46 Functional Heart Disease Cardiomyopathy

Pregnancy Issues

Cardiomyopathy symptoms are often seen in uncomplicated pregnancies. The significance may only be recognised late, when cardio-myopathy presents in an advanced state and treatment is difficult.

Puerperal cardiomyopathy manifests in the third trimester, the fetus is relatively mature and can be delivered reasonably safely prior to, or at, commencement of treatment.

• Referral and collaboration with cardiologist, obstetric, anaesthetic and paediatric teams for combined care

• Clear care pathways to be documented and agreed antenatally

• Acute care may need to be in critical care unit

Midwifery Management and Care

• If this condition was previously diagnosed, or when symptoms present in pregnancy, refer immediately to maternal medicine clinic

• Sensitivity - this is a major, life threatening illness

Labour Issues

First Stage

• Invasive monitoring, guided by individual case details, is generally recommended

• Pain relief may relieve cardiac stress

Second Stage

• Aim to minimise cardiovascular stresses whilst maintaining adequate analgesia

• Vaginal delivery safe in most women14; advantages of reduced blood loss, greater haemodynamic stability, avoidance of surgical stress, less chance of post-operative infection and pulmonary complications

• Short second stage by instrumental delivery can minimise cardiovascular compromise

Third stage

• Intravenous oxytocin produces a small reduction in arterial BP followed by an increase in cardiac output10,15

• Oxytocin is associated with decreased cardiac contractility and heart rate16, so ergometrine should be avoided17

• Carboprost and misoprostol are also con-traindicated; use only if benefit outweighs risk

• Consider compression and intrauterine balloons for PPH rather than pharmacological solutions16

• Plan the timing of induction of labour/delivery with extreme caution16

• Regional analgesia, with careful monitoring, unless anticoagulated

• Stabilisation of condition by multi-disciplinary team

• Monitoring for cardiac failure

• Avoid fluid overload

• Avoid hypotension

• Consider pulmonary arterial catheterisation

• ECG monitoring for cardiac arrhythmias

• Consider elective, instrumental, vaginal delivery

• Prophylactic antibiotics for labour and puerperium are recommended

• Once delivered, if condition unstable, transfer to the Intensive Care Unit

Midwifery Management and Care

• Labour may need to be induced; administration of oxytocin should be finely titrated and administered in low dosage to avoid hypotension16

• Care of the IVI throughout labour and maintain a strict fluid balance

• Vigilant monitoring and documentation of: BP, pulse, respiratory rate, ECG, oxygen therapy and oxygen saturation monitoring

• Continuous EFM

• Maintain adequate pain relief having conferred with anaesthetist

• Monitor progress of labour, and refer slow progress promptly

• Left lateral position for labour, with passive leg exercises if immobile

• The midwife might be able to conduct a normal vaginal delivery if second stage progress is brisk, alternatively, the midwife should assist an operative delivery and support the mother

• Physiological third stage may be most appropriate if labour has been spontaneous with no further risk factors (thrombo-prophylaxis)

• Avoid ergometrine and Syntometrine in the third stage17

• Care of the (pre-term) baby at birth and possible transfer to NNU

Postpartum Issues

• Major changes in cardiac output and plasma volumes continue >2 weeks postpartum, so ongoing cardiological surveillance required18

• Maternal condition usually returns to baseline by six months postpartum

• Cardiac function returns to normal in 50% women with PPCM but there is a risk of

19,20

reoccurrence19,20

• Increased risks of pulmonary oedema, thrombo-embolism and rhythm disturbances

• Treatment with ACEI, beta-blockers and full anticoagulation is appropriate10

• Prognosis for PPCM is dependent on recovery of left-sided ventricular function; if left ventricular dysfunction is on-going, mortality rates are 85% over five years

If myocardial dysfunction is severe, a cardiac transplant may be required18.

• Multi-disciplinary care plan, prior to discharge, addressing dynamic disease change with treatment modification and recovery potential12

• Life-long treatment may be required if condition does not recede, so enlist the cardiologist's support and promote outpatient attendance

• Advise on need for pre-conception care, and prescribe contraception

Midwifery Management and Care

• Continue observation of vital signs, reporting any anomalies

• Baby on NNU - facilitate maternal interaction and establish lactation

• Plan care and counsel the mother in caring for infant and own health -seek assistance from family, friends, and social services for household and other support

• Advice in avoiding stress and anxiety and adequate rest

• Avoidance of extreme exertion - advise the family on adjustments to the baby's room and movement of equipment, to minimise exertion

• Extensive education regarding medications and their side effects

• Advice to mother/family of heart failure signs (weight gain, dyspnoea, cough, pallor, chest pain, arrhythmias) and reporting thereof

• Promote a healthy, low sodium, iron-rich diet

Incidence

Risk for Childbearing

2-4% simple arrhythmias in school girls and women >40yr1

Variable Risk

Incidence of each type of arrhythmia in pregnancy unknown1

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