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Repositioning mothers to a left lateral position to avoid compression of the inferior vena cava by the gravid uterus for women who experience supine syndrome is recommended for labour. However, this may be inappropriate for women with some specific cardiac conditions Canobbio et al. During each uterine contraction, a bolus of fluid is expelled into the intravascular space. Concurrently, anxiety and pain stimulate the systemic nervous system to further elevate the SBP and heart rate Canobbio et al. Physiological changes during labour affect various cardiac conditions differently, notably aortic diseases, obstructive valve disease and cardiomyopathy.
Midwives recognize that delivery and management are tailored to a mother's specific cardiac state following a multidisciplinary team review.
The proposed birth plan is also clearly documented, with vaginal delivery being the preferred mode and lower uterine segment caesarean section remaining limited to obstetric indications Canobbio et al. Table 5 summarizes the risks and commonly encountered problems during labour.
Thus, it is important to highlight the cardiovascular adaptations that exacerbate acquired cardiac conditions. The congenital defects that are likely to be problematic in pregnancy are complicated by pulmonary hypertension, cyanosis and severe left ventricular outflow tract obstruction, with cyanotic CHD posing the most significant risk to both mother and foetus Cantwell et al. In particular, hypoxaemia is poorly tolerated by the foetus and is associated with a high incidence of foetal loss, stillbirths, preterm delivery and IUGR. In these cases, the risk to mother and unborn child correlates with the former's resting oxygen saturation Cox et al.
Prophylactic antibiotics are administered in labour to women with valve disease or a history of endocarditis or increased risk of sepsis, and the guarded use of oxytocin infusion during the third stage is recommended Curtis et al. Further, primary pulmonary artery hypertension secondary to CHD is a contraindication for pregnancy due to the poor prognosis for mother and baby, so termination is recommended Canobbio et al. Acquired cardiac conditions are undetected or latent conditions where the stress of pregnancy precipitates clinical deterioration of a woman's cardiac state.
ACS is an umbrella term that describes the spectrum of conditions resulting from a reduced coronary blood flow to the heart and range from acute myocardial ischaemia unstable angina to injury and necrosism, as seen in acute myocardial infarction AMI Knight et al. Merrigan stressed the need for recommendations to be implemented across multiple nurse settings to educate and guide staff on the care of pregnant women with AMI. Often, their clinical presentation will be atypical of ischaemia, with dyspnoea, vomiting or dizziness present Cantwell et al.
Thus, women with AMI require complex care by a multidisciplinary team that includes the assistance of capable midwives Cantwell et al. Management of AMI is primarily interventional cardiac procedures i.
It seems, however, that valve involvement is uncommon in this syndrome. To assess whether gender differences exist in the clinical presentation, angiographic severity, management and outcomes in patients with coronary artery disease CAD. That is, you could have no symptoms at all, but have severe valve disease. Our sample of patients was small. In this registry, aortic stenosis and degenerative mitral insufficiency were the most common valve diseases, while the prevalence of rheumatic valve disease and other valve diseases was considerably lower Table 1.
The aim is to avoid the use of thrombolytics until after delivery because of the increased risk of heavy haemorrhage Knight et al. Aortic dissection, once considered rare in pregnancy, is now comparable to PPCM. In a recent Australian maternal mortality report, there were four deaths due to dissection of the aorta and four due to cardiomyopathy between — Humphrey et al. This condition is evident in women who are diagnosed with Marfan or Ehlers—Danlos syndrome connective tissue disorders , a bicuspid aortic valve, coarctation of the aorta and a previous repair or hypertension Cantwell et al.
Midwives need to be cognizant of the fact that when a pregnant woman presents with severe chest, abdominal or back pain that requires opiate analgesia excluding labour or postoperative pain , this warrants thorough investigation Knight et al. Cardiomyopathies in pregnancy include acquired and inherited diseases such as PPCM and toxic, hypertrophic, dilated, restrictive and idiopathic cardiomyopathies Knight et al.
Importantly, early recognition of Takotsubo syndrome for referral to cardiology services helps ensure a full recovery is made and avoids inappropriate use of vasopressors, which have been considered counterproductive Kucia, Women with AHF symptoms in the last month of pregnancy or up to six months' postpartum, with the diagnosis of PPCM by exclusion, will arrive with breathlessness, orthopnoea and peripheral oedema Johns, ; Knight et al. Women who experience severe AHF and cardiogenic shock may require urgent delivery, mechanical cardiovascular support i.
Midwives should know that subsequent pregnancies are considered high risk, regardless of whether a woman's left ventricular function has returned to normal. Valvular disease in pregnancy is the result of RHD and the most common lesion mitral stenosis. Aortic valve stenosis contributes to enlargement of the left ventricle, thus restricting the coronary blood supply and causing chest pain angina pectoris. The key message for midwives is that for women with valvular disease, the presence of a tachyarrhythmia, such as newly acquired atrial fibrillation, affects cardiac function and may cause secondary pulmonary hypertension Canobbio et al.
Benign and problematic arrhythmias are observed increasingly in women with heart disease during pregnancy Cantwell et al. Bradyarrhythmias are well tolerated, but some women will require insertion of a pacemaker Ruys et al. Midwives will need to monitor closely the maternal heart rate during labour. Sustained tachyarrhythmia is not tolerated in women with structural heart disease or CHD so they require selective drug therapy that is not toxic to the foetus Canobbio et al.
Autopsies have shown no histopathological abnormalities of the heart to account for these women's deaths Knight et al. In view of increased CVD in pregnancy, we need to improve multidisciplinary collaboration, as emphasized in Knight et al. Alternatively, should we instead explore advanced practice roles such as specialist midwifery tailored to CVD?
Women with previously undiagnosed heart disease during pregnancy require immediate referral to cardiologists. Hatchett, McLaren, Corrigan, and Filer reported on GUCH nursing services and found patients expressed enhanced feelings of safety in coping with the demands of pregnancy and a heart condition, as well as satisfaction with the information provided and continuity of care through important life transitions.
Their research findings demonstrated the value and contribution of a specialist nursing service to women's experiences, particularly in terms of effective care coordination, monitoring and support Hatchett et al. Merrigan stated that women have worse outcomes than men following midlife AMI, and therefore, innovative interventions responsive to women's unique recovery need to be developed.
An informative poster was distributed to all women in acute medicine and emergency departments to assist clinicians in recognizing the key causes of maternal death Knight et al. This clinical resource takes the initiative to address some of the factors contributing to maternal deaths from cardiac disease, including: Failure to accurately diagnose cardiac problems. Lack of early involvement of senior clinicians from obstetric and cardiology multidisciplinary teams, particularly when pregnant or postpartum women present to emergency departments.
Underestimation of the severity of the condition. Lack of communication between multidisciplinary staff. Absence of clear policies addressing cardiac problems. The Three Ps in a Pod clinical initiative in the UK highlights working as a team in multidisciplinary programmes to improve mothers' care and save lives Knight et al. Evidently, midwives play a key role during pregnancy and need to be appraised of the CVD observed in pregnancy, including its potential risks and anticipated problems and to consider their role within the continuum of care.
Midwives are well equipped to assist in the normal birthing process but require additional knowledge to address the changing needs of women with CVD. Alternatively, a specialist midwife could ensure surveillance and management that includes prompt recognition and response to clinical deterioration James et al. Future research is needed to explore the current continuum of care for women with CVD during pregnancy to identify gaps in clinical practice.
Improving the detection of women with newly acquired cardiac conditions, and improving surveillance and maintaining the continuum of cardiac care for women with CHD will together improve the outcome for both mother and baby. The authors of this paper have no conflicts of interest in conducting this study. The authors declare that this study was conducted in the absence of any financial or commercial relationships that could be construed as a potential conflict of interest.
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Please review our Terms and Conditions of Use and check box below to share full-text version of article. Abstract Aim This paper provides an overview of the two broad categories of cardiac conditions observed in pregnancy congenital and acquired. Design Discussion paper. Methods Data were collected by reviewing international evidence and by searching computerized databases. Results Research has identified that women with associated risk factors of a cardiac condition who delay pregnancy have an increased risk of experiencing cardiovascular complications in pregnancy with poorer outcomes.
Source: Mendelson ; Roberts and Adamson Source: Mendelson , p. Source: Ruys et al. Abdin, S. Care of pregnant women with heart disease: A multidisciplinary approach. Each year more women than men die from cardiovascular disease, mostly from myocardial infarction and sudden death [1]. With the advancement of health care in general and cardiac care in particular, understanding possible gender-based differences in clinical characteristics, management and outcomes will help in improving current management of women with CAD.
Several studies had reported differences in clinical presentation and baseline characteristics of men and women [2] — [5]. Women were older and had higher rates of hypertension and diabetes but less likely to smoke tobacco then men [6] — [8].