BRIEF DESCRIPTON

SMOKING IN PREGNANCY
Cigarette smoke contains more than 4,000 chemicals, including Nicotine, Carbon
monoxide, Cyanide, Lead, and at least 60 Carcinogenic (cancer-causing ) compounds.
All these chemicals mix with mothers bloodstream and passed to babies to cause
complications like -
20 to 30 percent of low-birth weight babies
up to 14 percent of preterm deliveries and
about 10 percent of all infant deaths
Maternal smoking has also been linked to asthma among infants and young children.

EFFECTS OF SMOKING ON THE BABIES

LOW BIRTH WEIGHT
PREMATURE BIRTH(being born too early)
STILLBIRTH
RESPIRATORY PROBLEMS
CONGENITAL HEART DEFECTS
CENTRAL NERVOUS SYSTEM EFFECTS

LOW BIRTH WEIGHT

The baby is born before 37 weeks gestation; a baby born early has less time in the
mother's uterus to grow and gain weight, and much of a fetus's weight is gained during
the latter part of the mother's pregnancy.
This occurs when a baby does not grow well in utero because of problems with the
placenta, the mother's health or birth defects. Babies with Intrauterine growth restriction
(IUGR) may be born early or full-term; premature babies with IUGR may be very small
and physically immature, and full-term babies with IUGR may be physically mature but
weak.

WHAT CAUSES LOW BIRTH WEIGHT

Any baby born prematurely is more likely to be small. However, there are other factors
that can also contribute to the risk of low birthweight. These include:

Mother's age
Teen mothers (especially those younger than 15) have a much higher risk of having a
baby with low birthweight.

Multiple birth
Multiple birth babies are at increased risk of low birthweight because they often are
premature.

Mother's health
Babies of mothers who are exposed to illicit drugs, alcohol and cigarettes are more likely
to have low birthweight. Mothers of lower socioeconomic status are also more likely to
have poorer pregnancy nutrition, inadequate prenatal care, and pregnancy
complications.

EFFECTS OF LOW BIRTH WEIGHT

If the baby has a low birth weight, it may be at increased risk for complications. Their
body is not as strong, and may have a harder time eating, gaining weight and fighting
infections. Because it has so little body fat, It may have a hard time staying warm in
normal temperatures.
The following are some of the common problems of low birth weight babies:
low oxygen levels at birth
inability to maintain body temperature
difficulty feeding and gaining weight
infection
breathing problems, such as respiratory distress syndrome (a respiratory disease of
prematurity caused by immature lungs)
Sign and symptoms of Respiratory Distress Syndrome:

Increased breathing rate

If your childs breathing rate increases, this may indicate that she is having trouble
breathing or not getting enough oxygen.

Color changes
A bluish color around your childs mouth, on the inside of her lips or on her fingernails
may occur when she is not getting enough oxygen. Her skin may also appear pale or
gray.

Grunting
You may hear a grunting sound each time your child exhales. The grunting is her body's
way of trying to keep air in the lungs so they will stay open.

Noseflaring
If your childs nostrils spread open while she breathes, she may be having to work
harder to breathe.

Retractions
our childs chest will appear to sink in just below the neck or under his breastbone with
each breath. This is another way of trying to bring more air into her lungs.

Sweating
There may be an increase of sweat on your childs head, but without his skin feeling
warm to the touch. More often, his skin will feel cool or clammy. This may happen when
his breathing rate is very fast.

Wheezing
If you hear a tight, whistling or musical sound each time your child breathes, this may
indicate that the air passages are smaller, which makes it harder to breathe.

Neurologic problems, such as Intraventricular hemorrhage (bleeding inside the brain)

Intraventricular hemorrhage (IVH)

is bleeding inside or around the ventriclesspaces in the brain that contain the
protective cerebral spinal fluid. VH is most common in premature babies, especially
babies weighing less than three pounds, five ounces.
Nearly all IVH occurs within the first three days of life.
It's not clear why IVH occurs.

gastrointestinal problems such as Necrotizing Enterocolitis (a serious disease of the

intestine common in premature babies)
Necrotizing enterocolitis is (NEC)
is a serious intestinal illness in babies that results in the death of intestinal tissues.
sick newborns are at the greatest risk for necrotizing enterocolitis.

Sudden Infant Death Syndrome (SIDS)

is the sudden death of an infant under 1 year of age that cannot be explained
following a thorough case investigation that includes an autopsy, a death scene
investigation and a review of the clinical history.
The syndrome is sometimes called crib death, because the death is usually
associated with sleep and often occurs while a baby is sleeping in a crib.
Causes of SIDS:
placing a baby on his side or stomach to sleep, rather than on his back
premature or low birth weight babies
overheating the baby during sleep
sleeping on too soft a surface, with loose blankets and bumper pads
having a sibling who died of SIDS, or a family history of failure to thrive
are under 20 years old when their babies are born
smoke during pregnancy
 have received little or no prenatal care

PREMATURE BIRTH(being born too early)

Premature birth gives the baby less time to develop in the womb.
Depending on how early a baby is born.
If you deliver your baby before 37 weeks, it's called a preterm birth and your baby is
considered premature.
Signs and symptoms of Premature Birth:
Call your midwife or doctor right away if you're having any of the following symptoms
before 37 weeks:
More vaginal discharge than usual
A change in the type of discharge if you're leaking watery fluid or your
discharge becomes watery, mucus-like, or bloody (even if it's pink or just tinged
with blood)
Any vaginal bleeding or spotting
Abdominal pain, menstrual-like cramping, or more than four contractions in one
hour (even if they don't hurt)
More pressure in the pelvic area (a feeling that your baby is pushing down)
Low back pain, especially if it's dull or rhythmic, or you didn't previously have
back pain

Effects of Premature Birth:

Physical development
Behavior problems, including attention deficit hyperactivity disorder (also called ADHD)
and anxiety
Neurological disorders, like cerebral palsy, that affect the brain, spinal cord and nerves
throughout the body
Autism, a group of disorders that affect a childs speech, social skills and behavior

STILLBIRTH
If the baby dies before 24 completed weeks, it's known as a miscarriage or late foetal
loss.
Cause of Stillbirth:
Stillbirths are linked to placental complications. This means that for some reason the
placenta (the organ that links the baby's blood supply to the mother's and nourishes the
baby in the womb) isn't functioning properly.

RESPIRATORY PROBLEMS
Shortness of breath.
Grunting, which is heard during the breathing out (exhaling) phase of breathing.
Wheezing.
Flaring the nostrils and using the neck, chest, and abdominal muscles to breathe,
causing a "sucking in" between or under the ribs (retractions).
Chest pain with exertion or when you take a deep breath

CONGENITAL HEART DEFECTS

The heart had a problem when you were born. You may have had a small hole in it or
something more severe. Although these can be very serious conditions, many can be
treated with surgery.
Causes of Congenital heart defect:
Problems with genes or chromosomes in the child, such as Down syndrome
Taking certain medications, or alcohol or drug abuse during pregnancy
A viral infection, like rubella (German measles) in the mother in the first trimester of
pregnancy
Signs and symptoms:
Shortness of breath
Problems with exercise
A bluish tint to the skin, fingernails, and lips (cyanosis)
Poor weight gain
Management:
 People with congenital heart defects are more likely to have inflammation of the inner
layer of their heart (a condition doctors call endocarditis), especially if their heart was
repaired or replaced through surgery.

CENTRAL NERVOUS SYSTEM EFFECTS

Smoking tobacco has powerful effects on the central nervous system. Cigarettes act as
a central nervous system stimulant, affecting the neurotransmitters.
Effects in CNS:
Learning disorders
Behavioral disorders

EFFECTS OF SMOKING ON THE MOTHERS

DIFFICULTY OF GETTING PREGNANT
PLACENTAL ABRUPTION(Early seperation of Placenta)
PLACENTA PREVIA(Placenta covers the cervix)
PREMATURE RUPTURE OF MEMBRANES(PROM) (Early breaking of water)
ECTOPIC PREGNANCY (Pregnancy occurs outside the womb)

DIFFICULTY OF GETTING PREGNANT

Smoking affects each stage of the reproductive process, including egg and sperm
maturation, hormone production, embryo transport, and the environment in the uterus. It
can also damage the DNA in both eggs and sperm.
It may result of to take longer to conceive or not able to be pregnant.

PLACENTAL ABRUPTION
A placental abruption is a serious condition in which the placenta partially or completely
separates from your uterus before your baby's born.
The condition can deprive your baby of oxygen and nutrients, and cause severe
bleeding that can be dangerous to you both.
A placental abruption also increases the risk that your baby will have growth problems (if
the abruption is small and goes unnoticed), be born prematurely, or be stillborn.

Causes of Placental Abruption

Had an abruption in a previous pregnancy (and if you've had an abruption in two or more
pregnancies, the risk is even higher)
Have chronic hypertension, gestational hypertension, or preeclampsia
Have their water break prematurely
Smoke tobacco or use methamphetamines or cocaine, or drink alcohol excessively

Signs and symptoms of Placental Abruption

Vaginal bleeding or spotting, or if your water breaks and the fluid is bloody
Cramping, uterine tenderness, abdominal pain, or back pain
Frequent contractions or a contraction that doesn't end
Your baby isn't moving as much as before

Effects of Placental Abruption

C- section
Premature Birth

Management:
Monitoring of the patient's haemodynamic status by monitoring BP, pulse, volume intake,
and urine output.
Continuous fetal monitoring.
Anti-D immunoglobulin in Rh-negative women.
Fluid, blood, or blood-product replacement, as indicated.
Sonographic examination for placental location and for evidence of abruption. Placenta
praevia found on sonography makes placental abruption unlikely.

PLACENTA PREVIA
Placenta is lying unusually low in your uterus, next to or covering your cervix.
 The placenta is the pancake-shaped organ normally located near the top of the uterus
that supplies your baby with nutrients through the umbilical cord.

Causes of Placenta Previa

You had placenta previa in a previous pregnancy.
You've had c-sections before. (The more c-sections you've had, the higher the risk.)
You've had some other uterine surgery (such as a D&C or fibroid removal).
You're pregnant with twins or more.
You're a cigarette smoker.
You use cocaine.

Signs and symptoms of Placenta Previa

Vaginal bleeding after the 20th week of gestation is characteristic of placenta previa.
Usually the bleeding is painless, but it can be associated with uterine contractions and
abdominal pain.
Bleeding may range in severity from light to severe.

Effects of Placenta Previa

Loss of blood

Management:
Treatment of placenta previa depends upon the extent and severity of bleeding, the
gestational age and condition of the fetus, the position of the placenta and fetus, and
whether the bleeding has stopped.
Cesarean delivery (C-section) is required for complete placenta previa and may be
necessary for other types of placenta previa.
Women who are actively bleeding or who have bleeding that cannot be stopped will be
admitted to the hospital for further care. I
Women with placenta previa who experience heavy bleeding may require blood
transfusions and intravenous fluids

PREMATURE RUPTURE OF MEMBRANES

Or pre-labor rupture of membranes, is a condition that can occur in pregnancy.
rupture of membranes (breakage of the amniotic sac), commonly called breaking of the
mother's water, more than 1 hour before the onset of labor.

Causes Premature Rupture of Membranes

Infections of the uterus, cervix, or vagina
Too much stretching of the amniotic sac (this may happen if there is too much fluid, or
more than one baby putting pressure on the membranes)
Smoking
If you have had surgery or biopsies of the cervix
If you were pregnant before and had a PROM or PPROM

Signs and symptoms

The main symptom of PROM is fluid leaking from the vagina. You may experience a
sudden gush of fluid or a slow, constant trickle. It can be difficult to distinguish between a
slow amniotic trickle and urine. Your doctor can do simple tests to determine this.

Management
Based on the Gestational Age

AFTER 37 WEEKS
If your pregnancy is past 37 weeks, your baby is ready to be born. You will need to go
into labor soon. The longer it takes for labor to start, the greater your chance of getting
an infection.

BETWEEN 34 AND 37 WEEKS

If you are between 34 and 37 weeks when your water breaks, your provider will likely
suggest that you be induced. It is safer for the baby to be born a few weeks early than it
is for you to risk an infection.
BEFORE 34 WEEKS
 If your water breaks before 34 weeks, it is more serious. If there are no signs of
infection, the provider may try to hold off your labor by putting you on bed rest. Steroid
medicines are given to help the baby's lungs grow quickly. The baby will do better if its
lungs have more time to grow before being born.

ECTOPIC PREGNANCY

the fertilized egg stays in your fallopian tube. In that case, it's called an ectopic
pregnancy or a tubal pregnancy. In rare cases, the fertilized egg attaches to one of your
ovaries, another organ in your abdomen, the cornua (or horn) of the uterus or even the
cervix.
In any case, instead of celebrating your pregnancy, you find your life is in danger.
Ectopic pregnancies require emergency treatment.

Causes of Ectopic Pregnancy

Current use of an intrauterine device (IUD), a form of birth control.
History of pelvic inflammatory disease (PID)
Sexually-transmitted diseases such as chlamydia and gonorrhea
Congenital abnormality (problem present at birth) of the fallopian tube
History of pelvic surgery (because scarring may block the fertilized egg from leaving the
fallopian tube)
History of ectopic pregnancy
Unsuccessful tubal ligation (surgical sterilization) or tubal ligation reversal
Use of fertility drugs
Infertility treatments such as in vitro fertilization (IVF)

Signs and symptom of Ectopic Pregnancy

Light vaginal bleeding
Nausea and vomiting with pain
Lower abdominal pain
Sharp abdominal cramps
Pain on one side of your body
Dizziness or weakness
Pain in your shoulder, neck, or rectum
If the fallopian tube ruptures, the pain and bleeding could be severe enough to cause
fainting.

Effects of Ectopic Pregnancy

If the doctor suspects that the fallopian tube has ruptured, emergency surgery is
necessary to stop the bleeding.
If the fallopian tube has not ruptured and the pregnancy has not progressed very far,
laparoscopic surgery may be all that is needed to remove the embryo and repair the
damage.
A laparoscope is a thin, flexible instrument inserted through small incisions in
the abdomen. During this surgery, a tiny incision is made in the fallopian tube
and the embryo is removed, preserving the fallopian tubes integrity.
After medical treatment for an ectopic pregnancy, you will usually have to have
additional blood tests to make sure that the entire tubal pregnancy was removed.

SECOND HAND SMOKE AND PREGNANCY

The mother and the growing baby are at high risk of developing lung cancer, heart
disease, emphysema, allergies, asthma, and other health problems, if the mother is
regularly exposed to secondhand smoke.
Secondhand smoke is also called passive smoke or environmental tobacco smoke and it
is the combination of smoke from a burning cigarette and smoke exhaled by a smoker.
Secondhand smoke contains more harmful substances such as tar, carbon monoxide,
nicotine, and others ,.
Babies exposed to secondhand smoke may also develop reduced lung capacity and are
at higher risk for sudden infant death syndrome (SIDS).

NURSING RESPONSIBILITIES
Render Health teaching
Give some tips to stop smoking
 Hide the matches, lighters, and ashtrays.
Designate the home a non-smoking area.
Ask people who smoke not to smoke around you.
Drink fewer caffeinated beverages; caffeine may stimulate the urge to smoke.
Avoid alcohol, as it may also increase the urge to smoke.
Change the habits connected with smoking. If you smoked while driving or
when feeling stressed, try other activities to replace smoking.
Keep mints or gum (preferably sugarless) on hand for those times when you
get the urge to smoke.
Stay active to keep the mind off smoking and help relieve tension.
Take a walk, exercise, read a book, or try a new a hobby.
Look for support from others. Join a support group or
smoking cessation program.
Do not go places where many people are smoking such as
bars or clubs, and smoking sections of restaurants.

Present benefits of quitting smoking in pregnancy

The baby will get more oxygen, even after just one day of not smoking.
There is less risk that the baby will be born too early.
There is a better chance that the baby will come home from the hospital with
mother.
Mother will be less likely to develop heart disease, stroke, lung cancer,
chronic lung disease, and other smoke-related diseases.
Mother will be more likely to live to know her grandchildren.
Mother will have more energy and breathe more easily.
Mothers clothes, hair, and home will smell better.
Mothers food will taste better.
Mother will have more money that she can spend on other things.
Mother will feel good about what she has done for herself and her baby.
Quitting Smoking Can Be Hard, But It Is One of the Best Ways a Woman
Can Protect Herself and Her Baby's Health.

REFERENCES

http://bestpractice.bmj.com/best-practice/monograph/1117/treatment/step-by-step.html
Breathing Problems: Causes, Tests, and Treatments
www.webmd.com
http://www.webmd.com/lung/breathing-problems-causes-tests-treatments#1
www.webmd.com
CURRENT Diagnosis & Treatment: Obstetrics & Gynecology, 11e
Alan H. DeCherney, Lauren Nathan, Neri Laufer, Ashley S. Roman
CURRENT Diagnosis & Treatment: Pediatrics, 21e
William W. Hay, Jr., Myron J. Levin, Robin R. Deterding, Mark J. Abzug, Judith M. Sondheimer
Behavioral Medicine: A Guide for Clinical Practice, 3e
Mitchell D. Feldman, John F. Christensen
Harrison's Online
Featuring the complete contents of Harrison's Principles of Internal Medicine, 18e
Dan L. Longo, Anthony S. Fauci, Dennis L. Kasper, Stephen L. Hauser, J. Larry Jameson,
Joseph Loscalzo, Eds.
https://www.ncbi.nlm.nih.gov/pubmed/1353943
Anatomy and Physiology
Fetal Circulation
Prior to birth the fetus is not capable of respiratory function and thus relies on the maternal
circulation to carry out gas, nutrient and waste exchange. The foetal and maternal blood never mix,
instead they interface at the placenta. Consequently the liver and the lungs are non-functional, and a
series of shunts exist in the foetal circulation so that these organs are almost completely by-passed.
Umbilical Cord
2 Umbilical Arteries: return oxygenated blood, fecal waste, CO2 to placenta
1 Umbilical Vein: brings oxygenated blood and nutrients to the fetus
Special Structure in Fetal Circulation
Placenta: where gas exchange takes place during fetal life
Umbilical Arteries: deoxygenated blood coming from the fetus to the placenta
Umbilical Vein: brings oxygenated blood coming from the placenta to the fetus
Foramen Ovale: connects the left and right atrium. It pushes blood from right atrium to the
left atrium
Ductus Venosus: carry oxygenated blood from umbilical vein to inferior vena cava, bypassing
the fetal liver
Ductus Arteriosus: carry oxygenated blood from pulmonary artery to aorta, bypassing fetal
lungs

Shunt 1: The Ductus Venosus

Oxygenated blood travels from the placenta via the umbilical vein and most of it bypasses
the liver by way of the ductus venosus. The ductus venosus links the umbilical vein to the caudal
vena cava and the flow of blood is controlled by a sphincter, enabling the proportion travelling to the
heart via the liver to be altered.
Shunt 2: The Foramen Ovale
The foramen ovale is an opening between the two atria enabling blood to be channelled directly into
the systemic circulation thereby bypassing the lungs. The septum secundum directs the majority of
the blood entering the right atrium through the foramen ovale into the left atrium. Here it mixes with a
small volume of blood returning from the non-functional lungs via the pulmonary veins.
Shunt 3: The Ductus Arteriosus
The ductus arteriosus connects the pulmonary artery to the aorta and allows equivalent ventricular
function in the foetus. The blood from the right ventricle is pumped to the pulmonary trunk where,
due to the high resistance in the collapsed foetal lungs, a larger volume passes through the ductus
arteriosus to the caudal aorta. Most of the blood in the aorta is then returned to the placenta for
oxygenation through the umbilical arteries. The ductus arteriosus empties blood into the aorta after
the artery to the head has branched off thus ensuring that the brain receives well-oxygenated blood.
Circulatory Changes at Birth
Important circulatory changes occur at birth due to the replacement of the placenta by the lungs as
the organ of respiratory exchange. When an newly born animal takes its first breath, the lungs and
pulmonary vessels expand thereby significantly lowering the resistance to blood flow. This
subsequently lowers the pressure in the pulmonary artery and the right side of the heart. On the
other hand the removal of the placenta causes an increase in the resistance of the systemic
circulation and hence an increase in the pressure of the left side of the heart.
The birth of the animal also triggers the closure of the foetal shunts:
Closure of the Ductus Venosus
The ductus venosus is weakly responsive to prostaglandin E2 (PGE 2) and prostacyclin (PGI2) which
behave as vasodilators. This influence is lost with the improved pulmonary clearance resulting from
the absence of an umbilical blood supply. This loss of blood supply also causes the sphincter in the
ductus venosus to constrict thereby diverting blood to the liver. Closure of the ductus venosus
becomes permanent after two to three weeks. The remnants of the ductus venosus form the
ligamentum venosum.
Closure of the Foramen Ovale
In the foetus the foramen ovale is kept open by the higher pressure of blood in the right atrium
compared to the left atrium. At birth the blood pressure in the right atrium decreases due to
termination of blood flow from the placenta, whilst pressure in the left atrium increases due to
increased pulmonary flow. As a result, the flap of the septum primum presses against the septum
secundum closing the foramen ovale. In most individuals, the foramen ovale closes a few months
after birth. A scar remains between the two atria once the foramen ovale has closed and this is
termed the fossa ovalis.
Closure of the Ductus Arteriosus
The ductus arteriosus is a muscular artery and immediately after birth, contraction of the
musculature closes the shunt. Factors which may contribute to the physiological closure of the
ductus arteriosus include the increased oxygen content of the blood passing through it and the
production of bradykinin, which causes smooth muscle contraction. This physiological closure
causes blood to be directed from the pulmonary arteries to the now functioning lungs. Anatomical
closure takes about two months and occurs by infolding of the endothelium and proliferation of the
subintimal connective tissue layer. The residual ligament is termed the ligamentum arteriosum.

Placental Blood Circulation

The placenta is a unique vascular organ that receives blood supplies from both
the maternal and fetal systems and thus has two separate circulatory systems for
blood: (1) The maternal- placental( uteroplacental) blood circulation, and (2) the
fetal- placental (fetoplacental) blood Circulation.
The Uteroplacental circulation starts with the maternal blood flow into intervillous
space through decidual spiral arteries.
Exchange of oxygen and nutrient takes place as the maternal blood flows
around terminal villi in the intervillous space.
The in- flowing maternal blood pushes deoxygenated blood into the endometrial
and then uterine veins back to the maternal circulation.
The fetal- placental circulation allows the umbilical arteries to carry deoxygenated
and nutrient- depleted fetal blood from the fetus to the villous core fetal vessels.
After the exchange of oxygen and nutrients, the umbilical vein carries fresh
oxygenated and nutrient- rich blood circulating back to the fetal systemic
circulation.
At term, maternal blood flow to the placenta is approximately 600- 700 ml/
mnute. It is estimated that the surface area of syncytiotrophoblasts is
approximately 12m2 and the length of fetal capillaries of a fully developed
placenta is approximately 320 kilometers at term.
The functional unit of maternal- fetal exchange of oxygen and nutrients occur in
the terminal villi. No intermingling of maternal and fetal blood occurs in the
placenta.