Pregnant

1
Pregnant addicted profile physical /mental
appearance

• Looks physically exhausted
• Pupils vasodilated/constricted
• Appearance of pregnancy does not coincide with
  gestational age

2
Care of the Woman Practicing Substance Abuse

• 10 of women in the childbearing years abuse
  substances
• Drug abuse may be most frequently missed
  diagnosis in all of maternity care
• Be alert for signs and symptoms of abuse of
  substances as often not verbally disclosed
• Track marks/inflamed nasal mucosa
• Not well oriented
• Hx ob complications

3
Pregnant addicted profile
psychosocial

• Parents often addicts
• Childhood abuse
• C/o pregnancies
• Multiple addictions
• Suffer shame and guilt
• Lack supports

• Lack relationships often single parents
• Lack parenting skills Often have inappropriate
  expectations of children

4
Concurrent addictions

• Drug users seldom use one drug poly drug users
• Cross addictions such as eating ,
• relationship or prescription addictions..

5
THE SOCIAL USER CAN STOP DRUG USE WHEN KNOWS SHE
PREGNANT

• THE ADDICT CAN NOT

6
Fetal alcohol syndrome (FAS)

• 1ST CLASSIFIED NAMED 1970S (U OF W)
• 2/1000 LIFE BIRTHS
• 1-2 OZ. ABSOLUTE OH INCREASES RISK 10
• 5-6 DRINKS/DAY LEADS TO 30-50 RISK
• SHORT AND LONG TERM EFFECTS
• FAS OR FAE CAN RESULT IN ADULT MENTAL ILLNESS
  (AM. J. PSY. , 1998)

7
FASCategories of Abnormalities

• 1. Prenatal/postnatal/growth
  
  
  retardation (iugr)
• Slow growth wt. Ht. Foc
• Appearanceslender malnourished
• With no catch-up to other children

8
FASCategories of Abnormalities

• 2. CNS abnormalities
• Infants tremors, poor muscle tone,
  abnormal sleep and feeding problems
• Preschool affectionate but active,
  behavioral problems, poor coordination fine and
  gross motor control
• School age ADHD, poor concentration and
  memory, iq-20-90

9
FASCategories of Abnormalities

• 3. Abnormal facial features
• Wide spaced eyes
• Small eye openings
• Flat midface
• Short nose, thin upper lip
• Smooth philtrum (area between
  
• nose and upper lip)
• ?Cleft palate/lip, slow bone growth

10
Fetal alcohol effects (FAE)

• 50,000/per year, 13.5/1000 live births
• Less specific dx but as serious
• Combination of major characteristics
• Learning/behavioral problems
• Poor academic performance
• Iq 39-105

11
Stimulant withdrawal syndrome (cocaine)

• Tremors/irritability/tachypnea
• Poor feeding/suck
• Hypertonia/hyperreflexia
• Vomiting/loose stools
• Visual tracking difficulties
• Long term effects unknown
• When1.5 to 2.5 days old (sym. Indicate either
  withdrawal, toxicity, or effects)

12
Management stimulant withdrawal syndrome

• Typically nonpharmacologic methods
• Tight swaddling/hands together
• Pacifiers
• Avoid sudden noises/eye contact
• Avoid jumpers/walkers when older
• Minimize abrupt transitions
• May use phenobarb or valium for aggitation

13
Cocaine/crack

• 10 childbearing families
• Acts at nerve terminals to prevent reuptake of
  dopamine and norepinephrine leading to
  vasoconstriction, tachycardia and
  hypertension..leading to decreased blood flow to
  fetus
• What expected potential changes in FHT strip
  expected??

14
Cocaine/crack

• Taken by snorting, smoking or IV injection
• Crack-free base cocaine made of baking soda,
  water and cocaine into a paste and heated in
  microwave to form a rock that can be smoked, a
  cheap method of use
• Effects quick last about 30 minutes excitement
  phase followed by depression, fatigue, craving

15
Cocaine/crack

• Signs symptoms
• Maternal effects
• Seizures, hallucinations, pulmonary edema,
  respiratory failure and cardiac problems

• Pregnancy SAB, abruptio placenta, PTB, IUGR,
  stillborn
• Infant small head circ.altered brain
  development, malformations GI tract, low Apgars
• NB irritability, poor suck/feed, increased
  SIDS,poor reciprocity with caregiver

16
Marijuana

• 15 women use MJ often with other substances
• No known teratogenic effects on infant
• Questionable precipitous labors
• NB fine tremors, prolonged startles,
  irritability, poor habituation to visual stimuli

17
Phencyclidine (PCP)

• Popular hallucinogen smoked, p.o., or IV
  administration with effects in 2-4 minutes for
  4-6 hours no withdrawal state
• Drug causes confusion, euphoria, delirium, double
  vision, dizziness diaphoresis
• In pregnant woman overdose may be psychotic
  response, hypertension or hyperthermia and
  possible coma
• Infants effects possible wild behavior states,
  flacid appearance and poor head control

18
Opioid abstinence syndrome (heroin/ methadone)

• Illicit CNS depressant alters perception and
  produces euphoria, associated with PIH, anemia,
  PTL, infant malposition, placental problems
• Infant yawning, fist sucking, poor feeding, poor
  wt. Gain, tremors, seizures, diarrhea, shrill
  cry, increased risk for meconium
  aspiration/hypoxia
• Heroin abstinence syndrome
  
• 4-7 days acute phase, protracted phase up to
  6 weeks

19
Methadone

• Methadone
• Withdrawal may last up to 6 weeks esp. If
  maternal dosegt30 mg
• Associated with PIH, hepatitis, placental
  problems
• Infant effects reduced head circumference, poor
  motor coordination, body tension

20
Heroin alternative methadone exposure

• Assists women in staying heroin free
• Leads to more consistent prenatal care
• Lessens possibility of fetal death
• Better growth pattern of newborn
• Reduces risk of HIV (because promotes less risky
  lifestyle patterns)
• Enables mother to breastfeed infant

21
Methadone exposure- - - - -

• LBW
• Neonatal methadone abstinence syn. (Can be
  worse than to heroin)
• Infant seizures
• Thrombocytosis
• Hyperthyroid state (elevation of t3/t4)
• SIDS (3-4 x higher than in general pop.)

22
DRUG EXPOSED BABIESEXPOSURE TO DRUG ONCE OR
MORE IN UTERO

• DRUG AFFECTED HAVE SYMPTOMS DX BY STAFF OR HX
  OF ABUSE BY MOTHER

23
NOT ALL DRUG EXPOSED INFANTS AFFECTED TO THE SAME
DEGREE!

• FROM SEVERELY ILL WITH DAYS/WEEKS IN NICU TO
  HEALTHY TERM BABIES WITHOUT OBVIOUS EFFECTS

24
NEONATAL WITHDRAWAL
25

• Wwakefulness
• Iirritability
• Ttremors, tachy, temp
• Hhyperactivity/high pitched cry
• D-diarrhea/diaphoresis/disorgan.Suck
• Rrub marks/rhinorrhea/resp. Prob.
• Aapnea/autonomic dysfunction
• W-weight loss/failure to gain
• Aalkalosis, respiratory
• Llacrimation

26
Alcohol other drug assessment (AOD)

• Assess use (frequency, duration, age started,rt.
  of adm.,past rx,type, when)
• Determine consequences (as perceived by patient
  and objective)
• Identify relapse factors for patient
• Obtain family hx abuse
• Assess pts. motivation for Tx/cont. use
• Obtain urine/blood toxicologies prn

27
PSYCHOSOCIAL ASSESSMENTS

• Assess support systems/roles/stress
• Assess pts perception of pregnancy
• Assess pts education level
• Assess hx. Abuse as adult or child
• Assess legal problems

28
PSYCHOSOCIAL ASSESSMENTS

• Assess current crises(, jail,hiv)
• Assess rel. with children/parenting
• Assess envir housing, child care,, car
• Assess for prenatal postpartal depression

29
PRENATAL INTAKE

• Detailed health hx AOD/psychosoc.Hx
• Complete physical exam
• Family Hx AOD/psychosoc. Hx
• Rt. prenatal toxicology/TB/sono/HIV
• Attention to special concerns c/o during
  pregnancy
• Referralsrehab,nutrition/parenting

30
LD ASSESSMENT/NO PRENATAL

• Detailed Hx/complete physical
• Baseline labs/urine /tox. screen
• Sono dating and r/o multiples
• Notify pedi/nsg. primary care providers
• Notify social services
• Fetal monitoring as indicated
• Pain management (central line prn)
• Universal precautions

31
COUNSELING TIPS

• Keep message clear, simple, realistic
• Ask about substance use from less threatening
  (smoking) to more threatening (street drugs)
• Stress the positive.be nonjudgmental
• Dont predict babys outcome
• Customize the message
• Help woman assess risks
• Motivate risk reduction/give hope
• Rec. counseling/parenting/follow-up/12 steps
• Be sensitive to legalities

32
DISCHARGE CRITERIAINFANTS

• Taking oral feedings and gaining wt.
• Physiologically stable (all v/s)
• Showing neurobehavioral recovery (can reach full
  alert state Responds to social stimuli and can
  be consoled)
• Completed all necessary assessments since
  follow-up can not be assured

33
DISCHARGE INSTRUCTIONSFOR MOTHERS

• Educate regarding late and subacute withdrawal,
  seizures, behavioral interventions, meds side
  effects
• Home follow-up in 7 days
• Pedi visit within 2-4 weeks
• Referral to parents for rehab
• Ob-gyn care follow-up with B.C. plans

34
BREASTFEEDING IN DRUG EXPOSED INFANTS WHEN
POSSIBLE??

• In methadone maintained mothers
• In recovering users of other substances including
  cocaine, who have complied with rehab a suitable
  time prior to deliverymust maintain recovery and
  allow random, frequent toxicology screens
• In sumcustomize to each individual

35
POSTNATAL FOLLOW-UP ISSUES

• Be aware of own attitudes and feelings regarding
  substance abuse
• Be aware of clients personal environment which
  may include homelessness, parents/partner who use
  drugs, Hx. abuse, depression and other
  co-existing psy. disorders and the absence of
  healthy parenting

36
POSTNATAL FOLLOW-UP ISSUES

• Be aware that chronic substance use is known as a
  relapsing disorder..
• Keep patients in treatment/f-u as can, recognize
  critical times/relapse triggers
• Provide safety and well-being of infant with
  referrals to many resources CPS, healthy start,
  maternity services, parenting guidance, public
  benefits, protection from abuse, vocational
  training

37
COSTS OF CARE

• Drug exposed infant in NICU ranges from 750/day
  to 1,768/day depending on severity of
  consequences
• Overall charges found to be 4x higher for drug
  exposed infant than non-drug exposed infant

38
URINE TOXICOLOGY GUIDELINES

• Screening tests batch runs ,fast, cheap
• Confirmatory tests more accurate
• Factors affecting results handling/collection
  test errors/interpretation client deception
  urine dilution, foods, switches
• Drug detection times (varies by volume,dose and
  duration of drug use)

39
DRUG DETECTION TIMES

• Amphetamines
• Alcohol
• Cocaine
• Heroin
• Marijuana
• Methadone

• 48 hours
• 12 hours
• 24-72 hours
• 24 hours
• 3-30 days
• 3 days

40
INFLUENCING POLICY RELATED TO HEALTH AND SOCIAL
ISSUES

• Educational strategies (community education)
• Research strategies (more women in research
  clinical trials)
• Community consultation (working in community with
  civic leaders)
• Political activism (involvement in politics,
  recruiting women in politics, memberships in
  AWHONN ,ANA, TNA)

41
MATERNAL-FETAL ATTACHMENT IN WOMEN USING ILLICIT
DRUGS

• Findingsmaternal-fetal attachment is a struggle
  manifested by guilt, concern and uncertainty
• guilt-over potential injury to infant (mother is
  aware of possibilities) and unplanned/unwanted
  baby
• concern uncertainty- baby deformed, stillborn
• Many change bad lifestyles during pregnancy as
  much as can
• (JOGNN, March/April 2002, p. 162)

42
DRUG SCREENING DURING PREGNANCY? AN ETHICAL
DILEMMA

• Should drug screening be mandated?
• Should women with positive drug screens be
  criminally prosecuted?
• Small group discussion
• (JOGNN March/April, 2002, p. 133)