Transcript Medical-Surgical Problems in Pregnancy 2015 use this

Medical-Surgical Problems
with Pregnancy
Cardiovascular Disorders
Degree of disability experienced by the woman with
cardiac disease is often more important in treatment and
prognosis of cardiac disease complicating pregnancy
than is the diagnosis of cardiovascular disease
New York Heart Association (NYHA’s)
Class I –asymptomatic at normal levels of activity
Class II- symptomatic with ordinary activity
Class III-symptomatic with less than ordinary activity
Class IV- symptomatic at rest
A clinic nurse has provided home care instructions to a client with a
history of cardiac disease who has just been told that she is pregnant.
Which statement by the client indicates a need for further instruction?
1.“During the pregnancy I need to avoid contact
with other individuals as much as possible to
prevent infection.”
2.“I need to avoid excessive weight gain to
prevent increased demands on my heart.”
3.“It is best that I rest by lying on my left side to
promote blood return to the heart.”
4.“I need to try to avoid stressful situations
because stress increases the workload on the
heart.”
Congenital Cardiac Disease
Septal Defects
Atrial Septal Defect-an abnormal opening
between the atria
One of the causes of a left-to-right shunt
Most common congenital defects seen during
pregnancy
Defect may go undetected because the woman
usually is asymptomatic
Woman will have an uncomplicated pregnancy
Some women have right-sided heart failure or
arrhythmias as the pregnancy progress as a
result of increased plasma volume
Congenital Cardiac Disease
Septal Defects
Ventricular Septal Defect-an abnormal
opening between the right and left
ventricles
Another cause of a left-to right shunt
Usually diagnosed and corrected early in
life
Congenital Cardiac Disease
Septal Defects
Ventricular Septal Defect
Women with large ventricular septal
defect-there is a higher risk arrhythmias,
heart failure and pulmonary hypertension
Medical management includes-rest and
decreased physical activity, as well as
administration of anticoagulants
Acyanotic Lesions
Coarctation of the Aorta-localized
narrowing of the aorta near the insertion of
the ductus
Should be corrected surgically before
pregnancy
Pregnancy is usually relatively safe for the
woman with uncomplicated uncorrected
coarctation
Acyanotic Lesions
Coarctation of the Aorta
Complications include hypertension,
congestive failure, infective endocarditis,
cerebrovascular accident, aortic
dissection, aneurysm and rupture
Treatment during pregnancy-rest and
antihypertensive medications, preferably
beta adrenergic agents
Acyanotic Lesions
Coarctation of the Aorta
Beta blockers should be continued
throughout labor
Risk of endocarditis, antibiotic prophylaxis
is recommended at birth
Cyanotic Lesions
Tetralogy of Fallot-most common cyanotic
heart disease observed during pregnancy
Include a ventricle septal defect,
pulmonary stenosis, overriding aorta, and
right ventricular hypertrophy, leading to a
right-to left shunt
Encouraged to have surgical repair before
conception
Cyanotic Lesions
Tetralogy of Fallot
Women with uncorrected tetralogy of
fallot-experience more right-to-left
shunting during pregnancy
Reduced blood flow through the
pulmonary circulation and increasing
hypoxemia
Cause syncope and death
Cyanotic Lesions
Tetralogy of Fallot
Most dangerous time for these women is
the late third trimester of pregnancy
Venous return is reduced by the large
pregnant uterus
By peripheral venous pooling after birth
Cyanotic Lesions
Tetralogy of Fallot
Use of pressure-graded support hose is
recommended
Prophylactic antibiotics should be given
during the intrapartum period
Acquired Cardiac Disease
Mitral Valve Stenosis-narrowing of the
opening of the mitral valve caused by
stiffening of valve leaflets
Which obstructs blood flow from the left
atrium to the left ventricle
Characteristic lesion resulting from
rheumatic heart disease
Acquired Cardiac Disease
Mitral Valve Stenosis
Tight stenosis plus the increase in blood
volume and cardiac output of normal
pregnancy may cause:
Pulmonary edema, atrial fibrillation, rightsided heart failure, infective endocarditis,
pulmonary embolism and massive
hemoptysis
Acquired Cardiac Disease
Mitral Valve Stenosis
Pharmacologic treatment for women with a
history of rheumatic heart disease may
include: diuretics such as furosemide
(Lasix) to prevent pulmonary edema
Beta-blockers or calcium channel blockers
to prevent tachycardia
Acquired Cardiac Disease
Mitral Valve Stenosis
Women who have chronic atrial fibrillation
may require digoxin and beta-blockers or
calcium channel blockers to control heart
rate
Anticoagulant therapy may be needed to
prevent embolism
Acquired Cardiac Disease
Mitral Valve Stenosis
Care of the woman with mitral stenosis
typically is managed by: reducing her
activity, restricting dietary sodium and
monitoring weight
Should be assessed clinically for
symptoms with echocardiograms to
monitor the atrial and ventricular size as
well as heart function
Acquired Cardiac Disease
Mitral Valve Stenosis
Prophylaxis fir intrapartum endocarditis
and pulmonary infections may be provided
for women at high risk
Acquired Cardiac Disease
Mitral Valve Prolapse
Common usually benign, condition
Mitral valve leaflets prolapse into the left
atrium during ventricular systole, allowing
some backflow of blood
Most cases are asymptomatic
Few women have atypical chest pain
(sharp and located in the left side of the
chest) that occurs at rest, unrelated to
exercise, and does not respond to nitrates
Other Cardiac Diseases and
Conditions
Marfan Syndrome-auotosomal dominant
genetic disorder characterized by
generalized weakness of the connective
tissue
Resulting in joint deformities, ocular lens
dislocation and weakness of the aortic wall
and root
Other Cardiac Diseases and
Conditions
Marfan Syndrome-associated
cardiovascular changes include mitral
valve prolapse, mitral regurgitation, aortic
regurgitation, aortic root dilatation, and
possible dissection or rupture of the aortic
root
Majority of deaths from Marfan Syndrome
are caused by aortic dissection and
rupture
Other Cardiac Diseases and
Conditions
Marfan Syndrome
Management during pregnancy includes
restricted activity and use of beta-blockers
Surgery may be indicated in some women
Other Cardiac Diseases and
Conditions
Peripartum Cardiomyopathy-is congestive
heart failure with cardiomyopathy
Clinical manifestations include: dyspnea,
fatigue, edema as well as radiologic
findings of cardiomegaly
Other Cardiac Diseases and
Conditions
Peripartum Cardiomyopathy
Medical management includes a regimen
used for congestive heart failure; diuretics,
sodium and fluid restrictions, after-loadreducing agents and digoxin
Anemia
 Most common medical
disorder of pregnancy
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Results in reduction of the
oxygen-carrying capacity of
the blood, and the heart tries
to compensate by increasing
the cardiac output
An indirect index of the
oxygen-carrying capacity is
the packed red blood cell
(RBC) volume, or hematocrit
level
Woman who have anemia
during pregnancy, the loss of
blood at birth, even minimal, is
not well-tolerated
A nurse is reading the physician’s notes following assessment of a
pregnant client seen in the health care clinic and notes that the client is
diagnosed with physiological anemia. The nurse plans care knowing
that:
1.The client definitely requires additional
iron supplementation
2.This condition indicates a true anemia
3.Reduced plasma volume occurs in
pregnancy, causing this condition
4.This condition reflects the dilution of red
blood cells
Iron Deficiency Anemia
Diet alone cannot
replace gestational
iron losses
Oral iron supplements
Woman should be
instructed in dietary
ways to decrease the
GI side effects of iron
therapy
Folic- Acid Deficiency Anemia
During conception
and early pregnancy
increases the
incidence of neural
tubes, cleft lip and
palate
Second most
common anemia
Recommended daily
intake is 400 mcg of
folic acid per day
Sickle Cell Anemia
 Sickle Cell Hemoglobinopathy

A disease caused by the presence
of abnormal hemoglobin in the
blood
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Sickle cell trait-sickling of the
RBCs but with a normal
RBC lifespan, usually causes only
mild clinical symptoms
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Sickle cell anemia-is a recessive,
hereditary, familial hemolytic
anemia that affects those of
African-American or
Mediterranean ancestry
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Increase in urinary tract infections
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Deficient in iron
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Fetal complications include being
small for gestational age,
intrauterine growth restriction, and
skeletal changes
Asthma
o Most common respiratory crisis
complicating pregnancy
Effect of pregnancy on asthma
is unpredictable
Severity of symptoms usually
peaks between 17 and 24
weeks gestation
Therapy for asthma has three
objectives
Almost all asthma medications
are considered safe in
pregnancy
Cystic Fibrosis
A common autosomal recessive genetic disorder
in which exocrine glands produce excessive
viscous secretions, which cause problems with
both respiratory and digestive functions
Throughout pregnancy-frequent monitoring of
the woman’s weight, blood glucose, hemoglobin,
total protein, serum albumin, prothrombin time,
and fat soluble vitamins A and E is suggested
Cystic Fibrosis
Fetal assessment is essential given that
the fetus is at risk for Uteroplacental
insufficiency, which can result in IUGR
Fundal height should be measured
routinely
Ultrasound examinations performed to
evaluate fetal growth and amniotic fluid
volume
Cystic Fibrosis
Fetal movement counts are often
recommended starting at 28 weeks of
gestation
NST should be initiated at 32 weeks or
sooner if evidence of feta compromise
exists
Integumentary Disorder
 Pruritis
A common symptom in
pregnancy-specific
inflammatory skin disease
Most common cause of
pruritis are polymorphic
eruption of pregnancy
(also known as pruritic
urticarial papules and
plaques of pregnancy
{PUPPP})
Usually appears in the
third trimester and usually
subsides in the
postpartum period
Neurologic Disorders
Epilepsy
Disorder of the brain causing
recurrent seizures
Increased incidence of
congenital anomalies
Cleft lip and palate, congenital
heart disease, and neural tube
defects
IUGR
Most important goal during
pregnancy
Prevention of seizures
Take folic acid of 4 mg daily
Prenatal vitamins containing
Vitamin D
Neurologic Disorders
Epilepsy
Take folic acid of 4 mg daily
Prenatal vitamins containing Vitamin D
Only one anticonvulsant medication-at the
lowest level that is effective at keeping the
woman seizure free
Blood levels of anticonvulsant medications
should be checked and drug dosages
adjusted as necessary
Neurologic Disorder
 Bell’s Palsy
 Idiopathic facial paralysis
of pregnancy
 Clinical manifestations
include the sudden
development of a
unilateral facial weakness,
often discovered first thing
in the morning
 Taste on the anterior two
thirds of the tongue may
be lost
 Pain may occur in and
around the ear
Autoimmune Disorders
Systemic Lupus
Erythematosus
Most common serious disorder
of childbearing age
Chronic multisystem
inflammatory disease
Pericarditis is often presenting
symptom
Anti-inflammatory drugs such
as prednisone and aspirin may
be used
Nursing care focuses on early
recognition, education and
support of the woman and
family, and assessment of fetal
well-being
Gastrointestinal Disorders
Cholelithiasis and Cholecystitis
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Inflammation of the gall
bladder
More common in pregnancy
Women with acute
cholecystitis usually have fatty
food intolerance along with
colicky abdominal pain
radiating to the back or
shoulder, nausea, and
vomiting
Women can be treated with
medical therapy, consisting of
antibiotics, analgesics,
intravenous fluids, and bowel
rest,
Cystitis
Characterized by dysuria, urgency, and
frequency, along with lower abdominal or
suprapubic pain
Usually white blood cells, as well as
bacteria are found in the urine
Microscopic or gross hematuria also may
be present
Cystitis
Treated with a 3-day course of antibiotics
Antibiotics often prescribed include
amoxicillin, ampicillin, cephalexin (Keflex),
ciprofloxacin (Cipro), levofloxacin
(Levaquin), nitrofurantoin (Macrodantin),
and trimethoprim-sulfamethoxazole
(Bactrim DS)
Phenazopyridine (Pyridium), a urinary
analgesic is often prescribed
Pyelonephritis
Most common serious medical
complication and the leading cause of
septic shock during pregnancy
Develops most often during the second
trimester of pregnancy
Usually caused by the E coli organism
Infection often develops in the right kidney
in at least half of the cases
Pyelonephritis
Onset of pyelonephritis is often abrupt,
with fever, shaking chills, and aching in the
lumbar area of the back
Women diagnosed with pyelonephritis are
usually admitted to the hospital
immediately
Pyelonephritis
Treated with IV antibiotics-Ceftriaxone
(Rocephin)
Usually antibiotic therapy is continued for
7 to 14 days after the woman is
discharged from the hospital
A urine culture will likely be repeated 1 to
2 weeks after antibiotic therapy has been
completed
Surgery During Pregnancy
Appendicitis
Occurs in approximately 1000 pregnancies
Signs and symptoms mimic some normal
changes of pregnancy
Appendiceal rupture and peritonitis occur
two to three times more often in pregnant
women
Diagnosis of appendicitis requires a highlevel of suspicion
Trauma During Pregnancy
Blunt Abdominal Trauma-most commonly
the result of MVAs but also may be the
result of battering or falls
When the mother survives, placenta
abruption is the most common cause of
fetal death
Pelvic fracture may result from severe
injury and may produce bladder trauma or
retroperitoneal bleeding with the two-point
displacement of pelvic bones
Trauma During Pregnancy
Blunt Abdominal Trauma
Direct fetal injury as a complication of
trauma during pregnancy most often
involves the fetal skull and brain
Uterine rupture as a result of trauma is
rare
Traumatic uterine rupture almost always
results in fetal death
Trauma During Pregnancy
Penetrating Abdominal Trauma
Bullet and stab wounds are the most
frequent cause of penetrating abdominal
trauma
Uterus sustains penetrating wounds, the
fetus is more likely than the mother to be
seriously injured
Trauma During Pregnancy
Penetrating Abdominal Trauma
Second half of pregnancy the fetus usually
sustains a direct injury from the bullet
Gunshot wounds requires surgical
exploration to determine the extent of
injury and repair damage as needed
Trauma During Pregnancy
Penetrating Abdominal Trauma
Stab wounds are limited by the length and
width of the penetrating objects and are
usually confined to the pathway of the
weapon
Stab wounds usually require surgical
exploration to clean out debris, determine
extent of injury and repair damage
Trauma During Pregnancy
Thoracic Trauma
Pulmonary contusion results from nearly
75% of blunt thoracic trauma and is a
potentially life-threatening condition
Penetrating wounds into the chest can
result in pneumothorax or hemothorax
Stab wounds into the chest also may
occur as a result of violence