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. TIME OBJECTIVES ACTIVITIES Aids EVALUATION
1. 2 min Introduce about INTRODUCTION Explain
cardiovascular L cardiovascular
disease in The physiological changes during pregnancy place a E disease in
pregnancy. considerable load on the heart and the cardiovascular system. C pregnancy.
Most cases of heart diseases with efficient and good T
management can go through pregnancy and labour U
successfully but there is always an additional risk. R
E
2. 1 min INCIDENCE
C
Cardiac disease occurs in approximately 1% of all U
pregnancies and it is most important non-obstetrical cause of M
maternal death. Formerly rheumatic heart disease was 8-9 P
times common than congenital heart disease. D P
I T
3. 3 min Discuss the PHYSIOLOGICAL CHANGES IN PREGNANCY S Explain the
physiological C various changes
changes in Profound changes occur in cardiovascular system during U in
cardiovascular pregnancy and the changes observed are: S cardiovascular
system during  There is a 45% to 50% increase in blood volume S system during
pregnancy expansion, which is about 75% plasma and 35% red I pregnancy.
blood cells. O
 Cardiac output is increases 25% to 50%, peaking at N
28 to 32 weeks.
 Heart rate increases 10 to 15 beats per minute in the
latter half of pregnancy.
 Blood pressure may drop slightly in second trimester
and rises back to normal in the third trimester. There
is a widening of pulse pressure.
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 White blood cells, fibrinogen and other clotting
factors increase. L
 Varicose veins of legs, vulva and perineal area may E
occur. C
 Oedema of extremities common in the last 6 weeks T
of pregnancy because of stasis of blood. U
 Supine hypotension syndrome: In supine position R
weight of enlarged uterus obstructs venacava, which E
decreases blood return to heart; decreased cardiac
output ensues with hypotension, light headedness, C P
faintness and palpitation. U P
M T
4. 5 min Enumerate the types TYPES OF HEART DISEASE List down the
of heart disease in D types of heart
pregnancy. 1. Rheumatic Heart Disease I disease in
Valvular lesions predominate in rheumatic heart disease S pregnancy.
(RHD) and constitute approximately 50% of all heart C
diseases seen in pregnancy. U
S
i. Mitral and Aortic Valve Incompetence S
Pregnancy can be helpful in this case as it lowers the I
pressure in the arterial system, encouraging blood to O
flow the right way through the valves. There is N
however, a risk of endocarditis.
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ii. Mitral Stenosis
As the demand for cardiac output rises in pregnancy, L
pressure in the left atrium rises. This may lead to E
back pressure in the pulmonary system and C
pulmonary oedema. The left atrium being unable to T
cope with the demands made upon it, begins to U
fibrillate and heart failure may occur. R
E P
2. Congenital Heart Disease P
The most common congenital defects, which may remain C T
uncorrected during the childbearing years are: U
 Atrial septal defect M
 Patent ductus arteriosus
 Ventricular septal defect. D
All of these are openings, which allow communication I
between the right and left sides of the heart or in the case of S
patent ductus arteriosus between the pulmonary artery and C
the aorta. Problems arise when pulmonary vascular U
resistance rises, as it does in preeclampsia and blood flows S
from right to the left instead of passing through the lungs S
leading to cyanosis. This may also happen in the third stage I
of labour when there is a sudden return of blood to the heart. O
N
5. 3 min Enlist the grading GRADING OF HEART DISEASE List down the
of heart disease in Depending upon the cardiac response to physical activity, grading of heart
pregnancy. heart disease is graded into four grades according to the disease in
classification of the New York Heart association (NYHA). pregnancy.
They are as follows: -
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1. Grade -I
 Uncompromised L
 The patient has no any complaint. E
 The heart lesions are found on physical examination. C
 No limitation of physical activity. T
 Uncomplicated U
R
2. Grade-II E
 Slightly compromised.
 The patient complains of breathlessness on exertion C
palpitation troubles and they are tired easily. C H
 The patients are comfortable at rest but ordinary U A
physical activity causes discomfort. M R
 Slight limitation of physical activity. T
D
3. Grade -III I
 Markedly compromised S
 These patients have breathlessness on slightest C
exertion such as climbing steps and ordinary house U
work is beyond them. S
 The patients are comfortable at rest but discomfort S
occurs with less than ordinary activity I
 Patients with cardiac disease with marked limitation O
of activity. N

4. Grade -IV
 Severely compromised
 These patients are in a state of congestive failure,
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breathless, distressed and anginal pain even at rest. L
 Patient feels discomfort even at rest. E F
C L
6. 2 min Enlist the sign and SIGNS AND SYMPTOMS T A List down the
symptoms of heart  Intense breathlessness U S sign and
disease in  Cyanosis R H symptoms of
pregnancy.  Rapid and irregular pulse E heart disease in
 Cold, sweating extremities C pregnancy.
 Cough with blood-stained sputum A
 Generalised oedema and pulmonary oedema. R
C D
DIAGNOSIS U
7. 2 min Elaborate the  Past medical history of rheumatic fever, chorea, M
diagnosis and repeated tonsillitis, diphtheria or history of heart Explain the
investigation of trouble. D diagnosis and
heart disease in  Present signs and symptoms such as tiredness, I investigation of
pregnancy. breathlessness on exertion, rapid or irregular pulse S P heart disease in
rate, cyanosis, pain over the heart region, swollen of C P pregnancy.
the ankles and oedema etc. U T
 Complete assessment of patient with vital sign. S
S
INVESTIGATION I
 Complete blood count O
 ECG (Electrocardiography) N
 Echocardiography
 Chest radiograph to assess cardiac size and outline.
 Clotting studies
 Effects of Cardiac Disease
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 Chest X-ray (with lead apron shield over abdomen)
L
8. 2 min Discuss the effect of EFFECTS OF CARDIAC DISEASE E Explain the
heart disease in C effect of heart
pregnancy. i. Maternal T disease in
 May go to acute heart failure, which is also U pregnancy.
aggravated, by anaemia, respiratory infection, R
excessive exercise any febrile illness, emotional E
upset, over weight etc.
 Maternal death may occur due to cardiac failure and
other causes such as pulmonary oedema, pulmonary C P
embolism, acute rheumatic carditis, sub-acute U P
bacterial endocarditis etc. M T

ii. Foetal D
 Risk of premature labour I
 IUGR (Intra Uterine Growth Retardation) S
 Low Birth Weight C
 Increase Incidence of spontaneous abortion and still U
birth. S
 Increased risk of congenital malformation. S
 Increase incidence of congenital heart disease. I
 foetal death. O
N
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9. 3 min Elaborate the MANAGEMENT Explain the
management of L management of
heart disease in Principles. E heart disease in
pregnancy.  Early diagnosis and evaluation of the functional C pregnancy.
grading of the cases. T
 To prevent, to detect and to institute effective therapy U
for cardiac failure. R
 To prevent and to control the additional E
complications e.g. High-risk factors.
 Mandatory hospital delivery.
C P
Preconception Care and Advice U P
 Ideally all women with heart disease should have M T
periconceptional counselling. The women with
contraindication should be advised against pregnancy D
while women with valvular lesion should conceive I
when they are in NYHA class I or II. S
 Similarly, women with severe mitral stenosis or C
congenital heart disease needing cardiac surgery U
should have surgery (like mitral valve replacement) S
before they venture for pregnancy for optimum S
outcome. I
 Women who know that they have heart disease must O
seek advice from both cardiologist and obstetrician N
before becoming pregnant so that the risks of her
condition can be discussed.
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 The women should be helped to control obesity and
choose a diet, which will prevent anaemia in order to L
minimize risk. E
 It is advisable that family size should be limited, as C
the risks increase with each pregnancy. T
 Contraceptive advice is therefore an important aspect U
of management. R
E
10. 1 min Discuss the INDICATIONS OF ADMISSION TO HOSPITAL
indication of  Woman with grade III and IV disease should be Explain the
admission to admitted whenever diagnosed and should stay in C indication of
hospital. hospital until delivery or until their functional cardiac U P admission to
status improves to lower grade. M P hospital.
 Grade 1: At least 2 weeks prior the expected date of T
delivery. D
 Grade II: At 28th week especially in case of I
unfavourable social surroundings. S
 Worsening of functional cardiac status C
 Cardiac failure, infective endocarditis or anaemia. U
 Appearance of high-risk factors like cough, S
dyspnoea, tachyarrhythmias or basal lung S
crepitations. I
 Women with prosthetic heart valves (mechanical) for O
heparin switch over. N
 Pulmonary hypertension.
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11. 2 min Discuss MANAGEMENT DURING ANTENATAL PERIOD Explain
management during  Restriction of activity and emotional stress. L management
antenatal period.  Adequate rest - The women should have 10 hours E during antenatal
rest in bed at night and 2 hours rest in the afternoon. C period
 Avoid undue excitement and strain to limit the T
activities. U
 Avoid caffeine, alcohol and spicy diet. R
 Diet should contain low salt, less carbohydrate and E
fat but more protein.
 Anaemia should be corrected by appropriate therapy. P
Iron tablet and iron containing food. C P
 Excess weight gain or obesity is discouraged. U T
 Prevent infection by avoiding crowded places and M
encourage taking prophylaxis antibiotic because
infection and febrile illness are dangerous. D
 Adequate dental care should be advised to avoid the I
potential source of infection. S
 Encourage patient for irregular antenatal check-up C
for early diagnosis and treatment. U
 Monitor maternal and foetal wellbeing continuously. S
 Medication-Frusemide 40-60mg/daily for moderate S
to severe mitral stenosis. Digoxin is used for atrial I
fibrillation. O
N
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12. 7 min Discuss MANAGEMENT DURING LABOUR Explain
management during L management
labour. During first stage of labour E during labour.
i. Patient should rest in bed in a semi-recumbent C
position. T
ii. Intravenous fluids should be avoided or restricted to U
75 ml./hour. R
iii. Central venous pressure monitoring is useful E
especially in high-risk patients.
iv. Intranasal oxygen, if needed, should be given at a
rate of 5-6 litres per minute (in grades III and IV C
diseases) U
v. Analgesia especially combination of a narcotic with a M P
sedative is preferred to reduce anxiety and to ensure P
quite rest. D T
vi. Careful observe foetal heart rate in every 15 to 30 I
minutes S
vii. Careful monitoring of vitals regularly to see any sign C
of cardiac failure as follows: U
 Pulse rate > 100 beats per minute S
 Oedema feet S
 Dyspnoea (respiratory rate > 24 per minute) I
 Cyanosis. O
 Basal crepitations N
viii. Prophylactic antibiotics- The recommended regimens
include IV ampicillin 2 g and gentamicin 1.5 mg/kg
(not to exceed 80 mg), at the onset, followed by
repeat doses at 8 hours interval.
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i. Watch the progress of labour carefully and maintain
documentation on a partograph. L
E
During Second Stage of Labour C
 This stage should be short and without undue T
exertion on the part of the mother. U
 In order to avoid the additional strain that is R
imposed on the heart by bearing down, the second E
stage may be shortened with the application of an
outlet forceps or vacuum.
 Prolonged pushing withheld breath may be C
dangerous for a woman with heart disease. U P
 The nurse needs to suggest to the woman that she M P
avoids holding her breaths and follows her natural T
desire to push; giving several short pushes during D
each contraction. I
 Oxygen therapy as needed. S
C
During Third Stage of Labour U
 Conventional management is to be followed slight S
blood loss is beneficial but if it is excess, oxytocin S
can be given by infusion. I
 Ensure that the patient is well sedated and rest. O
 Close observation of vital signs such as pulse, N
respiration, blood pressure, skin colour etc.
 No ergot containing preparations should be used for
the third stage of labor as it causes a tonic
contraction, which returns 300-500 mL of blood to
the venous system.
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 If the blood loss is excess, Syntocinon may be used
as it has less effect on blood vessels than L
ergometrine. E
 If the woman is in heart failure, oxytocic should be C
avoided. If Syntocinon is required, it is to be given T
by infusion accompanied by IV furosemide to U
prevent pulmonary oedema. R
E