Unit 6 Pregnancy:

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Unit 6Pregnancy mental illness and substance
use Developed by Dr Adam R Winstock MRCP
MRCPsych FAChAM
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Overview

• Maternal drug use may harm both mother and foetus
  
• Tobacco and alcohol are the worse culprits
• Being pregnant may be a window for attracting
  female drug users into treatment
• Adverse consequences are mediated by direct
  toxicological effects and behavioural
  consequences (malnutrition, poorer ante natal
  care, other substance use, mental illness)
• There are higher rates of ante natal and post
  natal complications
• In some cases there are adverse childhood
  behavioural/ developmental consequences

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Tobacco and pregnancy

• Wide variety of adverse outcomes for pregnancy
• Dose response relationship for many peri-natal
  harms
• Intrauterine growth restriction
• Ectopic pregnancy
• Placenta praevia
• Threatened and spontaneous miscarriage
• Premature rupture of membranes
• Pre term delivery
• Sudden infant death syndrome (SIDS)
• Possibly longer term effects on the health of the
  child

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Smoking, depression and pregnancy

• High rates of depression in treatment-seeking
  cigarette smokers
• Depressed smokers have lower quit rates than non
  depressed smokers
• Cessation of smoking may be associated with
  exacerbation of depressive illness
• Depression may trigger relapse to smoking
• Pregnant women with a history of depression need
  to have their mood monitored for weeks following
  cessation

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Pharmacotherapies in pregnancy

• Many women will have sufficient motivation to
  quit without assistance
• Harm from tobacco use outweighs that from
  replacement therapy
• Intermittent preparations (lozenge/ gum/
  microtab) of Nicotine Replacement Therapy NRT
  should be considered for those who have been
  unsuccessful with other interventions (use NRT
  for the shortest time needed)
• Require follow up and support
• Buproprion/ TCAs should be avoided - not licensed
  for use in pregnancy

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Tobacco and schizophrenia

• The metabolism of some anti psychotic medications
  can be impacted by the use of nicotine
• Cessation of smoking during pregnancy may alter
  the medication stability in some patients
• Changes in medication dose may be needed
• Cessation should be supported and closely
  monitored and should take place in liaison with
  the patients psychiatrist

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Mental illness and pregnancy

• Highest prevalence of depression in women is
  during child bearing years
• For most women, pregnancy is associated with a
  general reduction in rate of major mental illness
  and suicide
• Of pregnant women 10 16 fulfill the DSM-IV
  diagnostic criteria for major depression
• Contraception use is often inadequate in those
  with chronic psychosis leading to higher rates of
  unwanted pregnancies and abortions

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Mood disorders in pregnancy

• Post partum blues (PPB) are experienced by 50 -
  60 of mothers
• Transient (2 days), commencing 3 - 5 days post
  delivery
• Crying, irritable, labile mood, depressed,
  maximal on day 5 post partum
• Severe PPB associated with increased risk of post
  natal depression
• Concurrent drug withdrawal symptoms may cloud
  picture

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Post natal depression (PND)

• 10 - 15 of mums develop PND within 6 - 8 weeks
  of birth
• Often missed, stigmatised, dismissed early on as
  the baby blues
• Risk factors
• past psychiatric history
• life events
• younger age
• marital problems
• poor support
• unplanned pregnancy
• not breastfeeding
• unemployment
• early discharge (lt 72 hours)
• past history sexual abuse in 50

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Post natal depression symptoms

• Deep sadness
• Tearful
• Negative self assessment as a mother
• Marked anxiety of babys health status as
  normal
• Other usual depressive features
• Specifically assess for infanticidal ideas/ self
  harm

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Treatment

• Psychological support/ parenting programs/ family
  support
• Anti depressants if indicated
• Breast feeding should be avoided for a time after
  dosing or when there is risk of sedation
• Some possible use for oestrogen

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Anti depressants in pregnancy

• Exposure to tricyclic antidepressants or
  fluoxetine throughout gestation does not appear
  to adversely affect cognition, language
  development, or the temperament of preschool and
  early school children
• Untreated depression is associated with higher
  rates of mortality and morbidity
• If untreated, a mothers depression is associated
  with less cognitive and language achievement by
  their children

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Anti depressants in pregnancy

• Sudden cessation of anti depressant medication in
  women with medication-responsive illness carries
  a high risk for relapse and suicide attempts
• Sudden cessation may expose mother and developing
  foetus to discontinuation syndrome
• Studies suggest no association between tricyclic
  antidepressant or SSRI exposure and either
  congenital malformations or developmental delay

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Anti depressants in pregnancy

• SSRI exposure associated with earlier delivery
  and lower birth weight
• In general these medications can be regarded as
  safe and appropriate when taken during pregnancy
  for the treatment of depression
• If required anti depressant medication should be
  taken throughout pregnancy and postpartum

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Bipolar and post partum psychosis (PPP)

• Incidence of bipolar 0.5 - 1.5
• Onset in teens and twenties
• At high risk of PPP (7 x)
• - if past history of PPP (50)
• Onset post delivery - few days / few months

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Mood stabilisers

• Lithium is associated with 20 fold increase of
  Ebsteins anomaly (right tricuspid valve)
• Ultrasound monitoring required as well as
  specialist review
• High risk of relapse off lithium
• May introduce prophylactic lithium post delivery
  in high risk patients
• -may reduce risk of relapse from 50 to 10
• Observe for post delivery increases in lithium
  level and signs of toxicity

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Other mood stabilisers

• Carbamazepine, valproate are both known
  teratogens (may cause foetal abnormalities)
• Advise mother of risk
• Ensure comprehensive ante natal care
• Increase monitoring if mother is considering
  stopping medication
• Conduct ongoing peri natal reviews
• Provide information about family support

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The effects of substance use on pregnancy
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Risks to the unborn child

• Direct toxicological effects
• Withdrawal
• Malnutrition
• Perinatal viral transmission
• Associated physical disease
• Behavioral risks
• Lifestyle

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Opioids and pregnancy

• Heroin use increases the risk of perinatal and
  infant morbidity and mortality
• Miscarriage
• Placental abruption
• Premature rupture of membranes/ labour and
  delivery
• Chorioamnionitis
• Intrauterine growth restriction (IUGR)
• Low birth weight
• Pre-eclampsia (PET)
• Restriction (IUGR) and of low birth weight for
  gestational age

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Opioids and pregnancy

• Intra-uterine death (IUD)
• Postpartum haemorrhage (PPH)
• Respiratory distress syndrome (RDS)
• Neonatal abstinence syndrome (NAS)
• Neonatal mortality
• Neurocognitive abnormalities
• increases the risk of intrauterine growth

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Recognition of pregnancy

• Late presentation in pregnancy is not unusual
  and is often driven by the fear of disclosing
  heroin use when pregnant
• Priority access into D A treatment
• Coordination of care
• Facilitation of engagement of the woman her
  family with services
• Screening for Blood Borne Viruses (BBV)
• Referral for specialist assessment and care
• Comprehensive assessment and treatment planning
• Identify partner/ support person for ante natal,
  delivery and post natal support

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Benefits of methadone in pregnancy

• Ideally pregnancies are planned
• Pregnancy may be a window of opportunity for
  engagement with drug and alcohol/ primary care
  services
• Pregnant women should be offered highest priority
  access to methadone treatment program
• Optimal benefits are seen in compliant patients
  who do not use other drugs, are on an adequate
  dose of methadone and who are engaged with
  antenatal and other support services/ GP
• Reduced rates of peri natal complications
• Higher birth weight and improved foetal outcomes
  
• NOTE Methadone treatment during pregnancy is
  not associated with adverse postnatal development
  in children of opioid-dependent women

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What to do with the late presenter?

• Reassure and commend them for seeking treatment
• Offer priority access to treatment
• Seek specialist advice regarding obstetric
  review/ drug and alcohol issues
• If opioid dependent, provide optimal induction
  onto methadone
• Consider inpatient stabilisation and ante natal
  reviews
• Consider psychosocial assessment and child
  protection issues

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General aims of managing pregnant opiate users

• Engage the patient
• Maintain contact with the patient
• Promote the health and well being of mother and
  foetus
• Coordinate proactive collaborative ante natal
  care
• Avoid sudden cessation of use, for fear of
  withdrawal related complications
• Aim to reduce risk-taking behaviours
• Stabilise (if opioid dependent) on
  non-injectables such as methadone
• If considering detoxification then choose 2nd
  trimester

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General aims of managing pregnant opiate users

• Good primary health and psychosocial care should
  be provided (screen for partners DA use and
  domestic violence)
• Liaison with obstetric, midwifery, paediatric
  teams and social services where appropriate
• Social stability and provisions for motherhood
• Social work/ parenting assessment
• Ensure other drug and alcohol behaviours are
  assessed
• HIV and hepatitis screening

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Optimal outcomes with maintenance

• Pregnant women may need an increase in dose in
  the later trimesters
• Split dosing may need to be considered
• Monitor patients for early post consumption
  nausea and vomiting
• Those patients who are adamant that they do not
  want to remain on methadone should be advised to
  wait till the second trimester when a safer
  reduction process can be completed
• A specialist should be consulted in such cases

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Dosing in pregnancy

• Depends upon wide range of factors
• Regular review of mother with emphasis on
  identifying if she is on a dose that keeps her
  free from withdrawal for at least 24 hours
• Many patients require an increase in dose during
  3rd trimester
• Keep free from toxicity/ severe side effects
• Encourage/ reassure mum
• No clear relationship between maternal methadone
  dose and the intensity of neonatal withdrawal
• High rate of relapse if mums get off methadone

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Post delivery

• Examine mum for post delivery sedation occurring
  on the same pre-delivery dose, which has now led
  to higher plasma level with the reduction in body
  mass
• May need to reduce dose at day 2 - 4 post
  delivery
• Mother and child care issues need to be assessed
  on an individual basis
• Schedule a post natal planning meeting
• Suggest new parent support groups (parenting
  advice and skills training)

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Neo natal abstinence syndrome (NAS)

• There is no clear doseresponse relationship
  between methadone and risk of NAS
• All babies born to known opioid dependent mums
  should be kept in hospital for at least 5 days to
  exclude the incidence of NAS (50)
• Treatment with gradually tapering dose of
  morphine

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Breastfeeding

• Breast food is the best food
• Available, cheap and easy to prepare and deliver
• Mothers who are drug dependent should be
  encouraged to breastfeed with appropriate support
  and precautions
• Advise not to feed when intoxicated or when high
  levels of drug likely to pass to child (dependent
  upon T ½)
• In addition, it is now recognised that
  skin-to-skin contact is important, regardless of
  feeding choice and needs to be actively
  encouraged for the mother who is fully conscious
  and aware and able to respond to her babys needs
• NB. Advise not to stop weaning suddenly if using
  substances

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Contraindications to breastfeeding

• HIV ve / hepatitis C
• High dose benzodiazepine use
• Poor nutritional status/ systemic illness
• METHADONE IS NOT A CONTRAINDICATION TO BREAST
  FEEDING. IT SHOULD BE ENCOURAGED

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Storage of methadone and the provision of
takeaways to those with young children at home

• Methadone in very small doses may be fatal to
  children and babies
• Methadone must be stored in locked cabinet (not
  in the fridge)
• Parents should avoid sleeping with their child if
  drug affected or after recent use
• All clinicians should ensure patients are aware
  of these risks and should be given advice on safe
  storage
• The clinician should document the advice has been
  given and continually reassess any risk
  associated with their ongoing provision

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Benzodiazepine and anti depressant medications
in pregnancy

• Sudden cessation of either class of drug may lead
  to a withdrawal syndrome
• Both medications should only be reduced when the
  patient can be safely monitored and clinically
  supported
• Those on benzodiazepines should be converted to
  diazepam equivalents
• Gradual taper with regular review
• Aim to avoid any significant withdrawal distress
  in the newborn

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The Community Pharmacist and pregnant drug users

• Advise on folic acid intake and nutrition
• Ensure registered either with a GP or with a drug
  agency
• Close liaison between pharmacists and treatment
  agencies
• After the birth Community Pharmacists can provide
  advice and information on
• feeding
• child health
• over the counter medication where necessary

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Summary

• All women of child bearing age should be advised
  of the risks of substance use on fertility and
  foetal development.
• Dependent substance users should be given
  priority access to treatment, but advised not to
  stop use suddenly
• Coordinated care focusing on the provision of
  close monitoring and ante natal provision are
  central
• Risk reduction is achieved by not only reducing
  toxicological harm but also associated lifestyle
  and route related risk such as viral
  transmission, malnutrition and mental illness

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End of Slide Show
The Can Do Initiative Managing Mental Health
and Substance Use in General Practice
Overview Session A Definitions prevalence
Session B Assessment history taking Session
C Common explanations Unit 1 Alcohol Unit
2 Benzodiazepines Unit 3 Cannabis Unit 4
Amphetamines Unit 5 Opioids and pain Unit 6
Pregnancy