Pregnancy-Related Issues in the Management of Addictions

1
Pregnancy-Related Issues in the Management of
Addictions
Train the Trainer Workshop Problematic Substance
Use in Pregnancy (PSUP) www.addictionpregnancy.ca
Last modified March 2008
2
Conflict of Interest Disclosure

• Financial support for this workshop was provided
  by Health Canada
• Funding for the PRIMA Pocket Reference was
  provided by the Lawson Foundation
• No commercial sponsorship has been received to
  support this program

3
Pregnancy-Related Issues in the Management of
Addictions

• Problematic Substance Use in Pregnancy
• Community Presentation

4
Objectives

• Define an approach to care for problematic
  substance use in pregnancy (PSUP)
• screening and epidemiology
• Describe prenatal care in the context of
  substance use treatment
• Describe the effects of common substances
• Describe care at delivery and postpartum
• Describe resources available

5
Reasons Women Use Drugs

• Cope with history of mental health problems /or
  sexual abuse
• Cope with stressors of poverty and racism
• Cope with problems/stress, e.g., violence, family
  separation
• Cope with feelings of lack of self-worth or
  inadequacy
• Influenced by substance use of partners
• Control weight gain
• Desire for recreation

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High Risk Groups of Women

• History of abuse (physical, sexual, emotional)
• Low income status
• Young age with little or no support
• Unplanned unwanted pregnancy
• Previous child with developmental delay
• History of mood/anxiety disorder or eating
  disorder

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Approach to Care - Principles

• Woman-centered, nonjudgmental care is crucial
• Establishing rapport is the single most important
  aspect of the initial encounter
• Disclosure of use should be seen as positive
• The antenatal period is often a time when women
  are ready to change
• Address the womans needs and withdrawal symptoms
  before moving on
• Try not to fix everything!!!

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Approach to Care-Principles (2)

• Prior relationships with health care providers
  have often been negative
• There is a high percentage of survivors of sexual
  abuse among women with PSUP - sensitive
  interviewing is required (defer pelvic exam
  unless required)
• Work to establish trust through communication
• Ensure she is safe to leave - increased risk for
  intimate partner violence
• Meet her needs as she identifies them (i.e.,
  food, shelter, etc.)
• (contd)

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Approach to Care-Principles (3)

• Watch for nonverbal cues
• Is she feeling vulnerable?
• Is she in withdrawal?
• Does she understand what you are saying?
• Does she appear hungry?
• Does she require clothing or shelter?
• Does she have a mental health problem?
• Remember that the appearance of belligerence or
  anger may signify fear, pain or withdrawal!

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Identify Key Issues at First Visit

• Explore whether she is in withdrawal
• Enquire about acute and chronic medical
  conditions
• Ask about medications OTC and herbal products
• Ask if she is safe and has adequate nutrition
• FIFE
• What does she feel about her substance use?
• What are her ideas about how she started using?
• How is she functioning?
• What are her expectations about provider
  involvement?
• Plan for follow-up soon after initial encounter

It is better to do less than more at the first
visit so that she will come back!
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Comprehensive Assessment

• Screening by interviewing for substances used
• Alcohol
• Nicotine
• Marijuana
• Cocaine and other Stimulants
• Opiates, illegal and prescribed
• Benzodiazepines
• Inhalants
• Hallucinogens and Designer Drugs
• (contd)

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Screening Test T-ACE

• T ToleranceHow many drinks does it take for
  you to feel the effects?
• A AnnoyedHave people annoyed you by
  criticizing your drinking?
• C Cut downHave you ever felt you should cut
  down on your drinking?
• E Eye-openerHave you ever had a drink in the
  morning to steady your nerves or get going?

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T-ACE Scoring

• T 2 points if it takes 2 or more drinks
• A,C,E 1 point each for yes
• A total score of 2 points or more indicates the
  woman is likely to have a problem with alcohol

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Screening Test TWEAK

• T How many drinks before you feel high?
  (Tolerance record of drinks)
• W Has anyone worried about your drinking in past
  year?
• E Do you need a drink in the morning to get
  going? (Eye opener)
• A Has anyone ever told you about things you said
  or did while you were drinking that you could not
  remember? (Amnesia or blackouts)
• K (C) Have you felt the need to cut down?

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TWEAK Scoring

• T 2 points if it takes 3 or more drinks to feel
  the
• effects of alcohol
• W 2 points if yes
• E, A, K 1 point each for yes
• A total score of 3 or more points indicates that
  the woman is likely to have a drinking problem.

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Comprehensive Assessment

• This comprehensive history may be completed over
  several visits
• Complete drug history name of drug, amount,
  frequency, duration, route(s), last use, needle
  sharing or injection drug use (IDU)
• History of withdrawal symptoms
• Consequences of drug use
• Previous treatment programs, mutual aid groups
• Medical history HIV, Hepatitis B C, STIs
• Obstetrical history GxPy, LMP, cycle regularity
• Social History partner, living children
• (contd)

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Comprehensive Assessment

• Further issues to identify after the
  establishment of a therapeutic relationship
• Psychiatric history eating disorders, mood
  disorders
• Social history family situation (partner, of
  children), housing nutrition, legal (current
  charges court dates), finances, domestic
  violence child abuse (safety)
• Family history substance use, psychiatric
  disorders, genetic and congenital disorders
• Sexual abuse history very common among substance
  using women so use sensitive interviewing
  techniques

(contd)
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Comprehensive Assessment

• Consider screening for intimate partner violence
• ALPHA (Antenatal Psychosocial Health Assessment)
• Three key questions
• Have you ever experienced abuse?
• Are you or have you ever been afraid of your
  partner?
• Are you safe?
• ALPHA http//dfcm19.med.utoronto.ca/research/alph
  a

(contd)
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Comprehensive Assessment

• Child Protection Concerns
• Remember - there is no legal obligation to report
  the unborn child
• Not all women will require child protection
  services some will require support services
• Be honest about your legal obligation to inform
  child protection services once the baby is born
• Identify any risks to children that may be living
  with woman - will need to clarify disposition of
  all living children
• Encourage voluntary self-reporting

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Physical Examination

• Unless clear medical emergency can defer detailed
  medical exam
• Vital signs, fetal heart rate and mothers weight
  are key components at each encounter
• Defer pelvic exam until rapport has been
  established (possible history of sexual abuse
  will require sensitivity during exam)
• Obstetrical exam - FHR, Symphysis fundal height
• Target exam to reflect / detect substance use
• Skin for injection sites, cellulitis, cuts,
  bruises nasal passages
• Cardiac exam murmur
• Abdominal exam enlarged liver

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Investigations

• Bloodwork Quantitative Serum B-hcg, routine
  prenatal bloodwork, liver enzymes, HIV and
  Hepatitis C serology (with consent)
• Urine routine and microscopy, culture and
  sensitivity
• Ultrasound for dates (if uncertain) and
  morphology
• Consider drug toxicology testing (with consent),
  as needed

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Screening for Infections

• Screen as required for
• Hepatitis B with HbsAg and Antibody levels
• Hepatitis C antibody testing
• Syphilis
• HIV (requires informed consent to perform test)
• Mantoux (need to ascertain her previous status)
• Chlamydia and gonorrhea
• Retest as exposure dictates due to window periods
  for conversion

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Hepatitis C (HCV) Infection

• Rates of HCV infection up to 90 following more
  than 5 years injection drug use
• Seroconversion occurs most frequently in the
  first year of injection use
• Rate of vertical transmission 0 to 5
• No treatment for HCV during pregnancy
• Confirm if acute or chronic HCV infection
• Consider Hepatitis A B vaccines for Hep C
  positive mothers

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Urine Drug Testing (Toxicology)

• If urine drug screening is required by protection
  services, it must be with maternal consent
• If there has been maternal drug use, and there
  are medical concerns for the neonate and mother
  is unable or unwilling to give consent, then drug
  screens on neonate may be taken without consent
• Note An unexpected positive result merits
  confirmatory testing! (same sample if possible)
• (contd)

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UDS - Toxicology

• Voluntary urine testing
• PROS agreement provides medical information for
  caregiver and suggests co-operation with medical
  care
• Negative urine toxicology reports can show
  abstinence has been achieved and is helpful in
  interviews with child protection agencies
• Valuable for monitoring treatment progress and
  enhancing motivation
• Necessary in some centers if considering
  methadone maintenance therapy
• CONS coercion can set up adversarial
  relationship between woman and care provider -
  open communication is critical component

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Ongoing Care

• Frequent visits
• Consider pros and cons of multiple care providers
  (i.e., methadone prescriber and obstetrical
  provider should ideally be the same person or
  work in the same clinic)
• Ongoing fetal health surveillance dependent on
  care provider

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Strategies to Engage Women into Care

• Reduce harm related to drug use - if abstinence
  is not achievable at present, focus on harm
  reduction
• Focus on womans needs (woman-centered care
  food, housing, safety, emotional support)
• Help women re-connect with the healthcare and
  social systems
• Advocate on behalf of women with substance use
  issues with child protection authorities

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Harm Reduction

• When abstinence is not an option - consider harm
  reduction philosophies
• Harm Reduction refers to any strategy that
  focuses on reducing the harmful consequences of
  drug use and associated high-risk behaviors
• Example With some substances, abstinence is not
  a safe option during pregnancy methadone
  maintenance therapy is considered a harm
  reduction approach for opioid dependence in
  pregnancy

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Management of Drug Use

• Manage withdrawal symptoms
• Consider pharmacological maintenance options,
  e.g., nicotine replacement therapy (NRT),
  methadone maintenance therapy (MMT) for opioid
  dependence
• Encourage treatment program attendance if the
  patient is at a stage of change where she is
  ready for treatment
• Discuss inpatient versus outpatient programs
• Educate about fetal and maternal effects
• Counsel about risks of Hepatitis BC, HIV

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Management of Withdrawal

• Drug withdrawal can potentially cause miscarriage
  in T1, premature labour in T3,adverse fetal
  effects including fetal distress
• If a woman wishes to withdraw from Methadone or
  opiates, T2 (12-28 weeks GA) may be safest time
  for taper
• The woman should be aware of her increased opiate
  needs during pregnancy, and risk of relapse with
  taper
• Treatment is based on specific substance(s) used
  by woman so enquire about polydrug use (very
  common)
• Medical detoxification recommended for opiates,
  benzodiazepines and alcohol

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Management of Hepatitis C in Labour and Postpartum

• Counsel all women about risk factors for
  hepatitis C and offer screening (repeat lab work
  if re-exposed)
• If anti-HCV positive, monitor liver enzymes
• Mode of delivery and breastfeeding have not been
  documented in transmission
• Role of scalp clip in possible transmission may
  alter care patterns
• Test babies with PCR at 3 to 6 months and if
  positive, repeat again at 18 months

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Pain Management in Labour What can affect a
womans pain?

• Hospital factors
• Lack of support
• Unwanted support
• Loss of control
• Hypervigilence
• Lack of privacy
• Harsh behaviour by staff

• Personal factors
• Past negative experience
• Sexual abuse history
• Fear, anxiety
• Cultural perspective
• Tolerance
• Labour Occiput Posterior position
• Previous pelvic fracture

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Labour and Delivery Issues

• Adequate analgesia opioid-dependent women may
  require larger doses of analgesics ? will not
  worsen addiction
• Avoid a fetal scalp clip to prevent transmission
  of Hep B/C HIV
• Injection drug users may have poor IV access ?
  planned IV access is recommended in case of
  emergency

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Postpartum Issues

• Rooming-in is the best option to encourage
  attachment and good parenting
• Women may room in even if there is a planned
  removal of infant (to promote bonding and
  resilience)
• If baby needs to go nursery, parents should
  accompany and be encouraged to hold and cuddle
  infant 24/7 if wanted
• Encourage breastfeeding and regular visits with
  infant
• Frequent f/u visits for mom baby to assess
  coping skills and neonatal growth
• If UDS are medically needed, better to obtain
  consent from the mother

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Postpartum Care

• Ensure there are enough community supports in
  place before discharge to prevent relapse
• Assess social support
• Assist with basic needs (food, clothing, shelter)
• Monitor for mood disorders
• Link parents to community supports and parenting
  resources
• Work with child protection as needed

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Risks of Heavy Prenatal Alcohol Use

• Alcohol passes through placenta fetus has
  limited ability to metabolize alcohol
• Alcohol is a known teratogen ? can damage
  developing fetal cells, umbilical cord placenta
• Prenatal exposure to alcohol results in
• Increased risk of spontaneous abortion and
  stillbirth
• Increased risk of fetal alcohol spectrum disorder
  (FASD) umbrella term encompassing fetal alcohol
  syndrome (FAS), alcohol-related birth defects and
  alcohol-related neurodevelopmental disorders

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Safe Limits of Alcohol

• Dose-response relationship between the amount of
  prenatal alcohol consumed and the extent of
  damage in the infant
• There is NO safe timing for alcohol use during
  pregnancy
• There is NO confirmed safe limit for alcohol use
  in pregnancy
• Therefore, NO alcohol is the safest choice!

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Social Alcohol Use Prior to Pregnancy

• A meta-analysis failed to show any adverse fetal
  effects after social drinking (defined as greater
  than 2 drinks/week and up to and including 2
  drinks/day)
• Moderate alcohol consumption before realizing
  that conception had occurred showed no increased
  risk of spontaneous abortion, stillbirth or
  premature birth
• Women should be reassured and counseled to
  abstain for the duration of the pregnancy
• Advise Folic Acid during pregnancy

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Assisting if Low-Risk Alcohol Use

• Brief interventions have been shown to be
  effective in modifying alcohol use during
  pregnancy
• Consider the following for pregnant woman with
  history of low-risk drinking
• Advise patient that it is safest to stop
  drinking.
• Advise patient to reduce drinking, if unable to
  stop.
• Advise by providing personalized feedback info.
• Assist by providing continued follow-up support
  and referral to appropriate resources, as needed.

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Assisting if High-Risk Use

• If the pregnant woman indicates high-risk
  drinking
• Assess level of motivation and readiness to
  change drinking behaviour severity of
  dependence
• Offer intervention(s) depending on stage of
  change and level of alcohol dependence (e.g.,
  medical detoxification)
• Advise her to reduce drinking, if unable to stop
• Arrange referral to appropriate programs/services
• Deal with barriers to attending treatment (e.g.,
  family)

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Effects of Smoking in Pregnancy

• Increased risk of spontaneous abortion
• Increased risk of vaginal bleeding (placental
  abruption and placenta previa) and premature
  delivery
• Increased risk of lower birth weight baby
  (150-200g less)
• Increased risk of sudden infant death syndrome
  (SIDS), bronchitis pneumonia, otitis media in
  children

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Smoking Cessation

• Advise women to quit smoking
• Advise woman to avoid exposure to second-hand
  smoke family/friends should not smoke around
  pregnant woman or infant, do not allow smoking in
  home or vehicle
• Educate about effects of smoking in pregnancy
• Refer to Smokers Helpline or Motherisk
• Offer Nicotine Replacement Therapy (NRT)

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Nicotine Replacement Therapy

• Nicotine replacement therapy (NRT) poses no more
  adverse effects than smoking during pregnancy
• Offer NRT if unable to quit on own
• 1 pack/day 20mg nicotine (plasma level)
• 1 Patch 7-21mg
• Gum 2-4 mg/piece (max 12mg/day)
• NRT doubles smoking cessation rates at 1 year

44
Marijuana

• No studies have established safe limits in
  pregnancy
• No significant neonatal effects
• Heavy users may be at risk for preterm delivery
• Possible neurobehavioural effects in neonate
  (increased jitteriness, increased tremors)
• Possible long-term effects described in children
  exposed in utero
• contd

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Marijuana (2)

• No specific therapy for withdrawal
• Dependence managed by encouraging decrease in
  amount used if unable to abstain from marijuana
  use (harm reduction)
• Marijuana is transferred into breast milk and
  abstinence is encouraged

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Cocaine and Other Stimulants

• Possibly teratogenic renal tract abnormalities
  (conflicting evidence in the literature)
• Increased rate of obstetrical complications
• Spontaneous abortion
• Placental abruption, placenta previa
• Premature rupture of membranes
• Preterm labour
• Low birth rate
• Cerebral hemorrhage in utero
• contd

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Cocaine and Other Stimulants (2)

• Can stop use safely during pregnancy
• No specific therapy for withdrawal care is
  supportive
• Can initially use short-acting benzodiazepines
  for anxiety and craving
• contd

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Cocaine and Other Stimulants (3)

• If mother intoxicated at time of delivery neonate
  can have mild central nervous system effects
  such as poor feeding and sleepiness
• Comfort Measures for neonate
• Touch and cuddles by mother
• Room-in with mother
• Breastfeeding
• contd

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Cocaine and Other Stimulants (4)

• Enters breast milk
• Avoid breastfeeding within three days of use
  (pump and discard)
• Long-term effects have been reported in
  literature (not definitive)
• Language delays (expressive and verbal
  comprehension)
• Behavioural problems at school

50
Opiates (1)

• Women can take medically prescribed opiates in
  moderate doses during pregnancy without being
  considered dependent
• Opioids can have a direct effect on fetal outcome
  with intrauterine growth restriction and
  low-birth weight especially heroin use and
  prescription opioid abuse
• Women who are opioid-dependent also have higher
  rates of obstetrical complications spontaneous
  abortion, preterm labour in T3 and fetal distress
• contd

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Opiates (2)

• Standard of care for opioid dependence in
  pregnancy- Methadone Maintenance Therapy (MMT)
• Methadone maintained pregnancies have improved
  outcomes
• Methadone dose should be maintained during labour
  
• Some women will need a reduction in methadone
  dose postpartum
• contd

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Opiates (3)

• Maternal Withdrawal
• If not on methadone, can use morphine for the
  management of withdrawal
• Neonatal Withdrawal
• Some babies of women on opiates will experience
  neonatal withdrawal
• Comfort measures
• Some babies will need replacement opiates
• Oral Morphine can be used in small doses to
  manage symptoms
• contd

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Opiates (4)

• Methadone enters breast milk
• Safe to breastfeed on methadone regardless of
  dose
• Neonates should be observed at least 4-5 days for
  signs of withdrawal
• Ensure close follow-up of mother and baby

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Conclusion

• Woman-centered, nonjudgmental care needed
• Know the substances commonly used in your
  community
• Treat substance use when woman is ready for
  treatment
• Consider Harm Reduction if abstinence is not
  possible initially

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Resources (1)

• Pregnancy-related issues the management of
  addictions (PRIMA) www.addictionpregnancy.ca
• Best Start www.beststart.org
• PREGNETS www.pregnets.org
• Smokers Helpline Ontario 1-877-513-5333
• Project CREATE www.addictionmedicine.ca
• Motherisk www.motherisk.org

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Resources (2)

• BC Doctors Stop Smoking Program www.bcdssp.com
• BC HealthFile info Sheet. http//www.bchealthguid
  e.org/healthfiles/hfile38d.stm
• Babies Best chance Handbook http//www.healthserv
  ices.gov.bc.ca/cpa/pulications/babybestchance.pdf
• Is it Safe for my Baby? Booklet CAMH
  www.camh.net
• Info sheets, posters AADAC www.aadac.com
• AADAC Help Guide for Professionals www.aadac.com
• BCRCP Guidelines www.rcp.gov.bc.ca
• Smart Guide
• Exposure to Psychotropic Medications and Other
  Substances During Pregnancy and Breastfeeding A
  Handbook for Health Care Providers. Free from
  CAMH. www.camh.net

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Pregnancy-Related Issues in the Management of
AddictionsSlide presentation developed by
members of the National PRIMA group

• Ron Abrahams
• Talar Boyajian
• Jennifer Boyd
• Wendy Burgoyne
• Katherine Cardinal
• Rosa Dragonetti
• Lisa Graves
• Phil Hall

• Samuel Harper
• Georgia Hunt
• Meldon Kahan
• Theresa Kim
• Lisa Lefebvre
• Nick Leyland
• Margaret Leslie
• Deana Midmer

• Stephanie Minorgan
• Pat Mousmanis
• Alice Ordean
• Sarah Payne
• Peter Selby
• Melanie Smith
• Ron Wilson
• Suzanne Wong

Principal Authors
Prima.medicine_at_utoronto.ca