Cardiac Diseases in Pregnancy Presentation

Introduction

• USA experiences an increase in cardiovascular diseases.
• Pregnancy affects the cardiovascular system.
• 50% increased heartbeat rate and decrease in blood pressure and up to 4% of pregnancies may have complications (Balci et al., 2014).

The USA is one of the leading nations in the number of cardiovascular complications per capita. This, along with being the first place in the world for child and adult obesity, creates a plethora of potential complications during pregnancy. Pregnancy affects a woman’s cardiovascular system, as she now has to supply the blood not only for herself, but also for the baby, which means an increased heartbeat rate and decreased blood pressure for prolonged periods of time (Balci et al., 2014). Such conditions can cause the development of cardiac diseases and potential complications. The purpose of this presentation is to provide the class with theoretical and practical information about the disease, its incidence, and the appropriate nursing process.

Causes of the Disease

• Rheumatic heart disease (75% of all cases).
• Congenital heart diseases (10-20% of all cases).
• Other causes (5%) (Balci et al., 2014).

The majority of complications during pregnancy are caused by the rheumatic heart disease. It is a condition derived from damage to the heart valves caused by a rheumatic fever. Mitral valve is the one most likely to be affected, though the aortic valve can sometimes cause RHD as well. These make up for roughly 75% of all cardiac complications during pregnancy. Congenital heart diseases are the second most likely causes of RHD (Balci et al., 2014). These include acyanotic and cyanotic complications, based on the location of the shunt. Acyanotic RHD typically includes septal defects and ductus arteriosus, whereas cyanotic RHD is characterized by Fallot’s tetralogy and Eisenmenger’s syndrome. The latter is responsible for roughly 25% of total maternal mortalities (Balci et al., 2014).

Nursing Process: Diagnosing the Disease

• Patient’s history (Ruys et al., 2013):
  • Rheumatic fever;
  • Dyspnea and Nocturnal Dyspnea;
  • Hemoptysis and Prophylaxis using long-acting penicillin.

The process of assessing the patient for the likelihood of developing a cardiac disease during pregnancy should begin with the analysis of the patient’s history of diseases. If there is evidence of previously-encountered symptoms of heart disease, such as dyspnea, hemoptysis, and rheumatic fever, there is a high chance of developing a rheumatic heart disease or some other anomaly (Ruys et al., 2013). The use of long-acting penicillin is a good indication of a patient having suffered through an episode of rheumatic fever, which is the primary cause of cardiac complications during pregnancy.

Nursing Process: Primary Examination

• Heart murmurs and Arrhythmia.
• Central cyanosis.
• Manifestations of left or right-side heart failure (Ruys et al., 2013).

During the primary examination, the nurse should listen to the heart rhythm for any abnormalities. Although the heartbeat rate of a pregnant patient should be increased by 30-50%, especially in the later stages of pregnancy, it is necessary to look for sounds that indicate improper heart rhythms. The most common symptoms of a cardiac abnormality during pregnancy include heart murmurs, arrhythmia, central cyanosis, and manifestations of left or right-side heart failure, which could be attributed to Fallot’s tetralogy and Eisenmenger’s syndrome (Ruys et al., 2013). It is important to rule out these possibilities early on, due to their increased danger to the patient.

Nursing Process: Investigations

• Chest X-ray.
• Electrocardiography.
• Echocardiography (Van Hagen et al., 2016).

After the primary inspection has been completed, the patient would be required to undergo several tests in order to ensure that the preliminary diagnosis was correct. Chest X-ray is one of the most common methods of studying the heart, as it may show signs of cardiac enlargement, pulmonary congestion, or pleural effusion (Van Hagen et al., 2016). Electrocardiography and echo cardiography are commonly used to show the patient’s cardiac structure and functionality. It is more accurate and efficient than simply listening to the heartbeat during the initial healthcare assessment.

Chances of Heart Failure

• Most likely to occur during the 28-32nd week of pregnancy.
• During the 2nd stage of birth.
• After child delivery (Van Hagen et al., 2016).

The presence of a heart disease during pregnancy increases the potential chances of heart failure during various stages of pregnancy. The majority of heart failures occur during the last month of pregnancy as well as during birthing, as it is when the cardiovascular system experiences the most stress. The blood volume and cardiac output can overwhelm the heart muscle and cause a failure. After delivery, the failure may occur because of the overload of the circulatory system by the blood from the placenta and the retraction of the uterus (Van Hagen et al., 2016).

Mini-Care Plan (Potential Diagnosis)

• Potential diagnosis: Congenital Heart Disease (CHD):
  • May include acyanotic or cyanotic heart lesions;
  • Fetal echocardiogram at 20 weeks of gestation;
  • May require tertiary care and adult cardiac care (“Cardiac disease,” 2014).

Congenital heart failure may present itself through a variety of symptoms, such as acyanotic and cyanotic heart lesions. The care plan includes checking for atrial and ventricular defects, aortic coarctations, and signs of Fallot’s tetralogy. Fetal echocardiogram is required to determine if the fetus is the cause of irregularity, as there is a 5% risk of associated chromosomal abnormalities (“Cardiac disease,” 2014). Tertiary care is associated with amniocentesis with antibiotic prophylaxis.

Mini-Care Plan (Actual Diagnosis)

• Actual Diagnosis: Heart Failure and Cardiomyopathy:
  • Can be left or right-sided, or biventricular. Clinical assessment includes ECG, exercise testing, and stress echocardiography;
  • Beta-blockers, diuretics, rhythm control, and internal cardiac defibrillation;
  • Regular vaginal birth preferred (“Cardiac disease,” 2014).

Heart failure and cardiomyopathy during pregnancy are typically caused by iatrogenic fluid overload, thyrotoxicosis, peri-partum cardiomyopathy, anemia, and previous cases of rheumatic or congestive heart diseases. The diagnosis and care plan for a patient with this disease includes ECG, exercise testing, and stress echocardiography to confirm the diagnosis (“Cardiac disease,” 2014). The primary treatment for the disease would include the use of various medicines, such as beta blockers and diuretics, as well as rhythm control exercises. In extreme cases of likely heart failure, an internal defibrillator may be installed to keep the heart beating. Regular vaginal birth is recommended, as a C-section would put unnecessary strain on the body.

References

Balci, A., Sollie-Szarynska, K. M., van der Bijl, A. G. L., Ruys, T. P. E., Mulder, B. J. M., Roos- Hesselink, J. W., … Pieper, P. G. (2014). Prospective validation and assessment of cardiovascular and offspring risk models for pregnant women with congenital heart disease. Heart, 100(17), 1373–1381.

Cardiac disease in pregnancy. (2014). Web.

Ruys, T. P. E., Roos-Hesselink, J. W., Hall, R., Subirana-Domènech, M. T., Grando-Ting, J., Estensen, M., … Pieper, P. G. (2013). Heart failure in pregnant women with cardiac disease: Data from the ROPAC. Heart, 100(3), 231–238.

Van Hagen, I. M., Boersma, E., Johnson, M. R., Thorne, S. A., Parsonage, W. A., … Escribano Subías, P. (2016). Global cardiac risk assessment in the Registry Of Pregnancy And Cardiac disease: Results of a registry from the European Society of Cardiology. European Journal of Heart Failure, 18(5), 523–533.