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OBG: Pregnancy, labour, breast feeding > Substance misuse in pregnancy > Flashcards

Substance misuse in pregnancy Flashcards

Alcohol, opioids, sedative-hypnotics, stimulant drugs, smoking

1
Q

What are 5 reasons why there is under-identification of substance abuse in pregnancy?

A
  1. Inadequate history taking
  2. Relucance to admit to substance abuse
  3. Late booking
  4. Poor antenatal attendance
  5. Poor communication between GPs, social services, midwives, obstetricians
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2
Q

What is the definition of harmful use of substances?

A

a pattern of psychoactive substance use that is causing damage to physical or mental health

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3
Q

What is the definition of intoxication?

A

transient syndrome due to recent substance ingestion that produces clinically significant psychological/physical impairment.

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4
Q

What is the definition of dependence syndrome?

A

cluster of physiological, behavioural, and cognitive phenomena in which the use of a substance or a class of substances takes on a much higher priority for a given individual than other behaviours that once had greater value

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5
Q

What is the definition of tolerance?

A

homeostatic adaptation to chronic administration of a drug; to ameliorate longer-term toxicity; and to allow the organism to continue functioning while chronically intoxicated.

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6
Q

What is the definition of withdrawal?

A

characteristic pattern of signs and symptoms (psychological and physical) that occur when a drug is stopped after a period of chronic administration, or an antagonist to the drug is given

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7
Q

What are 3 other mental illnesses that are closely associated with substance misuse?

A
  1. Personality disorder
  2. Depression
  3. Anxiety
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8
Q

What are 7 risks associated with IV drug administration?

A
  1. HIV infection
  2. hepatitis C (prevalence of between 50 and 80% in UK drug users) and hepatitis B (30–50%)
  3. venous thrombosis
  4. subcutaneous abscesses
  5. bacterial endocarditis
  6. sepsis (may be fungal)
  7. poor venous access in an emergency situation
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9
Q

What is the usual overall effect of withdrawal?

A

symptoms can be distressing but are rarely life-threatening

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10
Q

What are 4 social damage effects of substance misuse?

A
  1. problems with employer and work-related accidents.
  2. financial strain with damaging effects on the family.
  3. Antisocial and criminal activities may arise from behavioural changes and need for money.
  4. May be child protection issues as a result of neglect or abuse.
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11
Q

What is the mortality in opioid users over 10 years?

A

10-15%

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12
Q

What is the most frequent cause of death in substance misuse?

A

accidental due to overdose

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13
Q

What are 4 causes of death in drug addicts?

A
  1. accidental overdose
  2. suicide
  3. HIV
  4. hepatitis
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14
Q

What are 8 things that the perinatal risk of is increased with substance abuse?

A
  1. Preterm birth and prematurity.
  2. IUGR
  3. Low birth weight.
  4. Symptoms of withdrawal from drugs.
  5. Increased stillbirth and neonatal mortality.
  6. Sudden infant death syndrome.
  7. Physical and neurological damage from drugs or violence.
  8. Fetal alcohol syndrome.
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15
Q

What should the management of women using opiates in pregnancy be?

A
  • prescribe substitution therapy - methadone
  • should not undergo opiate detoxification during pregnancy
  • may be at risk of abuse, other complex social/psychiatric/psychological problems - handle senstivitely, encourage to attend antenatal car
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16
Q

What are 4 services to involve for women who have a drug addiction during pregnancy?

A
  1. GP
  2. Social services
  3. Obstetrician (including specialist midwife)
  4. Local addiction services (possibly including psychiatrist)
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17
Q

What are 3 key things to consider doing during pregnancy to address fetal issues of maternal drug addiction?

A
  1. Detailed anomaly USS: consider need for later cardiac anomaly USS
  2. Serial USS for growth and wellbeing - increased risk of FGR
  3. Increased awareness of obstetric risks such as preterm labour, placental abruption
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18
Q

What is the definition of alcohol abuse?

A

drinking that causes mental, physical or social harm to an individual

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19
Q

What are 5 types of alimentary disorders that alcohol abuse can lead to in the mother?

A
  1. Liver damage
  2. Gastritis
  3. Peptic ulcer
  4. Oesophageal varices
  5. Acute and chronic pancreatitis
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20
Q

What are 4 types of maternal liver damage that can occur due to alcohol abuse in the mother?

A
  1. Fatty infiltration
  2. Hepatitis
  3. Cirrhosis
  4. Hepatoma
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21
Q

What are 3 neurological and 2 cardiovascular effects of alcohol in the mother?

A

neuro - epilepsy, peripheral neuropathy, cerebellar degeneration

CVS - hypertension, stroke

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22
Q

What is the name of the disease caused to the fetus when a mother abuses alcohol during pregnancy?

A

Fetal alcohol spectrum disorders (FASD)

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23
Q

What is the current recommendation for maximum alcohol consumption during pregnancy?

A

limit to 1 unit a day - but exact relationship unknown, no known safe lower limit

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24
Q

What is the chance of fetal alcohol syndrome in a woman who drinks 18 units or more in a day?

A

1/3

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25
Q

What are 12 possible features of fetal alcohol spectrum disorder?

A
  1. IUGR
  2. Short stature
  3. Developmental delay
  4. Micro-ophthalmia
  5. Short palpebral fissure
  6. Short nasal bridge
  7. Microcephaly with prominent forehead
  8. Thin upper lip and smooth philtrum
  9. Cleft palate
  10. Maxillary hypoplasia
  11. Gait abnormalities
  12. Cardiac abnormalities
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26
Q

What are 6 ways to attempt to reduce harm in a woman who drinks excessive alcohol during pregnancy?

A
  1. counselling about risks and encouraging ↓ alcohol intake
  2. encouraging antenatal attendance (ensure supportive, non-judgemental environment)
  3. facilitating contact with support groups such as Alcoholics Anonymous (AA)
  4. facilitating contact with social services (for help with benefits and improving housing)
  5. screening for domestic abuse
  6. offering help with smoking cessation if required.
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27
Q

What are 4 aspects of the management of a woman who abuses alcohol in pregnancy?

A
  1. Detailed anomaly USS
  2. Serial USS to assess growth and wellbeing
  3. MDT management - paeds, anaethetics, social serices, local specialist alcohol support workers
  4. may need child protection case conference
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28
Q

What are 5 examlpes of opiates and what are 5 ways that they can be ingested?

A

examples:

  1. morphine
  2. heroin
  3. methadone
  4. buprenorphine
  5. codeine

routes:

  1. snorting (intranasally)
  2. smoking
  3. subcutaneous (skin popping)
  4. orally
  5. IV
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29
Q

What are the maternal effects of opiates?

A
  • drowsiness, repiratory depression, nausea, hypotension, pupillary constriction
  • mood altering effects, produing sensation of euphoria or intense pleasure (act on pain receptors)
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30
Q

In what way are opiates addictive?

A

both physically and psychologically

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31
Q

When do withdrawal symptoms occur after removal of opiates, when do they peak and how long do they last?

A
  1. 4-12 hours after last opiate dose
  2. Peak at 48-72 hours
  3. Subside by the end of 7-10 days
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32
Q

What are 7 characteristics symptoms of opiate withdrawal?

A
  1. myalgia
  2. arthralgia
  3. dysphoria
  4. insomnia
  5. agitation
  6. diarrhoea
  7. shivering
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33
Q

Is withdrawal from opiates life-threatening?

A

no

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34
Q

What is the annual mortality rate of opiates?

A

1-2%, mostly due to overdose

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35
Q

What congenital abnormalities do opiates during pregnancy cause?

A

not known to cause any specific congenital abnormalities

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36
Q

What are 3 things that babies of mothers abusing opiates are at increased risk of?

A
  1. Fetal growth restriction
  2. Stillbirth
  3. Sudden infant death syndrome
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37
Q

What are 5 symptoms of withdrawal in a baby born of an opiate-addicted mother?

A
  1. Irritability
  2. Exaggerated startle response
  3. Jitteriness and tremors
  4. Poor feeding
  5. Hypotonicity
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38
Q

When do symptoms of withdrawal usually occur in a baby born of an opiate-addicted mother?

A

within 24 hours

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39
Q

Why is methadone used as maintenance treatment in women who are addicted to methadone and withdrawing babies?

A

it has a longer half-life than heroin, resulting in a more stable plasma concentration and allowing once-daily administration

40
Q

What may happen to a methadone dose in the mother during pregnancy?

A

may need increased dose due to the physiological plasma dilution effect of pregnancy

41
Q

What are 4 ways that starting methadone in the mother may help risk reduction?

A
  1. reduced physical risks of injecting
  2. stabilising lifestyle
  3. reduced financial burden of purchasing street drugs
  4. improving contact with healthcare professionals
42
Q

What are 2 effects on the fetus of starting methadone in an opiate-addicted mother and compliance with treatment?

A
  1. Reduced neonatal mortality
  2. Increased birth weight
43
Q

What can cause the benefits of starting methadone in an opiate-addicted mother to be lost?

A

if she still also uses street drugs

44
Q

What are 5 ways of reducing harm to the fetus in a mother who abuses opiates?

A
  1. Starting methadone
  2. Encouraging antenatal attendance
  3. Facilitating contact with social services
  4. Screening for domestic abuse
  5. Offering help with smoking cessation if required
45
Q

What are 8 aspects of the management of a pregnancy in a mother who abuses opiates?

A
  1. Screening for STIs including HIV and hepatitis
  2. Monitor injection sites for infection
  3. Low threshold for anitbiotics with symptoms of sepsis (may be atypical pathogens)
  4. High index of suspicion with any symptoms of VTE (may be unusual sites)
  5. Detailed anomaly USS
  6. Serial USS to assess growth and fetal wellbeing
  7. MDT management
  8. Child protection case conference
46
Q

What is the major route of cocaine use and what are 2 other routes?

A

major route: intranasal

  1. IV - either alone or with heroin
  2. Smoking freed alkaloid base as crack
47
Q

What is the mechanism of cocaine?

A

inhibits reuptake of neurotransmitters including dopamine; stimulant effects from sympathetic overdrive

48
Q

What are 4 effects of cocaine on the user?

A
  1. Euphoria
  2. Anorexia
  3. Verbosity
  4. Sense of well-being
49
Q

What 3 things are deaths from cocaine mostly caused by?

A
  1. Accidents
  2. Cerebrovascular complications (intracranial bleed and emboli)
  3. Cardiac arrhythmias
50
Q

What are 5 groups of effects of cocaine on the fetus?

A
  1. Teratogenicity: microcephaly, cardiac effects, possible geintourinary, limb and gut defects
  2. Vasoconstriction may cause abnormal placentation: PET, abruption, FGR
  3. Down-regulation of myometrial beta-adrenoreceptors: miscarriage, uterine irritability, preterm labour
  4. Neonatal effects
  5. Detrimental effect on neurodevelopment
51
Q

What are 3 teratogenic effects of cocaine on the fetus?

A
  1. Microcephaly
  2. Cardiac defects
  3. Genitourinary, limb and gut defects
52
Q

What are 3 effects on the fetus of the vasoconstriction caused by cocaine?

A
  1. Increased risk of pre-eclampsia
  2. Increased risk of abruption
  3. Fetal growth restriction
53
Q

What are 3 effects of cocaine caused by down-regulation of myometrial beta-adrenoceptors in the fetus?

A
  1. Miscarriage
  2. Uterine irritability
  3. Preterm labour
54
Q

What are 3 neonatal effects of cocaine use during pregnancy?

A
  1. Limited withdrawal syndrome may occur
  2. Occasionally show hypotension and cardiac arrhythmias
  3. Increased risk of sudden infant death
55
Q

What are 5 ways to attempt to reduce harm to the fetus of cocaine use in pregnancy?

A
  1. counselling about the risks and encouraging ↓ cocaine use
  2. encouraging antenatal attendance (ensure supportive, non-judgemental environment)
  3. facilitating contact with social services if needed
  4. screening for domestic abuse
  5. offering help with smoking cessation if required.
56
Q

What are 5 ways to manage cocaine abuse during pregnancy?

A
  1. Detailed anomaly USS
  2. Fetal cardiac USS at 23-24 weeks
  3. Serial USS to assess growth and wellbeing
  4. MDT management
  5. Child protection case conference
57
Q

In addition to cocaine what are 2 other types of stimulants to be aware of that may be used during pregnancy?

A

amphetamine sulphate (speed) and ecstasy (MDMA)

58
Q

What are the 3 routes of administration for illicit amphetamine sulphate?

A
  1. oral
  2. intranasal
  3. IV
59
Q

What is the mechanism of action of amphetamine sulphate?

A

enhances the dopaminergic neurotransmitter system

60
Q

What causes the symptoms produced by amphetamine sulphate and what are they?

A

stimulant properties are dose related and characterised by sympathetic overdrive

tachycardia, sweating, dry mouth, tremor

61
Q

Does amphetamine sulphate cause congenital abnormalities?

A

no proven syndrome

62
Q

What are 5 effects of amphetamine use in pregnancy on the fetus/ neonate?

A
  1. Neonatal hyperactivity
  2. Neonatal poor feeding
  3. May have similar effects as cocaine - risk of miscarriage
  4. pretem labour
  5. FGR
63
Q

What is the mode of action of ecstasy (MDMA)?

A

increases releas eof dopamine and also release 5-hydroxytryptamine (5-HT) which may account for its hallucinogenic properties

selectively neurotoxic to fine serotonergic neurons

64
Q

What are 3 routes of administration of MDMA (ecstasy)?

A
  1. most commonly oral - capsule in dose of 50-150mg
  2. injected
  3. snorted
65
Q

What are 11 possible effects of MDMA (ecstasy)?

A
  1. Positive mood state
  2. Euphoria
  3. Sociability
  4. Intimacy
  5. Panic
  6. Paranoia
  7. Psychosis
  8. Neuroses
  9. Visual hallucinations
  10. Delusions
  11. Suicidal feelings
66
Q

What are the effects of ecstasy (MDMA) on pregnancy? 3 major things

A
  1. Similar teratogenicity to cocaine: increase in cardiac defects, limb and gut abnormalities
  2. Neonates occasionally show hyperactivity and poor feeding
  3. May have similar risk of miscarriage, preterm labour, FGR as cocaine
67
Q

What are 5 ways to reduce harm in women abusing stimulants in pregnancy?

A
  1. counselling about the risks and encouraging ↓ drug use
  2. encouraging antenatal attendance (ensure supportive, non-judgemental environment)
  3. facilitating contact with social services if needed
  4. screening for domestic abuse
  5. offering help with smoking cessation if required.
68
Q

What are 5 ways to manage a mother in pregnancy who abuses stimulants?

A
  1. Detailed anomaly USS.
  2. If using ecstasy, consider fetal cardiac USS at 23–24wks.
  3. Serial USS to assess growth and fetal well-being.
  4. Multidisciplinary team management
  5. May need child protection case conference.
69
Q

What are benzodiazepines usually prescribed for now?

A

anxiolytics

70
Q

What is the mode of action of benzodiazepines?

A

act on GABA-A receptors and enhance response to GABA

71
Q

What are 3 routes of administration of benzodiazepines?

A
  1. Oral - almost complete bioavailability
  2. IV
  3. IM - latter 2 may lead to unpredictable absorption rate
72
Q

What is the time taken for benzodiazepines to reach peak concentration when taken orally and what is the bioavailability?

A
  • almost complete bioavailability
  • peak within 30-90 min
73
Q

How do benzodiazepines move to different body compartments and how might they affect the baby after birth?

A

lipid solible so diffse rapidly through blood brain barrier and placenta

appear in breast milk

74
Q

How soon can tolerance develop when taking benzodiazepines in a mother and when does tolerance become marked?

A

develops after 2-3 days

marked after 2-3 weeks

tachyphylaxis reported

75
Q

When is the onset of withdrawal after stopping benzodiazepines? When does it peak and how long does it last?

A

2-3 days after stopping (depending on the drug) peaking at 7-10 days and abating by 14 days

76
Q

What are 2 key effects of benzodiazepines in the baby?

A
  1. Increased congenital abnormalities, especially cleft lip and palate
  2. Withdrawal symptoms in baby include hypotonia, respiratory problems, poor feeding
77
Q

What are 3 symptoms of withdrawal in the baby of benzodiazepines?

A
  1. Hypotonia
  2. Respiratory problems
  3. Poor feeding (floppy baby syndrome)
78
Q

What are 8 symptoms of withdrawal from benzodiazepines that may be seen in an adult?

A
  1. Sensory disturbance such as hyperacusis
  2. Photosensitivity
  3. Abnormal body sensations
  4. Anxiety symptoms
  5. Features of depression
  6. Psychosis
  7. Seizures
  8. Delirium tremens
79
Q

What is the mode of action of cannabic?

A

acts of specific cannabinoid receptor (anandamide) in the CNS

80
Q

How is cannabis prepared?

A

dervied from plant Cannabis sativa, consumed either as dried plant in form called marijuana or grass, or as the resin secreted by the flowers

81
Q

What are 2 ways cannabis may be administered?

A

mostly smoked, often with tobacco

ingested with food or in herbal solution

82
Q

What are 4 possible maternal effects of cannabis?

A
  1. Exhiliration
  2. Depression
  3. Hallucinations
  4. Appetite stimulant
83
Q

Is there evidence of teratogenicity of cannabis?

A

no

84
Q

What is the technical name for LSD and what type of drug is it?

A

lysergic acid diethylamide - hallucinogenic

85
Q

What is another example of a hallucinogenic drug in addition to LSD?

A

mescaline

86
Q

How are hallucinogens most often taken?

A

consumed orally as small squares of blotting paper soaked in the substance e.g. lysergic acid diethylamide (LSD)

87
Q

What are the effects of hallucinogens?

A
  1. cause hallucinations and visual illusions without lowering consciousness
  2. raised heart rate
  3. raised lood pressure
88
Q

What is the mode of action of lysergic acid diethylamide?

A

mediated through the activation of the 5-HT2 receptors

89
Q

What are the risks to the mother of lysergic acid diethylamide?

A

adverse myocardial and cerebrovascular effects

but overdosage doesn’t have significant physiological reaction

90
Q

What is the risk to the fetus of using hallucinogens in pregnancy?

A

miscarriage and congenital abnormalities if mother is regular users

91
Q

What type of volatile substances may be sniffed as a form of drug abuse?

A

generally solvents and adhesives (glue sniffing) - toluene, petrol, acetone, cleaning fluids, aerosoles

92
Q

What is the inhalation of volatile substances often associated with?

A

other addictions such as tobacco and alcohol

93
Q

What can volatile substance inhalation lead to in the mother and what effects might it have on the fetus?

A

mother - sudden death from acute intoxication due to respiratory depression and cardiac arrhythmias

little known about effects in pregnancy

94
Q

What is the most common substance of abuse?

A

tobacco

95
Q

What are 4 risks to the fetus of tobacco use in pregnancy?

A
  1. Risk of miscarriage
  2. Increased risk of placental abruption
  3. Low birth weight
  4. Risk of neonatal death and SIDS
96
Q

What management should be used for mothers who smoke during pregnancy? 3 aspects

A
  1. advise to stop or at least cut down in pregnancy
  2. help frmo specialist smoking cessation advisors should be available
  3. Nicotine replacement therapy (patches or gum) may be used in pregnancy

OBG: Pregnancy, labour, breast feeding (14 decks)

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