PRE-GESTATIONAL CONDITIONS: SUBSTANCE ABUSE
AND ANEMIA 03/09/2023
Substance Abuse
- Use of alcohol, illicit drugs and other psychoactive
substances during pregnancy can lead to multiple
health and social problems for both mother and
child.
Includes:
 miscarriage
 Stillbirth
 low birth weight
 Prematurity
 physical malformations
 neurological damage
- 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.
- As many as 10% - 20% of pregnant women use illegal
drugs during pregnancy.
- Drugs that are commonly misused includes:
Tobacco, alcohol, cocaine, marijuana,
amphetamines, barbiturates, hallucinogens, club
drugs, heroin, and narcotics.
Etiology of Substance Abuse
- Remains unclear at the present time
- Increasing one's susceptibility to life stressors with
poor coping skills
- Limited social support systems
- Easy access to alcohol and illicit substances
- Previous traumatic crises
- Identity/self-esteem problems
- *** Those individuals with mental health disorders,
reproductive problems, and eating disorders appear
more likely to develop substance abuse problems. In
fact, the prevalence of all psychiatric diagnoses is
higher among female alcoholics than non-alcoholics.
Detecting Substance Abuse
- Most women with substance abuse problems do not
manifest.
- Indicators suggesting substance abuse during
pregnancy includes:
 self-reported use
 avoidance of prenatal care
 premature labor and delivery,
 placental abruption, and fetal death.
- A detailed history and physical examination followed
by pertinent laboratory studies assist the nurse in
detecting those pregnant women with substance
abuse problems.
- When performing a substance use history, the nurse
should ask the patient about the type, amount, and
frequency of substance use in a nonjudgmental
manner, with emphasis on forming a patient-nurse
alliance.
EFFECTS OF SUBSTANCE ABUSE ON THE WOMAN AND
HER FETUS
- Classified into three categories:
 effects on the mother
 effects on the course of pregnancy and delivery, and
 effects on the fetus, newborn, and developing child
- Maternal complications may be:
 respiratory, such as bacterial infections
 cardiovascular, including hypertension and
endocarditis;
 neurologic, with seizures, cerebrovascular accidents,
and psychoses;
 infectious, such as sexually transmitted diseases and
human immunodeficiency virus;
 renal and gastrointestinal, including acute tubular
necrosis and hepatitis
- Obstetric and fetal complications associated with
maternal substance abuse include
 Placenta previa,
 Abruptio placentae,
 Premature rupture of membranes,
 Spontaneous abortion,
 Intrauterine growth retardation,
 Premature delivery, birth defects, and neonatal and
long-term developmental
 Specific neonatal medical complications of
 Child 'more likely to use drugs if mum smoked when
pregnant maternal substance abuse include sudden
infant death syndrome (SIDS), neonatal abstinence
syndrome (NAS), and respiratory distress syndrome
SUDDEN INFANT DEATH SYNDROME
 Risk Factors
- Prone and side sleeping, soft bedding, bed sharing,
inappropriate bed surtaces, exposure to tobacco
smoke, and prematurity
 Protective Factors:
- Breastfeeding, paciferuse, room sharing, and
immunizations
 Risk Reduction.
- Safe sleeping environment
Alcohol
- Can depress the central nervous system so much that it
results in impairment such as slurred speech, unsteady
movement, disturbed perceptions, and an inability to
react quickly
- It quickly passes from your blood to your baby's blood
through the placenta and umbilical cord
- Your fetus has the same blood alcohol level that you do
if you drink, but it doesn't have the same ability to break
down the alcohol
- Teratogen
- Fetal alcohol syndrome (FAS) is marked by a pattern of
birth defects
- Small head and body size
- Specific abnormal facial features
- Learning and behavioral problems
ALCOHOL ABUSE DURING PREGNANCY
- Chronic alcohol use during pregnancy, defined as the
ingestion of two or more drinks per day, is associated
with increased rates of spontaneous abortion, higher
rates of low-birth-weight infants, placental
abruption, increased perinatal mortality, amnionitis,
and preterm deliveries.
- Alcohol impairs the placental transfer of essential
amino acids and zinc, thus increasing the risk for
intrauterine growth retardation.
- Fetal alcohol syndrome (FAS) is characterized by
varying degrees of craniofacial dysmorphism,
impaired prenatal and postnatal growth, central
nervous system abnormalities, and cardiac defects.
- The effects of alcohol exposure on the fetal brain,
findings revealed that severe prenatal alcohol
exposure produces a specific pattern of brain
hypoplasia.
- Alcohol withdrawal in pregnant women, which may
be treated with benzodiazepines or phenobarbital, is
rare, and withdrawal in affected infants is even rarer.
- When neonatal withdrawal does occur, it is
characterized by agitation and hyperactivity, with
marked tremors lasting for 72 hours, followed by 48
hours of lethargy, before recovery.
Cocaine & Crack
 Cocaine Derived from erythroxylum coca
 Is a powerful and addictive stimulant that can be
shorted, smoked, or injected
 Acts at the nerve terminals to prevent the reuptake
of dopamine and norepinephrine, which in turn
results in vasoconstriction, tachycardia, and
hypertension
 This causes the brain and spinal cord to speed up
activity
 Potent Vasoconstrictor
 Crosses into breastmilk and may cause symptoms in
the breastfeeding infant:
 extreme irritability
 vomiting
 diarrhea
 dilated pupils and apnea
COCAINE ABUSE DURING PREGNANCY
 Cocaine use during pregnancy, affecting 1% to 5% of
neonates, is associated with decreased uterine blood
flow leading to poor fetal oxygenation and increased
fetal blood pressure and heart rate.
 Cocaine use during early gestation is associated with
an increased risk of spontaneous abortion, whereas
later use is associated with premature labor and
delivery, placental abruption, low birth weight, SIDS,
intrauterine growth retardation, low Apgar scores,
meconium staining, fetal death, microcephaly,
neurodevelopmental delay, and
structural/congenital anomalies, especially involving
the gastrointestinal and renal systems.
Marijuana
- Refers to the dried leaves, flowers, stems, and seeds
from the Cannabis sativa or Cannabis indica plant
- Tetrahydrocannabinol or THC
 The most widely used illicit drug among women,
both pregnant and non-pregnant
- Stimulates tachycardia & sense of well-being
- Low birth weight, may make it hard for your child to
pay attention or to learn
- These issues may only become noticeable as your
child grows older
- Chemicals from this substance can be passed to your
baby through breast milk
- May affect a mother's ability to be able to properly
care for her baby
MARIJUANA USE DURING PREGNANCY
 Marijuana is a commonly abused substance, with
greater than 25% of women in their reproductive
years admitting to past or current marijuana use.
 Although marijuana use during pregnancy has been
associated with few short-term or long-term effects
on the exposed neonate, its risks are dose-
dependent, with an increased incidence of
intrauterine growth retardation and SIDS seen in the
infants born to heavy users.
 The use of marijuana may be most beneficial as an
indicator of poly-substance abuse and lower
socioeconomic status that may influence both
prenatal care and the home environment.
3,4-Methylenedioxy methamphetamine
MDMA Ecstacy"
 Given that most people who Use MDMA are young
and in their reproductive years
 Experience psychedelic and hallucinogeni effects
(meaning they see or hear things that are not really
there)
 Induce miscarriage & premature labor
 Prenatal MDMA exposure was associated with motor
delays in the offspring up to 2 years after birth
 MDMA in the breast milk of people who were
breastfeeding
Heroin
 CNS depressant narcotics
 The fetus of a heroin-addicted woman is at increased
risk for lUGR, meconium aspiration, and hypoxia Can
result in Neonatal Abstinence Syndrome (NAS)
 Occurs when heroin passes through the placenta to
the fetus during Pregnancy, causing the baby to
gecome dependent, along with the mother
 Symptoms include:
 High-pitched cry, fever, irritability, seizures, slow
weight gain, tremors, diarrhea, vomiting, and
possibly death

NARCOTIC ABUSE DURING PREGNANCY
 Narcotic abuse during pregnancy is associated with a
higher-than-normal incidence of premature labor,
chorioamnionitis, SIDS, premature rupture of the
membranes, meconium staining, preeclampsia, and
placental abruption. Infants exposed to heroin are at
higher risk for congenital abnormalities.
 Heroin abuse during pregnancy is associated with a
50% incidence of low-birth-weight infants, with up to
50% of these infants being small for gestational age,
many of whom experience respiratory depression
and low Apgar scores.
 Methadone, Morphine, Demerol most commonly
abused narcotic drugs
NURSING MANAGEMENT
 Assessment of a client with substance abuse disorder
include:
 History
 Client with a parent or other family members with
substance abuse problems may report a chaotic
family life, although this is not always the case.
 Thought process and content
 During the assessment of thought process and
content, clients are likely to minimize their substance
abuse, blame others for their problems, and
rationalize their behavior.
Sensorium and intellectual process
 Clients generally are oriented and alert unless they
are experiencing lingering effects of withdrawal.
 General appearance and motor behavior
 Assessment of general appearance and behavior
usually reveals appearance and speech to be normal.
 Self concept
 Clients generally have low self-esteem, which they
may express directly or cover with grandiose
behavior
 A team approach to the care of the pregnant woman
with substance abuse problems ensures the
management necessary to provide safe labor and
birth for the woman and her child
 The management of drug addiction may include
hospitalization if necessary to start detoxification
 Urine screening is also done regularly throughout the
pregnancy if the woman has a known or suspected
substance abuse problem. This testing helps to
identify the type and amount of drug being abused
NURSING DIAGNOSIS
 Risk for injury related to substance intoxication or
withdrawal
 Ineffective denial related to underlying fears and
anxieties
 Ineffective coping related to inadequate support
system or coping skills
 Imbalance nutrition: less than body requirements
related to drinking alcohol instead of eating
nourishing food
 Chronic low self-esteem related to retarded ego
development
MANAGEMENT AND TREATMENT
- Abstinence should be the ultimate goal of the
management and treatment of substance abuse
during pregnancy.
- Researchers have found that participating in prenatal
care alone can improve the outcome of the
substance abuse pregnancy and that ceasing
substance use during the pregnancy can further
decrease perinatal morbidity.
- Most infants exposed to substances still have good
outcomes, and early neonatal interventions can
prevent or lessen future neurodevelopmental
problems.
- Common obstacles to treatment include poor social
support systems, failure to identify substance
abusers during pregnancy, inadequate financial
resources, and fear of custody loss with admission to
problems of substance abuse.
- To attract enrollment, treatment should include
multidisciplinary health care, family therapy, child
care, vocational/parenting skills training, and
psychiatric services.
- According to Schrager and coworkers, a residential
treatment program combined with consistent
outpatient follow-up is the best way to prevent or
decrease maternal substance use.
- Other treatment options include formal counseling
programs, self-help groups, and women's shelters.
- Involuntary treatment should be considered when
the substance abuser refuses to enter a treatment
program and when her behavior creates significant
problems for herself and the fetus.
ANEMIA
- Anemia in Pregnancy
- Anemia is a condition of few RBC or a lowered ability
of the RBC
- In pregnancy, it is defined as hemoglobin level less
than 11 g/dL in the 1st and 3rd trimester and 10.5
g/dL in the 2nd trimester. (WHO)
- TYPES
- Iron Deficiency Anemia (IDA) - common in pregnant
women
- Vitamin B12 deficiency
- Folate Deficiency Anemia d Anemia due to blood loss
ANEMIA AND PREGNANCY
- Because the blood volume expands during pregnancy
slightly ahead of the red cell count, most women
have a pseudoanemia in early pregnancy.
- This condition is normal and should not be confused
with true types of anemia that occur as
complications of pregnancy.
- True anemia is typically considered to be present
when a woman's hemoglobin concentration is less
than 11 g/dl (hematocrit <33%) in the first or third
trimester of pregnancy or when the hemoglobin
concentration is less than 10.5 g/dI (hematocrit
<32%) in the second trimester.
body uses iron to make
hemoglobin
⬇️
Hemoglobin is a protein in the red blood cells that
carries oxygen to tissues
⬇️
Increase the volume of blood in your body and
amount of iron you need
⬇️
body uses iron to make more blood to supply oxygen
to your baby
⬇️
NOT enough iron stores
during pregnancy, you could develop Iron deficiency
anemia
- A woman's body goes through significant changes
when she become pregnant. The amount of blood in
her body increases by about 20-30 percent, which
increases the supply of iron and vitamins that the
body needs to make hemoglobin.
- Hemoglobin is the protein in red blood cells that
carries oxygen to other cells in your body.
- Many women lack the sufficient amount of iron
needed for the second and third trimesters. When
your body needs more iron than it has available, you
can become anemic.
- Mild anemia is normal during pregnancy due to an
increase in blood volume.
- Severe anemia can put your baby at higher risk for
anemia later in infancy.
- In addition, if the mother is significantly anemic
during your first two trimesters, she is at greater risk
for having a pre-term delivery or low-birth-weight
baby.
- Being anemic also burdens the mother by increasing
the risk of blood loss during labor and making it more
difficult to fight infections.
Mother is at higher risk for becoming anemic during
your pregnancy if she:
 Have two pregnancies close together
 Are pregnant with more than one child
 Are vomiting frequently due to morning sickness
 Do not consume enough iron
 Have a heavy pre-pregnancy menstrual flow
Symptoms of anemia during pregnancy includes:
 Feeling tired or weak
 Progressive paleness of the skin
 Rapid heartbeat
 Shortness of breath
 Trouble concentrating
Diagnosis
- ***Doctors typically perform several tests to check
the percentage of red blood cells in your plasma and
the amount of hemoglobin in your blood. These are
indicators of whether you are at risk for becoming
anemic.
- Hemoglobin test - It measures the amount of
hemoglobin - - an iron-rich protein in red blood cells
that carries oxygen from the lungs to tissues in the
body.
- Hematocrit test - It measures the percentage of red
blood cells in a sample of blood.
Is Pregnancy-Related Anemia Preventable?
- Good nutrition is the best way to prevent anemia if
you are pregnant or trying to become pregnant.
- Eating foods high in iron content (such as dark green
leafy vegetables, red meat, fortified cereals, eggs,
and peanuts) can help ensure that you maintain the
supply of iron your body needs to function properly.
- Your obstetrician will also prescribe vitamins to
ensure that you have enough iron and folic acid.
Make sure you get at least 27 mg of iron each day.If
you do become anemic during your pregnancy, it can
usually be treated by taking iron supplements.
Types of Anemia during Pregnancy
- Iron-deficiency anemia. This type of anemia occurs
when the body doesn't have enough iron to produce
adequate amounts of hemoglobin. That's a protein in
red blood cells. It carries oxygen from the lungs to
the rest of the body.
- In iron-deficiency anemia, the blood cannot carry
enough oxygen to tissues throughout the body.
- Iron deficiency is the most common cause of anemia
in pregnancy.
- Folate-deficiency anemia. Folate is the vitamin found
naturally in certain foods like green leafy vegetables
A type of B vitamin, the body needs folate to
produce new cells, including healthy red blood cells.
- During pregnancy, women need extra folate. But
sometimes they don't get enough from their diet.
When that happens, the body can't make enough
normal red blood cells to transport oxygen to tissues
throughout the body. Man made supplements of
folate are called folic acid.
- Folate deficiency can directly contribute to certain
types birth defects, such as neural tube
abnormalities (spina bifida) and low birth weight.
- Vitamin B12 Deficiency. The body needs vitamin B12
to form healthy red blood cells. When a pregnant
woman doesn't get enough vitamin B12 from their
diet, their body can't produce enough healthy red
blood cells. Women who don't eat meat, poultry,
dairy products, and eggs have a greater risk of
developing vitamin B12 deficiency, which may
contribute to birth defects, such as neural tube
abnormalities, and could lead to preterm labor.

Treatment for Anemia
- If you are anemic during your pregnancy, you may
need to start taking an iron supplement and/or folic
acid supplement in addition to your prenatal
vitamins. Your doctor may also suggest that you add
more foods that are high in iron and folic acid to your
diet.
- In addition, yoU'll be asked to return for another
blood test after a specific period of time so your
doctor can check that your hemoglobin and
hematocrit levels are improving.
- To treat vitamin B12 deficiency, your doctor may
recommend that you take a vitamin B12 supplement.
just learned that she is a carrier. Also assess for signs
of infection throughout the pregnancy.
- In a pregnant client with sickle cell disease, assess
iron and folate stores, and reticulocyte counts;
complete screening for hemolysis; provide dietary
counseling and folic acid supplements; and observe
for signs of infection.
- In a pregnant client with G-6-PD, provide iron and
folic acid supplementation and nutrition counseling,
and explain the need to avoid oxidizing drugs.

- The doctor may also recommend that you include

more animal foods in your diet, such as:
 meat
 eggs
 dairy products
 Your OB may refer you to a hematologist, a doctor
who specializes in anemia/ blood issues. The
specialist may see you throughout the pregnancy and
help your OB manage the anemia.

Preventing Anemia
- To prevent anemia during pregnancy, make sure you
get enough iron. Eat well-balanced meals and add
more foods that are high in iron to your diet.
- Aim for at least three servings a day of iron-rich
foods, such as:
 lean red meat, poultry, and fish
 leafy, dark green vegetables (such as spinach,
broccoli, and kale)
 iron-enriched cereals and grains
 beans, lentils, and tofu o nuts and seeds
 eggs
- Foods that are high in vitamin can help your body
absorb more iron. These include:
 citrus fruits and juices
 strawberries
 kiwis
 tomatoes
 bell peppersTry eating those foods at the same time
that you eat iron-rich foods. For example, you could
drink a glass of orange juice and eat an iron-fortified
cereal for breakfast.

Nursing Management
- Provide client and family teaching.
- Discuss using iron supplements and increasing
dietary sources of iron as indicated.
- Prepare for blood-typing and cross-matching, and for
administering packed PBCs during labor if the client
has severe anemia.
- Provide emotional support.
- Provide support and management for clients with
hemoglobinopathies.
- In a client who has thalassemia or who carries the
trait, provide support, especially if the woman has