Hyperemesis Gravidarum And Preterm Labor

1. Hyperemesis Gravidarum and Premature Labor Reynel Dan Galicinao Ma. Lourdes Balucan Angelia Galinato Geraldine Ridad

2. Hyperemesis Gravidarum

3. 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.

4. 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

5. 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. Priority Nursing Diagnoses with Interventions

11. 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

12. 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.

13. 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.

14. 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.

15. 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.

16. 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.

17. Premature Labor

18. 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.

20. Habitual abortion

21. Heavy work and long travel to work

22. Hx of cone biopsy of the cervix

23. Hx of GU infections or renal disease

24. Hx of induced abortion, preterm delivery

25. Low socioeconomic class

26. Maternal under nutrition and inadequate wt gain during pregnancy

27. Multiple gestation

28. Inadequate prenatal care

29. Single parenthood

30. Smoking

31. Substance abuse

32. ChorioamnionitisPredisposing: 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

33. 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

34. 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

35. 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

36. 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.

37. 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.

38. 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.

39. Priority Nursing Diagnoses and Interventions

40. 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

41. 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.

42. 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.

43. 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.

44. 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.

45. 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.