Substance Use Disorder in Pregnancy Flashcards
Epidemiology
33% adults who access drug services are women of reproductive age
Tobacco > Alcohol > cannabis > other illicit substances
Polysubstance use is common + psych comorbidities, environmental stressors, limited/disrupted parental care
Social problems
Housing, crime, children in care/abuse
Co-existent addictions – alcohol or smoking
Malnutrition – iron, vitamin B, C
Risk of viral infections – HIV, Hep B
Alcohol
more cognitive and behavioural abnormalities:
Crosses the placenta
Intake of < 100g per week (~ 2 glasses of wine or 1 pint of beer) is not associated with adverse effects
- Miscarriage, stillbirth, infant mortality, congenital abnormalities, LBW, preterm delivery, SGA, FGR
- Foetal alcohol spectrum disorders with later neurodevelopmental abnormalities
- Prenatal drinking associated with long-term effects – cognitive/behavioural change, adverse language outcomes
- Executive functioning defects, psychosocial consequences in adulthood
- Massive doses, > 2g/kg of body weight (17 drinks per day), have been associated with foetal alcohol syndrome (FAS)
FAS is irreversible
=> poor growth, birth defects, seizures and other neuro problems, developmental delay, behavioural issues (babies may be fussy or jittery, and have trouble sleeping)
Characteristic facies: smooth philtrum, thin vermillion, small palpebral fissures
This is not consistently seen in infants born to women who are heavy consumers
Mx:
- Involve social workers to arrange for formal psychiatric/ addiction assessment
- Vitamin B supplements
- Iron supplements
Smoking
more distinct outcomes:
ACUTELY REDUCES PLACENTAL PERFUSION
Smoking < 5 cigarettes per day has barely discernible obstetric effects
MOTHER
- Damage to umbilical cord structure
- Miscarriage
- Increased risk of ectopic pregnancy
- Placental abruption
- preterm birth
FOETUS
- Increased foetal mortality
- LBW
- FGR
- Stillbirth
- SIDS
Mx:
- Smoking cessation @ booking app
Cannabis
Preterm labour, LBW, SGA, increased NICU admission
o Prenatal cannabis use linked to:
- Adverse consequences of growth of foetal and adolescent brains
- Reduced attention and executive functioning skills
- Poorer academic achievement
- Behavioural problems
Cocaine
Cocaine use results in vasospasm and so placental pathology
MATERNAL
- PROM
- Placental abruption - VERY IMP RISK FACTOR
- Preterm birth
FOETAL
- LBW, SGA
- NAS
Similar to cocaine, methamphetamine use linked with shorter gestational ages, LBW, foetal loss, developmental and behavioural defects, preeclampsia, gestational HTN, intrauterine foetal death
Opioids
MOTHER
- Placental pathology e.g. abruption and insufficiency
- Premature rupture of membranes, preterm labour
- Pre-eclampsia
- Miscarriage, stillbirth
- PPH
FOETUS
- Greater risk of LBW
- Respiratory problems
- 3rd trimester bleeding
- Toxaemia
- Mortality
- Growth deficiency
- Microcephaly
- Behavioural problems
- SIDS
Neonatal abstinence syndrome (NAS) à opiate exposure in utero triggers postnatal withdrawal syndrome
45-94% of infants exposed to opioids in utero (inc. methadone, buprenorphine)
NAS = substantial neonatal morbidity + increased healthcare utilisation
Presentation:
- Irritability
- Feeding difficulties
- Tremors
- Hypertonia
- Emesis
- Loose stools
- Seizures
- Respiratory distress
Most babies do not require medical treatment for NAS, however, the length of the withdrawal process varies
Neonatal abstinence syndrome (NAS) -> opiate exposure in utero triggers postnatal withdrawal syndrome
- 45-94% of infants exposed to opioids in utero (inc. methadone, buprenorphine)
- NAS = substantial neonatal morbidity + increased healthcare utilisation
Management of opioid use
Try NOT to reduce opiate dose too rapidly in pregnancy
Sudden detoxification can be dangerous for the baby, especially in the 3rd trimester where mild maternal withdrawal can lead to foetal stress, foetal distress, stillbirth
For HEROIN USERS: Administer the lowest effective dose of methadone liquid, divided into 3 doses per day
Screen for infections e.g. Hepatitis B and HIV
General symptoms and signs
Tiredness/ fatigue, sleepiness
Depression
Antepartum haemorrhage
Headaches
Tremors
Restlessness, agitation
Mood changes- irritability, euphoria, dysphoria
Heroin- pinpoint pupils, needle track marks
Cocaine use- dilated pupils, hyperreflexia
Investigations/ Prognosis
Ix
- Basic observations
- Bloods- FBC, U&Es, LFTs (gGT for women with alcohol misuse), toxicology screen
- Foetal CTG if indicated
Management
- AIM: stabilise the mother’s drug-taking abits and ensure contact with social/ care workers and psychiatric/ drug liaison services as appropriate
- MULTIDISCIPLINARY CARE!
Prognosis
- Cessation of smoking by 15 weeks reduces the risk as much as quitting BEFORE pregnancy
- Cessation of drug use in pregnancy will help improve maternal and foetal outcomes, preventing complications from occurring