • Insulin pump therapy
  • Education related to pump care and use
  • Placental function and fetal testing
  • Recording fetal movement
  • Postpartum management of blood glucose

High-Risk Pregnancy: Renal and Urinary System Assessment

• Assessment: Elevated blood pressure, flank pain, proteinuria, frequent urination with burning, and increased serum creatinine. Edema may also be present.

High-Risk Pregnancy: Interventions Related to Prevention of Renal and Urinary Tract Disorders

• Nutritional counseling and monitoring of fluid intake
• Proper hygiene
• Frequent urination, especially after intercourse
• Cranberry juice intake

Caring for Woman With Multiple Threats to Her Pregnancy #1

• Presents a case study of a pregnant woman with cardiac disease and gestational diabetes.
• Details of family and patient assessment, nursing diagnosis, outcome criteria, team member activities and responsibilities are described in detail.

Caring for Woman With Multiple Threats to Her Pregnancy #2

• Presents information about patient-centered care, psychosocial and spiritual needs, informatics for seamless healthcare planning, and further treatment of those with multiple potential pregnancy complications.

Question #1

• Clinical Question: Which assessment of a pregnant patient with cardiac disease should nurses follow up on most closely?
  • Answer: Weight gain of 4 lbs in 1 week, especially in the first 8 weeks of pregnancy, is worth close monitoring, as this may indicate impending heart failure.

Question #2

• Clinical Question: What is the most accurate statement regarding exercise and nutrition during pregnancy for a woman with diabetes?
  • Answer: Ideally, dietary calorie intake from protein (20%), carbohydrates (40-50%), and fats (30%) will help in glycemic control. Extreme exercise should be avoided, as extreme exercise may cause glucose fluctuations.

Question #3

• Clinical Question: What is a reliable measure for evaluating an intervention?
  • Answer: A fasting blood glucose level of 85 mg/dl is the most reliable measure for evaluating an intervention. Activity or food intake are not reliable measures.