Heart disease during pregnancy : Heart disease during pregnancy * Out Lines .
* 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
- 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 .
- 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.
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.*
*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.  nursing assessment :-
(1) history of dyspnea ,palpation ,
(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.  nursing Care during Antenatal Period :- :  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
(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.  nursing management during labor and delivery :- :  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 . (cont.) nursing management during labor and delivery :- : (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 .  nursing care during post partum period:- :  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 .  (cont.) nursing care during post partum period:- :  (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 .  (cont.) nursing care during post partum period:- :  (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 . Slide 26: Thank you