Substance Abuse
SUBSTANCE DEPENDENT
- Is a growing health problem in women of childbearing age.
- 10% to 20% of pregnant women use illegal drugs during
pregnancy (NCHS, 2009)
SUBSTANCE ABUSE
- Inability to meet major role obligations, an increase in legal
problems or risk-taking behavior, or exposure to hazardous
situations because of an addicting substance.
SUBSTANCE DEPENDENT
- Illicit drugs tend to be of small molecular weight, so they readily
cross the placenta.
- Fetus of the addicted mother has a drug concentration of about
50% of that of the mother.
- Injected drugs- higher risk for hepatitis B or human
immunodeficiency virus (HIV) infection.
NSG DX: Risk for injury to self and fetus related to chronic
substance abuse
Common substances abused during pregnancy
- Cocaine
- Amphetaminess
- Marijuana and hashish
- Phencyclidine
- Narcotic agonists
- Inhalants
- Alcohol
COCAINE
- Derived from the ERYTHROXYLUM COCA, a plant grown almost
exclusively in South America
- One of the most frequently abused drugs during pregnancy and
its use is exceptionally harmful during pregnancy because
extreme vasoconstriction that occurs can severely compromise
the placental circulation, leading to premature separation of the
placenta, which results in preterm labor or fetal death.
- Can be detected by urinalysis because the metabolites of
cocaine can be detected in urine to 1 week after use
ASSESSMENT: (COCAINE)
- Sense of well-being and excitement
- Increased blood pressure
- Congenital anomalies
- Decreased fetal heart rate variability from poor tissue perfusion
- Vasoconstriction – Tachycardia
- Abruptio placenta
COCAINE EFFECTS
- Premature birth - a baby is born too early (before 37 weeks).
Babies born preterm may have a higher risk of serious health
problems.
- Low-birth weight - (less than 5 Ibs. 8 oz.} Some babies with a low
birth weight can be healthy, but others can suffer from health
problems such as eating problems, chronic infections, and
difficulty gaining weight-issues that may require medical
intervention.
- Miscarriage - baby dies before 20 weeks of pregnancy. This
usually depends on the amount of cocaine a woman uses.
However, if a woman has a miscarriage due to cocaine, the use of
other drugs, or natural causes, it's still possible to have a healthy
pregnancy later on.
- Placental abruption - Without immediate medical attention, this
could lead to the death of a mother and her baby.
AMPHETAMINES
- Has a pharmacologic effect similar to cocaine.
- Ice, a rock type of methamphetamine that is smoked, can
produce high concentrations of the drug in the maternal
circulation
- Newborns whose mothers used the drug show jitteriness and
poor feeding at birth and may be growth restricted.
MARIJUANA AND HASHISH
- Both are obtained from the hemp plant, cannabis.
- When smoked, they produced tachycardia and a sense of
wellbeing.
EFFECTS
- PREMATURE BIRTH - This is a birth that happens too early,
before 37 weeks of pregnancy.
- LOW BIRTH WEIGHT - a baby is born weighing less than 5
pounds, 8 ounces. Your baby also may have a short body length or
a small head size.
- ANENCEPLAHY- This is one of the most severe neural tube
defects (also called NTDs). NTDs are birth defects in the neural
tube, the part of a developing baby that becomes the brain and
spine. Babies with this condition are missing major brain, skull,
and scalp parts.
- ANEMIA - This is when your baby doesn't have enough healthy
red blood cells to carry oxygen throughout the body.
- STILLBIRTH - this is when a baby dies in the womb after 20
weeks of pregnancy.
PHENCYCLIDINE
- is an animal tranquilizer that is frequently used street drug.
- Causes increased cardiac output and a sense of euphoria.
- Can cause potential long-term hallucinations (flashback
episodes)
- has been shown to cross the placenta and may cause harmful
effects in the fetus.
NARCOTIC AGONISTS
- Used for treatment of pain (e.g. morphine or meperidine
[Demerol]) and cough suppression (codeine) are also widely
abused because of their potent analgesic and euphoric effect.
- Heroin, a raw opiate, is the main opiate used recreationally to
the point of dependence, and its use is increasing in incidence in
young adults.
- It may be administered intradermally (" skin popping") through
inhalation ("snorting"), or intravenously ("shooting")
- Produces an immediate and short-lived feeling of euphoria
followed by sedation.
COMPLICATIONS:
- PIH
- Hepatitis B
- HIV
EFFECT OF HEROIN:
- SGA-small gestational age
- Increase incidence of fetal distress
- Meconium aspiration
INHALANTS
- Refers to the "sniffing" or "huffing" of aerosol drugs.
- Frequently abused substances include airplane glue, cooking
sprays, and computer keyboard cleaner.
- Most of these substances contain Freon as a propellant and can
lead to severe respiratory and cardiac irregularities.
ALCOHOL
- Can be detrimental to fetal growth as illegal drugs.
- Excessive use tends to occur in women with impulsive
personalities.
- Drinking alcohol during pregnancy increases the risk of
miscarriage, premature birth and your baby having a low birth
weight.
- Drinking during pregnancy can cause your baby to develop a
serious condition called fetal alcohol spectrum disorder (FASD).
NURSING IMPLICATIONS
- Be aware it is impossible to define a safe level of alcohol
consumption because of individual variations in metabolism.
- Advice the client to abstain from alcohol completely or at least
limit intake to less than 1 ounce per day.
- Refer the client to an alcohol treatment program early in
pregnancy.
- Obtain a thorough history, especially medication history, to
establish a baseline and identify the potential for drug use.
- Encourage the client to check with the health care provider
before taking any medication
- Teach the client about the potential teratogenic effects of drug
use.
- Advise recreational drug users to stop using drugs; if necessary,
assist with the referral to drug dependency and detoxification
programs.
- Anticipate the care of a woman with a drug dependency and an
infant of drug- dependent mother
A woman with a urinary tract infection
- As many as 4% to 10 % of nonpregnant women have
asymptomatic bacteuria (organisms present in the urine without
symptoms of infection)
- Pregnant woman, because the ureters dilate from the effect of
the prostaglandin , stasis of urine occurs.
- The minimal glucosuria that occurs with pregnancy allows more
than the usual number of organisms to grow.
- asymptomatic infections are potentially dangerous, because
they can progress to pyelonephritis ( infection of the pelvis of the
kidney and are associated with preterm labor and premature
rupture of the membrane.
- Women with known vesicoureteral reflux (backflow of urine into
the ureters) tend to develop UTIs or pyelonephritis more often
than others.
- Organism most commonly responsible for UTI is Escherichia coli
from an ascending infection.
- can also occur as a descending infection, or begin in the kidneys NURSING INTERVENTIONS
from the filtration of organisms present from other body
- NPO until cessation of vomiting (rest stomach}
infections
- Administer IV fluids as ordered until the patient can tolerate oral
ASSESSMENT
feedings
- Manifested by frequency and pain on urination with
- Monitor l and 0, v/s, skin turgor, daily weight, serum electrolyte
pyelonephritis- a woman lumbar region (usually on the right side)
balance, and urine for ketones
that radiates downward.
- Provide frequent mouth care
- feels tender to palpation
- Instruct the patient eat two or three dry crackers before getting
- She may have accompanying nausea and vomiting, malaise, pain
out of bed in the morning to alleviate nausea
and frequency of urination
- Avoid greasy, gassy and spicy foods
- Temperature maybe elevated 39 to 40 C
- Offer emotional support.
- infection usually occurs on the right side because there is a
greater compression and urinary stasis on the right ureter from GESTATIONAL TROPHOBLASTIC DISEASE
the uterus being pushed that way by the large bulk of intestine on (HYDATIFORM MOLE OR MOLAR PREGNANCY)
the left side.
- Rapid deterioration of trophoblastic villi cells
THERAPEUTIC MANAGEMENT
- Trophoblast cells are located in the outer ring of the blastocyst (
- obtain clean catch urine sample for culture and sensitivity the structure that develops around the third or fourth day after
- Amoxicillin fertilization) and eventually become part of the structure that
forms the placenta and fetal membranes.
- Ampicillin
- As trophoblast cells begin to deteriorate, they fill with fluid
- Cephalosporins
- The cells become edematous, appearing as grapelike clusters of
HYPEREMESIS GRAVIDARUM
vesicles.
- Sometimes called PERNICIOUS VOMITING, is nausea and
- As a result of these cell abnormalities, the embryo fails to
vomiting of pregnancy that is prolonged past week 12 of
develop past the early stages.
pregnancy or is so severe that dehydration and significant weight
loss occur within the first 12 weeks.

ETIOLOGY/ CAUSES

- High levels of HCG in early pregnancy

- Metabolic or nutritional deficiencies

- Ambivalence toward pregnancy or family related stress

- reduced serum levels of sodium, potassium and chloride

ASSESSMENT

- Severe nausea and vomiting TYPES OF H-MOLE

- vomits initially containing undigested food, bile and mucus; later 1. COMPLETE MOLE
containing blood and material that resembles coffee grounds - Characterized by swelling and cystic formation of all
OTHER FINDINGS: trophoblastic cells

- Pale, dry skin - No fetal blood is present

- Rapid pulse - If an embryo does develop, its most likely only 1 to 2 mm in size
and will probably die early in development
- Fetid, fruity breath (from acidosis) acetone breath

- appear confused or delirious, stupor and possibly coma

2. PARTIAL MOLE
- Characterized by edema of some of the trophoblastic villi with
some of the normal villi
- Fetal blood may be present in the villi, and an embryo up to the
size of 9 weeks gestation may be present
- 69 chromosomes in which there are 3 chromosomes for every
one pair
CAUSES: UNKNOWN
CINICAL MANIFESTATION
- Vagina bleeding- ranging from brownish red spotting to bright
red hemorrhage and containing grapelike tissue
- Lower abdomen cramps
- Signs and symptoms of pre-eclampsia (BP elevated before 20
weeks gestation)
- Absence of fetal heart tones
- Severe nausea and vomiting
LABORATORY AND DIAGNOSTICTESTS:
- HCG serum levels are abnormally high
- Ultrasonography performed after the 3rd month shows grape-
like clusters instead of fetus
- Doppler ultrasonography shows the absence of fetal heart tones
NURSING MANAGEMENT:
- Prepare for uterine evacuation by dilatation and suction
curettage
- Labor induction with oxytocin or prostaglandins is
contraindicated because of increased risk of hemorrhage
- HCG levels monitored for 1 year to rule out metastasis from
choriocarcinoma (continued elevation may require Hysterectomy
and chemotherapy
- Pregnancy is discourage for 1 year
- Contraceptive methods are used to prevent another pregnancy
until at least 1 year after all titers and X-ray findings are negative
- Report the following signs and symptoms immediately: irregular
vaginal bleeding, persistent secretion for breast, hemoptysis and
persistent headaches (spread to the other organs)
- Address psychological and emotional needs.
INCOMPETENT CERVIX
- Characterized by painless dilation and effacement of the cervical
os without contractions of the uterus in the early trimester
resulting in expulsion of the products of conception.
- Commonly occurs at about 20th week of pregnancy
ETILOGY AND CAUSES
- Increased maternal age and congenital development or
endocrine factors
- Trauma to the cervix- such as might have occurred with a
dilatation and curettage or traumatic delivery, is often the cause
- Congenital short cervix
- Uterine anomalies
ASSESSMENT
- Painless cervical dilation
- Pink-stained vaginal discharge
- Rupture of membranes and discharge of amniotic fluid (birth of
dead or nonviable fetus)
- Uterine contractions
THERAPEUTIC INTERVENTIONS
- CERCLAGE - a procedure during 14 to 16th week of gestation or
before next pregnancy
- Suture or ribbon placed beneath the cervical mucosa to close
the cervix
A. end a pregnancy that is unwanted because it is the result of
PERMANENT rape or incest, or to end a pregnancy of a woman who chooses
SUTURE not to have a child at this time.
(SHIRODKAR
TYPES OF ABORTION
PROCEDURE)

- subsequent
delivery by
cesarean
section

B. TEMPORARY
PURSE STRINGG (MC
TYPE OF ABORTION
DONALD
PROCEDURE) 1. SPONTANEOUS - also called a miscarriage, occurs from
natural causes, it is termed early if it occurs before week 16 of
- suture removed at
pregnancy; late if it occurs between 16 to 24.
term with vaginal
delivery. - most common causes of bleeding during the 1st trimester of
pregnancy.

a. THREATENED ABORTION - moderate bright red vaginal

bleeding

-no cramping, mild cramping, backache with feeling of pelvic

NURSING INTERVENTION pressure
- Obtain thorough history and physical examination - Cervix is closed
- Pink tinged vaginal discharge, increased pelvic pressure b. INEVITABLE ABORTION/IMMINENT ABORTION
and rupture of the membranes
- Moderate bright red vaginal bleeding
- Prepare the client for CERCLAGE if appropriate
- Cervix opened
- Anticipate the removal of these sutures at about weeks 38 to
- Possible passage of tissue fragments
39 weeks of pregnancy so that the fetus may deliver vaginally; if
sutures are left in place, prepare the client for cesarean birth - Uterine contractions

- Maintain activity restrictions as prescribed - Membranes rupture

- Discuss the need for vaginal rest (no intercourse or orgasm) c. COMPLETE ABORTION

- Provide emotional support and guidance to the client and her
partner to help alleviate fears and anxieties
ABORTION
- The termination of pregnancy at any time before the fetus has
attained viability (20 weeks gestation or fetal weight of 500 gm
or 1.1 lbs)
EFFECTIVE ABORTION
- is a procedure performed deliberately to end a pregnancy
before fetal viability; also referred to as therapeutic, medical or
induced abortion.
- Moderate bright red vaginal bleeding
- Uterine contractions cervical dilation
- sponrous expulsion of the entire products of conception
within 24-48 hours (fetus, membranes and placenta
d. INCOMPLETE ABORTION
- Moderate bright red vaginal bleeding
- Uterine contractions
-spontaneous expulsion of part of the products of conception
(usually fetus only)

- to end a pregnancy that threatens a woman's life or involves a

fetus found on amniocentesis to have a chromosomal defect, to
 - Administer oxygen if indicated. Measure and record IV fluids

- Prepare for D and C if indicated

- Prepare for RhoGAM administration to an Rh (-) mother as

prescribed

- Recommend iron supplements and increased dietary iron as

indicated to help prevent anemia.

- Offer anticipatory guidance relative to expected recovery, the

need for rest and delay of another pregnancy until client fully
recovers
e. MISSED ABORTION
- Suggests avoiding intercourse until after the next menses or
- Fetal intrauterine death without expulsion of the products of using condoms when engaging in intercourse.
conception.
PLACENTA PREVIA
- Cervix is closed
- Implantation of the placenta in the lower uterine segment.
- Dark brown vaginal bleeding
TYPES OF PLACENTA PREVIA
- Inaudible heart sounds (previously present)
1. LOW-LYING PLACENTA\ LOW MARGINAL
- Painless
- A small placental edge can be felt through the maternal os.
f. RECURRENT/ HABITUAL ABORTIONS
2. PARTIAL PLACENTA PREVIA
- Spontaneous abortion of 3 or more consecutive pregnancies.
- Occurs when the placenta partially covers the internal os.
CAUSES AND ETIOLOGY
3. TOTAL PLACENTA PREVIA
FETAL FACTORS:
- The placenta completely covers the internal os.
- Detective embryonic development

- Faulty ovum implantation

- Rejection of the ovum by the endometrium

- Chromosomal abnormalities

PLACENTAL FACTORS:

- Premature separation of the normally implanted placenta

- Abnormal placenta separation

PREDISPOSING FACTORS:
ASSESSMENT FINDINGS
- Multiparity 80%
- Vaginal bleeding in the first 20 weeks of pregnancy
- The number of past caesarean birth
- Complaints of cramping in the lower abdomen
- The number of past uterine curettages
- Fever, malaise or other symptoms of infection
- Advance maternal age
NURSING CARE FOR CLIENTS WITH ABORTION
ASSESSMENT:
- Monitor amount and type of bleeding. Save and count number
of pads - Low lying placenta on ultrasonography

- Monitor fundus for firmness after products of conception are
expelled
- Monitor CBC, hematocrit, hemoglobin and prepare for BT if
indicated
- Abrupt, painless red vaginal bleeding
NURSING INTERVENTION
- Caution the client to avoid coitus, to get adequate rest
preferably in a side-lying position, and to notify the physician of
any sign of vaginal bleeding.
- Take and record VS, assess bleeding, and maintain a perineal pad TREATMENT:
count.
- Replacement of blood loss
- Assess for shock and administer oxygen as indicated.
- With moderate or severe separation or maternal/ fetal distress:
- Monitor FHR continuously. EMERGENCY CEASAREAN BIRTH

- Administer IV therapy and blood replacement. - With mild separation without fetal distress and in the presence
of some cervical effacement and dilatation: INDUCTION OF LABOR
ABRUPTIO PLACENTA
MAYBE ATTEMPTED.
- Premature separation of a normally implanted placenta after the
NURSING MANAGEMENT
20th week of pregnancy, typically with severe hemorrhage.
- Assess the patient’s extent of bleeding and monitor fundal
ETIOLOGYCAUSES:
height every 30 minutes for changes
- Cause is unknown
- Count the number of perineal pads
TYPES OF ABRUPTIO PLACENTA
- Monitor maternal BP, pulse rate, respiration, I and O and
CONCEALED (CENTRAL) amount of vaginal bleeding every 10 to 15 minutes
HEMORRHAGE
- Monitor FHR and maternal vs
- Placenta separates centrally
- Administer oxygen by mask to minimize fetal anoxia
- Large amount of blood
- Position the client in a lateral position to prevent pressure on
accumulates under the placenta.
vena cava, further compromising fetal circulation

EXTERNAL
(MARGINAL) HEMORRHAGE

- Placenta separates marginally

- Blood flows under the membranes and

through the cervix.

ASSESSMENT

- Sharp stabbing pain high in uterine fundus as initial separation

occurs.

- Pain over and above the pain of contractions if labor begins with
separation.

- Tenderness on uterine palpation with contractions if labor

begins with separation

- Hard, board like uterus with minimal or no apparent bleeding

(especially if the center of placenta separates first)

- Uterine contractions

- Uterine outline possibly enlarged or changing shape

- FHR present or absent

THERAPEUTIC INTERVENTIONS

LABORATORY AND DIAGNOSTIC FINDINGS

- Ultrasound may be able to identify the extent of abruptio