High-Risk Antepartum Nursing

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Chapter 7 High-Risk Antepartum Nursing
Pre-gestational Complications
For some women, pregnancy represents significant risk because it is superimposed on preexisting illness Cardiovascular Disorders
Classifications
Risks for woman
Risks for newborn
Assessment findings
Management
Nursing actions
Cardiovascular Disorders
Congenital heart disease is becoming more common as more women are surviving into their reproductive years.  Stuff you already know:
Normal heart compensates for increased workload
Major cardiovascular changes during pregnancy are:
Increased intravascular volume – 1500 cc’s
Decreased systemic vascular resistance d/t peripheral vasodilation Cardiac output changes during labor and birth –
During each contraction, an average of 400 ml of blood is emptied from the uterus into the maternal vascular system increases cardiac output by about 12% to 31% in the first stage and by about 50% in the second stage

Intravascular volume changes that occur just after childbirth  Diseased heart is hemodynamically challenged
Cardiac conditions account for 10-25% maternal mortality Pulmonary HTN - Maternal mortality rate of more than 50% during pregnancy associated with pulmonary hypertension Endocarditis
CAD
Cardiomyopathy
Sudden arrhythmias
Maternal and neonatal outcomes based on classification (severity) of maternal heart disease – Degree of disability often more important in treatment and prognosis Greatest risk for women who have had at least one of the following: A prior cardiac even or arrhythmia

Think of my patient with Lupus and hx of MI who ended up dying two weeks postpartum NY Heart Assn functional Class II or greater
Cyanosis
Left heart obstruction
Systematic ventricular dysfunction
Estimated risk of cardiac event during pregnancy
If they have:
None of the abovethen risk is5%
One of the above then risk is27%
More than one then risk is75% (!!!)
Preconception counseling crucial
Women with cardiac disease must be assessed and diagnosed as soon as possible Peripartum cardiomyopathy (PPCM) –
40 yo primip who presented to triage, delivery was imminent, precipitous (fast) delivery there in triage, She was getting ready to go home, walking around the room getting dressed and hit the floor … CODED !!! Postpartum MI secondary undiagnosed cardiomyopathy.

Rheumatic heart disease (RHD)
Mitral valve stenosis
Mitral valve prolapse (MVP) – antibiotics during labor Atrial septal defect (ASD)
Tetralogy of Fallot
Marfan syndrome
Heart transplantation
Increasing numbers of heart recipients are successfully completing pregnancies Before conception, woman must be assessed for quality of ventricular function and potential rejection of transplant Vaginal birth is desired, but transplant recipients have increased rate of cesarean births Neonate may exhibit immunosuppressive effects during first week of life Breastfeeding is not advised for infants of mothers taking cyclosporine  Assessment

Weekly assessments for high risk pregnancy
Interview
Physical examination
Laboratory and diagnostic tests
Plan of care and interventions
Therapy focused on minimizing stress on heart
Signs and symptoms of cardiac decompensation
Pg 695 Table 22-4, Nsg Dg, S/S complications
Bed rest
Infections treated promptly
Cardiac medications as needed
Anticoagulant therapy
Heparin or LMWH
Does not cross the placenta
Heart surgery during pregnancy – wouldn’t want to go there Intrapartum care – this woman is not going to deliver in Stephenville, Texas or Jasper, Ga. She needs access to specialized care – possibly even ICU admission. I admitted a patient to the ICU for labor. The anesthesiologist wanted me to monitor central venous pressures in the LD unit … I refused, chg nurse refused … labored her in...
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