MANAGEMENT OF CARDIAC

DISEASE IN LABOR, DELIVERY AND PEURPERIUM

PRESENTER: H.OSMAN

Objectives

 Define cardiac disease

 List the two main types of cardiac disease in pregnancy
 Explain 3 congenital heart defects in pregnancy
 Verbalize 3 types rheumatic heart disease in pregnancy.
 Name 4 risk factors of heart disease to the mother and to fetus in pregncy.
 Explain 2 medical and 2 nursing management during labor, delivery and peurperium.

introduction

 Cardiovascular disease in pregnancy is a relatively uncommon in women of child bearing age

complicates about 1% of pregnancies.
 the numbers of women who have a pre- existing cardiovascular disease or develop cardiac
problems during pregnancy are increasing and, due to the lack of evidenced-based data, this
provides challenges for the treating physician.
 Maternity mortality related to heart disease has decreased remarkably over the past 50 years
(from 6.6 to 0.3/100 000 live births.

Cardiac disease.

structural or functional abnormality of the heart, or of the blood vessels supplying the heart, that impai
rs its normal functioning.

Types of cardiac conditions

majority of cardiac conditions encountered during pregnancy will be either;

 congenital heart disease

 rheumatic vulvar disease.

Congenital heart disease

Most common congenital defects are:

I.Atrial septal defect is a hole in the wall between the two upper chambers of your heart (atria)
II.Patent ductus arteriosus is a persistent opening between two major blood vessels leading from the
heart

III.Ventricular septal defect is a hole that occurs in the wall that separates the heart's lower chambers
(septum) and allows blood to pass from the left to the right side of the heart.

Rheumatic heart disease

 it is Permanent damage to the valves of the heart usually caused by repeated

 attacks of rheumatic fever.includes:
 Mitral and aortic valve incompetence .(MR)
 is defined as an abnormal reversal of blood flow from the left ventricle (LV) to the left atrium
(LA). It is caused by disruption in any part of the mitral valve (MV) apparatus. Aortic valve
incompetence is where blood leaks back through the aortic valve.
Mitral stenosis is a disorder in which the mitral valve does not fully open. This restricts the flow
of blood.

Risk to the mother and fetus

Mother

 Predispose to bacterial endocarditis

 Thromboemboli
 Cyanosis
 Heart failure

Risk to the fetus

 Growth retardation
 Fetal loss is high
 Increase incidence of congestive heart disease.

Grading of heart disease

 Class I (no symptoms) You have no symptoms and can perform daily activities without feeling
tired or short of breath.
 Class II (mild symptoms)You are comfortable when resting, but moderate activity makes you
tired or short of breath.
 Class III (moderate symptoms) You are comfortable when resting, but even limited physical
activity makes you tired or short of breath.
 Class IV (severe symptoms) You are unable to do any physical activity without discomfort
and experience some symptoms at rest.

Aims of management
The main aims of management are:

 to optimize the mother's condition during the pregnancy.

 To monitor for deterioration; and minimize any additional load on the cardiovascular system
from delivery and the post-partum period.
 Women with heart failure can be safely treated with diuretics, digoxin, and hydralazine, nitrates,
or both as vasodilators to offload the left ventricle

Intrapartum care

a. The first stage of labour

 In view of the increase in cardiac output during labour and immediately after the birth it is
important to plan for and manage labour carefully.
 A coordinated team approach with good communication between the midwife, obstetrician,
cardiologist, neonatologist, anaesthetist, the woman and her family is essential
 Women with heart disease often have quite rapid, uncomplicated labours. Vaginal birth is
preferred unless there is an obstetric indication for caesarean section.
 Optimal management involves monitoring the maternal condition closely; this will include the
measurement of temperature, pulse, respiration,blood pressure and urine output.

Coronary artery disease is uncommon in premenopausal women of child.

– majority of cardiac conditions encountered during pregnancy will be either congenital heart disease or
rheumatic valvar disease.

Pulse oximetry may be utilised to assess arterial haemoglobin saturation, which may be reduced in
women with heart disease owing to disruption of normal gas exchange between the lungs and blood.

If oxygen saturation levels fall below 92%, oxygen therapy will be required.

Blood and urine test.

Blood and urine tests are utilised to determine the haematological and metabolic changes occurring
during labour. There also needs to be a risk assessment for the stress of labour and the maintenance of
an adequate blood volume

Fluid balance

•Women with significant heart disease require care concerning fluid balance in labour.

•Indiscriminate use of intravenous crystalloid fluids will lead to an increase in circulating blood volume,
which women with heart disease will find difficult to cope with and they may easily develop pulmonary
oedema

Pain relief
midwife should help the woman to use the techniques that she has learned for coping with stress, as
she and her labour companion are likely to be very anxious.

In the majority, an epidural would be the analgesia of choice, inserted by a skilled anaesthetist. It is an
effective form of analgesia that decreases cardiac output and heart rate. It causes peripheral
vasodilatation and decreases venous return, which alleviates pulmonary congestion

Positioning

•Cardiac output is influenced by the position of the labouring woman.

•It is important to remember that women with heart disease are particularly sensitive to aortocaval
compression by the gravid uterus in the supine position. This decreases the cardiac output by inhibiting
venous return to the heart resulting in maternal hypotension and fetal bradycardia.

• It is better that all labouring women, as well as those with heart disease, adopt an upright or left
lateral position and are encouraged by the midwife to find a position in labour that is comfortable.

Preterm labour

• If a woman with heart disease should labour prematurely then beta sympathomimetic drugs widely
used for the treatment of premature labors are contraindicated, the vasodilatory side-effects of these
cause tachycardia, and an inaease in the circulating blood volume and cardiac output.

•This may lead to the development of pulmonary oedema. In addition, these drugs have metabolic
effects that may further impair myocardial function

Induction

•The least stressful labour for a woman with cardiac disease will be spontaneous in onset; induction is
considered safe only if the benefits outweigh the disadvantages.

•Prostaglandins should be used with caution as they are potent vasodilators and cause a marked
increase in cardiac output.

•Oxytocin by intravenous infusion causes a degree of fluid retention and it is important for the midwife
to keep a careful record of fluid balance if this is used.

b.The second stage of labour

•This should be short without undue exertion on the part of the mother.

•Prolonged pushing with held breath such as the Valsalva manoeuvre, which is undesirable for healthy
women, may be dangerous for a woman with heart disease.

•It raises the intrathoracic pressure, pushes the blood out of the thorax and impedes venous return,
with the result that cardiac output falls.
•Preferably the woman should not lie in. the lithotomy position, where the lower part of the body is
higher than trunk, as this produces a sudden increase in venous return to the heart, which may result in
heart failure.

c.The third stage of labour

•This is usually actively managed owing to the increased risk of postpartum hemorrhage (PPH).

•Oxytocin is the drug of choice but its use in the prevention of PPH must be balanced against the risk of
oxytocin-induced hypotension and tachycardia in women with cardiovascular compromise.

•Administration should follow the policy of the institution. Ergot-containing preparations such as
ergometrine (R) are contraindicated as this act on smooth muscle and will have a direct effect on the
heart as well as producing a tonic uterine contraction

2.Postnatal care

•During the first 48 hours following birth the heart must cope with the extra blood from the uterine
circulation and it is important that the midwife monitors the woman’s condition during this time.

•Close observation should identify early signs of infection, thrombosis or pulmonary oedema.

•Breastfeeding is not contraindicated as cardiac output is not affected by lactation.

•The importance of rest and an adequate diet whilst breastfeeding must be emphasized

•Discharge planning is particularly important for women with heart disease.

•The woman and her partner will need to discuss the implications of a future pregnancy with the
cardiologist and obstetrician.

•Family planning should be encouraged.

conclusion

Although there is still a challenge in management of cardiac disease in pregnancy, there is an increase in
advance in methods of management. It is therefore very crucial to follow them effectively.

references

Fraser, M.D., Cooper, MA. & Nolte, A.G.W.2003. Myles textbook for midwives 2nd ed. Philadelphia:
Churchill Livingston.

Pilliteri A. 2009. Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family. 6th ed.
Philadelphia: Wolters Kluwer/ Lippincott Williams and Wilkins

http://cardiovascres.oxfordjournals.org/content/101/4/555