Substance Use in

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Substance Use in Pregnancy
A Project CREATE Module
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Substance Users of Child-rearing Age (USA)

• Household Survey
• 14.1 used an illicit drug in the last year
  (Substance Abuse and Mental Health Services
  Administration Study, 1993)
• Chasnoff (1988)
• 11
• 375,000 drug affected births
• No difference in income status
• NIDA (national Institute of Drug Abuse 1992)
• 5 of the 4 million women who gave birth in the
  in the US in 1992 used illicit drugs during
  pregnancy

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Substance Users AmongTeenage Population
A 1998 survey of teenagers in Ontario revealed

• 28 tobacco use
• 25 cannabis
• 60 alcohol
• 6 barbiturates
• 1.8 heroin
• 3.6 amphetamines
• 2.7 cocaine

CMAJ 1998 159 (5) 451-454
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Definitions

• Addiction
• use despite harm
• Dependence
• physiological
• withdrawal in the absence
• the pattern of consumption enhances function
• intoxication absent

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Strategies That Dont Work

• Just Say No
• has done as much forsubstance abuse treatment as
  
• Have a Nice Day
• has done for the treatment
• of major depression

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Strategies That Work

• Non-judgmental approach
• Motivational enhancement
• Honesty
• Patient-centred approach

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Screening and Detection of Women Substance
Abusers of Child-bearing Age

• Miller Hyatt (1992)
• 16 of hospital patients
• Only 3 detected

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Opportunities for Screening

• Gynecological visits
• Prenatal care
• Postnatal visit
• Obstetrical emergencies

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Screening Techniques
The majority of substance users show no physical
symptoms of use. Therefore

• Screen everyone
• Record a thorough substance-use history for all
  patients
• Screen repeatedly
• Ask patient about substance use when you take
  initial history AND during several follow-up
  visits

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General Guidelines for Screening and Assessment

• Elicit patients point of view of her alcohol,
  tobacco or other drug use (ATOD)
• Determine context of use and potential for change
• Determine motivational factors for change

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Minimal Screening Intervals

• Pre-conception visit
• Intake or initial visit
• Mid-pregnancy (24-28 weeks gestation)
• Third trimester (32-36 weeks gestation)
• Postpartum

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ATOD Red Flags

• Repeated injuries
• Numerous Emergency Room visits
• Avoidance of prenatal care until the third
  trimester and/or limited prenatal care
• Missed appointments
• Patient intoxicated
• Previous child with Fetal Alcohol Syndrome

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ATOD Red Flags

• Previous premature delivery
• Previous fetal demise, fetal abruptionor SA
• Family history of substance abuse
• STDs (including HIV/AIDS)
• Compliance problems
• Psychiatric history and other indicators of a
  chaotic lifestyle

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Remember the CAGE?

• Have you ever felt a need to Cut down on your
  drinking/drug use?
• Have you ever been Annoyed at criticism of your
  drinking/drug use?
• Have you ever felt Guilty about your
  drinking/using drugs?
• Have you ever had a morning Eye-opener, i.e.,
  taken a drink/drugs to get going or treat
  withdrawal symptoms?

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Use the T-ACE Questions With Pregnant Patients

• How many drinks does it take to make you feel
  high? Tolerance
• Have people Annoyed you by criticizing your
  drinking?
• Have you ever felt you ought to Cut down on your
  drinking?
• Have you ever had a drink first thing in the
  morning to steady your nerves or get rid of a
  hangover? Eye-opener

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Signs and Symptoms of Substance Use

• Physical findings
• Track marks and other evidence of injection drug
  use
• Alcohol on breath
• Scars, injuries
• Skin abscesses
• Hypertension
• Tachycardia or bradycardia
• Tremors

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Signs and Symptoms of Substance Use

• Physical findings
• Slurred speech
• Self-neglect or poor hygiene
• Chronic cough
• Cheilosis
• Nervous mannerisms
• Fequently licking lips
• Jitters
• Foot tapping
• Pinpoint or dilated pupils

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Psychological Problems

• Memory loss
• Depression
• Anxiety
• Panic
• Paranoia
• Unexplained mood swings

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ALCOHOLEffects on the Developing Fetus

• Maternal alcohol use is the leading preventable
  cause of mental deficiency in children
• A direct teratogenic effect with a dose response
  curve has been demonstrated in animal studies
• Alcohol is the most common major teratogen to
  which the fetus is likely to be exposed

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ALCOHOLEffects on the Developing Fetus

• Alcohol passes freely through the placenta fetal
  concentrations are as high as those in the mother
• 10-20 of all mental deficiency (IQ 50-80) in
  children is attributed to maternal alcohol use

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Diagnostic Criteria for FAS andAlcohol-related
Effects(Institute of Medicine - FAS Committee)

• FAS with confirmed maternal alcohol exposure
• alcohol exposure in the mother is heavy and
  characterized by intoxication and withdrawal,
  including several consequences in various domains
  of her life.
• characteristic facial anomalies in the infant
• growth restriction
• CNS neurodevelopmental abnormalities
• FAS without confirmed alcohol exposure
• same as above except alcohol exposure is not
  confirmed

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Diagnostic Criteria for FAS andAlcohol-related
Effects(Institute of Medicine - FAS Committee)

• Partial FAS with confirmed alcohol exposure
• alcohol exposure in the mother is heavy and
  characterized by intoxication and withdrawal,
  including several consequences in various domains
  of her life
• characteristic facial anomalies in the infant
• OR
• growth restriction
• OR
• CNS neurodevelopmental abnormalities

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Diagnostic Criteria for FAS andAlcohol-related
Effects(Institute of Medicine - FAS Committee)

• Alcohol-related effects with a history of
  maternal alcohol exposure
• Alcohol-related birth defects (ARBD)
• these birth defects can be cardiac, skeletal,
  renal, ocular and/or auditory.
• Alcohol-related neurodevelopmental disorder
  (ARND)
• CNS neurodevelopmental abnormalities
• complex behavioural or cognitive abnormalities

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Potential Obstetrical Complications of Excessive
Alcohol Use

• Fetal distress
• Spontaneous abortion
• Risk doubles with 1-2 drinks per day
• Risk 3.5 times for 3 or more drinks per day
• Prenatal mortality is approximately 17 with
  chronic alcohol use

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Management Issues with the Alcohol-intoxicated
Woman in the Delivery Room

• 1) Problems with acute intoxication
• 2) Problems with withdrawal
• 3) Need for additional psychological support

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Alcohol Withdrawal

• 6-48 hours after drinking stopped
• autonomic hyperactivity
• tremor
• anxiety
• insomnia
• Seizures GTC
• DTs usually after 72 hours

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Treatment of Alcohol Withdrawal

• Complete history including quantity and frequency
  of alcohol and other drugs
• Blood alcohol including urine tox screen
• Thiamine 100 mg IM, folate, vitamins and iron
• Alcohol is eliminated at a rate of one standard
  drink per hour (10 mg / dl / hr)

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Treatment of Alcohol Withdrawal

• Provide non-pharmacological interventions
• TLC
• quiet room
• Pharmacological management
• Diazepam loading 10-20 mg per os according to
  withdrawal severity
• once withdrawal stabilized - no tapering required
  due to long half-life of diazepam

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Monitoring Alcohol Withdrawal

• Vital signs
• Delirium
• Wernickes
• Fetal well-being according to gestational age
• Hold medications if sedated

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COCAINEEffects on the Developing Fetus

• Increased incidence of pre-term birth
• Low birth-weight
• Reduced length
• Reduced head circumference
• Possible genitourinary malformation
• Increased minor congenital anomalies
• Possible intrauterine CVA

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COCAINEEffects on the Course of Pregnancy and
Possible Obstetrical Complications

• Embryopathy
• Fetal intracerebral hemorrhage
• Risk of HIV infection (increased number of sexual
  partners)
• Abruptio placentae (most prevalent)
• Spontaneous abortion
• Fetal hypoxia
• Increased rate of PROM

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COCAINEEffects on Labour and Delivery

• Early onset of labour and pre-term delivery
• Premature labour most likely if cocaine used
  during the third trimester
• Patient may not handle pain well

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COCAINEPotential Obstetrical Complications of
Excessive Cocaine Use

• POSTPARTUM
• MOTHER
• Lactation - cocaine found in breast milk
• Breastfeeding is contraindicated for
  cocaine-using women
• HIV testing and counselling should be recommended
  for all women (whether they breastfeed or not)
• Consider infectious comorbidities when
  counselling about breastfeeding (including HIV
  and TB)

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COCAINEPotential Obstetrical Complications of
Excessive Cocaine Use

• POSTPARTUM
• NEONATE
• IUGR
• Reduced head circumference
• Neurobehavioural abnormalities
• Post-excitatory depression
• Slightly increased risk of SIDS

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HEROINEffects on the Developing Fetus

• Small for gestational age but catch up in the
  first year
• Small head circumference
• Average birthweight 2500 grams

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HEROINEffects on the Course of Pregnancy

• Pre-eclampsia
• Anaemia
• Premature rupture of membranes
• Abruptio placentae
• Meconium-stained amniotic fluid
• Maternal withdrawal during pregnancy may result
  in fetal death
• Hypoxia
• Maternal appetite suppressed

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HEROINEffects on Labour and Delivery

• Patients may require higher amounts of
  anaesthesia
• Narcan is contraindicated for use in labour and
  delivery it may produce severe withdrawal

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Potential Obstetrical Complications of Excessive
Heroin Use

• POSTPARTUM
• Breastfeeding is contraindicated for heroin-using
  women and for all women who are HIV positive
  and/or inject with needles

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Potential Postpartum Obstetrical Complications
of Excessive Heroin Use

• 3 times higher rate of perinatal mortality
• Metabolic disturbances
• Hypoglycaemia (7)
• Narcan is contraindicated
• Heroin withdrawal in the neonate occurs within
  the first 24-48 hours after birth

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METHADONEEffects on the Course of Pregnancy

• If the patient is in a managed Methadone
  Maintenance Treatment Program (MMTP) and is not
  taking street drugs, methadone treatment improves
  perinatal outcome (compared to heroin use)

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METHADONEEffects on Labour and Delivery

• Patients may have lower pain thresholds and may
  not respond to narcotics in usual doses they are
  excellent candidates for epidurals
• Narcan is contraindicated

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Potential Postpartum Obstetrical Complications of
Excessive Methadone Use

• MOTHER
• Breastfeeding is NOT contraindicated for children
  of methadone-maintained mothers if they are not
  polydrug users and if they are HIV negative
• The advantages of breastfeeding, both for mother
  and infant, far outweigh the disadvantages

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Potential Postpartum Obstetrical Complications of
Excessive Methadone Use

• NEONATE
• Methadone withdrawal in the neonate generally
  occurs within the first 2-3 days after birth
• May occur up to the end of the first week some
  infants metabolize the drug especially slowly

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Other Opioids

• Codeine, Oxycodone
• If chronic user without abuse, attempt to taper
• If abusing, try tapering after switching to a
  long-acting preparation
• May require methadone

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Benzodiazepines

• DO NOT STOP SUDDENLY- may cause seizures
• Taper by 5-10 per day
• May convert to equivalent doses of diazepam and
  then taper
• Questionnable association with cleft lip/palate

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Marijuana

• Not teratogenic
• No well-defined long-term effects

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References

• 1. March of Dimes Substance Abuse Curriculum For
  Obstetricians and Gynecologists
• 2. Centre for Substance Abuse Treatment Substance
  Using Women TIPS 2
• 3. Clinics in Perinatology Chemical Dependency
  and Pregnancy, March 1991