Cardiac Disorders:
Functional cardiac status changes in pregnancy
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Increase in intravascular volume
Decreased systemic vascular resistance
Cardiac output changes during labor and delivery
Intravascular volume changes that occur after delivery
Heart disease classification
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Class 1- asymptomatic with normal levels of activity
Class 2- symptomatic with normal levels of activity
Class 3- symptomatic with less than ordinary activity
Class 4- symptomatic at rest
o Determined at 3 mo. And again at 7-8 mo. Progression may occur
Risk factors
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Maternal arrythmias
Heart failure
Preterm birth
Fetal growth restriction
Fetal/maternal death (small risk)
Complications
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Peripartum Cardiomyopathy
o Development of CHF in the last month of pregnancy or withing the first 5 months
post-partum.
o From extra fluid during pregnancy
o Presents with dyspnea, cough, orthopnea, tachydysrhythmias, edema and
cardiomegaly
o Treat with diuretics, Na+ restriction, afterload-reducing agents, anticoagulants,
and digoxin
o Usually goes away on own, will need cardiologist monitoring after pregnancy for
6 mo.
o Antepartum care
 Limit activity
 Daily weight I+O
 Infection prevention
 Nutrition (iron, folic acid, high protein, Na+ restriction)
 Stool softeners, fiber
 Meds as needed, heparin or lovonox only for pregnancy
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Cardiac Decompensation
o Presents with increasing fatigue, difficulty breathing, smothering feeling, frequent
cough, palpitations, edema, irregular weak rapid pulse (>100 b/m) crackles at base
of lung, orthopnea, rapid respirations, moist frequent cough, cyanosis
o Intrapartum care
 ECG Monitoring, continuous O2 BP and fetal monitoring, Resp. status
monitoring, hemodynamic monitoring, ABG’s
 Goal to prevent hypotension, optimize cardiac output, prevent tachycardia
 Maintain volume, positioning, epidural to decrease workload,
induction, Valsalva maneuver, open glottic pushing, operative
vaginal delivery (forceps/vacuum) bacterial endocarditis
prophylaxis
o Postpartum care
 Assess: hemodynamic (cardiac output, BP, ABG) )2 sat, lung and heart
sounds, edema, uterine tone and fundal height, lochia, urinary output, pain
 Progressive activity, encouraging side lying position, prevent constipation,
pain management, meds (cardiac and diuretics)
Hypertensive Disorders:
Definitions
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Gestational Hypertension
o Onset of hypertension without proteinuria after 20 weeks
Preeclampsia/Preeclampsia with severe features
o Pregnancy specific, hypertension develops after 20 weeks with proteinuria,
proteinuria not always, may also have thrombocytopenia, impaired liver function,
new-onset renal insufficiency, pulmonary edema, new-onset cerebral or visual
disturbances.
Eclampsia
o Seizure activity or coma in women with preeclampsia, no hx of preexisting
condition, can occur before, after or during birth.
Chronic hypertension
o Present before pregnancy or diagnosed before 20 weeks
Chronic hypertension with superimposed preeclampsia
o Hypertension and acquired preeclampsia
Hypertension in Pregnancy
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Classification: SBP >140mmHg DBP >90mmHg MAP >105mmHg, dx onset during
pregnancy recorded on 2 separate occasions 4-6 hr apart, proteinuria (30mg/dL or more
on 2 random specimens collected 6 hr apart or 24 hr collection of 300mg/dL)(dipstick,
+1=30mg/dL +2=100 +3=300 +4=1000)
Chronic Hypertension
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Maternal complications
o Superimposed preeclampsia, stroke, acute kidney injury, heart failure, placental
abruption, death
Fetal complications
o Perinatal death, preterm birth, SGA, IUGR
Postpartum: high risk women monitored for complications such as renal failure,
pulmonary edema, heart failure, encephalopathy
Management before conception ideally. Lifestyle changes
Meds: Methylopa, labetalol, nifedipine, no ACE inhibitors
Gestational Hypertension
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Hypertension w/o proteinuria after 20 weeks or in the first 24 hours after birth w/o other
s+s of preeclampsia and preexisting HTN
BP returns to normal w/in 6 weeks of birth
Managed with rest and antihypertensives
Preeclampsia
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Development of hypertension and proteinuria after 20 weeks or early postpartum. In
absence of proteinuria may have thrombocytopenia, renal insufficiency, impaired liver
function, pulmonary edema, cerebral or visual symptoms.
Risks:
o Nulliparity, >40 years, assisted fertility, greater than 7 years between pregnancy,
hx of preeclampsia, SGA, obesity, GDM, preexisting medical condition, renal
disease, chronic hypertension, type 1 DM
Complications
o Maternal: cerebral edema hemorrhage or stroke. DIC, pulmonary edema, CHF,
renal failure, abruption
o Fetal: SGA, IUGR, pre-term, mortality 10-20%
Manifestations
o BP >140/90 x2 at least 4 hr apart after 20 weeks, proteinuria >300mg in 24 hr
specimen and >1+ on dipstick, platelet <100,000/uL, elevated liver enzymes,
increased creatine
o w/ severe features: BP >160/110, massive proteinuria >5g in 24 hr specimen,
<100,000 platelets, elevated liver enzymes, renal insufficiency, cerebral or visual
disturbances, pulmonary edema.
Prevention
o Aspirin. 81mg daily starting between 12-28 weeks
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Interventions
o Bedrest, high protein and low sodium diet, frequent BP assessment, daily weight,
daily fetal movement assessment, NST 1-2 times per week BPP as needed
o w/ severe features: decrease stimuli, FE replacement, seizure precautions, mag
sulf, deliver at 34 if possible.
HELLP Syndrome
o Hemolysis, Elevated Liver enzymes, Low Platelets
o Associated with preeclampsia with severe features.
o Hemolysis due to distorted or fragmented RBC’s damaging blood vessels.
Elevated liver enzymes from obstructed flow from fibrin deposits. Low platelets
from vascular damage with vasospasm and platelet aggression.
o Increased risk for:
 Pulmonary edema, renal failure, liver hemorrhage or failure, DIC
(disseminated intravascular coagulation) placental abruption, acute
respiratory distress syndrome, sepsis, stroke, fetal/maternal death
Magnesium Sulfate
o Decreases CNS irritability, helps to prevent seizures.
o May have bolus or continuous
o Side effects
 Lethargy, weakness, sweating, warm feeling, N/V, constipation, headache,
slurred speech
o Toxicity
 Decreased DTR, oliguria, confusion, slowed respirations (less than 12)
o Interventions: VS every hour, DTR assessment every hour, monitor I+O, monitor
serum mag, fetal monitoring
o Calcium Gluconate antidote
Postpartum Care
o Assess VS, I+O, DTR, LOC
o Mag sulfate infusion after birth for seizure precaution usually 24 hour.
o Assess regularly for s+s of preeclampsia
Eclampsia
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Seizure activity or coma in woman diagnosed with preeclampsia, no hx of previous
activity
o Preceded by: persistent headache, blurred vision, severe epigastric pr right upper
quadrant pain, ALOC. Tonic clonic