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Substance Use & Abuse in Pregnancy

Substance Use & Abuse in Pregnancy. Janet L. Mitchell, M.D., M.P.H., F.A.C.O.G. Consultant on Women’s Health Addiction Research & Treatment Corporation Brooklyn, NY.

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Substance Use & Abuse in Pregnancy

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  1. Substance Use & Abusein Pregnancy Janet L. Mitchell, M.D., M.P.H., F.A.C.O.G. Consultant on Women’s Health Addiction Research & Treatment Corporation Brooklyn, NY

  2. "THE ALCOHOL OF GREAT BRITAIN AND TENNESSEE AND THE TOBACCO OF KENTUCKY UNDOUBTEDLY CREATE GREATER RATES OF MORBIDITY AND DEATH THAN THE POPPY SEED OF TURKEY AND MEXICO” BLINICK, ET AL., DRUG ADDICTION IN PREGNANCY AND THE NEONATEAMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGYVOL. 125, NO. 2, 1976

  3. Harlem Hospital’s Special Prenatal Program for Chemically Dependent Women • 1200 Pregnancies between 1988 - 1996 • 20% were HIV infected, 50% for those with a hx of IDU • 4%  21 years of age - primary drug of use marijuana • 80% listed crack and/or cocaine as their primary drug of choice • Avg # of drugs used 3.5 • Higher rates of HCV then HBV

  4. ADDICTION • Polydrug Abuse • Poor Nutritional Status • STD's • Hepatitis • HIV Infection • Other Medical Problems

  5. ADDICTION and PREGNANCY • Poor Dates • Late Registration • Inadequate Follow-up

  6. ADDICTION and PREGNANCYMATERNAL CONCERNS • Poor Pregnancy Self-image • Low Tolerance For Pain • Poor Bonding • Poor Parenting Skills

  7. ADDICTIONFETAL/NEONATAL CONCERNS • Low Birth Weight • Teratogenicity (Congenital Anomalies) • SIDS • Spontaneous Abortions • Abstinence Syndromes • Future Development

  8. ADDICTIONIS ACHRONIC RELAPSING, MEDICAL DISEASE !!

  9. ALCOHOL • CNS Depressant • Known Teratogen • Psychological and Physiological Dependence

  10. OTHER CNS DEPRESSANTS • Barbiturates • Benzodiazepines • Methaqualone

  11. COCAINE • CNS Stimulant • Psychological Dependence • ? Physiological Dependence • ? Neonatal Abstinence Syndrome

  12. OTHER CNS STIMULANTS • Amphetamines • ‘Ice’ • Diet Pills • Nicotine • Caffeine

  13. COCAINEMATERNAL COMPLICATION • Abruptio Placenta • Preterm and/or Precipitous Labor • Pre-eclamptic Like Syndrome • Cardio-pulmonary problems • Seizures

  14. COCAINEFETAL/NEONATAL COMPLICATION • Low Birth Weight • Seizures • Intracranial Hemorrhage • ? Neonatal Abstinence Syndrome • Not a Teratogen

  15. OPIOIDS • CNS Euphoria • Not a Teratogen • Psychological and Physiological Dependence • Well Documented Neonatal Abstinence

  16. METHADONEMAINTENANCEIS THETREATMENT OF CHOICEDURING PREGNANCY!!

  17. METHADONE and PREGNANCYMATERNAL CONCERNS • Inappropriate Medical Withdrawal • Inadequate Dosage • Chronic Constipation • Pain Management

  18. METHADONE and PREGNANCYFETAL/NEONATAL CONCERNS • Altered Antepartum Testing • Neonatal Abstinence Syndrome

  19. METHADONEMAINTENANCEIS THETREATMENT OF CHOICEDURING PREGNANCY!!

  20. ADDICTIONIS ACHRONIC RELAPSING, MEDICAL DISEASE !!

  21. CONCEPTS • TREATMENT READINESS • MOTIVATION TO TREATMENT

  22. DRUG DEPENDENCY AS DESCRIBED BY THE WORLD HEALTH ORGANIZATION (WHO): “A BEHAVIORAL PATTERN IN WHICH THE USE OF A GIVEN PSYCHOACTIVE DRUG IS GIVEN A SHARPLY HIGHER PRIORITY OVER OTHER BEHAVIORS WHICH ONCE HAD A SIGNIFICANTLY HIGHER VALUE” WHO, 1982

  23. STAGES TO SUCCESSFUL TREATMENT • DENIAL • NEGOTIATION • ACCEPTANCE

  24. PRENATAL INTAKE PROTOCOL • Complete history, especially psychosocial & drug use • Complete physical examination focusing on the multiple medical programs • Routine prenatal bloods + hepatitis screen for B & C • Tuberculin test • Counseling for HIV with strong recommendation for testing • Social service referral • Referral to therapeutic drug program • Methadone maintenance for opiod addiction • Establish rules, requirements and goals with patient and significant others

  25. PRENATAL FOLLOW-UP PROTOCOL • More frequent visits to identify medical and psychosocial problems early • Random urine toxicologies • Order and repeat appropriate tests as necessary • Establish an ongoing relationship with the patient’s therapeutic drug program • Establish an ongoing relationship with patient’s significant other(s) • Began to discuss contraceptive methods

  26. LABOR AND DELIVERY PROTOCOLS • Complete history and physical, especially recent drug history • Repeat hepatitis screens and serological test for syphilis • Urine toxicology • Alert pediatric and nursing staff • Alert social service • Pain management as appropriate • Method of delivery dependent on obstetrical indications only

  27. POST PARTUM PROTOCOL • Encourage continuation in a therapeutic drug program • Encourage use of an appropriate contraceptive method • Breastfeeding not contraindicated in methadone maintained women

  28. ADDICTIONIS ACHRONIC RELAPSING, MEDICAL DISEASE !!

  29. TREATMENT IMPROVEMENT PROTOCALS (TIPS)FORPREGNANT, SUBSTANCE-USING WOMENChair: Janet L Mitchell, MD, MPH, FACOGThe Centers for Substance Abuse Treatment (CSAT)Division for State ProgramsSubstance Abuse and Mental Health Services AdministrationSAMSA

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