1. CARDIAC DISEASES IN PREGNANCY

2. - pre-existing cardiac disease, or developing cardiac disease in pregnancy, has increased over recent years due to many factors:
1-the increased age of childbearing women
2- the association it has with co-existing medical conditions such as diabetes, hypertension, as well as obesity, smoking and previous illicit drug use.
3- improved life expectancy of women born with congenital cardiac disease

3. Risk for morbidity and mortality depends on ;
1-the nature of the cardiac lesion
2-its affect on the functional capacity of the heart
3- the development of pregnancy-related complications such as hypertensive disorders of pregnancy, infection, thrombosis and haemorrhage.

4. -Cardiac disease is the commonest cause of maternal death
-especially acquired heart disease was the cause of the majority of deaths with sudden adult death syndrome (SADS) and ischaemic heart disease (IMD) . -
The majority of deaths secondary to cardiac causes occur in women with no previous history.
-a midwife undertakes an accurate history from the woman at the first visit.
-Should any history of cardiac disease be revealed, a more detailed account should be elicited in order to ensure prompt and appropriate referral to an appropriately skilled and experienced multidisciplinary team

5. -address the psychosocial concerns model of care.
-The midwife's role involves not only being astute ذكى to any deviation that may arise in the course of the woman's pregnancy
-In a healthy pregnancy the homodynamic profile alters in order to meet the increasing demands of the developing feto-placental unit.
- Healthy pregnant women are able to adjust to these physiological changes quite easily; for women with co-existing cardiac disease,
- the added workload can precipitate complications.

6. - The three sensitive periods of cardiovascular stress (28–32 weeks of pregnancy, during labour and 12–24 hours postpartum) are the most critical and life threatening for women with cardiac disease.
-Understanding the changes in cardiovascular dynamics during pregnancy can support the midwife's recognition of key indicators and when limitations to cardiac function are occurring that require prompt referral

7. Diagnosis of cardiac disease
signs and symptoms
physical assessment of functional capacity
laboratory tests can assist with the diagnosis of cardiac disease and determine the type of lesion. These may include:

8. full cardiovascular examination, including personal history and assessment of lifestyle risk factors
blood tests: full blood count, clotting studies and cardiac enzymes (Troponin)
12-lead electrocardiogram (ECG)
echocardiogram: an ultrasound examination to examine cardiac structure and function
chest X-ray to assess cardiac size and outline, pulmonary vasculature and lung fields
(always undertaken when clinically indicated, e.g. in women presenting with chest pain)
other imaging: computerized tomography (CT) scan or magnetic resonance imaging (MRI) scan of the chest.

9. Care of women with cardiac disease
Pre-conception care
Women with a pre-existing cardiac problem should receive pre-conception counselling to inform them of any potential risks that a pregnancy may have on their health and that of their unborn baby in terms of inheriting any congenital malformations.

10. -This will enable them to make informed decisions and plan their pregnancy monitoring more carefully to reduce any subsequent morbidity and mortality.
- The risk of inheriting cardiac disease varies between 3% and 50% depending on the type of maternal heart disease.

11. -Children of parents with a cardiovascular condition inherited in an autosomal dominant manner (e.g. Marfan syndrome, hypertrophic cardiomyopathy, or long QT syndrome) have an inheritance risk of 50%, regardless of gender of the affected parent.
-increasing number of genetic defects, genetic screening by chorionic villous biopsy (CVS) can be offered in the 12th week of pregnancy.
- All women with congenital heart disease should be offered fetal echocardiography between the 19th and 22nd week of pregnancy.

13. -Measurement of nuchal fold thickness around the 12th to 13th week of pregnancy is an early screening test for Down syndrome in women over 35 years of age.
Antenatal care
-The symptoms of physiological pregnancy can mimic the signs and symptoms of cardiac disease, e.g. ;
dyspnoea on exertion
orthopnoea
palpitations
dizziness
fainting
a bounding pulse
tachycardia
peripheral oedema
distended jugular veins
and alterations in heart sounds.

14. *Observations and investigations of the woman's health should be undertaken prior to and at the beginning of pregnancy to obtain baseline referral points.
-Adapted antenatal records that include triggers such as shortness of breath, palpitations, pulse rate and rhythm as well as auscultation of the heart for any murmur and lung fields for signs of pulmonary oedema are useful to prompt the midwife into early detection of subtle increases of any worsening symptoms.

15. -These observations should be undertaken alongside the usual antenatal examination, but the midwife also needs to be mindful that women with cardiac disease can also develop other complications such as pre-eclampsia or gestational diabetes
-There should be frequent assessment of the woman with a multidisciplinary approach involving midwives, obstetricians, cardiologists and anaesthetists.
- The aim is to maintain a steady haemodynamic state and prevent complications, as well as promote physical and psychological wellbeing.

16. the fetal wellbeing is assessed by the following
means:
ultrasound examination to confirm gestational age and any congenital malformation
clinical assessment of fetal growth and amniotic fluid volume and by ultrasound
monitoring of the fetal heart rate by CTG
measurement of fetal and maternal placental blood flow indices by Doppler ultrasonography.

17. -A care plan for pregnancy, labour and the early postnatal period should be informed by the individual woman's situation with a view to optimizing outcomes for her and her baby.
-Such a plan should be shared with the woman with copies being available in her own hand-held records and those held at a central point.
-Potential interventions, such as afending parent education classes, can help in allaying the woman's general anxieties about motherhood alongside the antenatal care received from the midwife.

18. - This may involve advice regarding modifying and adjusting physical activity during pregnancy.
- Some women may need to commence maternity leave earlier than anticipated whereas others may require admission to hospital for rest and close monitoring.
-In addition, guidance about the constituents of a well-balanced diet with restricted intake of cholesterol, sodium-rich foods and salt should also be provided.
Monitoring of weight gain should be undertaken as excess weight gain will place additional strain on the heart. Compliance with taking iron and folic acid supplementation is also important in preventing anaemia.