Perinatal Addiction

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Perinatal Addiction

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

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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

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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

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Review the specific problems of women with
addiction
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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.

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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

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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

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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

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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

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Identification of the pregnant addicted woman
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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

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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

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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)

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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

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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)

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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)

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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

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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

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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

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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

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T-ACE
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TWEAK
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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

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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

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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

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Review the effects of drugs and alcohol on the
developing fetus
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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

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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
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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

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Central Nervous System Involvement

• Neurological abnormalities
• Developmental delay
• Behavioral Dysfunction/deficit
• Intellectual impairment/structural abnormalities
• Microcephaly (Head circumference lt3)
• Brain malformations

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Anomalies Microcephaly, absent Corpus Callosum,
flattened sulci
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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

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

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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

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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)

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

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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.

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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

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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

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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

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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

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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

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Cocaine and teratogenicity?

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

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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

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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

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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

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Review the treatment needs of the pregnant woman
and her newborn
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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

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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.

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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

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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)
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The Divine Miss Sarai!
Sarais favorite outfit
Sarai and Samantha
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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.

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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.