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Hyperemesis Gravidarum And Preterm Labor

Hyperemesis Gravidarum And Preterm Labor

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Hyperemesis Gravidarum And Preterm Labor Hyperemesis Gravidarum And Preterm Labor Presentation Transcript

  • Hyperemesis Gravidarum and Premature Labor
    Reynel Dan Galicinao
    Ma. Lourdes Balucan
    Angelia Galinato
    Geraldine Ridad
  • Hyperemesis Gravidarum
  • Unremitting nausea and vomiting that persists after the first trimester.
    Usually occurs with the first pregnancy and commonly affects pregnant women with conditions, such as hydatidiform mole or multiple pregnancy, that produce a high level of human chorionic gonadotropin.
    This disorder occurs among Blacks in about 7 in 1,000 pregnancies and among Whites in about 16 in 1,000 pregnancies.
  • Precipitating Factors:
    Pancreatitis
    Biliary tract disease
    Dec. secretion of free HCl in the stomach
    Dec. gastric motility
    Drug toxicity
    Inflammatory obstructive bowel disease
    Vitamin deficiency (B6)
    Psychological factors (neurosis)
    Predisposing Factors:
    Multiple pregnancies
    Heredity
    Sex: Female
    Race: White
    Morning Sickness
    High levels of hCG or estrogen
    Excessive vomiting
    Appetite disturbance
    Weight loss
    Starvation
    Emaciation
    Dehydration
    Fever
    Fluid and electrolyte imbalance
    Dry skin
    Dec urine output
    Hypokalemia
    Acetonuria
    Ketosis
  • Assessment Findings
    Unremitting nausea and vomiting (cardinal s/sx)
    Vomitus contains:
    initially: undigested food, mucus, and small amounts of bile
    later: bile and mucus
    finally: blood and material that resembles coffee grounds
    Substantial wt loss and eventual emaciation caused by persistent vomiting, thirst, hiccups, oliguria, vertigo, and headache.
    Evaluate 24-hr dietary recall.
  • Assessment
    Determine for pica.
    Inspection may reveal:
    pale, dry, waxy, and possibly jaundiced skin, with decreased skin turgor
    dry, coated tongue
    subnormal or elevated temperature
    rapid pulse
    fetid, fruity breath odor from acidosis
    May appear confused and delirious. Lassitude, stupor and, possibly, coma may occur.
  • Medical Management
    Diagnostic Test
    Serum analysis shows decreased protein, chloride, sodium, and potassium levels and an increased blood urea nitrogen level.
    Other laboratory tests reveal ketonuria, slight proteinuria, an elevated hemoglobin level, and an elevated white blood cell count.
  • Medical Management
    May require hospitalization to correct electrolyte imbalance and prevent starvation.
    I.V. infusions- to maintain nutrition until she can tolerate oral feedings.
    Progresses slowly to clear liquid diet, then to full liquid diet, finally, to small, frequent meals of high-protein solid foods.
    Midnight snack helps stabilize blood glucose level.
    Parenteral vitamin supplements and potassium replacement- help correct deficiencies.
  • Medical Management
    Jeopardized health due to persistent vomiting- antiemetic is administered.
    Meclizine (Antivert) and Diphenhydramine -low risk for teratogenicity.
    Total parenteral nutrition- rarely needed.
    If vomiting stops and electrolyte balance has been restored- pregnancy usually continues without recurrence of hyperemesis gravidarum.
    Most pts feel better as they begin to regain normal wt, but some continue to vomit throughout pregnancy, requiring extended treatment.
    If appropriate, some patients may benefit from consultations with clinical nurse specialists, psychologists, or psychiatrists.
  • Priority Nursing Diagnoses with Interventions
  • 1. Risk for deficient fluid
    volume may be r/t
    excessive gastric losses
    and reduced intake
    2. Imbalanced nutrition: less
    than body requirements
    may be r/t inability to
    ingest/digest/absorb
    nutrients
    (prolonged vomiting)
    5. Fear may be r/t
    concerns for fetal
    well-being
    Hyperemesis
    gravidarum
    4. Risk for ineffective coping
    may be r/t stress
    of pregnancy and illness
    3. Fatigue may be r/t
    muscle weakness
    2° emaciation
  • Risk for deficient fluid volumemay be r/t excessive gastric losses and reduced intake, possibly evidenced by dry mucous membranes, dec./concentrated urine, dec pulse volume and pressure, thirst, and hemoconcentration.
    Maintain I.V. fluids, as ordered, until the patient can tolerate oral feedings.
    Maintain NPO status until vomiting stopped. Ice chips may be given.
    Monitor fluid intake and output, vital signs, weight, serum electrolyte levels, and urine for ketones.
    Medicate with antiemetics as prescribed.
  • 2. Imbalanced nutrition: less than body requirementsmay be r/t inability to ingest/digest/absorb nutrients (prolonged vomiting), possibly evidenced by reported inadequate food intake, lack of interest in food/aversion to eating, and wt loss.
    Suggest dec. liquid intake during meals.
    Advise woman that oral intake can be restarted when emesis has stopped.
    Company and diversionary conversation at mealtime may be beneficial.
    Instruct the patient to remain upright for 45 minutes after eating to decrease reflux.
    Suggest that the patient eat two or three dry crackers on awakening in the morning, before getting out of bed, to alleviate nausea.
  • 3. Fatigue may be r/t muscle weakness 2° emaciation
    Teach the pt protective measures to conserve energy and promote rest.
    Teach relaxation techniques; fresh air and moderate exercise, if tolerated.
    Schedule activities to prevent fatigue.
  • 4. Risk for ineffective coping may be r/t stress of pregnancy and illness: risk factors may include situational/maturational crisis (pregnancy, change in health status, projected role changes, concern about outcome).
    Provide reassurance and a calm, restful atmosphere.
    Encourage the pt to discuss her feelings about her pregnancy and the disorder.
    Help the pt develop effective coping strategies.
    Refer her to the social service department for help in caring for other children at home, if appropriate.
  • 5. Fear may be r/t concerns for fetal well-being
    Praise mother for attempts of following therapeutic regimen.
    Explain the effects of all medications and procedures on maternal as well as fetal health.
    Accentuate the positive signs of fetal well-being.
  • Premature Labor
  • Premature labor (preterm labor)- onset of rhythmic uterine contractions that produce cervical changes after fetal viability but before fetal maturity.
    Usually bet 20th and 37th wk of gestation.
    Between 5% and 10% of pregnancies end prematurely; 75-85% of neonatal deaths and many birth defects result from this disorder.
    Fetal prognosis depends on birth wt and length of gestation:
    Neonate’s wt <1 lb 10 oz (737 g) and of <26 weeks gestation have a survival rate of 40-50%;
    Wt= 1 lb 10 oz to 2 lb 3 oz (737 to 992 g) and of 27 to 28 weeks' gestation have a survival rate of 70% to 80%;
    Wt= 2 lb 3 oz to 2 lb 11 oz (992 to 1,219 g) and of >28 weeks' gestation have an 85% to 97% survival rate.
  • Precipitating:
    • DHN
    • Habitual abortion
    • Heavy work and long travel to work
    • Hx of cone biopsy of the cervix
    • Hx of GU infections or renal disease
    • Hx of induced abortion, preterm delivery
    • Low socioeconomic class
    • Maternal under nutrition and inadequate wt gain during pregnancy
    • Multiple gestation
    • Inadequate prenatal care
    • Single parenthood
    • Smoking
    • Substance abuse
    • Chorioamnionitis
    Predisposing:
    Congenital uterine or cervical abnormalities
    Sex: female
    Genetics
    Age
    Race (African-American)
    Uterine contraction before end of 37th wk of gestation (persistent uterine contractions 4/20mins) with cervical effacement >80% and dilation >1cm
    Bleeding
    Feeling of pelvic pressure/ abdominal tightening
    Vaginal spotting
    Menstrual-like cramping
    Inc vaginal discharge (pink-tinged)
    Intestinal cramping
    Preterm Birth
    Persistent dull, low backache
    Primary neonatal complications:
    Respiratory distress syndrome
    Intracranial bleeding
    Chronic lung disease
    Infection
    Visual impairment
    Cerebral palsy.
    Possible diarrhea
  • Assessment findings
    Activity: Works outside home, job heavy/stressful; Unusual fatigue
    Circulation: HPN, pathological edema (signs of PIH); Preexisting CV disease
    Ego Integrity: Moderate anxiety apparent
    Elimination: Dark amber urine, dec frequency/amount
    Food/Fluid: Inadequate or excessive wt gain; Inadequate fluid intake; Dry mucous membranes
  • Assessment
    Pain/Discomfort: Intermittent to regular contractions (may not be painful) <10min apart and lasting @ least 30 sec for 30–60 min
    Respiratory: May be heavy smoker (7–10 cigarettes/d)
    Safety: Infection may be present (i.e., UTI and/or vaginal infection).
    Sexuality: Cervical os softening/dilated/effacing; Bloody show; PROM; 3rd trimester bleeding; Previous abortions, preterm labor/delivery, hx of cone biopsy, <1 yr since last birth; Uterus may be overdistended, owing to polyhydramnios, macrosomia, or multiple gestation.
    Social Interaction: May be low socioeconomic status
  • Medical Management
    Diagnostic Test
    Prenatal hx, PE, and presenting s/sx
    Ultrasonography - identify position of the fetus in relation to the mother's pelvis, document AOG, and estimate fetal wt
    Vaginal examination - confirm progressive cervical effacement and dilation
    Electronic fetal monitoring - confirms rhythmic uterine contractions and to monitor fetal well-being
  • Differential dx excludes Braxton Hicks contractions and UTI
    Nitrazine Test or “Ferning” Slide: Determines PROM.
    WBC Count: Elevation indicates presence of infection.
    Urinalysis and Culture: Rule out UTI.
    Amniocentesis: L/S ratio detects phosphatidyl glycerol (PG) for fetal lung maturity; or amniotic infection.
  • Medical and Surgical Managements
    Focuses on suppressing premature labor when tests show immature fetal pulmonary development, cervical dilation of less than 4 cm, and factors that warrant continuation of pregnancy.
    Bed rest and hydration
    If pt doesn't respond, tocolytic therapy is instituted.
    Beta-adrenergic stimulants stimulate the beta2 receptors, inhibiting the contractility of uterine smooth muscle.
    Terbutaline (Brethine)
    Betamethasone
    Ritodrine (Yutopar)
    Magnesium sulfate - to relax the myometrium.
    After successful tocolysis, oral therapy is maintained until 36 weeks' gestation.
    Some pts successfully deliver at term after this treatment.
  • Glucocorticoid administration to the mother at <33 weeks gestation enhances fetal pulmonary maturation and reduces incidence of respiratory distress syndrome.
    Continuous fetal monitoring
    Avoidance of amniotomy - to prevent cord prolapse or damage to the fetus' soft skull
    Maintenance of adequate hydration through I.V. fluids
    Avoidance of sedatives and opioids that might harm the fetus.
    Morphine or meperidine - to minimize maternal pain, have little effect on uterine contractions, but because they depress CNS, may cause fetal respiratory depression.
    They should be given in the smallest dose possible and only when needed.
    Cesarean birth may be planned to reduce pressure on the fetal head and reduce the possibility of subdural or intraventricular hemorrhage from a vaginal birth.
  • Priority Nursing Diagnoses and Interventions
  • 1. Risk for fetal injury
    may be r/t preterm birth
    5. Anxiety may be r/t
    situational crisis, perceived
    or actual threats to
    self/fetus, and inadequate
    time to prepare for labor
    2. Risk for poisoning
    Premature labor
    4. Activity intolerance may
    be r/t muscle/cellular
    hypersensitivity
    3. Acute pain may be
    r/t labor contractions
  • Risk for fetal injury r/t preterm birth: risk factors may include delivery of premature/immature infant.
    Maintain bed rest and administer medications as ordered.
    Minimize adverse effects by keeping the pt in lateral recumbent position.
    Maintain adequate hydration by drinking 8-10 glasses of water daily.
    If necessary, give oxygen to pt through nasal cannula.
  • 2. Risk for poisoning: risk factors may include dose-related toxic/side effects of tocolytics.
    Help the pt get through labor with as little analgesic and anesthetic as possible. To minimize fetal CNS depression, avoid administering analgesic when delivery seems imminent.
    Monitor fetal and maternal response to local and regional anesthetics.
    When giving a beta-adrenergic stimulant, a sedative, or an opioid, monitor BP, PR, RR, FHR, and uterine contraction pattern.
    When giving magnesium sulfate, monitor neurologic reflexes and be alert for maternal adverse reactions, such as tachycardia and hypotension. Keep calcium gluconate at the bedside.
  • 3. Acute pain may be r/t labor contractions
    Give analgesics sparingly, mindful of their potentially harmful effect on the fetus.
    Teach relaxation techniques and breathing exercises.
    Promote diversional activities such as watching TV, listening to calm music.
  • 4. Activity intolerance may be r/t muscle/cellular hypersensitivity, possibly evidenced by continued uterine contractions/irritability.
    Pace activities to promote frequent rest periods.
    Monitor VS and compare with baseline to assess for tolerance to activity.
    Encourage SO’s to assist pt with ADL’s.
  • 5. Anxiety may be r/t situational crisis, perceived or actual threats to self/fetus, and inadequate time to prepare for labor, possibly evidenced by inc. tension, restlessness, expressions of concern, and autonomic responses (changes in VS).
    Encourage the pt and her family to discuss their feelings and concerns. Offer emotional support, and help them to develop effective coping strategies.
    Provide pt and family teaching regarding s/sx and management of premature labor.
    If possible, arrange for the parents to see and hold the infant soon after delivery to promote bonding.