CARDIOVASCULAR DISORDERS AND PREGNANCY

Introduction

The number of women of childbearing age who have heart disease is diminishing as more and more
congenital heart anomalies are corrected in early infancy. Also rheumatic fever is being more actively
prevented and treated so that cardiac damage from this disorder is also reduced. For these reasons
cardiovascular disease w/c was once a threat to pregnancy, now complicates only approximately 1% of
all pregnancies. However, it is still a concern to pregnancy because it can lead to such serious
complications, still it is responsible for 5% of maternal death during pregnancy. With improved
management of women with cardiac disorders, women who might never have risked pregnancy in the
past are able to complete pregnancies successfully these days.

A woman w/ cardiovascular disease needs an inter-professional team approach to care during

pregnancy. Ideally the pregnant should visit her pregnancy care provider for pre-conception care so her
state of health and baseline data when she is not pregnant can be established. She should begin pre
natal care as soon as she suspect pregnancy, so her general condition and circulatory system could be
monitored from the beginning of pregnancy. The danger primarily in a woman w/ cardiac disease is the
increase in circulatory volume. And the most dangerous time for her is in 28-32 weeks.

The estimation of whether a woman w/ cardiovascular disease can complete a pregnancy successfully
depends on the type and extent of her disease. To predict a pregnancy outcome, heart disease is divided
into 4 categories based on criteria established by the New York Heart Association.

Classification of Heart Disease:

1. Class 1- uncompromised. (vey low risk) Ordinary physical activity causes no discomfort. No
symptoms of cardiac insufficiency and no angina pain.
2. Class 2- slightly compromised. (low to moderate risk) Ordinary physical activity causes excessive
fatigue, palpitation and dyspnea or angina pain.
3. Class 3 Markedly compromised. (high risk) During less than ordinary activity, woman
experiences excessive fatigue, palpitations, dyspnea or angina pain.
4. Class 4 severely compromised. (extremely high risk) Woman is unable to carry out any physical
activity without experiencing discomfort. Even at rest, symptoms of cardiac insufficiency or
angina pain are present. Pregnancy is contraindicated)

Categories Based on Criteria:

1. Class 1 or 2 heart disease --can expect to experience a normal pregnancy and birth.
2. Class 3 heart disease --can complete a pregnancy by maintaining special interventions such
as bed rest.
3. Class 4 heart disease --are usually advised to avoid pregnancy because they are in cardiac
failure even at rest and when they are not pregnant.
Classification of heart disease/Cardiovascular disease:

4 entities:

1. coronary artery disease (CAD) which is also referred to as coronary heart disease (CHD)--

is a medical condition characterized by the narrowing or blockage of the coronary arteries. These
arteries are responsible for supplying oxygen-rich blood to the heart muscle. CAD typically develops
when cholesterol-containing deposits (plaques) build up on the inner walls of the coronary arteries, a
process called atherosclerosis.

2. cerebrovascular disease,

Cerebrovascular disease refers to af medical conditions that affect blood vessels supplying the brain.
These conditions often result in abnormalities in the blood vessels, such as narrowing, blockage, or
rupture, which can impair blood flow to parts of the brain. The most common type of cerebrovascular
disease is stroke, which occurs when blood flow to a part of the brain is interrupted, either due to a
blockage (ischemic stroke) or bleeding (hemorrhagic stroke).

Other types of cerebrovascular diseases include:

1. Transient ischemic attack (TIA): Often referred to as a "mini-stroke," a TIA is a temporary

disruption of blood flow to the brain. Symptoms are similar to those of a stroke but typically last
for a shorter duration and do not cause permanent damage.

2. Cerebral aneurysm: A weakened area in the wall of a blood vessel in the brain that bulges
outward. If an aneurysm ruptures, it can cause bleeding into the brain, leading to a hemorrhagic
stroke.

3. Arteriovenous malformation (AVM): An abnormal tangle of blood vessels in the brain that
disrupts normal blood flow and can lead to hemorrhagic stroke or other neurological problems.

4. Cerebral venous sinus thrombosis (CVST): A rare condition characterized by the formation of
blood clots in the venous sinuses of the brain, which can obstruct blood flow and lead to stroke-
like symptoms.

3. Peripheral artery disease (PAD), also known as peripheral vascular disease, is a circulatory condition
that affects the arteries outside of the heart and brain, particularly those that supply blood to the limbs,
typically the legs. It's caused by the narrowing or blockage of the arteries due to atherosclerosis,-- a
buildup of fatty deposits (plaque) on the artery walls.

4.Aortic atherosclerosis -- is a condition characterized by the buildup of plaque (atherosclerosis) in the

walls of the aorta, the largest artery in the body that carries oxygen-rich blood from the heart to the
rest of the body. Similar to atherosclerosis in other arteries, the plaque in the aorta is made up of fatty
deposits, cholesterol, calcium, and other substances that accumulate over time.
Aneurysm: An aneurysm is an abnormal bulge or ballooning of a blood vessel wall, typically caused by
weakening of the vessel wall. Aneurysms can develop in various arteries throughout the body, including
the coronary arteries.

During pregnancy, there is a physiological increase in blood volume, heart rate, and cardiac output.
Patients with an underlying cardiac disorder do not tolerate these changes well and are at risk for
developing arrhythmias, pulmonary edema, and congestive heart failure

During pregnancy, there is an increase in blood volume which results in increased pressure on the heart
valves. For pregnant women with rheumatic heart disease, an increased pressure on the damaged heart
valve leads to increased maternal and fetal risks. These complications might include: Death of mother
and baby

***Prescription of potassium supplements, NSAIDs, and amoxicillin/clavulanic acid was significantly

associated with an increased risk for heart failure

Explanation:

Hyperkalemia (high potassium levels): Excessive potassium in the blood can lead to heart rhythm
disturbances, which can be dangerous for both the mother and the baby. In severe cases, it can even
cause cardiac arrest.

Hypokalemia (low potassium levels): Conversely, low potassium levels can also be problematic. It can
cause muscle weakness, cramps, irregular heartbeat, and in severe cases, can lead to complications such
as preterm labor or even fetal death.

Gestational hypertension: Potassium imbalance can contribute to gestational hypertension, which is

high blood pressure during pregnancy. This condition can increase the risk of complications such as
preeclampsia and eclampsia, which are dangerous for both the mother and the baby.

NSAIDs: NSAIDs are generally avoided during pregnancy, especially in the third trimester, because they
can interfere with the normal development of the baby's cardiovascular system, leading to a condition
known as premature closure of the ductus arteriosus. This condition can cause problems with blood flow
to the lungs after birth. Additionally, NSAIDs may increase the risk of miscarriage or cause other
complications during pregnancy. Hence, they are usually not recommended unless prescribed by a
healthcare professional and deemed necessary.
Assessment of Woman with Cardiac Disease:

1. Thorough health history to document pre pregnancy cardiac status.

Symptoms: Assess for symptoms suggestive of cardiac dysfunction:

-- chest pain or discomfort,
--dyspnea (shortness of breath)
--palpitations,
--syncope (fainting)
-- fatigue
-- swelling (edema)
-- exercise intolerance.

Risk Factors: Identify and address modifiable risk factors for cardiovascular disease;

--smoking

--obesity

-- diabetes mellitus

--hyperlipidemia

--sedentary lifestyle

-- illicit drug use.

Psychosocial Factors: Consider psychosocial factors that may impact cardiovascular health:
-- stress, anxiety, depression
--socioeconomic status
-- access to healthcare, or social support systems.

Family History: Inquire about a family history of inherited cardiac conditions:

-- hypertrophic cardiomyopathy
-- familial dilated cardiomyopathy
-- familial hypercholesterolemia
-- congenital heart defects
--history of sudden cardiac death or hereditary arrhythmias.

Medical History: Obtain a detailed medical history:

-- past cardiovascular events, surgeries, or interventions
-- congenital heart disease, valvular heart disease, coronary artery disease,
cardiomyopathy, arrhythmias, or hypertension
-- heart failure, stroke, or thromboembolic events.
 Functional Status: Evaluate the patient's functional capacity .Determine the patient's ability to
perform activities of daily living and exercise tolerance.

Medication History: Review current and past medications, including anticoagulants,

antiarrhythmics, antihypertensives, and medications for heart failure management. Ensure
optimization of medications for pre-pregnancy planning.

2. Document a woman’s level of exercise performance.

--obtain a comprehensive history, including:

-- the patient's exercise habits
-- previous experiences with physical activity
-- limitations or symptoms experienced during exercise.

-- Inquire about the type, frequency, duration, and intensity of physical activities performed.
-- Evaluate the presence and severity of symptoms related to cardiac function, such as chest
pain or discomfort, dyspnea (shortness of breath), palpitations, fatigue, dizziness, or syncope
(fainting), both at rest and during exertion.
-- Perform an exercise stress test, such as a treadmill or bicycle ergometer test, under medical
supervision. Monitor electrocardiographic changes, blood pressure response, symptoms, and
exercise capacity during the test. Assess for evidence of ischemia, arrhythmias, or exercise-
induced symptoms.
-- Conduct functional assessments, such as the 6-minute walk test or cardiopulmonary exercise
testing, to objectively measure exercise capacity, aerobic fitness, and functional status.

3. Ask if she normally has cough or edema.

Edema, or swelling, can be a common occurrence during pregnancy due to hormonal changes
and increased fluid retention. However, in pregnant women with underlying cardiac problems,
edema may require closer monitoring and management due to potential implications for both
maternal and fetal health.

Here's how edema related to a pregnant woman with a cardiac problem might be approached:

--Evaluate the extent and location of edema. Common areas of swelling include the ankles, feet,
and lower legs, but it can also occur in other parts of the body.

--Assess for signs of pitting edema (indentation that remains after pressure is applied) and
measure the severity of swelling.

--Monitor fluid balance and weight gain throughout pregnancy. Sudden or excessive weight gain,
especially in the presence of edema, may indicate fluid retention and worsening cardiac
function. Track urinary output and signs of fluid overload, such as dyspnea, orthopnea, or
paroxysmal nocturnal dyspnea.
 Grading Scale for peripheral edema:
Grade 0: Absent edema - No visible or palpable swelling.
Grade 1: Mild edema - Slight indentation or pitting with pressure, usually disappears rapidly
(within 15 seconds).
Grade 2: Moderate edema - Deeper pitting that persists for a longer duration after pressure is
applied (15-30 seconds). The area may appear visibly swollen.
Grade 3: Severe edema - Deep pitting that remains for a prolonged period (more than 30
seconds). The affected area is markedly swollen, and the skin may feel tense and shiny.
Grade 4: Very severe edema - Extreme swelling with significant distortion of the affected area.
Pitting may be absent due to the severity of swelling.

4. Record baseline BP, respiration, pulse rate in either a sitting or lying position at 1 st pre natal
visit, and always obtain in same position.

5. Assessment for nail bed filling should be < 5 seconds.

"Assessment for nail bed filling should be < 5 seconds" suggests that under normal
circumstances, capillary refill time should be less than 5 seconds. In other words, when pressure
is applied to the nail bed and then released, the color should return to the nail bed within 5
seconds. This rapid return of color indicates adequate peripheral perfusion and is considered
normal.

it's important to note that capillary refill time may vary depending on factors such as age,
temperature, and underlying health conditions. In infants and young children, for example,
capillary refill time may be naturally faster than in adults. Additionally, certain medical
conditions or situations, such as hypothermia, shock, dehydration, or peripheral vascular
disease, may prolong capillary refill time beyond the normal range.

6. For additional cardiac assessment an ECG may be done in periodic points in pregnancy.
It's a non-invasive diagnostic test that measures the electrical activity of the heart over time.
The electrical activity of the heart refers to the coordinated series of electrical signals that
trigger and regulate each heartbeat. These electrical impulses originate from specialized cells
within the heart's conduction system and propagate through the cardiac muscle, causing it to
contract and pump blood throughout the body.

Physiological changes during pregnancy, such as increased heart rate, cardiac output, and blood
volume, can influence ECG findings. For example, sinus tachycardia (heart rate >100 beats per
minute) is common in pregnancy and may obscure underlying arrhythmias. Additionally, the
presence of physiological left ventricular hypertrophy and displacement of the heart due to an
enlarging uterus may affect ECG morphology.
Positive actions a woman w/ heart disease to reduce/ eliminate complications:

1. Promote rest- 2 rest periods a day, fully resting, not getting up frequently, and a full night’s
sleep.
2. Promote healthy nutrition.
What foods improve heart health?
Foods to eat
Fish high in omega-3 fatty acids (salmon, tuna, and trout)
Lean meats such as 95% lean ground beef or pork tenderloin or skinless chicken or turkey.
Eggs.
Nuts, seeds, and soy products (tofu)
Legumes such as kidney beans, lentils, chickpeas, black-eyed peas, and lima beans.
3. Educate regarding medications.
4. Educate regarding avoidance of infection
5. Be prepared for emergency actions.

Nursing Intervention During Labor and Birth:

1. Assess vital signs including fetal heart rate and uterine contraction.
2. Assume a side lying position during labor to reduce the possibility of supine hypotension
syndrome.
3. Determine whether the fatigue a woman’s report is heart or labor related.
4. Women with extreme heart disease may need oxygen administered during labor.
5. Continuous hemodynamics monitoring.

Postpartum Nursing Intervention:

1. To compensate for circulatory changes, a woman may need a program of decreased activity and
possibly anticoagulant and digoxin therapy until circulation stabilizes.
How do you manage heart disease during pregnancy?
If the heart is not functioning well, women may be given digoxin (used to treat heart failure),
and bed rest or limited activity is advised, beginning at 20 weeks of pregnancy. During labor,
pain is treated as needed.
2. Anti-embolic stockings may be prescribed to increase venous return from the legs.
3. Prophylactic antibiotic be started immediately after birth.
4. Stool softener is advisable to prevent straining with bowel movements.
5. Promote uterine involution.
6. Kegel’s exercises are acceptable for perineal strengthening.
7. Postpartum exercises should be approved by the health care provider.
8. Ensure gynecological follow up and her cardiac status.

DIABETES IN PREGNANCY

Introduction
Diabetes mellitus is an endocrine disorders in which the pancreas cannot produce adequate insulin to
regulate glucose levels. The disorder affect 3% to 5% of all pregnancies and is most frequently seen
medical condition in pregnancy. Both T1 & T2 DM can be well managed with the 3 challenges have
developed.

1. How to manage both T1 & T2 DM during pregnancy to achieve a healthy glucose/insulin balance
during pregnancy.
2. How to protect an infant in utero from the adverse effects of increased glucose levels.
3. How to care for the infant in 1st 24 hours after birth until the infants- glucose regulatory
mechanism stabilizes.

Classification

1. Type 1 Diabetes Mellitus- affects 5% of adults, characterized by the destruction of the pancreatic
beta cells. Genetic susceptibility is a common underlying factor and auto immune response
wherein there is abnormal response in w/c antibodies are directed against normal tissues of the
body.
2. Type 2 Diabetes Mellitus- affects 95% of adults, commonly among people who are older than 30
years and obese.
3. Gestational Diabetes Mellitus- any degree of glucose intolerance with its onset in pregnancy.
Hyperglycemia developed during pregnancy because of the secretion of placental hormone w/c
causes insulin resistance. GDM occurs 18% of pregnant women and increases their risk for
hypertensive disorders during pregnancy.
4. Latent Autoimmune Diabetes of Adults (LADA)- is a subtype of diabetes in w/c the progression
of autoimmune beta cells destruction in the pancreas is slower than in T1 & T2. Clinical
manifestations shares on both T1 & T2.

Classic Clinical Manifestations:

1. Polyuria- increased urination.

2. Polydipsia- increased thirst.
3. Polyphagia- increased in appetite.

Other symptoms includes fatigue, weakness, dry skin, numbness and tingling sensation in hands or
feet, skin lesions or wounds that are slow to heal and recurrent infections. Sudden weight loss
nausea, vomiting and abdominal pain may also be associated w/ T1.

All pregnant women appear to develop an insulin resistance as pregnancy progresses that is
probably caused by the presence of the hormone human placental lactogen. This resistance is
helpful to women with healthy pregnancy because it prevents the maternal glucose from falling to
dangerous limits. Pregnancy with diabetes must then increase the insulin dosage beginning @ 24
weeks of pregnancy to prevent hyperglycemia.

Infants of pregnant w/ DM tend to be large 4,500 grams (macrosomia) because insulin serves as a
growth stimulant while the mother may develop Hydramnios because of increase glucose
concentration which causes extra fluid to shift and enlarge the amount of amniotic fluid.
 Approximately 2-3% women who do not begin pregnancy w/ DM. Usually it will occur in the
midpoint of pregnancy when there is insulin resistance. The symptoms fades at the completion of
pregnancy but the risk of developing type 2 later in life is 50-60%.

Risk Factors

1. Obesity
2. Age above 25 years
3. History of large babies
4. History of congenital anomalies of previous pregnancy
5. History of polycystic ovary syndrome
6. Family history
7. Member of population w/ high risk for DM
8. Native American, Hispanic, Asian

Treatment:

Insulin Short Acting given before breakfast and before dinner, subcutaneously.

Regular insulin

ANEMIA IN PREGNANCY

True anemia is typically considered to be present when woman’s hemoglobin concentration is less
than 11 grams in the 1st or 3rd trimester of pregnancy or when the hemoglobin concentration is less
than 10.5 grams in the 2nd trimester.

Types of Anemia

1. Iron deficiency anemia- most common anemia in pregnancy. These type of anemia is
characteristically microcytic (small red blood cell) and hypochromic (less hemoglobin) which
occurs due to inadequate supply of iron.
Prevention:
-take prenatal vitamins containing 27mg of iron as prophylactic therapy during pregnancy. Iron
is absorbed best in an acid medium. Usually prescribed as Ferrous Sulfate or Ferrous Gluconate.

- Eat a diet high in iron and vitamins (green leafy vegetables, meat, legumes)

2. Folic Acid Deficiency Anemia- one of the B vitamins, necessary in the normal formation of RBC

And associated with preventing neural tube defect and abdominal wall defect in the fetus. This

Deficiency commonly seen in multiple pregnancy due to increase fetal demand, who are taking
Anti-convulsant drug and those who had gastric bypass. The anemia that developed is Megaloblastic
anemia (enlarged red blood cells). All expecting to become pregnant are advised to begin a supplement
of 400 units folic acid daily in addition to eating folate rich food.

3.Sickle –Cell Anemia- recessively inherited hemolytic anemia caused by abnormal amino acid in
the beta chain of hemoglobin. Majority of the red blood cells are irregular in shape or sickled
shape so they cannot carry much hemoglobin as normally shaped hemoglobin.
Managing iron deficiency anemia typically involves addressing the underlying cause of iron
deficiency, such as dietary insufficiency, blood loss, or malabsorption, and replenishing iron
stores through supplementation and dietary changes.

Iron Deficiency Anemia:

Iron supplementation: Usually oral iron supplements are prescribed. In severe cases or when
oral supplements are not tolerated, intravenous iron may be necessary.
Dietary changes: Encouraging a diet rich in iron-containing foods like red meat, poultry, fish,
beans, lentils, spinach, and fortified cereals.
Treating the underlying cause: Addressing conditions such as gastrointestinal bleeding, heavy
menstrual bleeding, or malabsorption issues if present.

Folic Acid Deficiency Anemia:

Folic acid supplementation: Typically administered orally. Folic acid supplements are readily
available over the counter.
Dietary changes: Encouraging a diet rich in folate-containing foods such as leafy green
vegetables, fruits, whole grains, and fortified cereals.
Identifying and treating underlying causes: Malabsorption syndromes, alcoholism, and certain
medications can lead to folic acid deficiency.

Sickle Cell Anemia:

Pain management: Episodes of pain or "crises" are common in sickle cell disease and require
prompt and adequate pain relief.
Hydroxyurea therapy: This medication can reduce the frequency of pain episodes and acute
chest syndrome in some patients.
Blood transfusions: Regular transfusions may be necessary to prevent complications and
manage symptoms.
Hydration: Maintaining adequate hydration can help prevent sickling of red blood cells.
Antibiotics: Prophylactic antibiotics may be prescribed to reduce the risk of infections, which are
more common in individuals with sickle cell disease.
Bone marrow transplant: In severe cases, a bone marrow transplant may be considered as a
potential cure.