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Care of Mother, Child, Family and Population Group at Risk with Problems Substance Abuse + Gestational Problems Substance

Abuse Classifications of Substance Abuse - Alcohol - Cocaine - Marijuana - Heroin - Methadone 1. ALCOHOL A CNS depressant and a potent teratogen As a result of alcohol, a woman may experience withdrawal syndrome seizures in the intrapartal period as early as 12 48 hrs after she stops drinking Delirium tremens may occur in the postpartum MOTHER Malnutrition Folic Acid and Thiamine deficiency Bone marrow suppression Increase incidence of infection Liver disease Nursing Intervention Sedation to decrease irritability and tremors o Caution Fetal Depression Seizure precautions Intravenous therapy for hydration Prepare for an addicted newborn Breastfeeding is not CONTRAINDICATED 2. COCAINE o Results in vasoconstriction, tachycardia and hypertension o Placental vasoconstriction, decreased blood flow to the fetus o Feeling of euphoria and excitement o Usually followed by irritability SIGNS and SYMPTOMS: MOOD SWINGS and Appetite changes Effects to the Mother and Fetus Mother Fetus Seizure, hallucinations Intrauterine Growth Retardation (IUGR) Pulmonary edema Small head circumference Cerebral hemorrhage Cerebral infarction Respiratory failure Altered brain development Heart problems Shorter body length Spontaneous abortion Malformation of the genitourinary tract Abruptio placenta Apgar Score (Low/Poor) Preterm birth Stillbirth FETUS Fetal Alcohol Syndrome (FAS) Physical and mental abnormality Intoxicate the infant Inhibit the maternal letdown reflex

Effects of alcohol

Effects on Newborn Exaggerated startle reflex Irritability Labile emotions Sudden Infant Death Syndrome (SIDS) Exposed in utero may have neurobehavioral disturbances 3. Heroin Pregnant women: Increase incidence of poor nutrition, iron deficiency anemia and preeclampsia Fetus: Increased risk of IUGR, meconium, hypoxia Newborn: Restlessness shrill, increased pitched cry, irritable Fist suckling vomiting seizures Withdrawal: Appears within 72 hrs 4. Methadone Can cross the placenta and associated with preeclampsia, placental problems and fetal presentation i. Prenatal exposure: Reduced head circumference, low birth weight ii.Newborn: May experience withdrawal symptoms that are often severe and longer lasting

Nursing Diagnosis Planning and Implementation Evaluation

Pregnancy At Risk Gestational Problems Danger Signs of Pregnancy 1. Vaginal Bleeding 2. Persistent Vomiting 3. Chills and fever 4. Sudden escape of fluid from vagina 5. Abdominal / chest pain a. May mean tubal pregnancy b. Separation of placenta c. Preterm abortion d. Chest pains 6. Absence of fetal heart tone after being auscultated 7. Swelling of face and fingers * 8. Flashes of lights or dots (scotoma) * 9. Blurring of vision 10. Severe headache and dizziness * * = PIH (Pregnancy Induced Hypertension) I. HYPEREMESIS GRAVIDARUM Excessive nausea and vomiting that persists beyond 12 weeks gestation Etiology: *** Signs and Symptoms 1. Excessive nausea and vomiting not relieved by ordinary remedies persisting beyond 12 weeks 2. Signs of dehydration Management (Give crackers) D10 NSS 3000 ml in 24 hrs Rest Anti-emetic III ABORTION Interruption of pregnancy before a fetus is viable Expulsion / extraction of an embryo / fetus weighs 500 g or less Risk Factors: *** Causes: Abnormal fetal formation (Teratogenic factor?) Implantation abnormality Lack of progesterone produced Infection Teratogenic drugs Stress o o Early Abortion Before 16 weeks Late Abortion Between 16 20 weeks

TYPES of ABORTION~ 1. Threatened Sign / Symptoms - Vaginal Bleeding - Slight Cramping - No cervical dilatation during IE Management - Assess: 1. Avoid strenuous activities for 24 48 hours 2. Need for sympathetic and support person 3. No COITUS for 2 weeks after bleeding episode Imminent Inevitable Miscarriage when uterine contraction and cervical dilatation occurs Manifestation: - Dilated cervix - Contractions - Ruptured membranes - Bleeding Clinical Management - Moderate to profuse bleeding - Moderate to severe uterine cramping - Cervix dilated - Membranes ruptured Management - Save any tissues fragments and bring to the hospital for examination - If no FHR, D & C are advised - Assess FHR, D & E (Dilatation and Evacuation) is advised - Oxytocin after D & C - Inform that the pregnancy is lost Complete Abortion Entire products of conception are expelled spontaneously without any assistance Signs and Symptoms - Lower abdominal cramping - Vaginal bleeding - Visible passage of products of conception Incomplete Products of conception are expelled but membranes / placenta is retained in the uterus Signs and Symptoms - Vaginal Bleeding - Abdominal cramping Management - Dilatation and Curettage (D & C) - Inform the patient that the pregnancy is lost Missed Abortion Also known as Early pregnancy failure Fetus dies in utero but is not expelled Signs and Symptoms: - Fundic height reveals to be the same (Prenatal exam) - Previously heard FHR is no longer heard - Painless vaginal bleeding - UTZ confirmation that the fetus is dead Management - D&C






- If over 14 weeks, labor is induced by PROSTAGLANDIN SUPPOSITORY / miscarriage (cytotec); Oxytocin stimulant Recurrent Pregnancy A miscarriage pattern when a woman who had 3 spontaneous miscarriage that occurred at the same gestational age May be due to: - Defective spermatozoa / ova - Endocrine factors - Deviation of uterus - Infection - Autoimmune disorders COMPLICATIONS OF MISCARRIAGE 1. Hemorrhage Assess (Shock) Place client in SUPINE position Provide Fundal massage Demonstrate supportive attitude Prepare for D & C if possible Administer blood components (as prescribed) Administer oral medication (Methergine as prescribed) 2. Infection Assess Aseptic technique Proper perineal cleaning Avoid use of tampons 3. Isoimmunization Rhogam 4. Powerlessness and Anxiety


Septic Infection A. Abortion that is complicated by infection B. Signs and Symptoms - Foul smelling vaginal discharge - Uterine cramping - Fever C. Management - Assess (Infection) - Assist client during intensive treatment - Medications - Assist in D&E / D&C procedure ECTOPIC PREGNANCY Implantation occurs outside the uterine cavity Usually occurs in the fallopian tube, cervix and ovaries Secondary leading cause of BLEEDING


Predisposing Factors o Previous ectopic pregnancy o Tubal surgery o Previous genital infection o SMOKING o Previous pelvic and / abdominal surgery o Sexual intercourse early before 18 years old o IUD Usage

Signs and Symptoms Amenorrhea Early signs of pregnancy o Tubal rupture Kehrs Sign / NECK PAIN N&V Cullens Sign Bluish discoloration on the umbilicus Rectal pressure d/t blood in the cul-de-sac (+) pregnancy test Sharp localized pain when cervix touch Signs / symptoms of shock LAB Findings Hmg and Hct HCT WBC Diagnostic Test 1. Culdocentesis Aspiration of bloody fluid from cul-de-sac of Douglas 2. UTZ Pathophysiology of ECTOPIC PREGNANCY
Risk Factors

Dysfunction of the CILIA

Disruption/ Scarring of Fallopian Tubes

Blocks or slow movement of fertilized ovum in the fallopian tube to the uterus

Fertilized egg searches for an area where it implants

Complications of Ectopic Pregnancy 1. Hemorrhage 2. Infection 3. Rh Sensitization

Signs / Symptoms Appear

Management: Medical Management Conservatory Therapy Goal: Remove ectopic pregnancy and preserve reproductive function o SINGLE DOSE OF METHOTREXATE o *All chemotherapeutic agents, SE bone marrow suppression* Criteria for Methotrexate Therapy Eliminate side affect of multiple dosing

o Gastrostitis, stomatitis, leukopenia, thrombocytopenia Increase safety of patients acceptance

Surgical Intervention Goal: Planning for Future Pregnancy Salphingostomy Salphingectomy Salphingo-oopherectomy Administration of RHIG If not yet RUPTURED Salpingostomy Removal of a conceptus less than 2 cm located at the distal portion of the fallopian tube by performing a linear incision over the ectopic pregnancy. The conceptus will extrude from the incision and removed manually Salpingotomy Longitudinal incision is made over the ectopic pregnancy and the conceptus is removed using forceps or gentle suction Fimbrial Evacuation Removal of the conceptus by milking and suctioning of the fallopian tube If ruptured: Removal of the ruptured tube because the presence of a scar if tube is repaired and left can lead to another tubal pregnancy Nursing Management 1. Maintaining Fluid Volume Initiate IV line with a large bore catheter Assist in obtaining blood sample (CBC, Typing) Monitor VS and UO 2. Prevent and Treat hemorrhage which is the main danger of Ectopic Pregnancy Blood Transfusion (BT) Place client flat in bed with legs elevated Monitor VS I&O and amount of blood loss 3. Provide Comfort Administer analgesics Relaxation techniques 4. Provide supplement during grief Provide emotional support Refer client to counseling Listen to concerns 5. Provide Client Education Signs and symptoms of ectopic pregnancy Report to primary care Bring support person Chances of another ectopic pregnancy Contraception o Ovulation begins as early as 19 days or 3 weeks after resection of ectopic pregnancy

I V I HYDATIDIFORM MOLE (H-MOLE) Also known as Gestational Throphoblastic Disease (GTD) Abnormal proliferation and degeneration of throphoblastic villi Is a mass of abnormal rapidly growing throphoblastic tissue in which avascular vessels hang in grapelike clusters that produce large amounts of HCG Predisposing Factors 17 years old and 35 years above

Low socioeconomic status Low protein intake Previous mole Higher incidence in Asian women

ETIOLOGY: UNKNOWN!! Types of H Mole: Complete Mole o All throphoblastic villi swell and become cystic o If an embryo forms, it dies early at only 1 2 mm in size o Surgical Intervention Partial Mole o Some of the villi form normally, however the synctiotrophoblastic layer of the villus is swollen and misshapen o A macerated embryo of approximately 9 weeks gestation may be present and fetal blood might be present in the villi Signs and Symptoms Brownish / reddish vaginal bleeding (12th week) Rapid uterine enlargement HCG - 1 MILLION u/L Expulsion of molar cyst (16 18th week) N&V (+) Pregnancy test No fetal signs Abdominal pain UTZ ( - ) Assessment Uterus that expands faster than normally No fetal heart sounds Serum urine test of hCG (1 to 2 million IU compared with a normal pregnancy level of 400,000 IU) Symptoms of PIH appearing before 20th week of pregnancy Vaginal bleeding (at 16th week) that is eventually accompanied by discharge of the clear fluidfilled vesicles Treatment Suction curettage to evacuate the mole Following mole evacuation o Baseline pelvic examination o Chest x-ray o Serum test for beta subunit of hCG hCG is then analyzed every 2 weeks until levels are assessed every 4 weeks for 6 12 months GRADUALLY DECLINING hCG TITERS SUGGESTS NO COMPLICATION!! Levels that plateau for three times or increase suggest that malignant transformation has occurred Methotrexate Choice of drug for choriocarcinoma Interferes with WBC formation

Management D&C / D&E to remove the mole (If the woman is more than 40 y/o, hysterectomy is done since she has a higher chance of developing CHORIOCARCINOMA Monitor hCG for 1 year (hCG should be negative 2 6 weeks after removal of H-mole) Chest x-ray every 3 months for 6 months. The lungs are the mot common site of metastasis of choriocarcinoma Chemotherapy (Methotrexate) o hCG titers are increased for 3 consecutive weeks or double at anytime o hCG titers remain elevated 3 4 months after delivery The woman is advised not to get pregnant for 1 year, contraceptive method should NOT be the PILLS. Pills contain ESTROGEN which promote regrowth of the Chorionic villi Hysterectomy is the method of treating for women above 40 years old because of the higher incidence of malignancies and to clients who have completed childbearing and require sterilization Prognosis: Favorable if hCG titers do not recur after evacuation of the moke Unfavorable if malignancy develops and is untreated Complication: Gestational Trophoblastic Tumors Persistent trophoblastic proliferation after H-mole o CHORIOCARCINOMA MOST SEVERE MALIGNANT complication that involves the transformation of chorion into cancer cells that invade and erode blood vessels and uterine muscles Nursing Management: Maintain Fluid and Electrolyte Balance! Emphasize that pregnancy should be avoided for 1 year Administer blood replacement as ordered Emotional Support V IPREMATURE CERVICAL DILATATION Also known as Incompetent Cervix The cervix dilates prematurely and cannot hold the fetus until term Painless cervical effacement and dilatation in early mid-trimester resulting in expulsion of products of conception Most Common CAUSE of HABITUAL Abortion Risk Factors Increased maternal age Congenital structural defects Trauma to cervix Repeated D&C Signs and Symptoms Show Pink-stained vaginal discharge Increased pelvic pressure Premature rupture of membrane Contractions in mid-trimester Presence of painless cervical dilatation Management SURGICAL

Cervical cerclage (Shirodkar/McDonald Technique) 14 16 weeks of gestation o Purse string sutures are placed in the cervix by the vaginal route under regional anesthesia

To strengthen and prevent it from dilating

McDonalds (TEMPORARY) o Nylon sutures are placed horizontally and vertically across the cervix and pulled tight to reduce the cervical canal to a few mm Shirodkar (PERMANENT) o Sterile tape is the threaded in a purse-string manner under the sub mucous layer of the cervix and sutures in place to achieve a closed cervix After suturing the cervix: o Place a woman on bedrest for 24 hrs o Observe for bleeding, uterine contractions, and rupture of BOW o If BOW ruptures = the sutures are removed o If uterine contraction occur, the woman is given ritodrine to stop the contractions o Post-op care: Restrict activities for the next 2 weeks including coitus o Place in a slight or modified Trendelenburg position

VII PLACENTA PREVIA vs. VIII ABRUPTIO PLACENTA Characteristic Definition Placenta Previa Abnormal implantation of the placenta in the lower uterus 1. Marginal 2. Partial 3. Total Usually bright; may be profuse Painless or only present during labor Soft, no abnormal contractions or irritability May be breech position Normal blood clotting Abruptio Placenta Premature separation of the normally implanted placenta 1. Partial 2. Total 3. Marginal 4. Central Visible dark, or conceals bleeding within the uterus Enlarged uterus suggests that blood is accumulated within the cavity Gradual / abrupt onset of pain and uterine tenderness, possibly low back pain Firm and board like: may be irritable with frequent, brief contraction Usually normal Often accompanied by impaired blood clotting

Vaginal Bleeding

Pain Uterine Status of the Fetus Hematologic Affectation

Postpartum Complication 1. Infection 2. 3. 4. Hemorrhage Signs of fetal Compromise Fetal / neonatal

Placenta Previa Placental site is near the non-sterile vaginal Lower uterine segment does not contract as effective to compress bleeding vessel Signs of fetal compromise if maternal shock or extensive placental detachment occur May occur because of blood loss

Abruptio Placenta Bleeding into uterine muscle fibers predisposes to bacterial invasion Bleeding into uterine muscle fibers damages them inhibiting uterine contraction after birth Signs of fetal compromise depending on amount and location of the placental surface that is disrupted May occur because of blood loss



Nursing Care

Placenta Previa Goal: Maintain the pregnancy until fetal lungs are mature enough that respiratory distress is less likely (at about 34 weeks of gestation) Should lie on her side or have a pillow under one hip to avoid supine hypotension With low-lying placenta or marginal placenta previa may be able to deliver vaginally unless the blood loss is excessive Placenta Previa Observation of vaginal blood loss and signs and symptoms of shock Vital signs are taken every 15 minutes if the woman is actively bleeding O2 is given to increase amount delivered to the fetus Vaginal examination is NOT DONE because it may precipitate BLEEDING FHR is monitored

Abruptio Placenta Im mediate CS because of risk of maternal shock, clotting disorders and fetal death Blo od and clotting factor replacement may be needed because of DIC

Abruptio Placenta Pre paration for CS delivery Mo nitor VS Mo nitor FHR Sig ns of shock and bleeding from the nose, gums and other unexpected sites should be promptly reported Ass ess for the side of the uterus Fet us sometimes dies before delivery emotional support

VIIII PREMATURE RUPTURE OF MEMBRANE (PROM) Rupture of membranes BEFORE TERM! Assess: Report of passage of fluid Alkaline Amniotic Fluid Diagnostic Test Nitrazine Test Yellow to Blue Ferning Test Amniotic Fluid in Sodium (Na) Sterile Speculum Exam Complications Infection Cord prolapse Premature labor Management Bed rest (No contraceptive, cervical dilatation, and fetal compromise) Gestational Age? Observe and record characteristics of amniotic fluid Infection I X I PREGNANCY INDUCED HYPERTENSION Characterized by: (TRIAD SYMPTOMS: Occurs rarely before the 20th week of pregnancy) Hypertension Edema Proteinurua


Nulliparity with extremes of age: 17 y/o or 35 y/o Severe nutritional deficiency Coexisting conditions

Signs and Symptoms:

Generalized Vasospasms Arteriolar Vasoconstrictions

Peripheral Resistance

Blood flow to tissues

Tissue Ishcemia

Kidneys Proteinuria Hypoproteinuria * Altered u ratio /g * Altered blood osmolarity * Fluid shift from IV to IS EDEMA RAAS System Further vaso spasms and hypotension



Glomerular Lesions

Cerebral Hypoxia

CNS Irritability

Glomerular Damage

TYPES Signs HTN Proteinuria Edema

Mild Preeclampsia 140/90 +1 or 1g / day Generalized confined*** to face fingers Weekly weight gain = 1 lb/wk

* Visual disturbances - Double vision, blurry dimness of . Vision - Hyperreflexia hyperirritability , * Coma * Convulsion Preeclampsia Severe

Oliguria IUGR Others

160/110 +3 to +4 or 5g/ day Generalized severe facial puffiness Excessive weight gain = 5 lb/wk Epigastric pain Cerebral disturbance + + Hypoproteinuria Haemoconcentration Hypernatremia

Eclampsia Convulsion and Coma Nursing Management Prevention Well balanced diet high in CHON Iron supplements Calorie by 10% NO to Sodium!

Rest and Sleep (Sims) Regular Prenatal Care BP Treatment 1. Bedrest in LLR 2. CHON diet with moderate Sodium 3. Monitor maternal and fetal VS *** daily, weight, edema, reflexes, progress of labor 4. Medications MgSO4 Anti-convulsant / CNS depressant Hydralazine Diazepam Diuretics Blood volume expanders ***** 10% Calcium Gluconate (Antidote IF TOO MUCH MgSO4) 5. Prevent Convulsion

Environmental stimuli
MONITOR Provide Care if convulsion occurs i. PATENT AIRWAY ii.SAFETY iii. MONITOR / RECORD Epigastric Pain LLR O2 Promote Airway


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