- Email: [email protected]
Drug misuse in pregnancy
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OBSTETRICS& GYNAECOLOGY. Drugs
Drug misuse in pregnancy
M. Hepburn Use of illicit drugs during pregnancy is a growing problem which is under-reported, can be difficult to identify and is often associated with failure to attend for antenatal care. Maternal drug use gives rise to medical concerns over fetal well-being and social concerns regarding child care. In both cases concern focuses largely on direct effects of drug use per se without recognition of the importance of underlying social problems and lifestyle, and traditional views on management which advocate rigid regimes have little scientific evidence to support them. Obstetric management need be little different from the normal routine but overall, service provision should reflect the multiplicity of problems - especially social problems experienced by these women and should take account of their views and wishes. If such services are also delivered in a non-judgmental way it should be possible to provide drugusing women with effective health care and to achieve satisfactory pregnancy outcomes.
in use of cocaine seen in North America has not yet been observed in Britain where, while heroin has largely been the main drug of choice, there has been increased use of pharmaceutical products such as buprenorphine, particularly in Scotland. Benzodiazepine use, prescribed or non-prescribed, is also a major problem while polydrug use is more prevalent. Use of so-called designer drugs has increased but predominantly in a different section of society. While different drugs may differ in specific effects many of the problems of their use are not due to their precise pharmacological actions but to the way they are used, the illegality of their use and other adverse factors predisposing to or resulting from drug use. So, while this review focuses largely on experience in Glasgow, the issues involved are universally relevant and consequent management problems are similar elsewhere. While drug use occurs in all areas of society, problem injecting drug use is more prevalent in association with socio-economic deprivation when its medical and social complications are exacerbated by poverty. When the route of use is by injection there
Drug misuse in pregnancy In Britain both use of illicit drugs and illicit use of prescribed drugs have been increasing for a number of years.’ Not everyone who uses drugs has a problem, however, and there is a wide spectrum from intermittent recreational use to serious addiction. Furthermore, numbers of drug users are difficult to determine accurately because of the legal and social implications of admitting such use. Nevertheless there is evidence that not only are total numbers of problem users rising steadily but there has been a disproportionately large increase in the number of women using drugs, and a recent study in Glasgow estimated the number of injecting users in the city at approximately 9000 with one-third being women.’ This increased use by women is also observed in consumption of the legal drugs tobacco and alcohol. Differing patterns of drug use are observed internationally, nationally and locally. The huge increase Dr. Mary Hepburn, Women’s Reproductive Health Service, Glasgow Royal Maternity Hospital, Glasgow, G4 ONA, UK Currem Obsrerrics Q 1993 Longman
and Gynaeco/ogy Group UK Ltd
(1993) 3. 54-58
54
DRUG
are additional health hazards and when the user is a pregnant woman there are additional management problems. Drug use, therefore, should not be regarded as a problem in isolation and pregnant drug users need a comprehensive programme of care which deals with all these issues. In Glasgow the Women’s Reproductive Health Service (WRHS) was established to provide reproductive health care - including pregnancy care - for women with severe social problems and it is consequently not surprising that drug use is often encountered with the Service now caring for approximately 80-100 pregnant drug using women per annum. As with drug use in general, that among pregnant women is also under-reported while those who are identified are also reported to attend late - if at all ~ for antenatal care. Problems of caring for pregnant drug using women therefore centre as much on problems of effective health care delivery as on details of management per se. Delivery of health care
Socio-economic deprivation is associated with less effective use of health care services3 and this is even more marked in association with drug use. Pregnant drug using women who fail to attend for care do so for a variety of reasons. Firstly, because of the multiplicity of problems they experience and the chaotic lifestyles they lead, they find the organisation and administration of services ~ and often the content itself ~ inappropriate to their needs. Consequently, attendance at the Antenatal Clinic may be difficult when so many other problems have much greater urgency. Secondly, because they have very low self esteem and feel enormous guilt about their drug use. fears concerning the attitudes and responses of staff _ whether actual or anticipated - to an admission of drug use, discourages attendance. Specific anxieties about possible coercion to accept HIV testing (with all its possible consequences) and about implications for child custody are frequently voiced. Organisation
of services
Services will be more accessible to women who use drugs if they are based in the communities where the women live, preferably in Health Centres or other primary health care settings where other services also exist. Greater flexibility of access is required not only for individual appointments but also for referral systems. General practitioner referral may prove too rigid while for those without a general practitioner it is not even an option. Consequently in our Service we accept referral by any route including self-referral. We have also found it helpful not only to incorporate all types of reproductive health care within a single clinic but to invite participation by other relevant professionals including Health Visitors, Social Services Staff, Drugs Workers and HIV/Hepatitis B
MISUSE IN PREGNANCY
55
Counsellors. Admission to hospital provides another opportunity for input from a wide range of other services and for example the Community Education Department now provides weekly classes in basic health and lifeskills for in- or out-patients. While new services have been introduced others have been omitted or amended. Consequently we no longer hold traditional parentcraft classes (which the women said were inappropriate) but provide the necessary information or instructions on an ongoing individual basis. Conversely, weighing at every visit has been re-introduced for drug using women as a valuable indicator (for patients and staff) of stability of drug use. Women will still not use such services, however, if they encounter negative staff attitudes; it is important to recognise that while many aspects of their behaviour cannot be condoned neither should they be condemned and moral judgement is not the responsibility of health care services. Thus obstetricians, midwives and a range of other professionals all contribute to delivery of a comprehensive, multidisciplinary service which attempts to be nonjudgmental, easily accessible, tailored to individual needs and which makes effective use of women’s time by providing help with all their problems on a single site. Screening for HIV infection
Pressure for HIV testing of pregnant drug using women derives from the mistaken belief that this will identify all those infected and consequently either afford protection to health care staff and/or other patients or provide significant health care benefits for mother and/or baby. However. not even universal screening would identify all those infected because of the interval between infection and seroconversion. Selective screening of so-called ‘high-risk’ individuals, as recommended for low prevalence areas, would additionally fail since many such individuals may not be aware that they are engaging in high risk activity and indeed the importance of heterosexual intercourse as a transmission route and consequently a potentially high risk activity is inadequately recognised. It is therefore illogical to single out groups such as drug users either for screening or, in the absence of screening, for special precautions during management. To protect staff the only safe approach is to regard all pregnant women as potentially at risk from blood borne infections including HIV infection and to employ sensible precautions in high risk areas of care for all women rather than unnecessarily elaborate precautions for all aspects of care for perceived ‘high risk’ women. In other words, the level of precautions used should depend on the risk of the procedure, not the patient. For the woman who is immunologically well, the diagnosis of HIV infection does not alter obstetric management since under single tier management those procedures (such as use of fetal scalp electrodes)
56
CURRENT
OBSTETRICS
AND GYNAECOLOGY
which might be considered contraindicated for the HIV positive woman are, for all women, already restricted to only those situations where there is good medical indication. An additional benefit of such a single tier system with universal precautions is that it makes knowledge of an individual’s status unnecessary so screening need never be advocated in the interests of anyone other than the woman or her unborn baby. In our experience many pregnant women who use drugs want to be tested in the interests of their baby but not necessarily at a time when they are stressed by other problems such as bringing their drug use under control. Any potential benefits to mother or baby from earlier knowledge of serostatus are not sufficiently great to justify denial of choice while linkage of testing to perceived risk status would, as discussed, be a disincentive to admission of drug use. Therefore, HIV testing should be freely available to all pregnant women but only after appropriate nondirective counselling and with freedom of choice over if or when testing should be undertaken. In Glasgow, a low prevalence area, the Royal Maternity Hospital employs a policy of single tier management. Confidential testing for HIV (with appropriate pre- and post-test counselling) is available to all women. Those women with positive results are offered referral for ongoing surveillance and management of themselves and their babies; however, since it is not relevant to the obstetric care neither the occurrence of the test nor its result is recorded in the obstetric case records. This approach to management has not involved prohibitive cost and has proved acceptable both to staff, for whom it affords a greater degree of protection, and to all patients including drug using women who do not feel stigmatised and therefore no longer need to be deprived of information about HIV or help with their drug problem through fear of volunteering a history of drug use.
Maternal health Pregnant women who use drugs experience a range of medical problems, some specifically due to their drug use but many due to their background of multiple social problems and exacerbated by their drug use.
Nutrition Many women attending our Service are undernourished with inadequate or inappropriate diets and very low pre-pregnancy or early pregnancy weights. Drug use results in loss of appetite with reduced intake and vomiting, compounded in early pregnancy by similar effects of pregnancy per se. Consequently, as already noted, while weight gain during pregnancy is of limited clinical significance, routine frequent weighing of women, largely abandoned in obstetric
practice, is of value in monitoring the severity and stability of drug use. Iron deficiency anaemia occurs more frequently but only requires treatment if it does occur. If oral iron therapy is required it may exacerbate both the effect of poor diet and the action of opiates on the bowel which causes severe constipation, often with colic. Increase in dietary fibre and use of bulk agents provides the most effective approach to therapy. Another important complication of poor diet is poor dental health. This is of more than academic interest since a major consequence of detoxification from pain killing drugs can therefore be toothache and a sympathetic flexible dental service makes an invaluable contribution to the care of these women. Dosage Women rarely present complaining of under-dosage but accidental overdosage is not uncommon, particularly with use of street heroin though less so with pharmaceutical preparations such as buprenorphine. Street heroin is of variable but usually very low purity; a batch of unexpectedly higher purity can and does - cause fatal overdosage. Where drugs used include benzodiazepines the resulting intoxification with confusion may result in accidental overdosage of other drugs. Infection Injection as the route of drug administration causes major problems. The substances added to street drugs can themselves, if injected, be extremely harmful either through direct toxic or indirect chemical or irritant effects. Injection per se causes vascular trauma, and infection from dirty and/or shared needles or syringes is an important contributor to morbidity. Complications include peripheral vein thrombosis, local abscess formation, major vessel thrombosis with hemiparesis or loss (partial or total) of a limb, distal infection such as endocarditis and systemic infection including Hepatitis B and HIV infection. Additional complications can arise during pregnancy. For example peripheral vein thrombosis can be a major problem if rapid, adequate venous access is required. Thrombosis of breast veins (a common site of drug injection by women) can, in the presence of puerperal engorgement, be associated with breast abscesses; the aetiological importance of infection rather than trauma has been demonstrated by the reduction in incidence of breast abscesses observed after the establishment of effective needle exchanges in Glasgow. While the major impetus to establishment of these exchanges came from the need to control spread of HIV infection, the beneficial effects apply to infection in general while control of Hepatitis B infection will be further aided by the increase in numbers of services - including our own - offering
DRUG MISUSE IN PREGNANCY
immunisation against Hepatitis B to drug using women either before or after pregnancy. Obstetric complications Various obstetric complications including spontaneous abortion antepartum haemorrhage, placental abruption and hypertension are reported to occur with increased incidence4 but this has not been our experience. Elective delivery is sometimes advocated in these high risk pregnancies but this is rarely necessary and women who use drugs frequently deliver by term (although not necessarily preterm), labouring spontaneously and well. There is often reluctance to give the usual opiate drugs for analgesia either because they might be ineffective or because they might renew or increase addiction; while regional anaesthesia is often appropriate so are opiates although larger doses will be necessary for adequate pain relief.
Child health
Spec$ic qfjrects Babies of mothers who have used drugs during pregnancy may, shortly after birth, exhibit withdrawal symptoms. These can range from mild irritability through hypertonicity to convulsions. Poor feeding and a disturbed sleep pattern are also seen. The timing of onset, duration and nature of symptoms may vary depending on the drug or drugs used and the pattern of maternal drug use. In our experience, it is difficult to predict the likelihood or severity of withdrawal symptoms in an individual baby. While there have been reports of long-term sequelae in such children there is no good evidence to support such a claim. Prior to the establishment of the WRHS all babies born to drug using women in the Glasgow Royal Maternity Hospital went routinely at birth to the Special Care Nursery for observation. These babies now come directly to the postnatal ward with their mothers, who have proved even more diligent than staff in observing babies for signs of withdrawal! Non-spec$c effects Maternal drug use during pregnancy is reportedly associated with higher rates of perinatal mortality and morbidity, largely because of increased rates of delivery of babies who are preterm, of low birthweight or small for gestational age.4p6 There is also reported to be a higher incidence of sudden infant death syndrome among such babies. These outcomes, however, are very non specific, are also increased in association with socio-economic deprivation, and yet are frequently attributed to drug use per se without sufficient acknowledgement of the importance of underlying social problems.
57
Meconium staining of the liquor is more frequent, said to result from repeated minor episodes of antepartum drug withdrawal causing intestinal spasm. Since such muscle spasms can also cause in utero fetal gasping, antepartum meconium aspiration can be a problem. However, overall, while outcome of pregnancy among drug using women attending our service has reflected their background of multiple social problems, it has been largely unremarkable.
Management
of drug use
Medical management Maternal drug use in pregnancy is widely regarded as harmful to the fetus but detoxification during pregnancy (including the minor degrees arising from irregular supply or irregular purity of illicit drugs) is held to be even more dangerous.5,7*s Traditional management has therefore centred on substitutionprescribing during pregnancy with various regimes suggested. In opiate addiction methadone has been the most commonly used drug for maintenance since its long half-life helps eliminate potentially harmful fluctuations in drug levels. Detoxification - if advocated at all ~ has been reported as safe only with a rigid and very gradual reducing regime and largely in mid trimester since detoxification in the first or third trimester has been considered to carry an unacceptable risk of spontaneous abortion or preterm labour, respectively. Maternal drug use, however, has also been considered to cause indirect harm by compromising the woman’s parenting skills so abstinence after delivery has often been viewed as essential for adequate child care. These two philosophies of maintenance therapy during pregnancy and abstinence thereafter are obviously largely incompatible or at least represent an unrealistic objective. We have therefore included antenatal detoxification - at any speed and at any stage of pregnancy - among the treatment options offered to women and the social services now view stability of lifestyle and not abstinence as essential for adequate child care. Neither measure has in our experience proved harmful to the babies. We are therefore able to capitalise on the motivation for behavioural change provided by pregnancy but do not, however, view detoxification as of value only if it results in permanent abstinence. Rather we consider it a useful tool in overall control and reduction of total drug consumption which can therefore be used several times during the course of a pregnancy. Similarly the pattern of drug prescription can change from maintenance to reduction or vice versa. Detoxification can be attempted on an in- or outpatient basis although the former is often more successful and admission to hospital is also frequently used for reduction or simply stabihsation of drug use. As already pointed out an in-patient stay can also provide a useful opportunity for introduction of
58
CURRENT OBSTETRICS AND GYNAECOLOGY
other services. While ‘cold turkey’ opiate detoxification may be acceptably safe for mother and baby, the same cannot be said of benzodiazepine withdrawal which carries a risk of maternal convulsions and should therefore always be covered by prescription of substitute drugs. In this situation we have found a 5 day in-patient course of diazepam safe and effective. Detoxification and maintenance methadone are therefore not separate, mutually exclusive options but rather represent the opposite ends of a continuous spectrum of harm reduction. Recognising that neither is a guarantee against continued injection of illicit drugs, the risk from such injection should be dealt with as a separate issue. Furthermore, in the context of pregnancy there is no point in threatening sanctions if injection occurs; discharge from care is obviously inappropriate while withdrawal of prescribed drugs in this situation would be counter productive. Since, as already stated, stability of use not abstinence is the prime objective, we no longer use regular urinalysis to determine compliance; we do still carry out such tests for epidemiological and pharmacological information but the results are not made available for clinical management. Removal of this opportunity for confrontation and manipulation has been helpful in establishing cooperative relationships with the women, with a suggestion of greater honesty in self-reporting of drug use. Social management Drug using women frequently regard Social Workers with hostility and suspicion. This is hardly surprising since it has been common practice for Social Workers to become involved only after the baby has been born and problems have arisen. Their role has therefore effectively been limited to one of crisis intervention viewed by the women as confrontational and punitive; the emphasis on abstinence, as already discussed, has not been helpful. Our service has been developed in close collaboration with the Social Work Department so, in addition to the clinic input with provision of information and practical help, there are weekly meetings between the clinic and local Social Work Staff with early allocation of women to a named Social Worker in accordance with departmental management guidelines. Planning meetings are held at 32 weeks gestation and attended by all relevant to the woman’s care to allow exchange of information, setting of goals and identification of appropriate sources of help with the various problems. This
earlier involvement has not resulted in an increased workload for the Social Work Department but rather in a redistribution of workload with reduced crisis intervention, and it has helped the women to perceive the Social Worker’s role as supportive. Postnatally, before the woman’s discharge to the community, a further review meeting is held to allow forward planning and coordination of community services, both statutory and voluntary. Although thereafter less frequent, contact with the WRHS often continues either formally, for example with family planning follow-up, or informally on an ad hoc basis - and indeed an increasing number of women reach the Service sent or brought by women who have attended in the past. Conclusions Women who use drugs are often viewed as irresponsible because they do net attend for care or because they risk harming their unborn children through their drug use. The often reported poor pregnancy outcomes among these women are cited in support of these views and as justification for rigid and often punitive management. However, there must be recognition that such poor outcomes are multifactorial in aetiology with the social aspects of drug use no less harmful than the medical effects. If services are provided which are appropriate to their needs, and delivered in a non-judgmental manner, it should be possible to provide drug using women with health care which meets their wishes as well as their needs with satisfactory pregnancy outcomes. References 1. Ministerial Group on the Misuse of Drugs. Tackling drug misuse: a summary of the Government’s strategy, 3rd edn. London: Home Office, 1988 2. Frischer M, Bloor M, Finlay M, et al. A new method of estimating prevalence of injecting drug use in an urban population: results from a Scottish city. Int J Epidemiol 1991; 20: 997- 1000 3. Townsend P, Davidson N. Inequalities in health: the Black Report. Harmondsworth: Penguin, 1982 4. Pelosi MA, Frattarda M, Apuzzio J, et al. Pregnancy complicated by heroin addiction. Obstet Gynaecol 1975; 45: 512-515 5. Perlmutter J. Heroin addiction and pregnancy. Obstet Gynaecol Surv 1974; 29: 439-446 6. Connaughton JF, Reeser D, Schut J, et al. Perinatal addiction: outcome and management. Am J Obstet Gynaecol 1977; 129: 679-686 7. Rementeria JL, Nunag NN. Narcotic withdrawal in pregnancy. Stillbirth incidence with a case report. Am J Obstet Gynaecol 1973; 116: 1152-l 156 8. Fraser AC. Drug addiction in pregnancy. Lancet 1976; 2: 896-899
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r
r
e
n
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OBSTETRICS& GYNAECOLOGY. Drugs
Drug misuse in pregnancy
M. Hepburn Use of illicit drugs during pregnancy is a growing problem which is under-reported, can be difficult to identify and is often associated with failure to attend for antenatal care. Maternal drug use gives rise to medical concerns over fetal well-being and social concerns regarding child care. In both cases concern focuses largely on direct effects of drug use per se without recognition of the importance of underlying social problems and lifestyle, and traditional views on management which advocate rigid regimes have little scientific evidence to support them. Obstetric management need be little different from the normal routine but overall, service provision should reflect the multiplicity of problems - especially social problems experienced by these women and should take account of their views and wishes. If such services are also delivered in a non-judgmental way it should be possible to provide drugusing women with effective health care and to achieve satisfactory pregnancy outcomes.
in use of cocaine seen in North America has not yet been observed in Britain where, while heroin has largely been the main drug of choice, there has been increased use of pharmaceutical products such as buprenorphine, particularly in Scotland. Benzodiazepine use, prescribed or non-prescribed, is also a major problem while polydrug use is more prevalent. Use of so-called designer drugs has increased but predominantly in a different section of society. While different drugs may differ in specific effects many of the problems of their use are not due to their precise pharmacological actions but to the way they are used, the illegality of their use and other adverse factors predisposing to or resulting from drug use. So, while this review focuses largely on experience in Glasgow, the issues involved are universally relevant and consequent management problems are similar elsewhere. While drug use occurs in all areas of society, problem injecting drug use is more prevalent in association with socio-economic deprivation when its medical and social complications are exacerbated by poverty. When the route of use is by injection there
Drug misuse in pregnancy In Britain both use of illicit drugs and illicit use of prescribed drugs have been increasing for a number of years.’ Not everyone who uses drugs has a problem, however, and there is a wide spectrum from intermittent recreational use to serious addiction. Furthermore, numbers of drug users are difficult to determine accurately because of the legal and social implications of admitting such use. Nevertheless there is evidence that not only are total numbers of problem users rising steadily but there has been a disproportionately large increase in the number of women using drugs, and a recent study in Glasgow estimated the number of injecting users in the city at approximately 9000 with one-third being women.’ This increased use by women is also observed in consumption of the legal drugs tobacco and alcohol. Differing patterns of drug use are observed internationally, nationally and locally. The huge increase Dr. Mary Hepburn, Women’s Reproductive Health Service, Glasgow Royal Maternity Hospital, Glasgow, G4 ONA, UK Currem Obsrerrics Q 1993 Longman
and Gynaeco/ogy Group UK Ltd
(1993) 3. 54-58
54
DRUG
are additional health hazards and when the user is a pregnant woman there are additional management problems. Drug use, therefore, should not be regarded as a problem in isolation and pregnant drug users need a comprehensive programme of care which deals with all these issues. In Glasgow the Women’s Reproductive Health Service (WRHS) was established to provide reproductive health care - including pregnancy care - for women with severe social problems and it is consequently not surprising that drug use is often encountered with the Service now caring for approximately 80-100 pregnant drug using women per annum. As with drug use in general, that among pregnant women is also under-reported while those who are identified are also reported to attend late - if at all ~ for antenatal care. Problems of caring for pregnant drug using women therefore centre as much on problems of effective health care delivery as on details of management per se. Delivery of health care
Socio-economic deprivation is associated with less effective use of health care services3 and this is even more marked in association with drug use. Pregnant drug using women who fail to attend for care do so for a variety of reasons. Firstly, because of the multiplicity of problems they experience and the chaotic lifestyles they lead, they find the organisation and administration of services ~ and often the content itself ~ inappropriate to their needs. Consequently, attendance at the Antenatal Clinic may be difficult when so many other problems have much greater urgency. Secondly, because they have very low self esteem and feel enormous guilt about their drug use. fears concerning the attitudes and responses of staff _ whether actual or anticipated - to an admission of drug use, discourages attendance. Specific anxieties about possible coercion to accept HIV testing (with all its possible consequences) and about implications for child custody are frequently voiced. Organisation
of services
Services will be more accessible to women who use drugs if they are based in the communities where the women live, preferably in Health Centres or other primary health care settings where other services also exist. Greater flexibility of access is required not only for individual appointments but also for referral systems. General practitioner referral may prove too rigid while for those without a general practitioner it is not even an option. Consequently in our Service we accept referral by any route including self-referral. We have also found it helpful not only to incorporate all types of reproductive health care within a single clinic but to invite participation by other relevant professionals including Health Visitors, Social Services Staff, Drugs Workers and HIV/Hepatitis B
MISUSE IN PREGNANCY
55
Counsellors. Admission to hospital provides another opportunity for input from a wide range of other services and for example the Community Education Department now provides weekly classes in basic health and lifeskills for in- or out-patients. While new services have been introduced others have been omitted or amended. Consequently we no longer hold traditional parentcraft classes (which the women said were inappropriate) but provide the necessary information or instructions on an ongoing individual basis. Conversely, weighing at every visit has been re-introduced for drug using women as a valuable indicator (for patients and staff) of stability of drug use. Women will still not use such services, however, if they encounter negative staff attitudes; it is important to recognise that while many aspects of their behaviour cannot be condoned neither should they be condemned and moral judgement is not the responsibility of health care services. Thus obstetricians, midwives and a range of other professionals all contribute to delivery of a comprehensive, multidisciplinary service which attempts to be nonjudgmental, easily accessible, tailored to individual needs and which makes effective use of women’s time by providing help with all their problems on a single site. Screening for HIV infection
Pressure for HIV testing of pregnant drug using women derives from the mistaken belief that this will identify all those infected and consequently either afford protection to health care staff and/or other patients or provide significant health care benefits for mother and/or baby. However. not even universal screening would identify all those infected because of the interval between infection and seroconversion. Selective screening of so-called ‘high-risk’ individuals, as recommended for low prevalence areas, would additionally fail since many such individuals may not be aware that they are engaging in high risk activity and indeed the importance of heterosexual intercourse as a transmission route and consequently a potentially high risk activity is inadequately recognised. It is therefore illogical to single out groups such as drug users either for screening or, in the absence of screening, for special precautions during management. To protect staff the only safe approach is to regard all pregnant women as potentially at risk from blood borne infections including HIV infection and to employ sensible precautions in high risk areas of care for all women rather than unnecessarily elaborate precautions for all aspects of care for perceived ‘high risk’ women. In other words, the level of precautions used should depend on the risk of the procedure, not the patient. For the woman who is immunologically well, the diagnosis of HIV infection does not alter obstetric management since under single tier management those procedures (such as use of fetal scalp electrodes)
56
CURRENT
OBSTETRICS
AND GYNAECOLOGY
which might be considered contraindicated for the HIV positive woman are, for all women, already restricted to only those situations where there is good medical indication. An additional benefit of such a single tier system with universal precautions is that it makes knowledge of an individual’s status unnecessary so screening need never be advocated in the interests of anyone other than the woman or her unborn baby. In our experience many pregnant women who use drugs want to be tested in the interests of their baby but not necessarily at a time when they are stressed by other problems such as bringing their drug use under control. Any potential benefits to mother or baby from earlier knowledge of serostatus are not sufficiently great to justify denial of choice while linkage of testing to perceived risk status would, as discussed, be a disincentive to admission of drug use. Therefore, HIV testing should be freely available to all pregnant women but only after appropriate nondirective counselling and with freedom of choice over if or when testing should be undertaken. In Glasgow, a low prevalence area, the Royal Maternity Hospital employs a policy of single tier management. Confidential testing for HIV (with appropriate pre- and post-test counselling) is available to all women. Those women with positive results are offered referral for ongoing surveillance and management of themselves and their babies; however, since it is not relevant to the obstetric care neither the occurrence of the test nor its result is recorded in the obstetric case records. This approach to management has not involved prohibitive cost and has proved acceptable both to staff, for whom it affords a greater degree of protection, and to all patients including drug using women who do not feel stigmatised and therefore no longer need to be deprived of information about HIV or help with their drug problem through fear of volunteering a history of drug use.
Maternal health Pregnant women who use drugs experience a range of medical problems, some specifically due to their drug use but many due to their background of multiple social problems and exacerbated by their drug use.
Nutrition Many women attending our Service are undernourished with inadequate or inappropriate diets and very low pre-pregnancy or early pregnancy weights. Drug use results in loss of appetite with reduced intake and vomiting, compounded in early pregnancy by similar effects of pregnancy per se. Consequently, as already noted, while weight gain during pregnancy is of limited clinical significance, routine frequent weighing of women, largely abandoned in obstetric
practice, is of value in monitoring the severity and stability of drug use. Iron deficiency anaemia occurs more frequently but only requires treatment if it does occur. If oral iron therapy is required it may exacerbate both the effect of poor diet and the action of opiates on the bowel which causes severe constipation, often with colic. Increase in dietary fibre and use of bulk agents provides the most effective approach to therapy. Another important complication of poor diet is poor dental health. This is of more than academic interest since a major consequence of detoxification from pain killing drugs can therefore be toothache and a sympathetic flexible dental service makes an invaluable contribution to the care of these women. Dosage Women rarely present complaining of under-dosage but accidental overdosage is not uncommon, particularly with use of street heroin though less so with pharmaceutical preparations such as buprenorphine. Street heroin is of variable but usually very low purity; a batch of unexpectedly higher purity can and does - cause fatal overdosage. Where drugs used include benzodiazepines the resulting intoxification with confusion may result in accidental overdosage of other drugs. Infection Injection as the route of drug administration causes major problems. The substances added to street drugs can themselves, if injected, be extremely harmful either through direct toxic or indirect chemical or irritant effects. Injection per se causes vascular trauma, and infection from dirty and/or shared needles or syringes is an important contributor to morbidity. Complications include peripheral vein thrombosis, local abscess formation, major vessel thrombosis with hemiparesis or loss (partial or total) of a limb, distal infection such as endocarditis and systemic infection including Hepatitis B and HIV infection. Additional complications can arise during pregnancy. For example peripheral vein thrombosis can be a major problem if rapid, adequate venous access is required. Thrombosis of breast veins (a common site of drug injection by women) can, in the presence of puerperal engorgement, be associated with breast abscesses; the aetiological importance of infection rather than trauma has been demonstrated by the reduction in incidence of breast abscesses observed after the establishment of effective needle exchanges in Glasgow. While the major impetus to establishment of these exchanges came from the need to control spread of HIV infection, the beneficial effects apply to infection in general while control of Hepatitis B infection will be further aided by the increase in numbers of services - including our own - offering
DRUG MISUSE IN PREGNANCY
immunisation against Hepatitis B to drug using women either before or after pregnancy. Obstetric complications Various obstetric complications including spontaneous abortion antepartum haemorrhage, placental abruption and hypertension are reported to occur with increased incidence4 but this has not been our experience. Elective delivery is sometimes advocated in these high risk pregnancies but this is rarely necessary and women who use drugs frequently deliver by term (although not necessarily preterm), labouring spontaneously and well. There is often reluctance to give the usual opiate drugs for analgesia either because they might be ineffective or because they might renew or increase addiction; while regional anaesthesia is often appropriate so are opiates although larger doses will be necessary for adequate pain relief.
Child health
Spec$ic qfjrects Babies of mothers who have used drugs during pregnancy may, shortly after birth, exhibit withdrawal symptoms. These can range from mild irritability through hypertonicity to convulsions. Poor feeding and a disturbed sleep pattern are also seen. The timing of onset, duration and nature of symptoms may vary depending on the drug or drugs used and the pattern of maternal drug use. In our experience, it is difficult to predict the likelihood or severity of withdrawal symptoms in an individual baby. While there have been reports of long-term sequelae in such children there is no good evidence to support such a claim. Prior to the establishment of the WRHS all babies born to drug using women in the Glasgow Royal Maternity Hospital went routinely at birth to the Special Care Nursery for observation. These babies now come directly to the postnatal ward with their mothers, who have proved even more diligent than staff in observing babies for signs of withdrawal! Non-spec$c effects Maternal drug use during pregnancy is reportedly associated with higher rates of perinatal mortality and morbidity, largely because of increased rates of delivery of babies who are preterm, of low birthweight or small for gestational age.4p6 There is also reported to be a higher incidence of sudden infant death syndrome among such babies. These outcomes, however, are very non specific, are also increased in association with socio-economic deprivation, and yet are frequently attributed to drug use per se without sufficient acknowledgement of the importance of underlying social problems.
57
Meconium staining of the liquor is more frequent, said to result from repeated minor episodes of antepartum drug withdrawal causing intestinal spasm. Since such muscle spasms can also cause in utero fetal gasping, antepartum meconium aspiration can be a problem. However, overall, while outcome of pregnancy among drug using women attending our service has reflected their background of multiple social problems, it has been largely unremarkable.
Management
of drug use
Medical management Maternal drug use in pregnancy is widely regarded as harmful to the fetus but detoxification during pregnancy (including the minor degrees arising from irregular supply or irregular purity of illicit drugs) is held to be even more dangerous.5,7*s Traditional management has therefore centred on substitutionprescribing during pregnancy with various regimes suggested. In opiate addiction methadone has been the most commonly used drug for maintenance since its long half-life helps eliminate potentially harmful fluctuations in drug levels. Detoxification - if advocated at all ~ has been reported as safe only with a rigid and very gradual reducing regime and largely in mid trimester since detoxification in the first or third trimester has been considered to carry an unacceptable risk of spontaneous abortion or preterm labour, respectively. Maternal drug use, however, has also been considered to cause indirect harm by compromising the woman’s parenting skills so abstinence after delivery has often been viewed as essential for adequate child care. These two philosophies of maintenance therapy during pregnancy and abstinence thereafter are obviously largely incompatible or at least represent an unrealistic objective. We have therefore included antenatal detoxification - at any speed and at any stage of pregnancy - among the treatment options offered to women and the social services now view stability of lifestyle and not abstinence as essential for adequate child care. Neither measure has in our experience proved harmful to the babies. We are therefore able to capitalise on the motivation for behavioural change provided by pregnancy but do not, however, view detoxification as of value only if it results in permanent abstinence. Rather we consider it a useful tool in overall control and reduction of total drug consumption which can therefore be used several times during the course of a pregnancy. Similarly the pattern of drug prescription can change from maintenance to reduction or vice versa. Detoxification can be attempted on an in- or outpatient basis although the former is often more successful and admission to hospital is also frequently used for reduction or simply stabihsation of drug use. As already pointed out an in-patient stay can also provide a useful opportunity for introduction of
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CURRENT OBSTETRICS AND GYNAECOLOGY
other services. While ‘cold turkey’ opiate detoxification may be acceptably safe for mother and baby, the same cannot be said of benzodiazepine withdrawal which carries a risk of maternal convulsions and should therefore always be covered by prescription of substitute drugs. In this situation we have found a 5 day in-patient course of diazepam safe and effective. Detoxification and maintenance methadone are therefore not separate, mutually exclusive options but rather represent the opposite ends of a continuous spectrum of harm reduction. Recognising that neither is a guarantee against continued injection of illicit drugs, the risk from such injection should be dealt with as a separate issue. Furthermore, in the context of pregnancy there is no point in threatening sanctions if injection occurs; discharge from care is obviously inappropriate while withdrawal of prescribed drugs in this situation would be counter productive. Since, as already stated, stability of use not abstinence is the prime objective, we no longer use regular urinalysis to determine compliance; we do still carry out such tests for epidemiological and pharmacological information but the results are not made available for clinical management. Removal of this opportunity for confrontation and manipulation has been helpful in establishing cooperative relationships with the women, with a suggestion of greater honesty in self-reporting of drug use. Social management Drug using women frequently regard Social Workers with hostility and suspicion. This is hardly surprising since it has been common practice for Social Workers to become involved only after the baby has been born and problems have arisen. Their role has therefore effectively been limited to one of crisis intervention viewed by the women as confrontational and punitive; the emphasis on abstinence, as already discussed, has not been helpful. Our service has been developed in close collaboration with the Social Work Department so, in addition to the clinic input with provision of information and practical help, there are weekly meetings between the clinic and local Social Work Staff with early allocation of women to a named Social Worker in accordance with departmental management guidelines. Planning meetings are held at 32 weeks gestation and attended by all relevant to the woman’s care to allow exchange of information, setting of goals and identification of appropriate sources of help with the various problems. This
earlier involvement has not resulted in an increased workload for the Social Work Department but rather in a redistribution of workload with reduced crisis intervention, and it has helped the women to perceive the Social Worker’s role as supportive. Postnatally, before the woman’s discharge to the community, a further review meeting is held to allow forward planning and coordination of community services, both statutory and voluntary. Although thereafter less frequent, contact with the WRHS often continues either formally, for example with family planning follow-up, or informally on an ad hoc basis - and indeed an increasing number of women reach the Service sent or brought by women who have attended in the past. Conclusions Women who use drugs are often viewed as irresponsible because they do net attend for care or because they risk harming their unborn children through their drug use. The often reported poor pregnancy outcomes among these women are cited in support of these views and as justification for rigid and often punitive management. However, there must be recognition that such poor outcomes are multifactorial in aetiology with the social aspects of drug use no less harmful than the medical effects. If services are provided which are appropriate to their needs, and delivered in a non-judgmental manner, it should be possible to provide drug using women with health care which meets their wishes as well as their needs with satisfactory pregnancy outcomes. References 1. Ministerial Group on the Misuse of Drugs. Tackling drug misuse: a summary of the Government’s strategy, 3rd edn. London: Home Office, 1988 2. Frischer M, Bloor M, Finlay M, et al. A new method of estimating prevalence of injecting drug use in an urban population: results from a Scottish city. Int J Epidemiol 1991; 20: 997- 1000 3. Townsend P, Davidson N. Inequalities in health: the Black Report. Harmondsworth: Penguin, 1982 4. Pelosi MA, Frattarda M, Apuzzio J, et al. Pregnancy complicated by heroin addiction. Obstet Gynaecol 1975; 45: 512-515 5. Perlmutter J. Heroin addiction and pregnancy. Obstet Gynaecol Surv 1974; 29: 439-446 6. Connaughton JF, Reeser D, Schut J, et al. Perinatal addiction: outcome and management. Am J Obstet Gynaecol 1977; 129: 679-686 7. Rementeria JL, Nunag NN. Narcotic withdrawal in pregnancy. Stillbirth incidence with a case report. Am J Obstet Gynaecol 1973; 116: 1152-l 156 8. Fraser AC. Drug addiction in pregnancy. Lancet 1976; 2: 896-899