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Pregnancy Complicated by Cardiac Disease and Its Assessment: Nursing Case Study

Sunday, 13 April 2014

Women with cardiac disease who otherwise may not have thought of becoming pregnant are now choosing pregnancy because of medical improvements in cardiac care. The two main cardiac dysfunctions affecting pregnancy are congenital and rheumatic heart diseases. Congenital heart diseases include atrial septal defect, ventricular septal defect, pulmonary stenosis, and coarctation of the aorta. The risks for women with rheumatic heart disease are related to endocarditis that has caused heart valve stenosis or regurgitation. Women with mitral valve prolapse may require prophylactic antibiotic therapy during labor to prevent endocarditis.

The issue facing women of childbearing age and their cardiologists is whether a woman with cardiac disease can complete a pregnancy successfully, based on the type and extent of her disease. The New York State Heart Association has established four classes to describe cardiac status, regardless of the etiology of the dysfunction. Women with class I or II disease usually can have a normal pregnancy and delivery. Class III disease poses moderate to marked limitation on activity, with the woman becoming symptomatic during less than ordinary activity and, thus, needing to be on complete bed rest throughout her pregnancy to deliver successfully. A woman with class IV disease is symptomatic at rest and isn't a good candidate for having a successful pregnancy.

Pathophysiology
The underlying problem depends on the location and severity of the cardiac defect. Valvular stenosis decreases blood flow through the valve, increasing the workload on heart chambers located before the stenotic valve. Regurgitation permits blood to leak through an incompletely closed valve, increasing the workload on heart chambers on either side of the affected valve. A normal heart can compensate for increased demands; however, if myocardial or valvular disease develops or if the patient has a congenital heart defect, cardiac decompensation can occur. A patient with a cardiac disorder is at greatest risk when hemodynamic changes reach their maximum, from 28 to 32 weeks' gestation.

Complications
■ Maternal cardiac decompensation, including myocardial failure and cardiomyopathy
■ Intrauterine growth retardation
■ Fetal distress
■ Prematurity

Assessment
Health perception and management
■ Care provided by a cardiologist

Activity and exercise
■ Palpitations
■ Feeling of smothering
■ Shortness of breath with exercise
■ Chest pain related to exertion

Sleep and rest
■ Fatigue

Self-perception and self-concept
■ Fear
■ Anxiety

Coping and stress management
■ Inadequate support system
■ Inadequate coping measures for stress

Physical examination
Integumentary
■ Cyanosis
■ Clubbing

Respiratory
■ Dyspnea
■ Orthopnea
■ Cough, with or without hemoptysis
■ Basilar crackles
■ Paroxysmal nocturnal dyspnea

Cardiovascular
■ Vertigo
■ Syncope
■ Tachycardia
■ Pulse irregularities
■ Progressive generalized edema
■ Diastolic, presystolic, or continuous murmur
■ Loud, harsh, systolic murmur, especially if associated with a thrill
■ Arrhythmias
■ Unequivocal cardiac enlargement

Diagnostic studies
■ X-rays reveal abnormalities in cardiac or vessel size, contour, outline, position, or density; unequivocal cardiac enlargement confirms a diagnosis of cardiovascular disease in pregnancy. (Note: The need for X-rays must be carefully evaluated; if they're performed, a lead shield should cover the abdomen and pelvis; avoidance during the first trimester should be a priority.)

■ Electrocardiography reveals hypertrophy, arrhythmias, ischemia, conduction defects, heart block, pericarditis, and electrolyte abnormalities.

■ Echocardiography reveals valvular abnormalities, ventricular dysfunction, or other cardiac disorders.

■ Hemoglobin (Hb) level and hematocrit (HCT) decrease in response to expansion of blood volume (normal ranges from 12 to 15 g/dl and 35% to 45%, respectively); HCT may increase from constant hypoxia.

■ White blood cell count increases (normal ranges from 5,000 to 10,000/mm3 in first trimester; 10,000 to 12,000/mm3 by term).

■ Clotting factors decrease because depression of fibrinolytic activity occurs during normal pregnancy and the postpartum period.

■ Serum electrolyte levels increase (normal range of sodium level is 136 to 145 mEq/L and potassium level is 3.5 to 5 mEq/L).

Teaching checklist
■ Preconception counseling
■ Medications that are safe to use during pregnancy
■ Maternal and fetal risks
■ Long-term maternal morbidity and mortality
■ Signs and symptoms of heart failure
■ Labor and delivery plan
■ Nutrition
■ Limitations to physical activity
■ Fetal echocardiography
■ Fetal monitoring
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