Heart disease during pregnancy

Heart disease during pregnancy : 

Heart disease during pregnancy * Out Lines . * Introduction. * Etiology * Diagnosis. * Homodynamic changes during pregnancy. * Effect of HD on pregnant women . * Medical management . * Nursing management .

*Introduction:- : 

*Introduction:- the incidence of heart disease with pregnancy world wide is between 0.2 and 3.7 % . Rheumatic heart disease accountfor about half of the cases while congenital heart defects are responsible for most of the remaining half material mortality in pregnant cardiac patients is 10%world wide .12.8% in Egypt .

*Etiology :- : 

*Etiology :- *the main cardiac disease occurring with pregnancy are:- *Rheumatic heart disease. *Congenital heart disease. *Coronary heart disease & *Cardiomyopathies are rare duringpregnancy.

* Investigations:- : 

* Investigations:- - *ECG. - *Echo cardiology . - *Chest x- ray .

* Diagnosis :- : 

* Diagnosis :- *history of Rheumatic fever or Congenital heart disease *S & s :- manifestation of RHD :- (HF ,R/L dysfunction ) . - *Hyperventilation & dyspnea & Orthopnea , Cough (pul –congestive symptom). - *functional systolic murmurs during *physical examination . - *lower limb edema .

*Classification :- : 

*Classification :- the classification of HD is based on function not diagnosis . - According to new York heart association classification :- - class I Asymptomatic on ordinary physical activity. - class II symptomatic with ordinary physical activity. - class III symptomatic with less than ordinary physical activity. - class IV symptomatic are present at rest ( de-compensated )

*Homodynamic changes during pregnancy :- : 

*Homodynamic changes during pregnancy :- -Cardiac out put increases by as much as 30% ,40% (HR BY 10 TO 15 b/m) - blood volume increase by as much as 50% - peripheral resistance decrease due to progesterone vasodilatation effect . blood pressure in the half of pregnancy - HB &hematocrit in relation to plasma volume

* Effect of HD on pregnant women :- : 

* Effect of HD on pregnant women :- Mother :- -abortion the incidence of maternal motility . -preterm labor Fetus :- - Fetal death ( duo to hypoxia ). -fetus small for gestational age .

* Effect of pregnancy on HD :- : 

* Effect of pregnancy on HD :- - the critical periods during which HF is liable to occur are ; At the32nd week , as the cardiac out put& blood volume are at their maximum In the 2nd stage of labor as straining leads to stress on heart Immediately after labor as contraction &retraction of the uterus lead to over load on the heart . If ineffective endocarditis occur .

* Medical management:- : 

* Medical management:- The aim of management :- _Prevent of HF . _ Prevention of infected endocarditis .

(1) AntiPartum. : 

(1) AntiPartum. _ more frequent antenatal visits to the obstetrician &cardiologist _ Rest in bed , 10hrs each night & half an hour after each meal _ Diet :- Moderate salt restriction in needed (2-4 gm\day ) _Prevention of infection :- dental & Pulmonary infections . _TTT of anemia . _ Placental insufficiency tests to detect fetal hypoxia. _Hospitalization :- At 32 weeks & again at 38 week till the patient is delivered . At any time if there is HF .

(2)Intrapartum. : 

(2)Intrapartum. Position :- semi-recumbent.* *O2 . *Pain relief . *Ampicillin to prevent infective endocarditis . *Shorting of the 2nd stage by forceps under anesthesia.

(3)Post partum . : 

(3)Post partum . *Breast feeding is contraindicated if heart failure develops . *Hospitalization 3-4 weeks if heart failure develops . *Antibiotics to avoid infective endocarditis .

(4) Special Cases. : 

(4) Special Cases. _ PTs with prosthetic valves :- Heparin is given to prevent clots on artificial valves _ avoid oral anticoagulation as they are teratogenic Therapeutic abortion :- in the 1 st trimester for :- * class IV . * HF in aprevios pregnancy . * sever mitral stenosis .

Nursing management of the heart disease during pregnancy. : 

Nursing management of the heart disease during pregnancy. [1] nursing assessment :- * History (1) history of dyspnea ,palpation , easily Fatigability. (2) Identify other factor that would increase strain on heart e.g anemia , infection , anexity (3) Family history of heart disease (4) Determine the function capacity of the heart by talking the woman's Pulse or respiration and blood pressure.

[2] nursing Care during Antenatal Period :- : 

[2] nursing Care during Antenatal Period :- (1) assess cardiac status . (2) assess if symptoms of cardiac de compensation occur (3) teach signs and symptoms of deteriorating cardiac status such as (dyspnea ,orthopnea , cough and hemoptysis )and how to report them .

(cont.) nursing Care during Antenatal Period :- : 

(cont.) nursing Care during Antenatal Period :- * protection from infection :- (1) inform the woman about the importance of the protection from infection especially upper respiratory infection . (2) teach patient to report signs and symptoms of infection. * Decrease exertion reduces fatigue and promotes Adequate ventilation.

(cont.) nursing Care during Antenatal Period :- : 

(cont.) nursing Care during Antenatal Period :- * promotion of adequate nutrition :- (1) Adiet should be rich in Iron , Protein and essential nutrition. (2) Low In sodium . * Promotion of rest :- (1) Rest is necessary to reduce the work load on heart . (2) 8-10 hrs of sleep are essential with daily rest period . (3) the patient should be instructed to rest on the left Side. (4) lateral recumbent position to facilitate blood flow to the fetus .

(cont.) nursing Care during Antenatal Period :- : 

(cont.) nursing Care during Antenatal Period :- * The woman should understand her condition :- (1)Sings of de compensation . (2)any medication she is taking and how to use it . (3) Reason for the need to decrease activity if symptoms occur . * When therapy is being initiated the nurse must assisstethe patient by :- (1) Providing oxygenation . (2) Providing skin care . (3)Ensuring that constipation is avoided . (4) Promoting good nutrition .

(cont.) nursing Care during Antenatal Period :- : 

(cont.) nursing Care during Antenatal Period :- * Implementation of supportive therapy :- (1) Use of prophylactic antibiotic on doctors order . (2) Oxygen by mask if dyspnea occur . (3)Administration of :- #Diuretics to reduce the venous return to the heart and there by decrease the pulmonary and left atrial blood pressure so reducing pulmonary congestion . # Sedative to help to alleviate anxiety and decrease the voluntary muscles activity during the second stage of Labor.

[3] nursing management during labor and delivery :- : 

[3] nursing management during labor and delivery :- (1) Encourage relaxation and sleep between contractions. (2) Support the woman emotionally to be less anxious . (3) The nurse guards the woman against over exertion during Pushing by coaching her to use shorter more Moderate open glottis pushes with complete relaxation between pushes .

[3](cont.) nursing management during labor and delivery :- : 

[3](cont.) nursing management during labor and delivery :- (4)Monitor vital sings closely every 10 minutes during the second stage . (5) Oxytocin is contraindicated for heart disease in first and second stage . (6) Blood loss during 3rd and 4 rd stage of labor is kept to a minimum by promote delivery of the placenta and Oxytocin administration bimanual compression .

[4] nursing care during post partum period:- : 

[4] nursing care during post partum period:- *promotion of recovery :- (1)Monitor vital signs regularly . (2) Maintain the woman in semi- fowler's positions. (3)Facilitate bowel elimination by controlling the diet . (4) The woman resumes activity gradually and progressively .

[4] (cont.) nursing care during post partum period:- : 

[4] (cont.) nursing care during post partum period:- * promotion of physiological support :- (1) Encourage maternal and fetal attachment . (2) Continous monitoring of maternal status after Delivery scince cardiac work load is great . (3) Prevent post partum hemorrhage , infection and Thrombo –embolism that can cause crisis. (4) Education and assistance in new born care :- # The woman can breast feed her infant . # The nurse can assist the woman to comfortable Side lying position with her head moderately elevated or to semi-fowler's position .

[4] (cont.) nursing care during post partum period:- : 

[4] (cont.) nursing care during post partum period:- * Preparation for discharge :- (1)Realistic home care plans should be communicated With patient . (2)Plan with the woman an activity schedule that is gradual progressive and appropriate to her needs and home environment . (3) Give appropriate information counseling regarding sexual relations and contraception .

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