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Perinatal Addiction

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Title: Perinatal Addiction


1
Perinatal Addiction
  • Martha J Wunsch MD
  • Principles of Primary Care
  • Block 12, Class of 2008
  • July 10, 2006

2
How 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

3
Learning 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

4
Review the specific problems of women with
addiction
5
Women 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

7
Confounding 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

10
Identification of the pregnant addicted woman
11
Clues 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

12
Clues 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

13
Risk 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)

14
Clues 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

15
Medical 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)

16
Obstetrical 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)

17
Obstetrical 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

18
Obstetrical 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

19
Obstetrical 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

20
Screening
  • 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
22
TWEAK
23
T-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

24
Treatment 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

25
Treatment 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

26
Review the effects of drugs and alcohol on the
developing fetus
27
Alcohol
  • 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

28
Fetal 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
29
Perinatal 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

30
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31
Central Nervous System Involvement
  • Neurological abnormalities
  • Developmental delay
  • Behavioral Dysfunction/deficit
  • Intellectual impairment/structural abnormalities
  • Microcephaly (Head circumference lt3)
  • Brain malformations

32
Anomalies Microcephaly, absent Corpus Callosum,
flattened sulci
33
Characteristic 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

34
Facial Features
35
Alcohol Exposed Newborn
Flattened Midface
Shortened Palpebral fissures
Elongated, flat philtrum
36
Features change through childhood and into
adolescence
37
Microcephaly, changing facial features with age
38
Coarsening of facial features in adulthood
39
Fetal 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

40
Incidence 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

41
Even 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)

42
Psychoactive substances are used in combination
during pregnancy when abused making it difficult
to discern teratogenic effects
43
Sedative 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

44
Opioids
  • 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.

45
Fetal/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

46
Neonatal 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

47
Neonatal 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

48
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49
Cocaine
  • 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

50
Alcohol 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

51
Cocaine and teratogenicity?
  • Use associated with intrauterine
    death/spontaneous abortions
  • Low birth weight/IUGR
  • Preterm delivery
  • Neonatal seizures ( Its a stimulant!)
  • Autonomic instability

52
Teratogenicity?
  • 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

53
Nicotine
  • 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

54
Others
  • 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

55
Review the treatment needs of the pregnant woman
and her newborn
56
Maternal 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

57
Medication 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.

58
Newborn 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

59
Sarai
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)
60
The Divine Miss Sarai!
Sarais favorite outfit
Sarai and Samantha
61
Literature 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.

62
Literature 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.  
  • 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.
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