Alcohol, tobacco and other drugs

Question 1

Alcohol abuse - overview

Answer 1

Definition: alcohol abuse is defined as drinking that causes mental, physical, or social harm to an individual
1. Alcohol consumption by women has increased over the last 15yrs
2. Excessive consumption of alcohol can lead to alimentary disorders,
such as liver damage, gastritis, peptic ulcer, oesophageal varices, and
acute and chronic pancreatitis
3. Damage to liver, including fatty infiltration, hepatitis, cirrhosis, and
hepatoma, is particularly important
4. Neurological damage, such as peripheral neuropathy, epilepsy, and
cerebellar degeneration, and cardiovascular complications, such as
hypertension and stroke, are common
5. There may be child protection issues arising from potential neglect, as
well as direct harm

Question 2

Fetal alcohol syndrome - overview

Answer 2

No known safe level of alcohol intake in pregnancy. Some evidence that excessive drinking results in FAS.

Features of FAS:

1. IUGR, short stature (pre- and postnatal growth restriction
2. Dysmorphic features (5) = short palpebral fissure, microcephaly with prominent forehead, thin upper lip and small philtrum, cleft palate, micro-ophthalmia
3. Developmental delay, mental retardation

Other features:

4. Cardiac abnormalities
5. Gait abnormalities

Question 3

Alcohol abuse in pregnancy - mx

Answer 3

1. Attempt to reduce harm by (5):
   - Counselling about risks and encouraging decreased alcohol intake
   - Encouraging antenatal attendance (ensure supportive, non-judgemental environment)
   - Facilitating contact with support groups such as Alcoholics Anonymous (AA)
   - Facilitating contact with social services (for help with benefits and
   improving housing)
   - Screening for domestic abuse
2. Detailed anomaly USS.
3. Serial USS to assess growth and fetal well-being.
4. Multidisciplinary team management with involvement of paediatric team and social services
5. May need child protection case conference (?)

Question 4

Smoking - effect on reproductive health

Answer 4

1. Increased risk of infertility (by 50%), increased delay of conception. Effect seen with smoking by either partner, and even from exposure to passive smoke
2. Accelerated ovarian follicle depletion. Menopause occurs 1-4y earlier in smokers than non-smokers
3. Increased risk of spontaneous miscarriage in smokers
4. Increased risk of ectopic pregnancy in smokers (but difficult to control for confounding associated lifestyle factors)
5. IVF - smoking associated with increased gonadotrophin requirements, reduced numbers of oocytes collected, reduced fertilisation and implantation rates. Increases failure at every stage of tx

Question 5

Smoking - antenatal/labour risks

Answer 5

Increased risk of:

1. Placental abruption
2. Premature delivery and PPROM
3. Placenta praevia
4. FDIU
5. ?

Question 6

Smoking - neonatal risks

Answer 6

1. SIDS
2. Perinatal mortality
3. Respiratory illness in infants
4. LBW
5. Brain tumours in infant (?)

Question 7

Opiate abuse - overview

Answer 7

1. Routes of administration = snorting, smoking, SC, orally, IV
2. Physical effects = drowsiness, respiratory depression, nausea, hypotension, papillary constriction. sensation of euphoria or intense pleasure
3. Physically and psychologically addictive. Annual mortality rate 1-2%, mostly due to OD
4. Withdrawal syndrome occurs within 4-12h after last dose, peaking at 2-3d, and subsiding at the end of 7-10d. Withdrawal not life-threatening
5. Characteristic symptoms of withdrawal = myalgia, arthralgia, dysphoria, insomnia, agitation, diarrhoea, shivering

Question 8

Opiate abuse - effects on pregnancy (3)

Answer 8

1. (3) Increased risk of IUGR, stillbirth and SIDS
2. Withdrawal usually occurs within 24h of birth; symptoms include (3): irritability, exaggerated startle response, jitteriness/tremors, poor feeding, hypotonicity
3. Not known to cause any specific congenital abnormalities

Question 9

Opiate abuse in pregnancy - mx

Answer 9

1. Attempt to reduce harm by (5):
   - Starting methadone
   - Encouraging antenatal attendance (ensure supportive, non-judgemental environment)
   - Facilitating contact with social services (for help with benefits and
   improve housing)
   - Screening for domestic abuse
   - Offering help with smoking cessation if required
2. Screen for STIs including HIV and hepatitis
3. Monitor injection sites for infection. Low threshold for antibiotics with symptoms of sepsis (may be atypical pathogens)
4. Detailed anomaly USS. Serial USS to ax growth and feeding. Multidisciplinary team mx with involvement of paediatric team (baby will need admission to SCN), anaesthetic team (IV access may be difficult), social services and local specialist drug support workers
5. Child protection case conference

Question 10

Cocaine abuse - overview

Answer 10

1. Intranasal = major route. IV use alone or with heroin has a high mortaity rate. Smoking crack (freed alkaloid base) is becoming increasingly common

Maternal effects

2. Inhibits reuptake of neurotransmitters including dopamine
3. May result in euphoria, anorexia, verbosity and a sense of wellbeing
4. Also has stimulant effects from sympathetic overdrive
5. Deaths are mostly from accidents, cerebrovascular complications (intracranial bleed and emboli), and cardiac arrhythmias

Question 11

Cocaine abuse - effects on pregnancy

Answer 11

1. Teratogenicity - microcephaly, cardiac defects, possible genitourinary, limb and gut defects
2. Vasoconstriction may cause abnormal placentation, resulting in an increased risk of pre-eclampsia, abruption and IUGR
3. Down-regulation of myometrial beta-adrenoreceptors may cause miscarriage, uterine irritability and preterm labour
4. Neonates are at increased risk of SIDS. May have limited withdrawal syndrome
5. May have a detrimental effect on neurodevelopment, leading to developmental delay

Question 12

Cocaine abuse in pregnancy - mx

Answer 12

1. Attempt to reduce harm by (5):
   - Counselling about the risks and encouraging reduced cocaine use
   - Encouraging antenatal attendance (ensure supportive, non-judgemental environment)
   - Facilitating contact with social services if needed
   - Screening for domestic abuse
   - Offering help with smoking cessation if required
2. Detailed anomaly USS. Fetal cardiac USS at 23–24wks.
3. Serial USS to assess growth and fetal well-being.
4. Multidisciplinary team management with involvement of paediatric team, anaesthetic team, social services and local specialist drug support workers
5. Child protection case conference (?)

Question 13

Amphetamine abuse

Answer 13

1. Routes of administration = oral, intranasal, IV

Maternal effects
2. Enhances the dopaminergic neurotransmitter system
3. The stimulant properties are dose related and characterized by
sympathetic overdrive (tachycardia, sweating, dry mouth, tremor)

Effects on pregnancy

4. No proven syndrome of congenital abnormalities. May have similar risk of miscarriage, preterm labour and IUGR as cocaine
5. Neonates occasionally show hyperactivity and poor feeding

Question 14

Amphetamine abuse - mx

Answer 14

1. Attempt to reduce harm by (5):
   - Counselling about the risks and encouraging reduced drug use
   - Encouraging antenatal attendance (ensure supportive, non-judgemental environment)
   - Facilitating contact with social services if needed
   - Screening for domestic abuse
   - Offering help with smoking cessation if required
2. Detailed anomaly USS. Fetal cardiac USS at 23–24wks if using ecstasy
3. Serial USS to assess growth and fetal well-being.
4. Multidisciplinary team management with involvement of paediatric team, anaesthetic team, social services and local specialist drug support workers
5. Child protection case conference (?)