Cardiac disease in childbearing
- Created by: ljp101
- Created on: 20-02-20 14:54
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- Cardiac Disease in Pregnancy
- Normal cardiovascular changes in pregnancy
- Initial drop in BP in first trimester, then rise in BP from 34wks onwards
- Increase in blood volume
- Rise in pulmonary blood flow
- Hormones relaxin and progesterone reduce venous wall resistance
- Myocardial hypertrophy and chamber enlargement occur
- Mild multivalvular regurgitation occurs
- During labour cardiac output increases by 10-40% above pre-labour levels
- Rapid intravascular volume shifts in 1st 2wks postpartum
- Effects of these changes
- Haemodilution - drop in Hb
- Increased tiredness/ breathlessness on excretion
- Ankle oedema
- Varicose veins/ haemorrhoids
- Jugular veins distend, obvious pulsation
- Higher position of diaphragm, heart position moved
- Heart enlarges
- Effects of Cardiac disease (increased risk of...)
- Mother
- Miscarriage
- Pre-term labour
- C/S
- Worsening of some cardiac conditions
- Morbidity/ Mortality
- Fetus/baby
- Fetal death
- Pre-term labour
- IUGR
- Neonatal morbidity/ mortality
- Admission to NICU (side effects of maternal medication e.g. bradycardia, hypoglycaemia)
- Inheritance of certain cardiac conditions
- Requiring formula feeding (effects of some maternal drugs)
- Mother
- Incidence/ MBBRACE 2017
- 2013-2015 8.8 women per 100,000 died during pregnancy or the puerperium
- Two thirds of those women had pre-existing health problems.
- Cardiac disease is the greatest cause of indirect deaths
- Most deaths occurred in the postnatal period
- Rate has remained fairly constant in recent years
- Women with known heart disease are therefore high risk throughout
- Cardiac disease remains the leading cause of indirect maternal death during or up to six weeks after the end of pregnancy with a rate of 2.34 per 100,000 maternities
- 2013-2015 8.8 women per 100,000 died during pregnancy or the puerperium
- Pre-conceptional care and cardiac disease
- Expert assessment, advice and counselling
- Fully closed structural defects = low risk: otherwise high risk
- Risk of pregnancy, childbirth, puerperium explained.
- Echocardiography in some disorders (e.g. cardiomyopathy)
- Genetic counselling if necessary (risk of inheritance, e.g. Marfans)
- Long term affects of cardiac disease (Life expectancy)
- MRI scan, in some disorders
- Pregnancy Care
- Joint obstetric cardiac clinics and multidisciplinary care plans
- Communication shared with woman and all clinicians involved in her care, all writing in the womans hand held notes.
- Early involvement of senior obstetricians and cardiologists wherever cardiac disease is suspected (MBBRACE, 2016)
- Early booking is essential - accurate family and personal history
- Pregnancy increases risk of arrhythmia, heart murmurs, stroke, heart failure, PE, pre-eclampsia, endocarditis, pulmonary hypertension, aortic dissection, etc.
- Is it safe to continue the pregnancy? Advice and counselling
- Early and regular fetal screening
- Medication review- may need diuretics, anticoagulants, beta-blockers
- Some conditions may require pacemakers
- Follow up defaulters
- Obs at each AN appointment
- Clear plan of management for labour and birth
- Weight, diet management. Avoid anaemia
- Close vigilance for symptoms of deteriorating condition e.g. breathlessness
- Admission for bed rest, O2 therapy, O2 sats, may be required.
- Access to MRI and echocardiogram
- Preparation for possible pre-term delivery, IOL, or planned C/S
- Plan for PN support at home/care of baby in the event of maternal death
- Labour Care
- Raised resp. rate, chest pains, persistent tachycardia and orthopnoea (shortness of breath when supine) should always be fully investigated
- All consultant led maternity units should have ready access to an ECG machine and someone who can interpret ECGs.. Echocardiography should be available 7 days a week (MBBRACE, 2016)
- TED stockings
- Avoid fluid overload
- Anticoagulants as indicated - Warfarin for mums, Heparin for babies
- Anaesthetic review
- Prophylactic antibiotics as indicated
- IV access
- O2 sats if indicated
- Pain relief to reduce stress and BP - epidural
- 1 2 1 care
- Very close monitoring - EFM and maternal obs
- Avoid direct pushing, long second stage
- Elective CS or assisted birth may be indicated
- Oxytocin for third stage, NOT ergometrine/Syntocinon
- Postnatal Care
- Mother
- May need to be managed on ITU
- Medical review prior to discharge home
- Early ambulation if indicated
- Fluid balance monitoring
- Careful observations- longer than usual
- Plan of support at home to ensure sufficient rest, help with baby, minimize stress
- Promote compliance with ongoing care
- Plan of follow on care
- Advise on reporting any deterioration of symptoms or new symptoms
- Contraceptive advice
- Remember: Most maternal deaths occur in the postnatal period
- Baby
- BF check before advocating this, as may be contraindicated e.g. some forms of cardiomyopathy or with certain maternal medications
- NIPE by paediatric registrar or consultant, not midwife or student
- May require NICE/SCBU admission for treatment or monitoring
- May require referral to specialist unit or long term follow-up
- Ensure baby being suitably cared for if mother is unwell
- Mother
- Normal cardiovascular changes in pregnancy
- Cardiomyopathy
- 1:5000
- Characterised by ventricular dysfunction, cardiac failure
- Severe types
- May be genetic
- May occur for first time in late pregnancy
- Symptoms difficult to to differentiate from normal changes in pregnancy
- Requires multi-drug therapy and pacemaker/ defibrillator
- Risk of sudden death, hence TOP may be advised
- Ischaemic heart disease
- 1:10,000 - 1:30,000
- Due to inadequate blood flow to coronary arteries
- May lead to Angina and Myocardial Infarction (MI)
- Typical symptoms include...
- Chest pain
- Sweating
- Feeling of doom
- Breathlessness
- Dizziness
- Vomiting
- Can be asymptomatic
- Risk Factors
- Over 35years
- smokers
- obese
- diabetes
- cocaine use
- Family history
- Black or Asian ethnicity
- MI = 37-50% RISK OF DEATH
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