Title: Perinatal Addiction
1Perinatal Addiction
- Martha J Wunsch MD
- Principles of Primary Care
- Block 12, Class of 2008
- July 10, 2006
2How prevalent is drug and alcohol use in
pregnancy?
- 12-24 of women use drugs and alcohol during
pregnancy - 1 of every 3-4 women expose fetus to alcohol
- Alcohol and tobacco gt illicit drugs and
prescription drugs - Prevalence in public clinicprivate practice
- CaucasiansgtAfrican AmericansgtHispanic
- No significant variation by socioeconomic status
3Learning Objectives
- Review the specific problems of women with
addiction - Review strategies to identify the pregnant
addict/alcoholic - Review the effects of drugs and alcohol on the
developing fetus - Review the treatment needs of the pregnant woman
and her newborn
4Review the specific problems of women with
addiction
5Women and Addiction
- In the general population, women are not as
likely as men to be substance abusers yet these
addicted women have a specific profile of
confounding diagnoses, family history, current
social situation and pattern of substance use.
6 Addiction Males gtWomen
- Monthly prevalence Epidemiology studies
- Males 5X greater rates of alcoholism, 3X greater
rates for drugs - If given the opportunity, women may progress from
abuse to addiction at the same rate - Exception prevalence of addiction is similar
for males and females during the teen years - Alcohol, marijuana, cocaine, tobacco
7Confounding Diagnoses
- Most women in treatment for addiction have at
least one coexisting mental disorder - Anxiety
- Depression
- Personality Disorders
- More likely than men to have had a suicide
attempt or ideation prior to treatment - More likely than men to have a history of
previous treatment
8 Family History and Social Situation
- Often have a family history of addiction
- Exposed to parental violence as children
- Experienced emotional, physical, sexual abuse as
children - More likely to have a family history of mental
illness, particularly in their mothers - More likely to live with a violent, addicted
partner
9 Pattern of Substance Use
- Both women and men primarily abuse alcohol and
illicit drugs - Women are more likely to abuse prescription drugs
- Women are more likely to abuse sedative-hypnotics,
specifically benzodiazepines - Women are more likely to be poly substance abusers
10Identification of the pregnant addicted woman
11Clues Social history
- Positive family history of addiction
- Currently living with a partner who abuses drugs
and alcohol - Positive legal history (remember DUI, DIP)
- History of domestic violence in current living
situation - If FOB is abusing drugs and alcohol, look here
first
12Clues in the Social History
- Criminal involvement to get access to drug
- Selling
- Prostitution
- Robbery
- Forgery
- Chaotic living situation
- Other children are not in custody
- Unclear plans for care of the newborn
13Risk factors medical and psychiatric history
- Previous mental health diagnosis depression,
personality disorder - Previous problem pregnancies
- Infections secondary to
- Mode of use ( IV, snorting)
- Method of procurement (prostitution)
14Clues in the medical history
- No prenatal care
- May be because of fear of discovery of addiction
- May be secondary to general chaos in her life
- Tattoos or self scarring
- Secondary to IVDU or skin popping
- Burns on hands and clothing
- Nicotine abuse
15Medical Complications of Drug Abuse in Pregnancy
- Intravenous Drug Use
- Bacteremia Endocarditis
- Sexually Transmitted Diseases
- Hepatitis (acute, chronic)
- HIV
- Cellulitis/Phlebitis
- Malnutrition
- Pneumonia
- Tetanus
- Tuberculosis
- Urinary Tract Infections
- Endocrine Abnormalities (?ACTH and adrenal
function, ?ovulation)
16Obstetrical Complications Procuring, Using, and
Recovering..
- Animal studies cannot exactly replicate the
effect of a drug - Polysubstance abuse is the norm
- Poverty, homelessness, chaos
- Inadequate prenatal care
- Sexually Transmitted diseases
- Toxic adulterants (ie talc in cocaine)
17Obstetrical Complications (Opiate Abuse)
- ?Spontaneous Abortion, especially first trimester
- Amnionitis
- Intrauterine Growth Restriction
- Placental Insufficiency
- Postpartum Hemorrhage
- Pre-eclampsia and Eclampsia
- Premature labor/Premature rupture of membranes
- Septic thrombophlebitis
18Obstetrical Complications Cocaine
- Transported across placenta easily/high levels in
fetal circulation - Especially if IV or freebased
- Fetal circulation lacks plasma esterases to
metabolize - Potent vasoconstriction
- Decreased nutrients to fetus
- Acute hypoxic insult
- Teratogenicity secondary to lower blood flow
- Alcohol cocaine Cocethylene
19Obstetrical Complications Cocaine
- Increase in catecholamines, BP, and body
temperature - Increased early pregnancy loss
- Increase in placenta previa and abruptio
- Meconium staining of amniotic fluid
- IV or smoking use may precipitate labor
- Due to increase in uterine muscle tone and
contractility
20Screening
- All pregnant women should be screened for drug
and alcohol use - T-ACE
- TWEAK
- A positive screen indicates the need for a
further evaluation - Elements of the history and physical may indicate
need for a urine drug screen
21 T-ACE
22TWEAK
23T-ACE Score
- Tolerance Two or more drinks to feel high is a
positive screen - OR
- Two positive answers to the other three questions
is a positive screen - TWEAK Score
- Three or more points indicate that a pregnant
woman is a problem drinker
24Treatment Normalize the intrauterine environment
- Comprehensive, culturally and gender sensitive
- Addiction Treatment
- Medical Treatment
- Obstetrical Care
- Psychosocial Support
- Psychiatric Services
- Including long term planning that addresses the
needs of both the woman, her infant, and her
other children -
25Treatment Barriers
- Fear, shame, and guilt about use
- Will she lose other children if in treatment?
- Does she have family support?
- Attitudes of medical providers
- Lack of comprehensive clinical care services for
all the problems of pregnancy AND addiction - Can she get to treatment? Transportation
problems? - Lack of childcare while in treatment
- Basic needs must be met for her to engage in
treatment - Co-morbid diagnoses impacting ability to access
services - Difficulty addressing many issues simultaneously
- Depression, anxiety
- Personality Disorder
- Immaturity/lack of coping skills
26Review the effects of drugs and alcohol on the
developing fetus
27Alcohol
- Alcohol is a known teratogen
- There is NO safe level of drinking in pregnancy
- 25-30 of pregnant women expose the fetus to
alcohol fewer consume quantities known to be
dangerous - Alcohol exposure in pregnancy is the leading
preventable cause of neurobehavioral problems and
mental retardation - Alcohol crosses the placental barrier and is
poorly metabolized by the fetal liver - Levels of alcohol are found in amniotic fluid
after only one drinkdouble that of maternal serum
28Fetal Alcohol Syndromehttp//www.nofas.org
- Perinatal and/or postnatal growth retardation
- Central Nervous System involvement
- Characteristic facial features
- History of maternal alcohol use during pregnancy
Consensus Case Definition by Research Study of
Alcoholism, Fetal Alcohol Study Group
29Perinatal and/or postnatal growth retardation
- Height/Weight lt 10th for gestational age at
birth - Growth abnormalities persist into adulthood
- Reflects the effects of alcohol on neuroendocrine
function
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31Central Nervous System Involvement
- Neurological abnormalities
- Developmental delay
- Behavioral Dysfunction/deficit
- Intellectual impairment/structural abnormalities
- Microcephaly (Head circumference lt3)
- Brain malformations
32Anomalies Microcephaly, absent Corpus Callosum,
flattened sulci
33Characteristic Facial features
- Most evident/obvious 6 months-6 years old
- Short palpebral features
- Elongated mid face
- Long and flattened philtrum
- Thin upper lip
- Flattened maxilla
34Facial Features
35 Alcohol Exposed Newborn
Flattened Midface
Shortened Palpebral fissures
Elongated, flat philtrum
36Features change through childhood and into
adolescence
37Microcephaly, changing facial features with age
38Coarsening of facial features in adulthood
39Fetal Alcohol Spectrum Disorders
- Fetal Alcohol Effects Neonates and children who
exhibit fewer of the characteristics than deemed
necessary for the full diagnosis - Alcohol-related birth defects
- Alcohol-related neurodevelopmental disorder
40Incidence of FAS
- Varies across cultural, ethnic, and socioeconomic
groups in North America - Highest rates thought to be among Native American
and African American women - Actual incidence rates difficult to determine
- Underreporting by women
- Research methods use case reports or
retrospective studies - Confusion and overlap with FAE, ARNBD, ARBD
41Even if they dont meet the criteria for FAS,
alcohol exposed newborns grow up to be children
who
- Have a spectrum of learning and behavioral
problems - May have an average IQ of 100 but are still
affected - Are at increased risk for substance abuse,
especially if the mother does not stop drinking - Have life long disabilities (AVG IQ 67)
42Psychoactive substances are used in combination
during pregnancy when abused making it difficult
to discern teratogenic effects
43Sedative Hypnotic Drugs
- Barbiturates
- Often given for maternal seizure disorders
- Teratogenicity confounded by maternal variables
- If given close to birth may cause respiratory
depression - Benzodiazepines
- May be associated with increase in cleft
lip/palate - Usually combined with alcohol confounding
teratogenicity
44Opioids
- No evidence for teratogenicity
- Intrauterine Growth Restriction is probably due
to malnutrition and combination with other drugs
and alcohol - Infants born to mothers on methadone maintenance
have improved birth outcomes when compared to
mothers still using illicit opioids - Pain literature Opioids are tolerated well in
pregnancy by mom and baby - BUT.
45Fetal/Neonatal Opioid Withdrawal
- Abrupt cessation of opioid use during 1st and 3rd
trimester may be lethal for fetus - 20-70 of infants born to pregnant women abusing
or prescribed opioids may have symptoms and signs
of withdrawal - Life threatening if untreated
- Seizures
- Dehydration
- Pneumonia
- Autonomic instability
-
46Neonatal Opioid Withdrawal
- CNS Disturbed sleep, irritable, feed/suck
poorly, seizures - GI Vomiting, diarrhea, abdominal discomfort
- Autonomic sweating, yawning, temperature
instability, mottling, respiratory difficulties,
increased or decreased tone, myoclonic jerks
47Neonatal Opioid Withdrawal
- Assessment Neonatal Abstinence Scale
- Assigns points according to babies signs or
withdrawal every 4-6 hours - Treatment
- Symptom triggered according to FAS
- Opioid agonists
- Paregoric, Tincture of Opium, Oral Morphine,
methadone - Infants may have chronic withdrawal symptoms for
up to 6 months after birth
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49Cocaine
- Transported across placenta easily/high levels in
fetal circulation - Especially if IV or freebased
- Fetal circulation lacks plasma esterases to
metabolize - Potent vasoconstrictiondecreased nutrients for
fetus - Acute hypoxic insult may occur with
vasoconstriction - Teratogenicity? Secondary to lower blood flow
during morphogenesis
50Alcohol Cocaine Cocethylene
- Powerful stimulant
- Fetus has decreased plasma esterase and therefore
cannot metabolize - Presents as stimulant toxicity, not cocaine
withdrawal - Causes irritability, poor feeding, sleep
disturbance in newborn - Presence of other drugs and alcohol confounds
treatment
51Cocaine and teratogenicity?
- Use associated with intrauterine
death/spontaneous abortions - Low birth weight/IUGR
- Preterm delivery
- Neonatal seizures ( Its a stimulant!)
- Autonomic instability
52Teratogenicity?
- Increase in limb anomalies, cardiac and renal
anomalies - Increase in behavioral problems after birth,
especially in boys - Confounding variables
- Recall bias, research methods
- Use associated with alcohol, tobacco, marijuana
abuse - Use of solvents to prepare street cocaine is
teratogenic
53Nicotine
- Lower birth weight (7 ounces)
- Catch up growth occurs post-natal
- 4 fold increased risk of SIDS
- Possible associations
- Reduced IQ
- Increased rates of ADHD
- Confounds Use of other substances
54Others
- Caffeine Decrease in birth weight, usually
associated with smokers who drank gt3 cups of
coffee/day - Other stimulants ( Ritalin, Adderall) Data
inconclusive - Psychedelics ( PCP, LSD, THC) Low potential for
teratogenicity - Inhalants Some evidence of effects similar to
alcohol
55Review the treatment needs of the pregnant woman
and her newborn
56Maternal Treatment
- Detoxification In hospital to monitor fetal
wellness - Opioids
- Stabilize on methadone
- If necessary to withdraw, during 2nd trimester
only - Phenobarbital, clonazepam, lorazepam for alcohol
and sedative-hypnotic dependence - Substance Abuse Treatment
- Multi-agency
- Multidisciplinary
- Carefully coordinated to encourage engagement
57Medication Assisted Treatment
- Methadone
- Moms
- More likely to receive prenatal care/medical care
- May need a higher dose later in pregnancy (3
compartments) - Babies Improved newborn outcomes including birth
weight, head circumference, length - Neonatal opioid withdrawal
- Longer acting drugemergence of w/d later (72
hours) - May be life threatening if left untreated
- Buprenorphine Modality with increasing use
- If treated with Suboxone prior to pregnancy,
change to Subutex - Difficult to induce onto Suboxone if already
pregnant due to potential for induced withdrawal.
58Newborn Multidisciplinary Team
- Medical Treatment
- Withdrawal
- Congenital complications
- Infections (HIV)
- Psychological
- Developmental issues
- Social
- Child exposed prenatally is at high risk for
child abuse - Post natal environment increasingly recognized as
important - A stable post-natal environment prevents ongoing
developmental problems/assalt
59Sarai
High forehead
Microcephaly Frontal-Occipital Circumference (3)
Short palpebral fissures, small eyes
Mid-face hypoplasia
Maxillary hypoplasia
Thin upper lip, absent philtrum
Age 6 years and 7 months, weight 38 pounds (5 ),
height 44 inches ( 10-25)
60The Divine Miss Sarai!
Sarais favorite outfit
Sarai and Samantha
61Literature Women and addiction
- Blume S . Alcohol and other drug problems in
women. In JH Lowinson, P Ruiz, RB Millman et al.
(eds) Substance Abuse A Comprehensive Textbook,
Baltimore MD Williams and Wilkins 794-807. 1992. - Blume, SB. Women and Alcohol Public Policy
Issues. Women and Alcohol Health-Related Issues
(NIDA Research Monograph 16). Rockville, MD
National Institute on Drug Abuse, 294-311, 1986. - Westermeyer J and Boedicker AE . Course, severity
and treatment of substance abuse among women
versus men. American Journal of Drug and Alcohol
Abuse. 26 (4) 523-535. 2000. - Van Etten ML and Anthony JC. Comparative
epidemiology of initial drug opportunities and
transitions to first use marijuana, cocaine,
hallucinogens and heroin. Drug and Alcohol
Dependence. 54 117-125. 1999. - Hanna EZ, Grant BF. Gender differences in DSM-IV
alcohol use disorders and major depression as
distributed in the general population clinical
implications. Comprehensive Psychiatry. 38
202-212. 1997.
62Literature Fetal exposure
- Wunsch, MJ Conlon CJ, Scheidt PC. Substance
Abuse A Preventable Threat to Development. In
Children with Disabilities, Batshaw ML, Editor.
Baltimore, Maryland. Brookes Publishing
Company.107-122. 2002. - Sokol RJ, Delaney-Black V, Nordstrom B. Fetal
alcohol spectrum disorder JAMA. 2003
290(22)2996-9. Â -
- Links Delaney-Black V, Covington C, Nordstrom B,
Ager J, Janisse J, Hannigan JH, Chiodo L, Sokol
RJ. Prenatal cocaine quantity of exposure and
gender moderation. Journal of Developmental and
Behavioral Pediatrics. 2004 (4)254-63. - Frank DA, Augustyn M, Knight WG. Growth,
development and behavior in early childhood
following prenatal cocaine exposure A systematic
review. JAMA. 2001 2851613-1625.