206-Maternal

• Stages of Labor


  1. Stage 1: True signs of Labor to Full Cervical Dilatation

  2. Stage 2: Full Cervical Dilatation to Fetal Expulsion

  3. Stage 3: Fetal Expulsion to Placental Expulsion (Golden period of placental expulsion is 15 to 20 minutes)

  4. Stage 4: Placental expulsion to Recovery (Recovery starts after 6 hours of placental delivery until the patient goes back to its pre-pregnant state)
• During labor, each contraction increases the cardiac output by 20%
• 26% of pregnancy-related deaths include cardiovascular disease, including CARDIOMYOPATHY (losing the ability to pump blood)
• Classification of Heart Disease

  • Level 1: No s/sx, can do NSD (Normal Spontaneous Delivery)
  • Level 2: Minimal s/sx observation; can still do NSD but with close monitoring
  • Level 3: S/Sx are present even from a small action
  • Level 4: Evident s/sx even without action (Usually advised to do bed rest). Levels 3 and 4 prohibit pregnancy
• During pregnancy, blood volume increases by about 20-50%
• Prophylaxis for inflammation of the endocardium


  Preventive measures
• Reason why ANESTHESIA is bad for the baby: Decreases Fetal Heart Tone (FHT) leading to Fetal Distress, Decreases oxygen supply, and may result in Fetal Death
• If left untreated, rare complications of Mitral Valve Prolapse include Thrombi, Systemic emboli/embolism leading to Myocardial Infarction, Cerebrovascular Disease (stroke), and Pulmonary Embolism
• During labor

  Slow epidural infusion at levels 4 and 5 in the spinal. Below level 4 and above level 5 increase the risk of paralysis
• For atrial fibrillation

  Blood thinners [Heparin, Warfarin, and Aspirin] can be used
• If pulmonary edema occurs

  Loop diuretics can be used
• Congenital Heart Defects

  • Atrial Septal Defect
  • Ventricular Septal Defect
  • Aortic Coarctation
  • Tetralogy of Fallot
• Open heart surgery increases fetal risk
• Cyanotic Defects

  • Tetralogy of Fallot
  • Transposition of the Great Arteries
  • Total Anomalous Pulmonary Venous Return (TAPVR)
• Valvotomy is safe during pregnancy
• Contraindication for Digoxin: Shall not be administered to those with less than 60 bpm (<60 bpm)
• Important Key Concepts

  • Mitral Valve Prolapse occurs along with either Marfan’s syndrome or Atrial Septal Defect (ASD)
  • Marfan’s syndrome is described as the loss of elasticity in connective tissues
  • Atrial Septal Defect - there’s a hole between the RA and LA. The foramen ovale did not close
  • Due to regurgitation, there’s an enlargement in LA
• Truncus Arteriosus


  Only a single blood vessel is present instead of two
• Inadequate Iron Intake

  Insufficient iron intake is a significant factor
• Multiples Pregnancy


  Women carrying multiples are at a higher risk of anemia during pregnancy
• In pregnancy, anemia occurs due to high demand for blood by both the mother and the baby
• Iron helps to bind oxygen with hemoglobin
• Total Anomalous Pulmonary Venous Return (TAPVR)


  Oxygen-rich blood returns to the right side of the heart, resulting in mixing of oxygenated blood with deoxygenated blood
• Transposition of the Great Arteries


  Pulmonary Artery changes position with the Aorta
• Folate Acid Deficiency in Pregnancy usually happens at the end of the first trimester and the second trimester
• Normal Blood Values

  • Red Blood Cells (RBC): 3.77 to 5.28 million cells/mcL
  • Hemoglobin (Hb): 11.0 to 15.5 grams/dL
  • Hematocrit (Hct): 33% to 45%
  • White Blood Cells (WBC): 5,000 to 15,000 cells/mcL
  • Platelets: 150,000 to 450,000 platelets/mcL
• Red Blood Cells (RBC)

  • Hemoglobin gives color to the RBC
  • Oxygen goes inside RBC to bind with the hemoglobin
• Abnormal Physiology

  Decrease iron -> Decrease Hemoglobin -> Decrease oxygen -> Decrease of Adenosine Triphosphate (ATP) -> Shrinking of the RBC
• Folate acid contributes to DNA repair, cell replication work, and function during the early pregnancy stage
• Normal Pathophysiology

  Mouth -> Stomach (for digestion) -> Small Intestine (Jejunum) -> Blood Stream (with the help of
• Risk Factors for Folate Acid Deficiency

  Multiple pregnancies, Secondary hemolytic disorder, Hydantoin (antiepileptic drug), Poor gastric absorption
• Management for Iron Deficiency Anemia

  Increase iron supplementation: Iron + vitamin C = Enhance iron absorption in the duodenum, Iron + milk = Prevents iron absorption in duodenum, Ferrous Sulfate + Folic Acid should be taken once a day (OD) in between meals in the morning
• Lab Diagnostic Test

  Complete Blood Count (CBC), Hematocrit Measurement
• Normal Physiology (Iron to Red Blood Cells)

  Mouth -> Stomach (for digestion) -> Small Intestine (Duodenum, for absorption of nutrients) -> Blood Stream (via the capillaries in SI) -> Liver (metabolizes, converts ferrous to ferric) -> Bone Marrow (Production of RBC thru Hematopoiesis)
• Hypoplastic Left Heart Syndrome


  Weakening of the left side of the heart
• Short Intervals Between Pregnancies

  Women with back-to-back pregnancies and minimal time between them may face an increased risk of anemia
• Increased Maternal Morbidity

  Iron deficiency anemia during pregnancy is linked to elevated maternal morbidity and mortality
• Cardiovascular Defects

  • Patent Ductus Arteriosus (PDA)
  • Coarctation
  • Tetralogy of Fallot
  • Transposition of the Great Arteries
  • Total Anomalous Pulmonary Venous Return (TAPVR)
  • Truncus Arteriosus
  • Hypoplastic Left Heart Syndrome
• Signs and Symptoms of Iron Deficiency Anemia

  • Fatigue, Pale Skin, Difficulty of Breathing (dyspnea), Weakness, Dizziness, Cold hands and feet, Brittle nails, Headache, Irritability, PICA
• Prescribed dietary intake of folate acid per day is 400 mg in order to prevent Spina Bifida (Neural Tube Defects)