CHAPTER 25 1 Discuss the scope of substance abuse in pregnancy. 2 Recognize signs of substance abuse. 3 Describe the effects of drug use during pregnancy on the developing fetus. 4 Elicit appropriate history and pertinent information from the patient. 5 Describe the special needs of the drug-dependent pregnant woman. 6 Recognize the teaching needs and appropriate referrals for the pregnant substance abuser. 1. Drug use in pregnancy and its associated problems has become a major public health issue. 2. Polydrug use, such as alcohol and tobacco with marijuana or cocaine, has become more common. 1. The overall rate of current illicit drug use among persons ages 12 or older in 2007 (8%) was similar to the rate in 2006 (8.3%) and has remained stable since 2002 (8.3%) (U.S. Department of Health & Human Services [USDHHS], 2008). 2. Nearly 4% of pregnant women use illicit drugs such as marijuana, cocaine, and heroin (March of Dimes, 2006). C Outcomes of substance abuse are related to the following: 1. Molecular weight influences whether the drug crosses the placenta. 2. The first 8 weeks of pregnancy are the most critical in terms of embryonic development. During the third trimester, drug use has the greatest potential for impairing fetal growth. a. Drugs taken orally might reduce the drug’s ability to cross the placenta. b. Drugs taken intravenously and intranasally more readily cross the placenta. c. Intravenous (IV) drug use increases maternal and fetal exposure to human immunodeficiency virus (HIV). 5. Presence of obstetric or maternal complications 7. Lifestyle of mother, including poverty, homelessness or inadequate housing, lack of education, domestic violence, and social and emotional problems 9. Many medical conditions, including anemia, bacteremia/septicemia, cardiac disease, cellulitis, depression, diabetes, edema, hepatitis B and C, tuberculosis (TB), hypertension, phlebitis, sexually transmitted infections (STIs), urinary tract infections, and vitamin deficiency compromise many drug-involved pregnancies. 10. Obstetric complications include abruptio placentae, placenta previa, intrauterine death, spontaneous abortion, premature labor and delivery, premature rupture of membranes (PROM), intrauterine growth restriction (IUGR), and polyhydramnios. 1. Generalized growth restriction and its associated complications 2. Increase in the frequency of sudden infant death syndrome (SIDS) 3. Signs of withdrawal, which can occur from birth to 6 days of life, include: b. Gastrointestinal disturbances d. Excoriation of knees and elbows from increased restlessness and sleeplessness e. Perianal excoriation (chemical dermatitis due to acidic stool) 4. Many of the signs of drug withdrawal in the neonate are similar to other neonatal problems, such as sepsis, hypoglycemia, and central nervous system (CNS) disorders; therefore, testing to rule out these conditions should be considered in addition to drug screening. 1. Cocaine abuse and addiction is a complex problem involving biological changes in the brain as well as social, family, and environmental factors (National Institute of Drug Abuse and Addiction [NIDAA], 2008a). 2. The estimated number and percentage of persons ages 12 and older who used cocaine in the past month in 2007 (2.1 million users or 0.8% of the population) were similar to those in 2006 (2.4 million or 1%) and 2002 (2 million or 0.9%) (USDHHS, 2008). 3. Cocaine is found in the leaves of the Erythroxylum coca plant of Peru, Ecuador, and Bolivia; it can be snorted, sniffed, injected, or smoked; other names include coke, snow, flake, and blow. 4. Cocaine blocks the reuptake of catecholamines at nerve terminals, which increases circulating concentrations of catecholamines in the blood, resulting in vasoconstriction, tachycardia, hypertension, and uterine contractions. 5. Cocaine use is second only to marijuana in pregnant women who used an illicit drug during pregnancy. 6. Crosses the placenta by diffusion 7. Cardiovascular and neurologic complications, such as hypertension, tachycardia, myocardial ischemia, sudden death, dysrhythmias, subarachnoid hemorrhage, thrombocytopenia, and seizures have been described among parturients who abuse cocaine. 8. Used during early months of pregnancy, may increase risk of miscarriage 9. Acute cocaine use during the third trimester might result in preterm labor, abruptio placentae, a greater incidence of PROM, and an increased risk of meconium staining, precipitous delivery, premature and low birthweight infants. 1. Derived from seeds of the poppy plant Papaver somniferum; it produces an off-white or pale brown powder that can be sniffed, smoked, or injected parenterally; it is approximately 25 times stronger than morphine and crosses the placenta readily, appearing in fetal tissue within 1 hour of maternal consumption; may be called sugar, dope, horse, junk, white horse, or smack (National Institute of Drug Abuse [NIDA], 2009a) 2. The number of heroin users decreased from 338,000 in 2006 to 153,000 in 2007, and the corresponding prevalence rate decreased from 0.14% to 0.06% (USDHHS, 2008). 3. Heroin abuse during pregnancy and associated environmental factors have been associated with adverse consequences including low birthweight (NIDAA, 2008b). 4. Primary effects are analgesia, sedation, feeling of well-being, and euphoria. 5. Heroin is not generally thought to be a teratogen capable of producing congenital malformation. a. Easily crosses the placenta via simple diffusion b. Hazards of heroin to the fetus are thought to be the direct effects of the drug on the fetus and the maternal lifestyle associated with heroin use. 6. Neonatal effects of prenatal heroin exposure include the following: a. Neonatal abstinence syndrome (1) Causes severe neonatal withdrawal symptoms (2) Has an average onset of symptoms between 6 and 12 hours after birth, with an average peak of symptoms between 48 and 72 hours b. Withdrawal symptoms might persist in a subacute form for 4 to 6 months after birth. c. Increased incidence of meconium aspiration at birth d. Increased incidence of neonatal sepsis f. Neurodevelopmental behavioral problems 1. Marijuana was the most commonly used illicit drug (14.4 million past month users). In 2007, marijuana was used by 72.8% of illicit drug users and was the only drug used by 53.3% of them (DHHS, 2008). 2. Among persons ages 12 and older, the overall rate of past month marijuana use in 2007 (5.8%) was similar to the rate in 2006 and the rates in earlier years going back to 2002 (USDHHS, 2008). 3. Often called pot, grass, reefer, weed, herb, Mary Jane, MJ, skunk, blunt, dope, or joint (NIDAA, 2008a) 4. Causes tachycardia and decreased blood pressure, resulting in orthostatic hypotension 5. Research has shown that babies born to women who used marijuana during pregnancy display altered responses to visual stimuli, increased tremulousness, and a high-pitched cry, which may indicate problems with neurologic development (NIDAA, 2008c). 1. Developed as a substitute for morphine and heroin; frequently used to treat pregnant heroin-dependent women to prevent repeated episodes of heroin withdrawal in the fetus (National Institute of Drug Abuse International Program, 2009) 2. Blocks the craving of withdrawal 3. Is longer-acting and therefore is thought to stabilize the environment for the fetus, sustaining the addict and avoiding withdrawal, thus: 4. Methadone maintenance requires enrollment in a drug-treatment program, therefore increasing the likelihood of prenatal care. 5. Mother may breastfeed infant if not infected with HIV, hepatitis, or TB; long-term effects on the neonate have not been determined. a. Menstrual history: irregular menses in 60% to 90% of addicted women b. Obstetric/gynecologic history (1) Little or no prenatal care (2) Number of pregnancies and method of delivery, miscarriages, abortions, and living children (1) Preexisting medical conditions and treatments; the most common comorbid diagnoses for women are affective disorders, such as chronic or acute depression and anxiety disorders (4) History of physical or sexual abuse or family violence (5) Weight less than the 50th percentile and little or no weight gain during pregnancy g. Deterioration in personal hygiene j. Acquired immunodeficiency syndrome (AIDS) and other sexually transmitted infections a. Bloodshot eyes, conjunctivitis, and yellow sclera c. Dilated or constricted pupils f. Poor dental hygiene, abscesses, and gum disease g. Rhinitis, nasal or sinus irritation, septal erosion, and loss of sense of smell h. Hepatomegaly, jaundice, or distended neck veins secondary to liver failure i. Scars from injuries or surgery j. Subcutaneous abscesses or cellulitis and rashes k. Needle marks and ecchymotic spots or scars l. Unsteady walk and impaired coordination p. Altered moods and perceptions/inappropriate behavior s. Odor of substance on clothing t. Burns on fingertips or singed eyebrows or eyelashes d. Inability to maintain close relationships k. Late prenatal care, missed appointments, or late for appointments l. Difficulty following through on referrals a. Complete blood count (CBC), differential, and urinalysis (UA) b. Toxicologic urine screening (detects cocaine ingestion within past 24 hours) c. Venereal Disease Research Laboratory (VDRL) test d. Cervical culture for gonorrhea and chlamydia e. Papanicolaou test (Pap smear) h. Sonography (to detect IUGR) k. Sickle cell screening (when appropriate) l. Blood type and antibody screen m. Alpha-fetoprotein (if between 16 and 20 weeks’ gestation) n. Hepatitis panel (Hep B core antibody, Hep B surface antibody, Hep B surface antigen, Hep A antibody profile, Hep C antibody) o. Baseline liver and renal function tests p. Group B streptococcus culture 1. Identify substance abuse in patient. a. Unexplained late first obstetric visit or no prenatal care c. History of unexplained miscarriages, fetal growth restriction, stillbirths, abruptio placentae, and precipitous birth d. Children with developmental problems e. History of drug- or alcohol-related medical problems f. History of physical or sexual abuse g. Questions phrased positively to elicit honest responses (e.g., “To care for you and your baby, I need to know” or “I noticed track marks and I’m concerned for you and your baby and need to know”) 2. Give accurate and specific information on complications associated with drug use and the increase in morbidity and mortality in a nonjudgmental way. a. Explain that quitting or decreasing drugs at any time in pregnancy improves obstetric outcome. b. Explain dangers of operating vehicles or machinery while under the influence of drugs. c. Provide nutritional counseling, emphasizing protein intake; provide supplemental vitamins, iron and folate. d. Encourage listening to fetal heart rate by the mother and significant other at each visit. e. Show sonogram to the patient so she can visualize the fetus. f. Provide information on fetal growth and development. g. Reinforce patient’s understanding with printed material at a level she can understand and use a variety of teaching methods to reinforce education. h. Discourage breastfeeding if the mother is using a substance that might pass through the breast milk.
Substance Abuse in Pregnancy
SUBSTANCE ABUSE
CLINICAL PRACTICE
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Substance Abuse in Pregnancy
