Pregnancy and Homelessness

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Pregnancy and Homelessness

• William A. Ellert, M.D.
• Healthcare for the Homeless
• Phoenix, Arizona

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Disclosure

• I have NO financial relationships to disclose

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Learning Objectives

• Discuss critical risk factors related to
  pregnancy and homelessness
• Discuss resources needed by homeless pregnant
  women
• Discuss the impact of psychiatric illness on
  obstetrical care.

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Statistics

• There are approximately 744,000 Homeless in the
  United States.
• People with untreated psychiatric illnesses
  comprise one-third (or between 150,000 to 200,000
  people)
• One study found that 28 of the homeless people
  with previous psychiatric hospitalizations obtain
  some food from garbage cans and 8 percent used
  garbage cans as a primary food source

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Statistics Continued

• A 1995 study by Barves-Bomoz indicated that the
  incidence of rape among women with schizophrenia
  was approximately 22 with 2/3 of those having
  been raped multiple times.
• A 1988 study by Breakey revealed the nearly 1/3
  of the homeless women in Baltimore had been
  raped.
• Of the 400,000 to 600,000 individuals currently
  estimated to be living with AIDS in the USA,
  approximately 1/3 to ½ are either homeless or at
  imminent risk of homelessness.

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Pregnancy and Homelessness Which Comes First?

• Pregnant women have a higher risk of being
  victims of violence which frequently leads to
  homelessness.
• Homeless women have a higher risk of unplanned
  pregnancies due to
• Drug and Alcohol Use
• Prostitution
• Mental Illness
• Rape

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MENTAL ILLNESS
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Depression and Pregnancy

• 7.4 incidence of depression in the First
  Trimester
• 12.8 incidence of depression in the Second
  Trimester
• 12 - 17 incidence of depression in the Third
  Trimester
• (Level II Evidence)

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Biological Risk Factors for Developing Depression
During Pregnancy

• History of mood and anxiety disorders
• History of post-partum depression
• History of premenstrual dysphoric disorder
• Family history of psychiatric disorders
• (Level II Evidence)

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Psychosocial Risk Factors for Developing
Depression during Pregnany

• History of Childhood Abuse
• Younger Age
• Unplanned Pregnancy
• Ambivalent Feelings About the Pregnancy
• Single Motherhood
• Greater Number of Children

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• Limited Social Support
• Domestic Violence or Marital Conflict
• Low Level of Education
• Unemployment
• Substance Abuse and Smoking
• (Level II evidence)

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Considerations to Treatment in the First Trimester

• No Study has shown any antidepressant to be
  absolutely safe during any stage of pregnancy.
  Studies have shown no increased risk of major
  malformations.
• Paroxetine (Paxil) (Level II evidence
  unpublished data from the Swedish National
  Registery)
• Bupropion - Slightly Higher Rate of spontaneous
  Abortion.

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Considerations to Treatment in the Second
Trimester

• 68 of women who stopped taking antidepressant
  drugs had a relapse in the second trimester
• 26 of women who did not stop taking their
  medication had a relapse in the second trimester
• 90 of women who had a relapse, did so by the
  second trimester.
• (Level II evidence)

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Second Trimester continued

• A study of 8 women found that tricyclic
  antidepressant doses needed to be increased
  substantially during the second half of pregnancy
  to achieve therapeutic levels and response.
• Slight increased risk of persistent pulmonary
  hypertension in newborns exposed to SSRIs after
  the 20th week of gestation.

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Consideration to Treatment in the Third Trimester

• No evidence of long-term neurotranmitter function
  and behavior changes after prenatal exposure
  (study done only on fluoxetine and tricyclics).
• Transient Withdrawal Symptoms have been noted
  including respiratory distress, jaundice,
  jitteriness, increased fussing, tremors, and
  increased crying.

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Take Away Message

• Untreated Depression has been associated with
  IUGR, preterm delivery, a major cause of maternal
  death in pregnancy, increased alcohol and
  substance abuse.
• May want to consider avoiding Paroxetine and
  Bupropion in pregnancy. In patients at risk for
  pre-eclampsia, Bupropion should be avoided.
• Increased dosage may be needed in the second
  trimester of pregnancy, especially with
  tricylcics.
• Consider delivery in a hospital with at least a
  Level II Nursery that can handle infant SSRI
  withdrawal symptoms.

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Schizophrenia and Severe Depression with
Psychotic Features

• Low-potency antipsychotics (eg. Phenothyazines)
  slightly increased risk of congenital
  malformation in first trimester
• High-potency antipsychotics (eg. Haloperidol)
  no conclusive evidence of increased risk of
  malformation.
• Novel antipsychotics (respiridone, clozapine,
  olanzapine, quetiaprine, ziprasideon,
  aripirazola, amisulpride, sertindole) -
  Clozapine is FDA Category B all others are
  Category C.

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Bipolar and Mood Stabilizers

• Benzodiazepines Slight increased risk of oral
  clefts in first trimester exposure. Neonatal
  withdrawal syndrome in term exposure.
• Lithium Increased risk of Ebsteins Anomoly
  floppy baby syndrome. Recommendations fetal
  echocardiogram ultrasound between 16-18 wks
  weekly lithium levels starting at 36 wks monitor
  infant for 10 days for toxicity.

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• Valproic Acid teratogenic with a prevalence
  10-20 times greater than the general population.
  (neural tube defects, craniofacial anomalies,
  limb abnormalities, cardiovascular anomalies,
  genitourinary malformations, and low birth
  weight, hepatotoxicity, coagulopathies, and
  neonatal hypoglycemia).
• Carbamazepine similar to VPA but less frequent
  and less severe.

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• Lamotrigine/Oxcarbazepine Limited data and no
  neurobehavioral data. Oxcarbazepine has been
  used in Europe for more than a decade no
  congenital anomalies noted. Lamotrigine
  Pregnancy Registry indicates less than a 2 risk
  for fetal malformation with first trimester
  exposure. Folate supplementation is recommended
  (4-5 mg/day).

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Take Away Message

• For women with severe bipolar disorder who need
  to continue medication throughout pregnancy,
  lithium alone or in combination with an
  antipsychotic may be a safe alternative to
  Valproic Acid.
• Other alternatives Lamotrigine and a typical
  antipsychotic. OR Atypical antipsychotic with
  lithium or lamotrigine.
• Ideal is to transition PRIOR to pregnancy.
• Appropriate monitoring and Folic Acid as
  indicated.
• Increased risk of poor judgment regarding sexual
  promiscuity, ilicit and licit drug use,
  appropriate nutrition, and prenatal care if not
  adequately treated.

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Licit and Illicit Drug Use
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Illicit Drug Use

• Marijuana not signifcantly related to low birth
  weight, preterm birth, intrauterine growth
  retardation.
• Opiates show low birth weight, preterm birth,
  and intrauterine growth retardation and
  neurobehavioral effects
• Cocaine low birth weight, preterm birth, and
  IUGR (comparable to tobacco use). Abruptio
  placenta, premature rupture of membranes, and
  neurobehavioral effects.

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Licit Drug Use

• Alcohol fetal alcohol syndrome, intrauterine
  and postnatal growth restriction, cranial
  dysmorphology, and cognitive deficits.
• Tobacco Use related to growth restriction and
  later behavioral problems due to nicotine
  disruption of the central nervous system
  development.

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Sexually Transmitted Diseases

• HIV Chlamydia Gonorrhea Syphillis HPV
  Hepatitis B Hepatitis C Herpes Simplex
  Virus

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Screening Recommendations

• HIV recommend opt-out testing. Timing early
  in pregnancy. Consider retesting in third
  trimester (preferably before 36 weeks). Rapid
  testing in labor for undocumented HIV status.
• RPR At first prenatal visit. Consider repeat
  at 28 weeks and at delivery.
• HepBsAg At first prenatal visit. Consider
  repeat at time of delivery.
• Chlamydia First prenatal visit. Consider
  retesting if lt 25 years old or at high risk.

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Screening Continued

• Gonorrhea Test at first prenatal and consider
  repeat testing in third trimester.
• Consider Hepatitis C testing in the first
  trimester.
• HPV Papanicolaou smear should be considered if
  none has been done in the previous year.
• HSV A thorough history should be performed with
  testing of suspicious lesions.

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Special Treatment Considerations for HIV in
pregnancy

• In absence of antiretroviral and other
  interventions 15-25 of infants born to infected
  mothers will become infected.
• An additional 12-14 will become infected if
  women breast feed into the second year of life.
• HIV transmission can be reduced to lt2 with the
  used of antiretroviral regimens and elective
  c-section at 38 weeks (controversial if viral
  load is lt1000).

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Maternal Risk Factors for Vertical Transmission
of HIV

• Low CD4 and lymphocyte count
• High Viral load
• Advanced AIDS
• Preterm Delivery
• Placental membrane inflammation
• (Evidence Level II)

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Intrapartum Risk Factors of Vertical Transmission
of HIV

• Artificial Rupture of Membranes
• Fetal Scalp Monitors
• Instrumental Deliveries
• Scalp pH Testing
• DeLee Suctioning
• Rupture of Membranes gt 4 hours
• (Evidence Level II)

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Treatment of HIV Infected Patients

• Continue standard Treatment during pregnancy
  (usually 3-4 Agents)
• Include Zidovudine in every treatment regimen
• Prenatal 100 mg PO five time daily from 14
  weeks gestation until delivery.
• During Labor 2 mg/kg IV load over one hour then
  1 mg/kg per hour
• Neonatal 2 mg/kg per dose PO every 6 hours
  within 8 hours of birth until 5 weeks of age.

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Treatment Continued

• In patients who did not receive prenatal care,
  some consider a single dose of nevirapine
  (Viramune) 200 mg maternal and 2 mg/kg infant
  dose within 72 hours of birth.
• All care should be coordinated with an expert in
  HIV Disease management.
• Level of Evidence II

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Herpes and Pregnancy

• Risk of Transmission is high (30-50) if acquired
  near the time of delivery (Consider c-section
  and acyclovir therapy).
• Risk of Transmission is low (lt1) with recurrent
  Herpes at term or if acquired during the first
  trimester.
• If no lesions at time of labor may deliver
  vaginally
• If lesions present c-section is recommended but
  does not completely eliminate risk of
  transmission.

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Herpes Continued

• Consider Acyclovir in women with the first
  episode of genital herpes or severe recurrent
  herpes
• First Episode
• Acyclovir 400 mg PO, TID for 7-10 days
• Acyclovir 200 mg PO five times daily for 7-10
  days

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Herpes Continued

• Suppressive Therapy
• Acylcovir 400 mg PO BID
• Episodic Therapy for Recurrent Genital Herpes
• Acyclovir 400 mg PO TID for 5 days
• Acyclovir 800 mg PO BID for 5 days
• Acyclovir 800 mg PO TID for 2 days

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Syphillis in Pregnancy

• Pregnant patients who are allergic to penicillin
  should be desensitized and treated with
  penicillin

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HPV in Pregnancy

• Remember that the current guidelines are
  guidelines and should be adapted to your patient
  population and risk factors.
• Cervical Biopsies are not contraindicated in
  pregnancy and should be done when appropriate.
• ECC are contraindicated in pregnancy.
• Genital warts are not a contraindication to
  vaginal delivery unless the vaginal canal is
  obstructed.

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Hepatitis C

• Approximately 5 of every 100 infants born to HCV
  infected women become infected.
• Breastfeeding does not appear to transmit HCV,
  although HCV positive mothers should consider
  abstaining from breastfeeding if their nipples
  are cracked or bleeding.

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Hepatitis B

• Infants born to HBsAg positive women should
  receive single antigen Hepatitis B vaccine and
  HBIG (0.5 ml) less than or equal to 12 hours
  after birth.
• For preterm infants weight less that 2000 g, the
  first does should not be counted as part of the
  vaccine series.
• Infants of HBsAg-positive mothers can breast
  feed.
• If maternal status is unknown, give vaccine at lt
  12 hours and test mom. If positive HBIG within 7
  days.

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Vaccines and Pregnancy

• Risk to a developing fetus from vaccination of
  the mother during pregnancy is primarily
  theoretical.
• No evidence exists of risk from vaccinating
  pregnant women with inactivated virus, bacterial
  vaccines or toxoids.
• (MMWR 2006)

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Vaccinations
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Advisory Committee on Immunization Practices
Recommendations

• Recommended for all pregnant women
• Influenza
• Follow routine adult recommendations
• Hepatitis B, Td, Meningococcal (MPSV4)
• Pneumococcal (PPV23), Typhoid (unclear)
• Recommended only under special circumstances
  (exposure risk is high)
• Hepatitis A, Polio (IPV), Anthrax, Inactivated
  Japanese Encephalitis, Rabies, Smallpox, Yellow
  Fever, Tdap.
• Not Recommended for pregnant women
• Live attenuated Influenza vaccine, MMR,
  Varicella, Zoster. BCG, HPV

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FDA Pregnancy Categories

• All but two currently licensed vaccines are
  category C (due to lack of data)
• HPV (Category B)
• Anthrax (Category D)
• Pregnancy categories have led to confusion and
  the FDA is in the process of revision.

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What to do?

• Some considerations for discussion

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• The risk of a homeless woman or substance user
  giving birth to an infant weighing less than 2 kg
  was 6-7 times that of the control group.
• In mothers with both risk factors raises it to
  16.6 times that of the control group.
• Six studies showed that interactive methods such
  as role-play, video games, and group work led to
  a self-reported reduction in both risk from drugs
  and sexual activity.

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• A study by Wetzel et al indicated that homeless
  African American and Hispanic women had from two
  to almost five times greater odds than low-income
  housed women of having multiple sex partners in
  the last 6 months.

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• Smoking has the greatest effect on fetal growth
  and development
• Alcohol is the worse teratogen
• The women are probably more at risk from the
  social aspects of their habits and the
  environment they live in than from the drugs
  themselves.
• A multidisciplinary team approach is required.

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• Substance abuse is as much a sign of risk as the
  cause of the risk itself.
• Pregnancy is a life event that can provide the
  opportunity and motivation for the mother to
  change her lifestyle to her, and her babys long
  term benefit