Pregnancy and Cardiac Disease MK Porras Physiologic Changes of Pregnancy Cardiovascular System Changes a. Increased Blood volume b.

Iron needs c. Heart d. Blood pressure e. Peripheral blood flow f. Supine hypotension syndrome g. Blood constitution

Serial ultrasound and non-stress tests (monitor fetal health)

Right-Sided Heart Failure Occurs in conditions such as: o Pulmonary valve stenosis o Atrial / ventricular septal defects Would cause BACK PRESSURE Leading to SYSTEMIC VENOUS CIRCULATION o Jugular vein distention o Decreased pulmonary blood flow o Portal hypertension Manifestations Dyspnea Pain Ascites Peripheral edema Hepatomegaly Splenomegaly Treatment a. Advised NOT to become pregnant b. If they do a. Hospitalization in the last trimester b. O2 administration c. Frequent ABG assessment d. During labor PULMONARY CATHERIZATION

ARTERY

To predict pregnancy outcome in clients with cardiovascular problems, NYSHA Left-Sided Heart Failure Occurs in conditions such as: o Mitral stenosis o Mitral insufficiency o Aortic coarctation Which leads to PULMONARY HYPERTENSION (>mm Hg) Causing PULMONARY EDEMA Pulmonary Edema Altered O2-CO2 exchange Productive cough with blood speckled sputum Manifestations: Tachypnea Tachycardia Dyspnea on exertion/rest Hypertension Fatigue Dizziness Orthopnea Limited O2 exchange High risk for: Spontaneous miscarriage Preterm labor Maternal death Impaired uterine blood flow Poor placental perfusion Intrauterine growth restriction Fetal mortality Classification of Heart Disease in Pregnancy - No limitation with physical activity cause no discomfort - No symptoms of cardiac insufficiency and no angina pain - Slight limitation on physical activity - Ordinary activity causes excessive fatigue, palpitations, dyspnea, or angina pain - Moderate to marked limitation of physical activity - During less than ordinary activity, they experience excessive fatigue, palpitations, dyspnea, or angina pain - Unable to carry out physical activity without experiencing discomfort - Even at rest they experience symptoms of cardiac insufficiency or angina pain

Class I Uncompromised

Class II compromised

slightly

Class III compromise

markedly

Class IV compromised

severely

Treatment 1. Low sodium diet 2. Antihypertensive (beta-blockers / diuretics) 3. Mitral valve adhesions (Balloon valve angioplasty) 4. Anticoagulants heparin Post 30-21 weeks of pregnancy

Classification of Heart Disease in Pregnancy Class I and II Expected to experience normal pregnancy and birth Class III Can complete pregnancy by maintainting almost complete bed rest Class IV Poor candidates for pregnancy Advised to avoid pregnancy Prematurity The length of a normal pregnancy or gestation is considered to be 40 weeks (280 days) from the date of conception Infants born before 37 weeks gestation are considered premature and may be at risk for complications

24 weeks (age of viability) More than one out of every ten infants are born prematurely Advances in medical technology have made it possible for infants born as young as 23 weeks gestational age (17 weeks premature) to survive These prematre infants, however, are at higher risk for death or serious complications, which include heart defects, respiratory problems, blindness, and brain damage

Causes of Prematurity Birth of a premature baby can be brought on by several different factors including: o Premature labor o Placental abruption o Placenta previa o Premature rupture of membranes o Incompetent cervix o Maternal toxaemia and poisoning While one of these conditions are often the immediate reason for a premature birth, its underlying cause is usually unknown One of the few, and most important, identifiable causes of prematurity is drug abuse, particularly cocaine, by the mother Physical Assessment The major parts characteristic markers are: Term of the anatomy for physical

1. 2. 3.

Extra oxygen can be supplied to the infant through tubes that fit into the nostrils or by placing the baby under an oxygen hood In more serious cases, the baby may have to have a breathing tube inserted and receive air from a respirator or ventilator A surfactant drug can be given in some cases to coat lung tissue (given IV, must be given every 2 hours) Extra oxygen may be needed for a few days or weeks, depending on how small and premature the baby was at birth Bronchopulmonary dysplasia is the development of scar tissue in the lungs, and can occur in severe cases of RDS If stays in the ventilator too long, can cause BPD Inhalation Diffusion Perfusion

Ear Cartilage

Well-developed cartilage with instant recoil

Pre-Term Note the increased cartilage, recoil, and outer ridge curving inward (33 weeks gestation) Note small amount of ear cartilage and/or flattened pinna (28 weeks gestation) Anterior crease Flat sole ( 28 weeks) Preterm (33 weeks) Breast tissue less than 1 cm, areolae raised or pigmented Preterm (28 weeks) No breast tissue areolae are barely visible

Bronchopulmonary Dysplasia A chronic lung condition that is caused by tissue damage to the lungs Marked by inflammation, exudate, scarring, fibrosis, and emphysema Usually occurs in immature infants who have received mechanical ventilation and supplemental oxygen as treatment for respiratory distress syndrome When preemies are put on a ventilator their lungs are still immature and sometimes cannot withstand the constant pressure of the respirator Preemies that have been on a respirator for more than 28 days are at risk for developing BPD BPD is most common in immature neonates born at 22-23 weeks gestational age Apnea of Prematurity Condition in which the infant stops breathing for periods lasting up to 20 seconds Often associated with a slowing of the heart rate Baby may become pale, or the skin color may change to a blue or purplish blue Apnea occurs most commonly when the infant is asleep. Infants with serious apnea may need medications to stimulate breathing or oxygen through a tube inserted in the nose Some infants may be placed on a ventilator or respirator with a breathing tube inserted into the airway As the baby grows older, and the lungs and brain tissues mature, the breathing usually becomes more regular Usually a little tap or simple rub on the back helps remind the preemie to breath or brings the heart rate up Portal Circulation Circulation happening bringing the nutrients from the stomach to the small intestines to the liver to the different systems of the body Retinopathy of Prematurity (ROP) Previously known as retrolental fibroplasia (RLF) Disease of the eye that affects premature babies Thought to be caused by disorganized growth of retinal blood vessels which may result in scarring and retinal detachment ROP can be mild and may resolve spontaneously but may lead to blindness in serious cases Both oxygen toxicity and relative hypoxia can contribute to the development of ROP Intraventricular Hemorrhage Bleeding inside or around the ventricles, the spaces in the brain containing the cerebral spinal fluid Babies born at less than 34 weeks have an increased risk of bleeding in their brain Due to immature blood vessels may not tolerate the changes in circulation that take place during labor.

Sole Creases

Multiple creases

Breast Tissue

A full-term baby girl will have a prominent outer labia Genitalia Full-term baby boys the testicles should have descended and the scrotum might appear swollen

Premature baby may have a noticeable large clitoris and inner labia Premature baby boys tend to have flat scrotum with undescended testicles

Common Risks and Complications of Prematurity Respiratory Distress Syndrome (RDS) Most common problem seen in premature infants Babies born too soon have immature lungs that have not developed surfactant, a protective film that helps air sacs in the lungs to stay open With RDS breathing is rapid and the center of the chest and rib cage pull inward with each breath

Complications Cerebral palsy Mental retardation Learning difficulties Treatment No specific treatment for IVH Treat any other health problems that may worsen the condition Nursing Management (Supportive) 1. Correct anemia, acidosis, and hypotension with fluids and medications 2. Prevent fluctuations in blood pressure by slowly administering fluids 3. Limit stimulation to reduce stress 4. Reduce newborns exposure to noxious stimuli to avoid fluctuation in blood pressure and energy expenditure 5. Keep the newborn in a flxed, contained position with the head elevated to prevent or minimize fluctuations in ICP 6. Provide adequate oxygenation 7. Assess signs of hemmorrhage Necrotizing Enterocolitis (NEC) Occurs when a portion of the newborns intestine develops poor blood flow that can lead to infection in the bowel wall Part of the babys intestines are destroyed as a result of bacterial infection Corrected by anastomosis Because NEC is potentially fatal, doctors are quick to respond to its symptoms, which include: o Lethargy o Vomiting o Swollen and/or red abdomen o Fever o Blood in the stool Measures include: Off mouth feedings to IV feeding Administering antibiotics Removing air and fluids from the digestive tract via a nasal tube Approximately 70% of NEC cases can be successfully treated without surgery Surgical treatment includes resecting the affected portion of the bowel, which may be extensive. Initially, an ileostomy with a mucous fistula is typically performed, with reanastomosis performed later Severe infection that is present in the blood and spreads throughout the body sepsis neonatorum or neonatal septicaemia Can develop following infection by microorganisms including bacteria, viruses, fungi and parasites Infection in babies can be contracted during pregnancy from the mothers genital tract during labor and delivery or after birth from contact with others During delivery Group B strep e. coli Herpes simplex After birth Respiratory syncytial virus candida Haemophilus influenza type b Enterovirus

c. Decreased temp. or temp. instability d. Weak suck e. Jaundice Treatments Antibiotics Nursing Intervention a. Handwashing to prevent further infection b. Give antibiotics as ordered c. Assess for response from antibiotics Jaundice / Hyperbilirubinemia Accumulation of serum bilirubin above normal level Results from increased load of bilirubin: o From RBC destruction o Decreased clearance of bilirubin from plasma Signs and Symptoms Sclerae appearing yellow before skin appears yellow Skin appearing light to bright yellow Lethargy Dark, amber concentrated urine Poor feeding Dark stools Treatment Phototherapy o Uses blue light that converts bilirubin to be excreted in the urine and feces Note: Hyperbilirubinemia in much higher levels can cause brain damage Kernicterus leading cerebral palsy auditory neuropathy and dental enamel hypoplasia Nursing Intervention 1. Check light intensity for therapeutic range daily 2. Ensure that light is 45-60 cm from infant and plexiglass shield is in place 3. Make sure that the infant is under the light for prescribed time daily 4. Undress the infant completely to expose entire skin surface 5. Keep infants eyes covered to protect from constant exposure to high intensity light which may cause retinal injury 6. Have a systemic schedule of turning so all skin surface will be exposed 7. Shield gonads of newborn 8. Maintain thermo-neutrality as phototherapy may rise the ambient temperature The baby is exposed to the light usually 30 minutes, depending on the needs. Minimum of 15 minutes Stabilization in the delivery room with prompt respiratory management and thermal management Which are crucial to the immediate and long-term outcome of premature infants, particularly extremely premature infants Principles of Respiratory Management 1. Recruit and maintain adequate lung volume or optimal lung volume a. In infants with respiratory distress, this step may be accomplished with early continuous positive airway pressure (CPAP) given nasally, by mask (neopuff), or by using an endotracheal tube when ventilation and/or surfactant is administered Avoid hyperoxia and hypoxia by immediately attaching a pulse oximeter saturation (SaO2) between 86% and 93% Prevent barotrauma or volutrauma by using a ventilator that permits measurement of the expired tidal volume and by keeping it 4-7 mL/kg Administer surfactant early (<2H of age) when indicated and prophylactically in all extremely premature neonates (<29 weeks)

Sepsis -

Prenatal Rubella (German measles) cytomegalovirus Chickenpox (Varicella-Zoster Virus) Listeria monocytogenes

2. 3. 4.

Signs and Symptoms a. Apnea or DOB b. Bradycardia

Principles of Thermoregulation Management

1.

Maintenance of the neutral thermal environment is critical for minimizing stress and optimizing growth of the premature infant (selen wrap) a. The neutral environment is defined as the environmental temperature in which the neonate maintains a normal temperature and is consuming minimal oxygen for metabolism 2. Preterm infants are relatively unable to compensate for cold stress because of a small amount of subcutaneous tissue (insulation) and decreased brown fat to produce heat 3. Preterm infants do not shiver. The increased surface area to body mass allows for rapid heat loss, especially from the head 4. Decreased posturing ability further diminishes their ability to compensate 5. In extremely LBW infants, immature skin further complicates thermoregulation due to increased evaporative water loss. 6. Consequences of cold stress are increased metabolism with loss of weight or failure to gain weight and increased use of glucose with depletion of glycogen stores and hypoglycaemia 7. Metabolic acidosis results in a decreased surfactant production and loss of functional alveolar number which results in hypoxia. The hypoxia causes pulmonary vasoconstriction and further hypoxia 8. Increased oxygen consumption results in hypoxia, anaerobic metabolism, and lactic acid production 9. In intensive care nursery, radiant warmers may be used to compensate for heat loss, incubators are more efficient than radiant warmers because the heated environment decreases heat loss due to conduction, convection, and radiation a. With radiant warmers, consider using plastic wrap and a humidified environment for extremely LBW infants. New devices function as both an incubator and an overhead warmer to enable access for procedures. In all nurseries, maintain the environmental temperature at >20 F (>21 C) 10. Temperature maintenance is especially critical during neonatal rescucitation Thyroid Storm Thyrotoxic crisis Thyrotoxicosis An acute, life-threatening, hypermetabolic state induced by excessive release of thyroid hormones in individuals with hyperthyroidism Thyroid Hormone Amino acids that have the unique property of containing iodine molecules Thyroxine Thyroxine (T4) Contains 4 iodine atoms in each molecule Relatively weak hormone Maintains the body metabolism in a steady state Triiodothyronine (T3) Contains 3 iodine atoms in each molecule About 5 times as potent as T4 and Has more rapid metabolic action Iodine is essential for thyroid hormone synthesis Iodine in Diet iodine uptake from the blood Iodine concentration in the thyroid gland iodine molecules + tyrosine = Thyroid Hormones Thyroid Stimulating Hormone Negative feedback mechanism Thyroid Hormone Level in TSH Level Blood Decreased Increased Increased Decreased Causes Graves disease

Genetic Toxic nodular goiter Radioactive iodine therapy Drugs o Anticholinergic o Salicylates o NSAIDs o Chemotherapy Excessive TH ingestion Withdrawal of or noncompliance with antithyroid medications Exposure to iodine Direct trauma to the thyroid gland Vigorous palpation of an enlarged thyroid Pregnancy

Clinical Manifestations Increased O2 consumption o Fatigue o Dyspnea o Tachycardia o Chest pain o Palpitations o Cardiac arrhythmias o Seizure o Delirium o coma Excessive use of fuels o Heat intolerance o Hyperpyrexia > temp 38.5 C 41 C o Weight loss (over 40 lbs) o Decreased cholesterol level o Thin and silky skin and hair o Muscle cramps Increase sympathetic nervous system activity o Tachycardia o Hypertension o Palpitation o Diaphoresis o Restlessness o Nervousness o Irritability o Tremors o Arrhythmias o Delirium GI Manifestations of thyroid storm include: o Diarrhea, vomiting, jaundice, abdl pain Hypotension in later stages with shock Thyroid Studies Usual findings include: Elevated T3 and T4 Suppressed TSH levels Elevated 24 H iodine uptake Diagnosis Hyperthyroidism vs Thyroid Storm Thyroid storm diagnosis is based on clinical features, not on laboratory tests Medical Management ICU admission o For close monitoring of vital signs and for access to invasive monitoring and inotropic support, if necessary. Four-Pronged Approach to Treatment Immediate Objectives are Reduction of body temp Reduction of heart rate Prevention of vascular collapse A. B. C. D. Therapy directed against the thyroid gland Therapy directed against the effects of thyroid hormones Therapy directed against systemic decompensation Therapy directed against precipitating illness

Therapy Direct Against Thyroid Gland Propylthiouracil (PTU) Methimazole Inhibits synthesis of new thyroid hormones Inhibit synthesis of THs within 1-2 Hours

Therapy Directed against the effects of Thyroid Hormones Peritoneal dialysis and plasmapheresis have been used to reduce the high levels of circulating T4 and T3 in thyrotoxic storm Symptomatic treatment Cardiovascular Dysfunction Beta blockers olol o Propanolol (inderal) o Agent most commonly used o A nonselective beta-adrenergic agent Decreases heart rate, myocardial contractility, BP, and myocardial O2 demand Blocks peripheral conversion of T4 to T3 o Digitalis Thermoregulatory Dysfunction Acetaminophen Avoid Salicylates (ASPIRIN) o Salicylates inhibit thyroid hormone binding and could increase free hormone levels, potentially worsening the crisis Hypothermia mattress/blanket Ice packs Cool environment Humidified oxygen Dextrose containing IVF Therapy Directed against Systemic Decompensation Shock and Adrenal Insufficiency Hydrocortisone succinate (Solu-Cortef) Dexamethasone (Decadron) Provides mineralocorticoid and glucocorticoid effects o Glucocorticoids: inhibit hormone production and decrease peripheral conversion from T4 to T3 Therapy Directed against Precipitating Illness Sepsis/infection Stroke DKA Nursing Management Improving Nutritional Status Several well-balanced meals (small frequent meals) High in calorie and proteins Highly seasoned foods and stimulants are discouraged Enhancing Coping Measures Improving Self-Esteem Maintaining Normal Body Temperature Monitoring & Managing Potential Complications