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dc Is one in which a concurrent disorder, pregnancy related complication, or
external factor jeopardizes the health of the woman, the fetus or both.
dc `overty
dc 0ack of support people circumstances that
dc `oor coping mechanisms causes women to be
dc uenetic inheritance high- risk
dc `ast history of pregnancy complications

FACTORS THAT CATEuORIZES A `REu A CY AS HIuH RISK

`sychological Social `hysical

`repregnancy dc History of drug dc Occupation dc ÿisual or hearing
dependence ( involving handling challenges
including alcohol) of toxic, dc `elvic inadequacy
dc History of substances ( or misshape
intimate partner including dc -terine
abuse radiation and incompetency,
dc History of mental anesthesia gases) position or
illness dc Environmental structure
dc History of poor contaminants at dc Secondary major
coping home illness ( heart
mechanisms dc Isolated disease, diabetes
dc Cohnitively dc 0ower economic mellitus, kidney
challenged level disease,
dc Survivor of dc `oor access to hypertension.
childhood sexual transportation for Chronic infection
abuse care such as
dc High altitude tuberculosis,
dc Highly mobile hemopoietic or
lifestyle blood disorder,
dc `oor housing malignancy)
dc 0ack of support dc `oor gynecologic
people or obstetric
history
dc History of
previous poor
pregnancy
outcome (
miscarriage,
stillbirth,
intrauterine fetal
death)
dc History of child
with congenital
anomalies
dc Obesity ( BMI >30)
dc -nderweight (

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 BMI <18.5)
dc `elvic
inflammatory
disease
dc History of
inherited disorder
dc Small stature
dc `otential of blood
incompatibility
dc Younger than age
18 years or older
than 35 years
dc Cigarette smoker
dc Substance abuser
`regnancy dc 0oss of support dc Refusal of or dc Subject to trauma
person neglected prenatal dc Fluid or
dc Illness of a family care electrolyte
member dc Exposure to imbalance
dc Aecrease in self environmental dc Intake of
esteem teratogens teratogen such as
dc Arug abuse ( dc Aisruptive family a drug
including alcohol incident dc Multiple gestation
and cigarette dc Conception less dc A bleeding
smoking) than 1 year after disruption
dc `oor acceptance last pregnancy dc `oor placental
of pregnancy formation or
position
dc uestational
diabetes
dc utritional
deficiency of iron,
folic acid, or
protein
dc `oor weight gain
dc `regnancy-
induced
hypertension
dc Infection
dc Amniotic fluid
abnormality
dc `ostmaturity
0abor and birth dc Severely dc 0ack of support dc Hemorrhage
frightened by person dc Infection
labor and birth dc Inadequate home dc Fluid and
experience for infant care electrolyte
dc Inability to dc -nplanned imbalance
participate cesarean birth
because of dc 0ack of access to
anesthesia continued health
dc Separation of care
infant at birth dc 0ack of access to
dc 0ack of separation emergency
for labor personnel or

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 dc Birth of infant equipment
who is
disappointing in
some way ( such
as sex,
appearance, or
congenital
anomalies)
dc Illness in newborn

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dc The most common cardiovascular disorders during pregnancy are

]c ÿalve damage caused by rheumatic fever or Kawasaki disease
]c Congenital anomalies ( atrial septal defect or uncorrected coarctation of the
aorta
dc As women delays their first pregnancy until later in life increase in the
incidence of coronary artery disease and varicosities during pregnancy.
dc In contrast heart disease that occur s specifically with pregnancy (
peripartum heart disease) still only rarely occurs as it is apparently unrelated to age.
dc A woman with cardiovascular disease needs a team approach to care during pregnancy
( combination of the obstetrician, internist and nurse)
dc Ideally:
]c ÿisit her obstetrician before conception for the health care workers to be familiar
with her state of health, to establish baseline evaluations of her heart functions
such as ECu.
]c Should have prenatal check-up as soon as she suspects that she is pregnant( 1
week after the first missed period)
dc ormally:
]c Increase blood volume and cardiac output 30-50% also a sign of
]c Half of the increase occurs at 8 weeks cardiovascular
]c Transient murmurs can be heard due to increase blood flow disease
]c Heart palpitations during exertion
c Aisappears after pregnancy
c 6omen who had rheumatic or Kawasaki disease may have both valvular
and organic murmurs.
c The danger of pregnancy in a woman with cardiac disease occurs primarily
because of the increase in circulatory volume.
c 6eeks 28-32 are considered the most dangerous time for women just after
the blood volume peaks.
c As a rule, a woman with artificial but well functioning heart valves can be
expected to complete a pregnancy without difficulty as long as she has
consistent prenatal and postpartum care.

Four categories of heart disease:

1.c Class 1 and II ² can expect to experience a normal pregnancy and birth.
2.c Class III ² can complete a pregnancy by maintaining almost complete bed
rest.
3.c Class Iÿ ² are poor candidates for pregnancy because they are in cardiac
failure even at rest and when they are not pregnant.
-c Advised to avoid pregnancy.

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dc Cardiac disease affects either the left or right side of the heart
dc     occurs in conditions such as:
a.c Mitral stenosis the left ventricle cannot move the volume of blood
b.c Mitral insufficiency forward that it has received by the left atrium from
c.c Aortic coarctation the pulmonary circulation.

Heart becomes overwhelmed it fails to function

Reason for failure is due to the level of mitral valve

c The inability of the mitral valve to push blood forward causes back-pressure on the
pulmonary circulation causing it to become distended; systemic blood pressure
decreases in the face of lowered cardiac output and pulmonary hypertension occurs.
c 6hen pressure in the pulmonary vein reaches a point about 25mmHg

Fluid begins to pass from pulmonary capillary membranes into the interstitial spaces
surrounding the alveoli

If severe: can·t sleep in any

position except orthopneic
position= allows fluid to
settle to the bottom of her
lungs and free spaces for gas
exchange.

Also notices paroxysmal

nocturnal dyspnea ( sudden
waking at night with
shortness of breath)----
occurs bec heart action is
more effective at rest.------
more effective----interstitia
fluid returns to the
circulation
overburdens the
circulation
causing left side
failure and

Alveoli (pulmonary edema)

Ayspnea

If pulmonary capillaries rupture under the pressure= small blood leak into the alveoli and a
productive cough of blood speckled sputum develops.

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 c 6omen with pulmonary hypertension are extremely high risk for:
]c Spontaneous miscarriage
]c `reterm labor
]c Maternal death
c As o2 saturation decreases chemoreceptors stimulate the respiratory center

Increase respiratory rate

c As the systemic decrease in B` registers on pressoreceptors in the oarta

Heart rate increases and peripheral vasoconstriction occurs in an attempt

to increase the systemic blood pressure

c As the fall in B` is registered with the renal angiotensin system retention of

both sodium and water occurs.
c The placenta may not receive adequate blood because of the decreased peripheral
circulation.
c 
 
 difficult for the blood to leave the left atrium that a
secondary problem of thrombus formation can occur from noncirculating blood.
]c eed an anticoagulant to prevent mitral stenosis
c ?
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 is causing difficulty
]c Aissection of the aorta from high blood pressure from typing to push
blood past the constriction can occur.
]c `rescribed antihypertensive to control B`
]c Aiuretics to decrease blood volume
]c Beta blockers to improve ventricular filling
c If complications result in impaired blood flow to the uterus
a.c `oor placental perfusion needs -TZ and nonstress test
b.c Intrauterine growth restriction after 30-32 weeks of pregnancy
c.c Feta abnormality may occur to monitor fetal health

Balloon valve angioplasty- to loosen

mitral valve adhesions can be
perform safely during pregnancy



 ² drug of choice for early pregnancy . Anticoagulant

-c o teratogenic effect
-c Aoes not cross the placenta and the fetus

 

 ? ) ² can be used after week 12 but a woman will returned to
heparin therapy during the last month of pregnancy======for the fetus not to develop a
coagulation disorder at birth.

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 dc
     ² occurs when the output of the right ventricle is less than
the blood volume received by the right atrium of the vena cava.
]c Back pressure results in congestion of the systemic venous circulation and
decreased cardiac output to the lungs
]c 0ess blood B` decreases in the aorta
`ressure is high in the vena cava leading to:
From back pressure ob blood jugular venous distention

`ortal circulation
]c 0iver and spleen become distended
]c 0iver enlargement cause extreme dyspnea and pain enlarged uterus
pushes the enlarged liver upward and presses the diaphragm.
]c Aistended abdominal vessels can lead to exudates of fluid from the vessels into
the peritoneal cavity (ascites) and into the systemic circulation into lower
extremity interstitial spaces ( JJ !)
]c
"!"  #"$! ² a congenital anomaly apt to cause right sided heart
failure in women of reproductive age.
Àc Advised not to become pregnant
Àc If they become pregnant:
-c Hospitalized for the last part of pregnancy
-c eed oxygen administration
-c Frequent arterial blood gas assessment to ensure fetal growth
-c Auring labor: they need pulmonary artery catheter inserted to
monitor pulmonary pressure.
-c eed extremely close monitoring after epidural anesthesia to
minimize the risk of hypotension.
dc J %$!#$J#
]c Can originate in women with no previous history of heart disease
]c Occurs from previously undetected heart disease
]c Occurs most often in African American multiparas in conjunction with
hypertension.
]c Signs of myocardial failure:
Àc Shortness of breath
Àc Chest pain
Àc Edema
]c Reduce her physical activity
]c eed diuretic, arrhythmia agent, digitalis to maintain heart action
]c $& !$% &  J" may be administered to decrease the risk of
thromboembolism.
]c  %$!#$J# J J  J$J! J$----woman not to have
further pregnancies.
]c  %$"%J' are contraindicated because of danger of
thromboembolism

!" $  &$!" & %% (

dc Thorough health history---to document her prepregnancy cardiac status

]c Ask her level of exercise performance
]c Ask if she has cough or edema
]c Instruct the woman to report coughing during pregnancy---bec pulmonary
edema from heart failure may first manifest itself as a simple cough.
c ormal edema of pregnancy involves only the feet and ankles
c Edema of pregnancy induced hypertension usually begins after week 20.
]c  " $  :
Àc Edema

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 Àc Irregular pulse
Àc Rapid or difficult respirations
Àc Chest pain on exertion
]c Making comparison assessment for nail bed ( should be <5 seconds)
]c iugular venous distention
]c Assess liver size ( heart dss involves right sided heart failure)- difficult to
assess, since the uterus presses the liver upward under the ribs and difficult to
palpate.
]c Echocardiography
]c Chest radiograph----- abdomen is covered with lead apron during exposure
]c ECu------ less accurate because ty
]c He enlarge uterus presses upward on the diaphragm and displaces the heart.

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]c Cardiac failure affect fetal growth

Àc Maternal blood pressure becomes insufficient to provide an adequate supply of
blood and nutrients to the placenta.
Àc 0ow birth weight
Àc acidotic fetal environment
Àc `reterm labor
Àc Immaturity
Àc Infant may not respond to labor ( late decelerations)

ote: 6hen cardiac output is not enough to meet systemic body demands---peripheral
vasoconstriction occurs because the uterus is a peripheral organ that causes the
uterine/placental constriction.

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