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Cardiac Disease | 마이메르시 MyMerci
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Cardiac Disease

NCLEX Review Guide: Cardiac Disease in Pregnancy

Pathophysiology and Risk Assessment

Cardiovascular Changes in Pregnancy

  • Blood volume increases by 40-50% during pregnancy, placing additional strain on the cardiovascular system and potentially exacerbating existing cardiac conditions.
  • Cardiac output increases by 30-50% due to increased stroke volume and heart rate, with peak increases occurring in the second trimester.
  • Systemic vascular resistance decreases due to progesterone-induced vasodilation, which can mask symptoms of cardiac disease initially.

Memory Aid: "HEART" Changes

  • Heart rate increases
  • Edema may develop
  • Arterial pressure decreases
  • Red blood cell volume increases
  • Total blood volume increases

Key Points

  • Maximum hemodynamic stress occurs at 28-32 weeks gestation
  • Labor and delivery create additional 15-20% increase in cardiac output

Classification and Risk Stratification

New York Heart Association (NYHA) Functional Classification

ClassSymptomsPregnancy Risk
Class INo symptoms with ordinary activityLow risk
Class IISlight limitation, symptoms with ordinary activityLow-moderate risk
Class IIIMarked limitation, symptoms with less than ordinary activityHigh risk
Class IVSymptoms at restPregnancy contraindicated

Key Points

  • NYHA Class III-IV patients have maternal mortality risk >25%
  • Eisenmenger syndrome and pulmonary hypertension carry highest risk

High-Risk Cardiac Conditions

Contraindications to Pregnancy

  • Eisenmenger syndrome - cyanotic congenital heart disease with right-to-left shunting and pulmonary hypertension carrying 30-50% maternal mortality risk.
  • Pulmonary arterial hypertension with systolic pressures >50 mmHg increases risk of right heart failure and maternal death.
  • Marfan syndrome with aortic root dilatation >40mm significantly increases risk of aortic dissection during pregnancy.
  • Severe mitral or aortic stenosis with valve area <1.0 cm² creates risk of pulmonary edema and cardiovascular collapse.

Memory Aid: "RISKY" Conditions

  • Right heart failure/Pulmonary hypertension
  • Ischemic cardiomyopathy
  • Severe valve disease
  • Kartagener syndrome (if with cardiac anomalies)
  • Young women with Marfan syndrome

Clinical Management and Nursing Interventions

Antepartum Care

  1. Monitor vital signs closely including daily weights, oxygen saturation, and assessment for signs of heart failure.
  2. Administer prescribed medications while avoiding ACE inhibitors and ARBs which are teratogenic.
  3. Educate patient on activity restrictions and signs/symptoms of cardiac decompensation to report immediately.
  4. Coordinate care with maternal-fetal medicine specialists and cardiologists for optimal management.

Clinical Scenario

A 28-year-old pregnant woman at 30 weeks gestation with mitral stenosis presents with increasing dyspnea and orthopnea. Nursing priorities include positioning in semi-Fowler's position, administering oxygen, monitoring fetal heart rate, and preparing for potential emergency delivery if maternal condition deteriorates.

Intrapartum Management

  • Epidural anesthesia is preferred to reduce cardiac workload by minimizing pain and catecholamine release during labor.
  • Monitor for fluid overload as rapid fluid shifts during delivery can precipitate pulmonary edema.
  • Avoid ergot alkaloids for postpartum hemorrhage control as they cause vasoconstriction and increased afterload.

Key Points

  • Vaginal delivery preferred unless obstetric indications for cesarean
  • Continuous cardiac monitoring and pulse oximetry essential
  • Limit pushing time in second stage to reduce cardiac stress

Commonly Confused Concepts

ConceptCardiac DiseaseNormal Pregnancy
DyspneaProgressive, worsens with activityMild, improves with rest
Heart murmurPathologic, harsh qualitySoft systolic flow murmur
EdemaPitting, involves hands/faceDependent, resolves with elevation
FatigueSevere, limits daily activitiesMild to moderate, manageable

Warning Signs Memory Aid: "FACES"

  • Fatigue (severe, new onset)
  • Angina or chest pain
  • Cyanosis or color changes
  • Edema (sudden, pitting)
  • Shortness of breath at rest

Study Tips and Quick Checks

Common Pitfalls

  • Don't assume all dyspnea in pregnancy is normal - progressive dyspnea warrants cardiac evaluation.
  • Remember that anticoagulation management is complex - warfarin is teratogenic, heparin doesn't cross placenta.
  • Avoid giving ergot alkaloids to patients with cardiac disease due to vasoconstriction effects.

Quick Assessment Checklist

  • ☐ NYHA classification documented
  • ☐ Baseline echocardiogram obtained
  • ☐ Activity restrictions discussed
  • ☐ Signs of decompensation reviewed
  • ☐ Delivery plan established

Remember: You're preparing to save lives! Master these cardiac concepts to provide safe, competent care for high-risk pregnant patients. Every detail you learn brings you closer to becoming an exceptional nurse!

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