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What's New in Obstetric Medicine?

What's New in Obstetric Medicine?. 9 Key Questions (and Answers) about Substance Use and Psychiatric Disorders in Pregnancy. SOAP 40 th Annual Meeting Ellen D. Mason, M.D. May 2008. And, now for something completely different…….

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What's New in Obstetric Medicine?

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  1. What's New in Obstetric Medicine? 9 Key Questions (and Answers) about Substance Use and Psychiatric Disorders in Pregnancy SOAP 40th Annual Meeting Ellen D. Mason, M.D. May 2008

  2. And, now for something completely different…….

  3. Substance Use in Pregnancy Science versus Popular Myths

  4. What's New in Obstetric Medicine? 9 Key Questions (and Answers) about Substance Use and Psychiatric Disorders in Pregnancy Learning Objectives: • Review the epidemiology of behavioral and mental disorders in pregnancy and their impact on perinatal outcomes • Become familiar with recommendations for screening, intervention and treatment of substance use and psychiatric disease

  5. What's New in Obstetric Medicine? 9 Key Questions (and Answers) about Substance Use and Psychiatric Disorders in Pregnancy • Learning Objectives, continued: • Understand risk/benefit of some medications used to treat SUDS and psychiatric disease. • Review how patient and physician attitudes and beliefs might impact management of substance use and mental disease in pregnant patients

  6. 1. Why is this important? • Ubiquitous – common and in all groups • Effects on pregnancy outcomes • Effects on women’s health: short term and long term • Effects on offspring • Clinicians are often relatively unfamiliar with behavioral issues in pregnancy compared to other disease entities

  7. Prevalence of Medical/Obstetric Complications • Gestational Diabetes 3-14% • Chronic hypertension 3-5% • Asthma 3-8% • Thromboembolic disease 3-12% • Preeclampsia ~5% • Substance use disorders4-20% • Psychiatric disorders 0.4-7.0%

  8. 2. How many pregnant women use alcohol, tobacco or drugs?

  9. Substance Use in PregnancySurveys of Prevalence in Prenatal Patients • State surveys* -California: 11% used alcohol, illicit drugs or abused prescription drugs (urine) -Rhode Island: 10.7% used illicit drugs (meconium and self-report) -Utah: 5.5% illicit drugs (urine tox only) -South Carolina: 25.8% alcohol or drugs (meconium ) • Local surveys**Pinellas County Fla *Hollingshead, MMWR:1990, Vega, NEJM: 1993, Buchi Obstet/Gynecol 1993 ** Chasnoff, NEJM, 1990, Nalty Alcohol & Drug Abuse: 1991

  10. Substance Use in PregnancyPrevalence National Pregnancy and Health Survey*** -First and only pregnancy specific national survey, done in 1992 -Self report + anonymous toxicology data from 52 urban and rural hospitals Results: 221,000 women used illicit drugs in 1992 (5.5%), 820,000 (20.4%) smoked tobacco, 757,000 drank alcohol ((18.8%) *** NCADI : 1996 ,

  11. Substance Use in PregnancyTobacco DUHS/SAMHSA 2007

  12. Substance Use in PregnancyTobacco/Ethnicity • Percentages of Past Month Cigarette Use • Women 15-44; by Pregnancy Status, Age, and • Race/Ethnicity NSDUH SAMHSA 2005

  13. Alcohol Use in PregnancyNSDUH NSDUH Report SAMHSA 2007

  14. Pregnancy and Alcohol Use: Binge and Heavy Drinking by Groups USDHHS, HRSA, 2005

  15. Illicit Substance Use by Women NSDUH Report SAMHSA 2007

  16. Illicit Drug Use in PregnancyNSDUH Percentage Past Month Illicit Drug Use, Women 15-44, 2002, 2003 NSDUH Report, SAMHSA, 2005

  17. 3. How does ATD use affect maternal health and pregnancy outcomes?

  18. Adverse OutcomesLimitations of the Data • Single, intermittent, chronic use (abuse vs. dependence) • Timing, dose • Polysubstance exposure • Confounders: SES, environment, nutrition, education • Animal data, secondary endpoints • Publication bias

  19. Limitations of the LiteraturePublication Bias

  20. Substance Use in PregnancyAdverse Maternal Outcomes • Obstetric emergencies • Abruption • Previa • Catastrophic medical events • Infection • HIV/AIDS • Hepatitis • Pneumonia • UTI/Pyelonephritis • Death

  21. Substance UseAdverse Maternal/Obstetric Outcomes - Abruptio placenta* >Vasoconstrictors- nicotine, cocaine, amphetamines >Animal models suggest dose-response for tobacco, ? cocaine Tobacco: RR= 1.4-2.4, cocaine: OR 3.92 (CI 2.77-5.46)*- (? Confonders) -Placenta previa**-most data from case control studies >Tobacco: OR=2.3 (CI 1.5-3.5), dose response > Cocaine: AOR 2.5- 4.39 (CI 1.17-16.4) • * Hulse Addiction 1997, Ananth Obstet-Gyne, 1999 • **Handler Am J. Obstet Gyncol 1994, Macones Am J. Obstet Gyencol 1997

  22. Substance Use Adverse OutcomesMortality • California study- increased mortality for maternal death in polydrug, drug and alcohol, amphetamine and cocaine using parturients OR= 2.0, ( CI=1.74, 2.5)* • Increased rates of abuse, violent trauma and murder noted** • * Wolfe J. Perinatology. 2005 • **Tardiff NEJM, 1994, Thompson Addictive Behaviors 1998, • **Berenson Am J. Ob-Gyn 1991

  23. 4. What are the effects of ATD use on offspring?

  24. Substance Use in PregnancyAdverse Outcomes In Offspring • Congenital Anomalies • PTL/PTD • IUGR • Neonatal abstinence syndrome • SIDS/Infant Death • Behavioral Abnormalities Early Later

  25. Substance UseAdverse Obstetric Outcomes • Preterm labor/Preterm delivery - Uterine artery vasospasm -Increased catecholamines -Increased body temperature - Estrogen/progesterone potentiate contraction of cardiac and smooth muscle in vessels and myometrium Increased BP

  26. Substance AbuseFetal Growth Restriction • Seen with all substances: illicit drugs, alcohol, tobacco • Effects multifactorial: direct vasoconstriction with hypo-perfusion & altered oxygen delivery, placental disruption, poor maternal nutrition/micronutrient delivery, direct cytotoxic effects, binding carbon monoxide to fetal hemoglobin • Cigarettes – best evidence for effect, RR: ~1.5-2.9, dose response, positive response to cessation in early pregnancy

  27. Substance UseCongenital Anomalies • Cocaine • Nicotine ? • Hallucinogens • Opiates • Amphetamines • Marijuana • Alcohol • Sedative-hypnotics?

  28. Substance Use: Anomalies Fetal Alcohol Spectrum Disorder • Alcohol/Acetaldehyde • Dose dependent – cumulative/binge • Effects throughout gestation • Systems affected • Cardiac • Genitourinary • Oral/ocular/auditory • CNS

  29. Fetal Alcohol Spectrum Disorder Fetal Alcohol Syndrome/Effect Persistent growth deficits, behavioral problems and learning disorders

  30. Substance Use Neonatal Abstinence Syndrome • Opiates • Nicotine Chirboga, J Devel Peds 1998, Neuspiel Cocaine/Crack Res Newsletter 1991

  31. Perinatal Substance UseInfant Death • Michigan study- increased perinatal mortality in drug positive infants. Increased mortality in LBW infants exposed to cocaine, opiates (OR= 5.9, CI- 1.4-24)* • Meta-analysis of opioid exposure and neonatal mortality from 1970s to 1997: RR compared to non-using controls= 3.79 (95%CI 0.95-9,60) • SIDS-associated with tobacco, opiates and marijuana *Ostrea Pediatrics, 1997 **Hulse Aus/New Zealand J. Ob/Gyn, 1998 Klonoff-Cohen. Arch Ped Adol Med: 2001, Kahlert C. Arch Dis Children 92(11)2007 Kandall S. Neurotoxicity and Teratology. 1991, Cnattinguis. Nicotine and Tob Res: 2004, Scragg RKR. Acta Ped, 2001:90

  32. Substance UseNeurodevelopmental Abnormalities • Seen with all substances that affect the limbic system, both licit and illicit • ‘Vulnerable’ kids more affected • Often very subtle: include altered psychomotor, mental and behavioral functioning, poor emotional regulation and social interaction • Amenable to post-natal intervention

  33. Perinatal Substance ExposureSelected Studies -Ottawa Prenatal Prospective Study* Results in 9-12 and 13-16 year old- subtle deficits in “executive” functions, poorer self-regulation, mild attention deficit abnls.No change in IQ or language skills -Maternal Health Practices and Child Development Study** Head circumference differences by age 3.Height deficits by age 6, severe hyperactivity, deliquincy and behavioral problems -NIDA Methamphetamine Study • *J. Clin Pharmacology; 42, 2002 • ** Neurology Teratology; 24, 2002, Neurotoxicology/Teratology; 22, 2000

  34. Perinatal Substance ExposureSelected Studies • Maternal Lifestyles Study • Interagency- NICHHD, NIDA, PPB • 11,800 mother-infant dyads, 3 groups: O, C, N • SES matched controls, both cases and controls had alcohol, tobacco &/or marijuana

  35. Maternal Lifestyles Study • Phase I - Obstetric outcomes- Increased UTIs, STDs, hepatitis and HIV in opiate and cocaine using mothers. 19 fold higher hospitalization for violence-related injury.* Low prevalence of medical complications or acute events. • Phase II –Evaluation infants 1- 36 months of age Assessed q 4 to 20w. No significant differences in mental, psychomotor or behavioral functioning. Subtle differences in psychomotor and neuro-developmental parameters noted** • Phase III and IV-Focus on evaluation child outcome, school performance * Bauer, Am J. Obstet Gynecology 2002, ** Messinger, Pediatrics 2004

  36. 5. How should we screen for ATD use?

  37. Screening • Universal and also risk-based • Logical inclusion in behavioral history • Instruments designed and validated for different substances-choice of instrument based on patient and provider characteristics • Recommendation for screening is based on the level of evidence that intervention makes a difference

  38. Screening in PregnancyAlcohol • CAGE and AUDIT validated in many populations. Poor pick-up low level drinking. Excellent negative predictive performance in women (0.94, 0.97) • TWEAK , T-ACE –higher sensitivity for detection drinking in pregnancy-(90% and 79%) • TWEAK: (Tolerance, Worry by spouse, Eye-Opener, Amnesia, Cut down) • T-ACE: (Tolerance, Annoyed, Cut down, Eye-opener) USPHS Evidence Level B Bradley. JAMA. 1998

  39. Screening for Illicit Drug UseIn Pregnancy • Universal questioning – part of routine history (avoid-”You don’t use drugs, do you?”) versus • Risk based screening: repeat as needed - Medical clues: infections, trauma, GI dz, pain syndromes, dental dz, blackouts, depression/anxiety, tobacco - Obstetric clues: PTL, PPROM, abruptio, IUGR, IUFD, Sabs, neonatal abstinence -Social/behavioral clues: ‘noncompliance’, family/spouse abuse, ER visits, employment, unstable family/housing situation, relationship difficulties

  40. Screening for Illicit Drug UseIn PregnancyToxicology Testing • Not used to establish chronic use • Short half life drugs & metabolites • False positives and false negatives common • Meconium, hair analysis remain investigational • Legal issues

  41. Toxicology Testing for Substance Abuse in PregnancyMedical-Legal Issues • Informed consent: USSupreme Court: Ferguson v. City of Charleston, 2001- states that pregnant women cannot be non-consensually tox tested under the 4th Amendment for non-medical purposes. Rights of women both statutory and constitutional are not forfeited because of pregnancy • Non-discriminatory testing Testing only per hospital protocol and policy for medical cause • Confidentiality- Follow Federal and State guidelines for information transfer Annas NEJM, 2001, USDHHS, IDASA-1991

  42. 5% Screening: Brief Intervention US Preventive Services Task Force recommends screening & behavioral counseling in primary care and prenatal settings to reduce substance misuse by adults Dependent Use At-Risk + Problem Use 20% Intervene Screen Evidence Level B

  43. Screening/Brief Intervention The 5 As and FRAMES • ASK- 1 minute Use multiple choice questions: “a. I have never smoked, b. I stopped before I was pregnant, c. I stopped after pregnancy diagnosed, d. I smoke but cut down, e. I smoke regularly, same as before pregnancy” • ADVISE -1 minute • ASSESS- 1minutewillingness to quit • ASSIST- 3 minutes+skills, social support, pregnancy specific materials • ARRANGE- 1minute+reassess smoking at follow-up visits. FRAMES (Feedback, Reinforce, Advice, Menu, Empathy, Support) Melvin, Recommended smoking cessation counseling for pregnant women who smoke. Tobacco Control: 2000 Miller & Rollnick, Motivational Interviewing 1991 Evidence level B

  44. Evidence for BI with many substances Ballesteros et al. 2004; -meta-analysis alcohol • MTP Research Group et al. 2004. – cannabis (USA) • Copeland et al. 2001. – cannabis (Australia) • Heather et al. 2004. – benzodiazepines (UK) • McCambridge, Strang. 2004. – tobacco and cannabis (UK) • Berstein et al. 2005. – cocaine and heroin (US) • Significant literature for tobacco cessation

  45. Effectiveness BI in PregnancyRCTs • AUDIT +, BI- reduction Etoh, increased use contraception and reduction AEP* • + T-ACE, support partner, BI recipients had highest level of reduction in drinking, partner participation enhanced effect** • Protecting the Next Pregnancy: affected index pregnancy, 5 year f/u. Decreased drinking, better birth outcomes, less LBW, less PTD, better neurobehavioral scores on subsequent offspring*** * Floyd RL. Am J Preventive Med, 2006: 32 **Chang G. Obstet/Gynecol 2005: 105 Hankin JR. Alcohol Research and Health 2002: 26,

  46. 6. Does treatment work?

  47. Addiction treatment is effective • Goal of addiction treatment is to return to productive functioning, reduce excess health risk • reduces substance use by 40-60% • reduces crime by 40-60% • increases employment by 40% • Rates of adherence similar to treatment for other chronic diseases such as diabetes, asthma, hypertension • Every $1 spent for treatment saves up to $12 in reduced health care and crime-related costs McLellan AT, Lewis DC, O'Brien CP, Kleber HD, JAMA, 284 (2000): 1689­1695 NIDA, Principles of Drug Addiction Treatment: A Research-Based Guide, NIH Bethesda, MD, July 2000

  48. 90% of people with substance use disorders are untreated 23.2 million (9.5%) of US pop. > 12 years old have a current substance use disorder. Less than 10% of these get treatment National Survey on Drug Use and Health, SAMHSA 2005

  49. Substance Abuse Treatment Special Services for Pregnant Women • Parenting classes • Family therapy • On-site child care • Case management services • Coordination with medical/prenatal/pediatric care Improved outcomes in BW, addiction/prenatal program retention and perinatal mortality if women receive specialized services* *Daley, J. Psychoactive Drugs; 2001 Ashley, Am J. Drug and Alcohol Abuse; 2003 Brouekhuizen, Am J. Obstet/Gynecol; 1992

  50. Substance Abuse in PregnancyAlcohol Detoxification • ‘Cold turkey’ not safe in pregnancy at > 8oz Etoh/day • Hospital detoxification may be needed • Evaluate using standardized tool- • CIWA-Ar. Low score in pregnancy (8-14) should consider pharmacotherapy • Avoid high dose benzodiazepines in early first and late third trimesters-barbiturates better choice in later gestation

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