Substance use disorder in pregnancy Flashcards
Multidisciplinary care is often necessary to optimize outcomes because the:
- financial
- psychological
- social
- and domestic problems
associated with drug misuse are often greater than the physical and medical concerns.
How common is substance abuse in pregnancy?
Affects ~1% of pregnancies
Opioids, especially heroin, are the most common drugs used in the UK, although many take combinations which can have unpredictable effects on the user. Amphetamines, benzodiazepines and cannabis are also common, as well as smoking and alcohol.
What other social and medical problems are commonly found in drug addicts in pregnancy?
- Social problems: housing, crime, other children in care or abused.
- Coexistent addictions: alcohol and smoking.
- Malnutrition: especially iron, vitamins B and C
- Risk of viral infections (e.g. human immunodeficiency virus [HIV] or hepatitis B).
- Specific fetal and neonatal risks.
What are the risks of heroin/opiate use during pregnancy?
- Miscarriage
- IUGR
- Premature labour
- Stillbirth
- Neonatal withdrawal symptoms after birth
NB: offer hep B, hep C and HIV testing if infecting drugs. If wishing to become pregnant then advise to enter a detoxification programme before conception.
What are the risks of cocaine use during pregnancy?
Maternal risks
- hypertension in pregnancy including pre-eclampsia
- placental abruption
Fetal risk
- miscarriage
- IUGR
- prematurity
- fetal abnormalities - conflicting evidence
- neonatal abstinence syndrome
What are the risks associated with sudden opiate withdrawal in pregnancy? How is opiate withdrawal managed in pregnancy?
Can be dangerous for the baby especially in third trimester:
- Fetal stress
- Fetal distress
- Stillbirth
Management: lowest effective dose of methadone liquid divided into three doses instead.
What is the advice given to women regarding alcohol in pregnancy?
NICE, BMA, DofH and RCOG state that women should be advised to abstain if possible in view of the uncertainty (and in particular in the first 3 months) due to the increased risk of miscarriage.
If women choose to drink alcohol, they are advised to have no more than 1-2 units of alcohol no more than 1-2 times a week, as there is no evidence of harm at this level. They are also advised that binge drinking may harm the baby.
What levels of alcohol are likely to be harmful in pregnancy?
<100 g/week (~2 drinks/day) –> likely no adverse effects
>100g/week –> FGR
>18 units/day -> fetal alcohol syndrome occurs in 33%
Is FAH guaranteed to affect infants of heavy alcohol drinking mothers?
No, affects ~30-33% of infants of these mothers
What are the clinical feature of fetal alcohol syndrome?
- Typical facial abnormalities
- IUGR and failure to catch up
- Neurodevelopmental abnormalities - learning disability, cognitive impairment and behavioural problems
Where might you refer a pregnant woman if you suspect heavy alcohol use in pregnancy? What else should be done?
- Refer for psychiatry/addiction assessment
- Supplement B vitamins and iron - likely to be malnourished in heavy alcohol use
What are the risks of smoking in pregnancy?
Smoking causes educed placental perfusion.
- Miscarriage - risk increased by 47%
- Perinatal mortality
- IUGR
- Premature labour
- Placental abruption
Postnatally: sudden unexpected death in infancy, respiratory disease.
Is it still important to quit smoking in pregnancy despite smoking in the first trimester?
Quitting even by 15 weeks reduced the risk as much as quitting before pregnancy
NB: smoking <5/day has barely any discernable effect
What is the management of smoking in pregnancy?
Refer to smoking cessation service
Nicotine replacement therapy - little evidence but smoking gives greater nictine dose so this is likely safer; should remove patches at night.
Bruprion and varenicline should NOT be used in pregnancy.
