Cardiovascular

CARDIOVASCULAR
Disorders
of
DISORDERS OF
Pregnancy
PREGNANCY

P. 513
by: Ampe C. Asuncion,
RN, MAN

By:
Ampe C. Asuncion,
RN, MAN

CVDs that most commonly cause difficulty

during pregnancy:
Valve damage due to RF or Kawasaki disease
Congenital anomalies like atrial septal defect
or uncorrected coarctation of the aorta
Aortic dilatation due to Marfans syndrome
Increased circulatory volume: the danger of
pregnancy in a woman with cardiac disease.
30%- 50% increase in blood volume and
cardiac output at weeks 28-32 just after the
blood volume peaks
Prenatal check-up should be done as early as
1 week after the first missed period.

P
f
a

FACTORS THAT CATEGORIZE

A PREGNANCY AS HIGH
RISK
(P.515)

Disease
I-

uncompromised; ordinary physical activity

causes no discomfort; no s/s of cardiac
insufficiency/ no anginal pain
II- slightly compromised, excessive fatigue,
palpitation, dyspnea or angina during ordinary
physical activity.
III- markedly compromised; less than ordinary
activity causes excessive fatigue, palpitations,
dyspnea or angina.
IV- severely compromised; inability to carry out
activities, symptoms felt even at rest.

Left- Sided Heart Failure

Causes:

mitral stenosis and insufficiency and aortic

coarctation.
Pathophysiology:
Defective mitral valve causes back
pressure on pulmonary circulation,
decreased systemic blood pressure and
pulmonary hypertension occurs.
25 mm Hg pulmonary pressure causes
fluid to leak into alveoli and cause
pulmonary edema

Signs and Symptoms:

Blood- tinged sputum due to rupture of
capillaries leaking blood into alveoli
Fatigue, weakness, dizziness from lack of
oxygen
Orthopnea due to severe pulmonary edema
Paroxysmal nocturnal dyspnea
Management:
Anticoagulants for mitral stenosis
D.O.C.- Heparin in early and last month of
pregnancy, no teratogenic effects and does
not cross the placenta(no coag. problems at
birth)

Warfarin may used after week 12.

Antihypertensives
Diuretics to reduce blood volume
Betablockers to improve ventricular filling.
Serial UTZ after weeks 30-32 and non-stress

test to monitor fetal growth

Balloon valve angioplasty to loosen mitral
valve adhesions
Complications:
Poor placental perfusion; PTL; maternal death
Intrauterine growth restriction
Spontaneous miscarriage; Fetal death

Right- Sided Heart Failure

Causes:

-pulmonary valve stenosis

-atrial & ventricular septal defects
Pathophysiology:
Defective ventricle causes back-pressure
and systemic venous circulation is
congested causing jugular vein distention
and portal hypertension; liver and spleen
become distended.

Signs and Symptoms:

Hepatomegaly presses on diaphragm causing ?
Ascites due to distention of abdominal vessels
Peripheral edema; splenomegaly
Eisenmenger syndrome: (Tardive Cyanosis) rightto- left atrial or ventricular septal defect; most
common congenital anomaly causing RS heart
failure.
Effective contraception for uncorrected ES;
woman is advised not to get pregnant
Hospitalization in last trimester (Oxygen and ABG
analysis to ensure fetal growth); insertion of
pulmonary catheter
No dehydration (blood stasis)

PERI-PARTAL CARDIOMYOPATHY:
- 50% mortality rate; no previous hx of heart
disease
- common in African- American women with PIH
- myocardiac failure causes dyspnea, chest pain,
edema, cardiomegaly
Diuretics
Anti-arrhythmias
Digitalis
Anticoagulants to decrease thromboembolism
Corticosteroids
CI: oral contraceptives (avoid further
pregnancies; may need heart transplant)

A
w
m
n

1. When does blood volume increase to 30-

50% in pregnancy?
2. What classification of heart disease causes
extreme fatigue, palpitations and dyspnea
during ordinary physical activity?
3. How much pressure in the lungs causes
pulmonary edema?
4. 5,6 signs and symptoms of LSHF
7. when is heparin given in LSHF?
8. Why is heparin given?
9. When is warfarin given?
10. What causes jugular vein distention in
RSHF

11. Hepatomegaly causes what symptom?

12. Most common congenital anomaly
causing RSHF
13-14care given in last trimester to ensure
fetal growth
15. Signs and symptoms of RSHF

Assessment of a Woman with Cardiac

Disease
Check pre-pregnancy status for signs of cardiac
disease; a simple cough may be a sign of
pulmonary edema.
***Edema of PIH usually begins after week 20.
- Edema of heart failure can start anytime;
irregular pulse, rapid or difficult respirations,
chest pain on exertion
Assess RR in sitting/lying position on first visit
then take RR in the same position for accuracy
Assess for capillary refill (<5 secs.), liver size and
jugular vein distention
ECG, CXR, EEG

Nursing Diagnosis: Deficient knowledge regarding

steps to reduce the effects of maternal
cardiovascular disease on the pregnancy and fetus
Nursing Interventions during pregnancy, labor and
delivery, and postpartum:
Monitor fetal heart rate and maternal V/S and
contractions frequently
>100 bpm = left lateral position or SF if with
pulmonary edema
Avoid anemia by taking iron supplements; low Na
diet
Fatigue- symptom of heart decompensation
Swan- Ganz catheter- monitor heart function
Epidural- low forceps or vacuum extractor can be
used for birth; no pushing allowed

20-40% increase of blood volume within 5

minutes after placenta is released

Anticoagulants, digoxin, antibiotics
to prevent sub- acute endocarditis,
stool softeners.
Assure mother that acrocyanosis is
normal for the baby
Oxytocin is used with caution due
to increased BP

A CLIENT WITH ARTIFICIAL VALVE

PROSTHESIS
-Client is on anticoagulant therapy to
prevent clotting
-Warfarin can cause congenital anomalies
in infants
-Heparin does not cross placenta
-Subclinical bleeding from anticoagulant
can cause dislodgement of placenta;
observe for signs of petechiae and
premature separation of placenta

A CLIENT WITH CHRONIC

HYPERTENSIVE VASCULAR DISEASE
-associated with atherosclerosis or renal
disease
-Mother and child are at risk due to poor
placental perfusion
-Betablockers and ACE inhibitors to
reduce BP by peripheral dilatation
-Methyldopa (Aldomet) is usually
prescribed

A CLIENT WITH VENOUS

THROMBOEMBOLIC DISEASE
-Increased risk due to blood stasis in
lower extremities from uterine pressure
and hypercoagulability due to estrogen
-Stasis, vessel damage, hypercoagulation
leads to thrombus formation
Deep Vein Thrombosis (DVT) leads to
pulmonary emboli for women above 30
y/o; pain or redness in the calf of a leg
***avoid use of constrictive knee- high
stockings, sitting with legs crossed at
the knee, or standing too long

Diagnosis:
-Doppler U/S
Management:
bed rest, heat, elevation
IV Heparin for 24- 48 hours, then
SC Heparin every 12-24 hours for the
duration of pregnancy through rotation
of sites in arms and thighs
PTT monitoring
No additional heparin once labor
begins; NO routine episiotomies or
epidural anesthesia until at least 4 hours
has passed after last dose

Antiphospholipid antibodies (aPLA):

-women are more prone to thrombi
formation, spontaneous miscarriages,
fetal death and PIH
-clients are started on aspirin or SC
Heparin during pregnancy and d/c PP to
reduce DVT
-Corticosteroids to reduce antibody
formation
-Contraceptives not initiated after
pregnancy to avoid coagulation & thrombi
formation

Pulmonary embolism: chief danger of

thrombophlebitis (medical emergency)
Chest pain
Sudden dyspnea
Cough with hemoptysis
Tachycardia or missed beats
Severe dizziness or fainting from
hypotension

Sickle Cell Anemia:

Recessively inherited hemolytic anemia
caused by abnormal amino acid in the beta
chain of hemoglobin which replaces amino
acid valine (HbS results); lysine (nonsickling hemoglobin (HbC)
Cold temperature/ high altitudes cause
viscosity due to dehydration
1 in 10 African- American has it
Can cause blockage in major organs as
well as placental circulation causing LBW
and fetal death

Assessment:
6-8 mg/100 ml: hemoglobin level of a
woman with SCD
5-6 mg/100 ml: hemoglobin level during
a sickle cell crisis
Bacteriuria: increased incidence; obtain
a clean- catch urine sample
8 glasses/day: minimum fluid intake to
prevent dehydration and sickling
Avoid prolonged standing
UTZ at 16-24 weeks for IUGR
Weekly NST

Management:
Periodic exchange transfusions to
replace sickled cells and remove
accumulated bilirubin
Sickle cell crisis: control pain, give
O2, increase fluid volume to lower
viscosity (hypotonic- 0.45 saline)
NO iron/folic acid supplements during
pregnancy
Signs of infection that causes fever,
increased perspiration; respiratory infxn
(admission to rule out sickle cell crisis)

Keep woman well- hydrated in labor

Epidural anesthesia if CS
Early ambulation and pressure
stockings to prevent thromboembolism
3-6 months: screening of infants when
fetal hemoglobin converts to an adult
pattern
PUBS/ Amniocentesis: detects disease
in the few beta chains present in utero

:Thalassemia in Pregnancy
Autosomal recessive blood disorders
that cause poor hemoglobin formation and
severe anemia in children
Common in Med, African and Asian
populations
Treatment: folic acid and packed RBC to
combat anemia

Malaria in Pregnancy:
>caused by female Anopheles mosquito
RBC stick to surface of capillaries causing
obstruction and organ anoxia
Common in new US immigrants
Incubation period: 12-14 days
S/S: elevated LFT, fever, malaise,
headache
Complications: thrombocytopenia, anemia,
renal failure
Prevention: correct clothing, use of
mosquito repellent/ nets, closed windows,
delay travel to malarial areas

Treatment:
Chloroquine: drug of choice
Sulfadoxine- Pyrimethamine: 3rd trimester
Contraindicated Drugs: quinine, malarone,
tetracyclines should not be given during
pregnancy or lactation
***Antimalarials: reduce incidence of LBW
and PTL

Von Willebrand Disease:

>autosomal dominant trait in childhood
that causes menorrhagia and frequent
epistaxis
If undiagnosed/untreated, can cause
spontaneous miscarriage or PP
hemorrhage
Normal platelets but prolonged bleeding
time
Reduced factor VIII antigen and
coagulation activity
Transfusion of cryoprecipitate or fresh
frozen plasma before labor

Hemophilia B (Christmas Disease)

sex-linked male disorder
Female carriers have such reduced level
of factor IX (33%) that cause spontaneous
miscarriage or hemorrhage of labor
Screening before pregnancy
Blood transfusion of factor IX
concentrate or fresh- frozen plasma
PUBS: detects hemophilia in a male fetus;
contraindicated if fetus has a coagulation
disorder

There are four possible outcomes

for the baby of a woman who is a
carrier. These four possibilities
are repeated for each and every
pregnancy:
1.
2.
3.
4.

A
A
A
A

girl who is not a carrier

girl who is a carrier
boy without hemophilia
boy with hemophilia

With each pregnancy, a woman

who is a carrier has a 25% chance
of having a son with hemophilia.

Since the father's X chromosome

determines the baby will be a girl,
all the daughters of a man with
hemophilia will be carriers. None
of his sons, which is determined
by the father through his Y
chromosome, will have
hemophilia.

Idiopathic Thrombocytopenic Purpura:

>autoimmune illness causing decreased
platelets; can occur anytime, triggered
by a bout of viral infection
>minute petechiae or large hemorrhages
appear on womans body; frequent
nosebleeds
Thrombocytopenia: as low as
20,000/mm3 (N: 150,000/mm3)
PIH and HELLP: similar to ITP, 1-3
months duration

Management of ITP:
Platelet transfusion/ plasmapheresis
Oral prednisone
Complications:
decreased platelets leads to increased
bleeding at birth
Antiplatelet factor can cause placenta
and cause platelet destruction in the
newborn
Newborn may acquire disease