Substance Use Disorder during pregnancy is more common than people know or realize. In fact, it is very common among women of the reproductive age. Substance Use Disorder (SUD) during pregnancy is common, however, it is hard to detect because the signs and symptoms are sometimes often very subtle and women may inaccurately disclose their substance abuse or may seek very little or no prenatal care at all out of shame and fear. In addition to the avoidance of prenatal care, SUD is also suspected when unexplained pregnancy complications occur such as premature labor and delivery, placental abruption and unexplained cases of fetal death. Also, a chaotic lifestyle where there are frequent changes in their accommodations or employment and signs of domestic violence can also be an indicator.
The four main categories of substances abused by pregnant women are central nervous system depressants such as alcohol, sedatives, anxiolytics, and hypnotics, stimulants such as cocaine and amphetamines; opiates; and hallucinogens/psychotomimetic, including lysergic acid diethylamide (LSD) and phencyclidine (PCP).
Opioid addiction is a physical dependence on and subjective need and craving of opioid drugs. Maternal drug opiate use has been documented as early as 1800. Prenatal maternal opioid use has increased from 2000 to 2009. From 2009 to 2012 the incidence of neonatal abstinence syndrome (NAS) in the USA has increased from 3.4 to 5.8 per 1,000. In Florida, the prevalence of NAS has increased from 2009-2013.
The current obstetrical practice is not to withdraw opiate-addicted pregnant women during pregnancy. Detoxification during pregnancy has been traditionally associated with stillbirth, fetal distress, premature labor and most importantly a high rate of relapse.
Medical Assisted Treatment of substance use disorder can reduce the risk of preterm delivery, low birth weight, transmitting HIV and Hepatitis C to infants and decrease the risk of relapse. Currently, the accepted medications used for Medical Assisted Treatment in pregnancy are Methadone and more recently Buprenorphine. Methadone currently is the only opioid medication approved by the FDA to treat pregnant woman in MAT, however, a growing body of evidence suggests that Buprenorphine is associated with improved maternal fetal outcomes. Naturally, MAT should be used with counseling and other services to treat the pregnant individual addicted to heroin or opioid prescription pain killers.
A recent study suggested that medically supervised detoxification of the opioid addicted women was not harmful to the mother or the fetus and possibly decreased NAS if continued comprehensive behavioral health follow-up designed to decrease relapse occurred.
There are several factors that help decide the success of treatment in pregnancy.
1. The substance free support the patient receives
The patient with non-drug using individuals in her group who are supportive of her abstinence are more likely to succeed in medical assisted withdrawal.
2. Integrated treatment
A patient would be more likely to remain abstinent if she has an integrated treatment plan that includes counseling, antenatal and postnatal care, residential treatment in a facility offering child care, job training and cognitive behavioral skills.
3. The Availability of Medication Assisted Treatment
For many patients, especially those living in rural communities, the only solution is detoxification (medically supervised or abruption) which may increase the risk of relapse and NAS.
Benefits of MAT in pregnant women
When administered appropriately, MAT has the following benefits:
• Eliminates or reduces craving for opioids
• Prevents onset of withdrawal symptoms
• Blocks effects of opioid drugs
• Improves physical and mental health of the mother-to-be and raises her quality of life
• Decreases the incidence of NAS or neonatal abstinence syndrome in babies
The need for specialized treatment of pregnant women abusing drugs
Avoiding abrupt withdrawal from drug usage is very important for pregnant women because it has been thought to lead to uterine contractions and even miscarriage. In infants exposed to illicit substances, NAS or neonatal abstinence syndrome is common. The majority of opioid dependent women have chaotic lifestyles, poor nutrition and limited or no antenatal attendance. Hence, health care must be provided to these women in a gentle, safe, non-threatening and non-judgmental manner. It is important to provide stable staff for their attendance. Care should be taken to develop a rapport between the patient and the health providers. Mothers should be given knowledge on how to be effective parents and help in order to decrease the risk of relapse in the postpartum period.
What happens if the mother is not treated during pregnancy?
A mother using drugs like heroin or other long acting opioids unknowingly transfers nearly 50-100% of her drug levels to
the fetus based on results shown by blood tests conducted on infants. Neonatal drug usage could also lead to poor fetal growth, premature birth, or still births. The use of needles can also cause diseases like hepatitis, HIV or syphilis in the baby. The risk of the baby developing a major birth defect can increase by nearly 4-5% due to neonatal drug (Alcohol) use. Continued drug use can lead to unstable housing, limited income, domestic violence and crime.
Neonatal abstinence syndrome
NAS is a treatable disorder and 100% preventable if a woman does not use substances during pregnancy. Neonatal abstinence syndrome or NAS occurs in nearly 55-94% drug exposed infants and is seen in exposure to opioids, sedatives, polysubstance abuse and even exposure to alcohol. However, NAS symptoms are more common in infants exposed to opioids than other substances. It
is defined as the abrupt cessation of drug exposure at birth. On average, NAS symptoms may occur within 3 days of birth.
The symptoms are:
• High pitched cry
• Frequent yawning
• Poor weight gain
• Poor feeding
• Uncoordinated sucking
• Nasal stuffiness
• Elevated blood pressure
• Temperature fluctuations
The goal of treatment during pregnancy is to decrease or eliminate neonatal withdrawal syndrome and prevent relapse during pregnancy in the post-partum period. Mothers should be counseled on the benefits of maintenance therapy with methadone or buprenorphine. Informed consent should be obtained for the use of buprenorphine if utilized. If medical assistance therapy is declined, the importance of continued intensive behavioral therapy should be stressed. Close monitoring of the pregnancy and support in the postpartum period with a multidisciplinary team of behavioral practitioners, obstetrician and addiction specialists is essential for success.
Debra Anne Jones MD, FACOG, MBA is Board Certified in Maternal Fetal Medicine and Obstetrics and Gynecology. She holds a Masters in Business Administration in Health Sector Management and Policy from the University of Miami.
Dr. Jones has over 25 years of experience working in and managing medical practices. For twenty of these years she has provided medical care to the women of Palm Beach County.
Dr. Jones is the Founder and CEO of Mango Bay Retreat, a Premier Addiction Facility for Women Specializing in Pregnant Women.