Complications of Pregnancy

Complications of Pregnancy
Summer 2013 1 1 1

Risk Factors Age – under 17 over 35 Gravida and Parity
Socioeconomic status Psychological well-being Predisposing chronic illness – diabetes, heart conditions, renal Pregnancy related conditions – hyperemesis gravidarum, gestational hypertension

Goals of Care for High Risk Pregnancy
Provide optimum care for the mother and the fetus Assist the client and her family to understand and cope through education 1 1 1 1

Gestational Onset Disorders

Bleeding Disorders 2 2 2 2

Abortions induced – artificial
Termination of pregnancy at any time before the fetus has reached the age of viability Either: spontaneous – occurring naturally induced – artificial 3 3 3 3

Types of Abortions Threatened Imminent Complete Incomplete Missed
Recurrent/Habitual 5 5 5 5

Question??? What are two main complications related to a missed abortion? 1. 2.

Cerclage procedure -- purse-string suture placed around the internal os to hold the cervix in a normal state 11 11 11 11

Nursing Care post cerclage
Bedrest in a slight trendelenberg position Teach Assess for leakage Assess for contractions Assess fetal movement and report decrease movement Assess temperature for elevation Why trendelenburg? to decrease the pressure on the new sutures and allow the cervix to rest If client starts contracting, tocolytics can be given. Terbutaline or MgS04 Assess for fetal movement at 20 weeks or greater Delivery options: When time for delivery there are several options: physician will clip suture and allow patient to go into labor on her own induce labor or cesarean delivery. Why do a C/S? So not further trauma will be caused to the cervix in case they want to have another child.

Key Concepts Related to Bleeding Disorders
If a woman is Rh-, RhoGam is given within 72 hours of abortion Provide emotional support. Feelings of shock or disbelief are normal Encourage to talk about their feelings. It begins the grief process 13 13 13 13

Ectopic Pregnancy Implantation of the blastocyst in ANY site other than the endometrial lining of the uterus ovary (5) Cervical 14 14 14 14

Assessment Ectopic Pregnancy
Early: Missed menstruation followed by vaginal bleeding (scant to profuse) Unilateral pelvic pain, sharp abdominal pain Referred shoulder pain Cul-de-sac mass Acute: Shock – blood loss poor indicator Cullen’s sign -- bluish discoloration around umbilicus Nausea, Vomiting Faintness 15 15 15 15

Treatment Options / Nursing Care
Combat shock / stabilize cardiovascular Type and cross match Administer blood replacement IV access and fluids Laparotomy Psychological support Linear salpingostomy Methotrexate – used prior to rupture. Destroys fast growing cells

Gestational Trophoblastic Disease Hydatiform Molar Pregnancy
A DEVELOPMENTAL ANOMALY OF THE PLACENTA WITH DEGENERATION OF THE CHORIONIC VILLI As cells degenerate, they become filled with fluid and appear as fluid filled grape-size vessicles. 18 18 18

Assessment: Vaginal Bleeding -- scant to profuse, brownish in color (prune juice) Possible anemia due to blood loss Enlargement of the uterus out of proportion to the duration of the pregnancy Vaginal discharge of grape-like vesicles May display signs of pre-eclampsia early Hyperemesis gravidarium No Fetal heart tone or Quickening Abnormally elevated level of HCG Question 6 19 19 19

Interventions and Follow-Up
Empty the Uterus by D & C or Hysterotomy Extensive Follow-Up for One Year Assess for the development of choriocarcinoma Blood tests for levels of HCG frequently Chest X-rays Placed on oral contraceptives If the levels rise, then chemotherapy started usually Methotrexate 20 20 20

Critical Thinking Exercise
A woman who just had an evacuation of a hydatiform mole tells the nurse that she doesn’t believe in birth control and does not intend to take the oral contraceptives that were prescribed for her. How should the nurse respond?

Placenta Previa Low implantation of the placenta in the uterus
Etiology Usually due to reduced vascularity in the upper uterine segment from an old cesarean scar or fibroid tumors Three Major Types: Low or Marginal Partial Complete Question 8 21 21 21

Interventions and Nursing Care
Placenta Previa Bed-rest Assessment of bleeding Electronic fetal monitoring If it is low lying, then may allow to deliver vaginally Cesarean delivery for All other types of previa

Abruptio Placenta Premature separation of the placenta from the implantation site in the uterus Etiology: Chronic Maternal Hypertension Short umbilical cord Trauma History of previous delivery with separation Smoking / Caffeine / Cocaine Vascular problems such as with diabetes Multigravida status Defined as marginal, partial or complete 22 22

Treatment and Nursing Care
Abruptio Placenta Cesarean delivery immediately Combat shock – blood replacement / fluid replacement Blood work – assessment for complication of DIC

Placenta Previa Abruptio Placenta PAINLESS vaginal bleeding
Bright red bleeding First episode of bleeding is slight then becomes profuse Signs of blood loss comparable to extent of bleeding Uterus soft, non-tender Fetal parts palpable; FHT’s countable and uterus is not hypertonic Blood clotting defect absent Abruptio Placenta Bleeding accompanied by PAIN Dark red bleeding First episode of bleeding usually profuse Signs of blood loss out of proportion to visible amount Uterus board-like, painful and low back pain Fetal parts non-palpable, FHT’s non-countable and high uterine resting tone (noted with IUPC) Blood clotting defect (DIC) likely 23 23 23

Signs of Concealed Hemorrhage
Increase in fundal height Hard, board-like abdomen High uterine baseline tone on electronic fetal monitoring Persistent abdominal pain and low back pain Systemic signs of hemorrhage Why

Critical Thinking Mrs. A., G3 P2, 38 weeks gestation is admitted to L & D with scant amount of dark red bleeding. What is the priority nursing intervention at this time? Assess the fundal height for a decrease Place a hand on the abdomen to assess if hard, board-like, tetanic Place a clean pad under the patient to assess the amount of bleeding Prepare for an emergency cesarean delivery 25 25

Disseminated Intravascular Coagulation (DIC)
Anti-coagulation and Pro-coagulation effects existing at the same time. 27 27

Etiology Defect in the Clotting Cascade
An abnormal overstimulation of the coagulation process Activation of Coagulation with release of thromboplastin into maternal bloodstream ê Thrombin (powerful coagulant) is produced Fibrinogen fibrin which enhances platelet aggregation and clot formation Widespread fibrin and platelet deposition in capillaries and arterioles 26 26

Etiology continued Resulting in Thrombosis (multiple small clots)
Excessive clotting activates the fibrinolytic system Lysis of the new formed clots create fibrin split products These products have anticoagulant properties and inhibit normal blood clotting A stable clot cannot be formed at injury sites Hemorrhage occurs Ischemia of organs from vascular occlusion of numerous fibrin thrombi Multisite hemorrhage results in shock and can result in death

Assessment & Intervention
Precipitating factors Abruption PIH/HELLP syndrome Sepsis Anaphylactoid Syndrome Labs to review PT, PTT, Platelets, D-Dimer, FSP Interventions Remove the cause Replace fluids (Blood or blood products) Meds 28 28

Assessment/Signs and Symptoms
Spontaneous bleeding – from gums and nose (epistaxis, injection and IV sites, incisions) Excessive bleeding – Petechiae and ecchymosis at site of blood pressure cuff, pulse points Tachycardia, diaphoresis, restlessness, hypotension Hematuria, oliguria, occult blood in stool Altered LOC if cerebral circulation is decreased or cerebral bleed

Diagnostic Tests Lab work reveals: PT – Prothrombin time is prolonged
PTT – Partial thromboplastin time increased D-Dimer – increased, product that results from fibrin degradation. More specific marker of the degree of fibrinolysis Platelets – decreased, thrombocytopenia Fibrin Split Product – increased An increase in both FSP and D-dimer are indicative of DIC PT-Coumadin PTT-Heparin (involves clotting factors 2,5,8, 10, 11,12) Diagnosis will show thrombocytopenia (<150,000) and increased FSP and decreased fibrinogen levels What does FSP mean? Also referred to as test for fibrin degradation products (FDP). FSP, the product of the degradation of the fibrin, acts as an anticoagulant which causes bleeding from many sites.

Hyperemesis Gravidarum

Assessment Persistent nausea and vomiting
Weight loss from pounds May become severely dehydrated with oliguria AEB increased specific gravity, and dry skin Depletion of essential electrolytes Metabolic alkalosis -- Metabolic acidosis Starvation 5 5 5

Nursing Care / Interventions Hyperemesis Gravidarium
Control vomiting Maintain adequate nutrition and electrolyte balance Allow patient to eat whatever she wants If unable to eat – Total Parenteral Nutrition Combat emotional component – provide emotional support and outlet for sharing feelings Mouth care Weigh daily Check urine for output, ketones 6 6 6

Hypertension during pregnancy

Classification of HTN in Pregnancy
Gestational HTN = BP > or equal to 140/90 after 20 weeks (replaces term of PIH), protein negative or trace Pre-eclampsia = BP > or equal to 140/90 after 20 weeks, proteinuria, edema considered nonspecific Eclampsia = Progression of pre-eclampsia to generalized seizures not attributable to other causes Chronic HTN = BP > or equal to 140/90 that was known to exist before pregnancy or develops prior to 20 weeks gestation or does not resolve after 6 weeks after delivery 7 7 7

Predisposing Factors Primigravida Multiple gestation pregnancy
Vascular Disease Age >35 Obesity Hydatiform Molar Pregnancy Family History Lower SES (poor nutrition,/decreased protein intake, inadequate prenatal care)

PATHOLOGICAL CHANGES Gestational Hypertension due to: Endothelial
INCREASED PERIPHERAL RESISTANCE; IMPEDED BLOOD FLOW ( in blood pressure) GENERALIZED ARTERIOLAR CYCLIC VASOSPASMS Endothelial CELL DAMAGE (decrease in diameter of blood vessel) Intravascular Fluid Redistribution Decreased Organ Perfusion Multi-system failure Disease 9 9 9

Rationale for HYPERTENSION
The blood pressure rises due to: ARTERIOLAR VASOSPASMS AND VASOCONSTRICTION causing (Narrowing of the blood vessels) an increase in peripheral resistance fluid forced out of vessels HEMOCONCENTRATION Increased blood viscosity = Increased hematocrit

Key Point to Remember ! HEMOCONCENTRATION develops because:
Vessels became narrowed forcing fluid to shift out of the vascular space Fluid leaves the intravascular space and moves to extravascular spaces Now the blood viscosity is increased (Hematocrit is increased) **Very difficult to circulate thick blood 12 12 12

Proteinuria With renal vasospasms, narrowing of glomerular capillaries which leads to decreased renal perfusion and decreased glomerular filtration rate PROTEINURIA Spilling of 1+ of protein is significant to begin treatment Oliguria and tubular necrosis may precipitate acute renal failure 16 16 16

Significant Lab Work Changes in Serum Chemistry
Decreased urine creatinine clearance ( mL/ min) Increased BUN (12-30 mg/dl.) Increased serum creatinine ( mg/dl) Increased serum uric acid ( mg/dl)

Weight Gain and Edema Edema may appear rapidly
Clinical Manifestation: Edema may appear rapidly Begins in lower extremities and moves upward Pitting edema and facial edema are late signs Weight gain is directly related to accumulation of fluid

The Nurse Must Know The difference between dependent edema and generalized edema is important. The patient with pre-eclampsia has generalized edema because fluid is in all tissues.

Decreased Placental Perfusion and Placental Aging
Due to Vasospasms and Vasoconstriction of the vessels in the placenta. Decreased Placental Perfusion and Placental Aging Positive CST / __________Decelerations With Prolonged decreased Placental Perfusion: Fetal Growth is retarded - IUGR, SGA 17 17 17

Oliguria – 100ml/4 hrs or less than 30 ml. / hour
Edema moves upward and becomes generalized (face, periorbital, sacral) Excessive weight gain – greater than 2 pounds per week

Central Nervous System Changes
Cerebral edema -- forcing of fluids to extracellular Headaches -- severe, continuous Hyperreflexia LOC changes – changes in affect Convulsions / seizures

Visual Changes Retinal Edema and spasms leads to: Blurred vision
Double vision Retinal detachment Scotoma (areas of absent or depressed vision)

Nausea and Vomiting Epigastric pain –often sign of impending coma

Mild Pre-eclampsia Severe Pre-eclampsia
Systolic> or = to 140/90 but <160 mm Hg Diastolic > or = to 90 but < 110 mm Hg Protein > or = to 0.3 g but < 2 g in 24 hr specimen (1-2+ dipstick) Creatinine , serum normal Platelets normal ALT/AST normal or minimal increase Urine output normal No HA Absent RUQ pain/ no N/V Absent to minimal visual changes No pulmonary edema or heart failure Normal fetal growth > or = to 160 mm Hg 2 readings 6 hrs apart on bedrest > or = to 110mm Hg Protein > or = to 5 g in 24 hr specimen (3+ or higher dipstick) Creatinine elevated > 1.2 mg/ dL Platelets decreased < 100, 000 cells/mm3 ALT/AST Elevated levels Oliguria common, often <500 ml/day HA Often present N&V, epigastric pain may be present, often precedes seizures Visual disturbances common May be present IUGR, reduced amniotic fluid

Interventions and Nursing Care
Home Management Decrease activities and promote bed rest Sedative drugs Lie in left lateral position Remain quiet and calm – restrict visitors and phone calls Dietary modifications increase protein intake to g/day maintain sodium intake Caffeine avoidance Weigh daily at the same time Keep record of fetal movement - kick counts Check urine for Protein 20

Hospitalization CBC, platelets; type and cross match
If symptoms do not get better then the patient needs to be hospitalized in order to further evaluate her condition. Common lab studies: CBC, platelets; type and cross match Renal blood studies -- BUN, creatinine, uric acid Liver studies -- AST, ALT, LDH, Bilirubin DIC profile -- platelets, fibrinogen, FSP, D-Dimer

Hospital Management Nursing Care Goal
1. Decrease CNS Irritability 2. Control Blood Pressure 3. Promote Diuresis 4. Monitor Fetal Well-Being 5. Deliver the Infant 20 21 21

Decrease CNS Irritability
Provide for a Quiet Environment and Rest 1. MONITOR EXTERNAL STIMULI Explain plans and provide Emotional Support Administer Medications 1. Anticonvulsant -- Magnesium Sulfate 2. Sedative -- Diazepam (Valium) 3. Vasodilator-- Apresoline (hydralazine) Assess Reflexes Assess Subjective Symptoms Keep Emergency Supplies Available 21 22 22

Magnesium Sulfate ACTION CNS Depressant, reduces CNS irritability Calcium channel blocker- inhibits cerebral neurotransmitter release ROUTE IV effect is immediate and lasts 30 min. IM onset in 1 hour and lasts 3-4 hours Prior to administration: Insert a foley catheter with urimeter for assessment of hourly output 22 23 23

Magnesium Sulfate NURSING IMPLICATIONS
1. Monitor respirations > 14-16; < 12 is critical 2. Assess for hyporeflexia -- D/C if hyporefexia 3. Measure Urinary Output >100ml in 4 hrs. 4. Measure Magnesium levels – normal is mg/dl per hr Therapeutic is 4-8mg/dl.; Toxicity - >9mg/dl; Absence of reflexes is >10 mg/dl; Respiratory arrest is mg/dl; Cardiac arrest is > 15 mg/dl. Have Calcium Gluconate available as antagonist

Test Yourself ! A Woman taking Magnesium Sulfate has a respiratory rate of 10. In addition to discontinuing the medication, the nurse should: a. Vigorously stimulate the woman b. Administer Calcium gluconate c. Instruct her to take deep breaths d. Increase her IV fluids 23 24 24

Control Blood Pressure
Check B / P frequently. Give Antihypertensive Drugs Hydralazine Labetalol Nifedipine Check Hematocrit Do NOT want to decrease the B/P too low or too rapidly. Best to keep diastolic ~90. WHY? 24 25 25

Promote Diuresis **Don’t give Diuretic, masks the symptoms of Gestational Hypertension Bed rest in left or right lateral position Check hourly output -- foley catheter with urimeter Dipstick for Protein Weigh daily -- same time, same scale 25 26 26

Monitor Fetal Well-Being
FETAL MONITORING-- assessing for late decelerations. NST -- Non-stress test CST –contraction stress test BPP –biophysical profile If all else fails ---- Deliver the baby!! 26 27 27

HELLP Syndrome A multisystem condition that is life threatening and complicates 10% of pregnancies in women with severe HTN and may occur during PP period H = hemolysis of RBC EL = elevated liver enzymes LP = low platelets <100,000mm3 (thrombocytopenia) 28 28

Etiology of HELLP Hemolysis occurs from fragmentation and destruction of erythrocytes leading to anemia Release of bilirubin R/T liver impairment and hemolysis of erythrocytes causing hyperbilirubinemia Elevated liver enzymes occur from blood flow that is obstructed in the liver due to fibrin deposits Vascular vasoconstriction  endothelial damage  platelet aggregation at the sites of damage  low platelets

HELLP Syndrome Assessment:
1. Prominent symptom is right upper quadrant pain, lower chest or epigastric 2. Nausea and vomiting 3. Severe edema 4. Flu like symptoms Avoid traumatizing the liver, restrict palpation of abdomen This patient needs to be managed in a critical care setting due to severity of condition

HELLP abdominal pressure could lead to rupture
Intervention: 1. Bedrest – any trauma or increase in intra- abdominal pressure could lead to rupture of the liver capsule hematoma. 2. Volume expanders 3. Antithrombic medications 4. Includes all care directed at management of pre- eclampsia and eclampsia

Infections

T O R C H A Infections T = Toxoplasmosis O = Other R = Rubella
Syphilis, Gonorrhea, Chlamydia,Hepatitis A or B R = Rubella C = Cytomegalovirus H = Herpes A = Aids 26 26

Urinary Tract Infection
Most common infection complicating Pregnancy Etiology Pressure on ureters and bladder causing Stasis with compression of ureters Reflux Hormonal effects cause decrease tone of bladder Assessment Dysuria, frequency, urgency lower abdominal pain; costal vertebral pain fever 25 25

Group B Streptoccocus Infection (GBS)
Leading cause of life-threatening perinatal infections Gram positive bacteria colonizes the rectum, vagina, cervix and urethra of pregnant and non-pregnant women Associated with PROM and preterm birth 60% chance of transmission to NB Fetal effects Sepsis Pneumonia Meningitis

Therapeutic Management
Routine culture for all pregnant women between weeks gestation PCN drug of choice to decrease risk of transmission to fetus Risk for transmission to fetus is at time of labor so no treatment until patient presents in labor Administer PCN IV every 4 hours until delivery

Toxoplasmosis Etiology Maternal and Fetal Effects
Protozoan infection. Raw meat and cat litter Maternal and Fetal Effects Mom - flu-like symptoms, lymphadenopathy Fetus – stillborn, premature birth, microcephaly; mental retardation * Instruct to cook meat thoroughly * Avoid changing cat litter * Advise to wear gloves when working in the garden Treatment: Sulfa drugs 27 27

Syphilis Infant born with congenital anomalies Etiology
Spirochete – Treponema Pallium Maternal and Fetal Effects May pass across the placenta to fetus causing spontaneous abortion. Major cause of late, second trimester abortion Infant born with congenital anomalies 28 28

Syphilis Intervention: 1. Penicillin
2. Advise to return for prenatal visits monthly to assess for re-infection 3. Advise that if treated early, fetus may not be infected

Gonorrhea Etiology – Neisseria Gonorrhoeae Maternal and Fetal Effects:
May get infected during vaginal delivery causing Ophthalmia neonatorium (blindness) in the infant Mom will experience dysuria, frequency, urgency Major cause Pelvic Inflammatory Disease which leads to infertility. Treated with Rocephin Spectinomycin Treat partner!! 29 29

Chlamydia Three times more common than gonorrhea.
Etiology - Chlamydia trachomatis Maternal and Fetal Effects Mom – pelvic inflammatory disease, dysuria, abortions, pre-term labor Fetus -- Stillbirth, Chylamydial pneumonia Interventions Erythromycin, doxycycline, zithromax Advise treatment of both partners is very important 30 30

Hepatitis A or B Highly contagious when transmitted by direct contact with blood or body fluids Maternal and Fetal Effects: All moms should be tested for Hep B during pregnancy Fetus may be born with low birth weight and liver changes May be infected through placenta, at time of birth, or breast milk Intervention: Recommend Hepatitis B vaccination to both mother and baby after delivery. 31

Rubella Etiology Spread by droplet infection or through direct contact with articles contaminated with nasopharyngeal secretions. Crosses placenta Maternal and Fetal Effects Mom– fever, general malaise, rash Most serious problem is to the fetus--causes many congenital anomalies (cataracts, heart defects) Intervention Determine immune status of mother. If titer is low, vaccine given in early postpartum period 32 32

CYTOMEGALOVIRUS Etiology -- Member of the Herpes virus
Crosses the placenta to the fetus or contracted during delivery. Cannot breast feed because transmitted through breast milk Effects on Mom and Fetus Mom – no symptoms, not know until after birth of the baby Fetus -- Severe brain damage; Eye damage Intervention No drug available at this time Teach mom should not breast feed baby Isolate baby after birth 33 33

Herpes Simplex Type 2 Maternal and Fetal Effects
Painful lesions, blisters that may rupture and leave shallow lesions that crust over and disappear in 2-6 weeks Culture lesions to detect if Herpes, No cure If mom has an outbreak close to delivery, then cannot deliver vaginally. Must deliver by Cesarean birth *Virus is lethal to fetus if inoculated at birth Intervention: Zovirax 34 34

HIV/AIDS Etiology: Human Immunodeficiency Virus, HIV
Transmission of HIV to the fetus occurs through: The placenta; birth canal Through breast milk **The virus must enter the baby’s bloodstream to produce infection. 35 35

Diagnosis: ELISA test – identifies antibodies specific to HIV. If positive = person has been exposed and formed antibodies Western Blot – used to confirm seropositivity when ELISA is positive. Viral load - measures HIV RNA in plasma. It is used to predict severity – lower the load the longer survival. CD4 cell count – markers found on lymphocytes to indicate helper T4 cells. HIV kills CD4 cells which results in impaired immune system. Goal: reduce viral load to below 50 copies /ml. and increase the CD4 cell count.

Nursing Care: **Provide Emotional Support
**Teach measures to promote wellness AZT oral during pregnancy IV during labor liquid to newborn for 6 weeks. **Provide information about resources

Fetal Demise/ Intrauterine Fetal Death
2 2 2

Assessment: 1. First indication is usually NO fetal movement 2
Assessment: 1. First indication is usually NO fetal movement 2. NO fetal heart tones Confirmed by ultrasound 3. Decrease in the signs and symptoms of pregnancy

Pre-Gestational Onset Disorders

Diabetes in Pregnancy Diabetes creates special problems which affect pregnancy in a variety of ways. Successful delivery requires work of the entire health care team 13 13

Endocrine Changes During Pregnancy
There is an increase in activity of maternal pancreatic islets which result in increase production of insulin. Counterbalanced by: Placenta’s production of Human Chorionic Somatomammotropin (HCS) Increased levels of progesterone and estrogen--antagonistic to insulin Human placenta lactogen – reduces effectiveness of circulating insulin d. Placenta enzyme-- insulinase 15 15

Gestational Diabetes Diabetes diagnosed during pregnancy, but unidentifable in non-pregnant woman Known as Type III Diabetes - intolerance to glucose during pregnancy with return to normal glucose tolerance within 24 hours after delivery Glucose tolerance test: 1 hr oral GTT – if elevated, do 3 hour GTT Gestational diabetes if: Fasting – 95 mg / dl 1 hour mg/ dl 2 hour mg/ dl 3 hour – 140mg/dl 17 17

Treatment Controlled mainly by diet May use insulin
No use of oral hypoglycemics

Effects of Diabetes on the Pregnancy
MATERNAL Increase incidence of INFECTION Fourfold greater incidence of Pre-eclampsia Increase incidence of Polyhydramnios Dystocia – large babies Rapid Aging of Placenta FETAL increase morbidity Increase Congenital Anomalies neural tube defect (AFP) Cardiac anomalies Spontaneous Abortions Large for Gestation Baby, LGA Increase risk of RDS 21 21

Effects of Pregnancy on the Diabetic
Insulin Requirements are Altered First Trimester--may drop slightly Second Trimester-- Rise in the requirements Third Trimester-- double to quadruple by the end of pregnancy Fluctuations harder to control; more prone to DKA Possible acceleration of vascular diseases 18 18

Interventions/ Nursing Care
Diet Therapy Insulin Regulation Blood Glucose Monitoring Exercise Monitor Fetal Well Being 23 23

Heart Disease in Pregnancy

Cardiac Response in All Pregnancies
Every Pregnancy affects the cardiovascular system Increase in Cardiac Output 30% - 50% Expanded Plasma Volume Increase in Blood (Intravascular) Volume A woman with a healthy heart can tolerate the stress of pregnancy,but a woman with a compromised heart is challenged Hemodynamically and will have complications 1 1

Effects of Heart Disease on Pregnancy
Growth Restricted Fetus Spontaneous Abortion Premature Labor and Delivery 2 2

Effects of Pregnancy on A Diseased Heart
The Stress of Pregnancy on an already weakened heart may lead to cardiac decompensation (failure). The effect may be varied depending upon the classification of the disease 3 3

Classification of Heart Disease
Uncompromised No alteration in activity No anginal pain, no symptoms with activity Class 2 Slight limitation of physical activity Dyspnea, fatigue, palpitations on ordinary exertion comfortable at rest 4 4

Class 3 Class 4 Marked limitation of physical activity
Excessive fatigue and dyspnea on minimal exertion Anginal pain with less than ordinary exertion Class 4 Symptoms of cardiac insufficiency even at rest Inability to perform any activity without discomfort Anginal pain Maternal and fetal risks are high 5 5

Nursing Care - Antepartum
Decrease Stress teach the importance of REST! watch weight assess for infections - stay away from crowds assess for anemia assess home responsibilities Teach signs of cardiac decompensation 6 6

Assess for Signs of CHF Cough (frequent, productive, hemoptysis)
Dyspnea, Shortness of breath, orthopnea Palpitations of the heart Generalized edema, pitting edema of legs and feet Moist rales in lower lobes, indicating pulmonary edema 9 9

Education high in iron, protein low in sodium and calories ( fat )
Diet high in iron, protein low in sodium and calories ( fat ) Weight gain Medications Supplemental iron Heparin, not coumadin – monitor lab work Diuretics – very careful monitoring Antiarrhythmics –Digoxin, quinidine, procainamide. *Beta-blockers are associated with fetal defects. Reinforce physicians care 7 7

Nursing Care: During Labor
Labor in an upright or side lying position Restrict fluids On O2 per mask throughout labor and cardiac monitoring. Sedation / epidural given early Report fetal distress or cardiac failure Stage 2 - gentle pushing, high forceps delivery 10 10

Nursing Care Postpartum
The immediate post delivery period is the MOST significant and dangerous for the mom with cardiac problems because: Following delivery, fluid shifts from extravascular spaces into the blood stream for excretion Cardiac output increases, blood volume increases Strain on the heart! Watch for cardiac failure 11 11

Test Yourself ! Mrs. B. has mitral valve prolapse. During the second trimester of pregnancy, she reports fatigue and palpitations during routine housework. As a cardiac patient, what would her functional classification be at this time? a. Class I b. Class II c. Class III d. Class IV 12 12

Complications of Pregnancy

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