[Substance abuse and pregnancy from an obstetric point of view]. / Schwangerenbetreuung bei Drogenkonsum.

INTRODUCTION: In Germany we find about 2 000 newborns per year with a mother misusing drugs. It is to be feared that there is a substantial amount of underreported substance abuse in pregnant women. To care for these pregnancies from an obstetric point of view as well as from an addiction treatment point of view is a challenge for all health-care professionals, due to multiple drugs being used and the special psychosocial and health issues these mothers and babies -present. METHOD: A selective search was undertaken in Pubmed, retrieving reviews and original articles from 2001-2013, with consideration of statements, recommendations and guidelines from national and international associations and committees on the topic. This review is intended to assist gynaecologists, obstetricians and paediatricians during the complex peripartum care for the drug abusing pregnant patient. RESULTS: When offering obstetric care for these pregnancies, several issues have to be taken into account: the special psychological situation of the pregnant drug user, with frequent occurrence of psychiatric comorbidities like depression and anxiety disorders, as well as gynaecological complications like premature labour, intrauterine growth restriction and maternal infectious diseases. The pharmacological complexity of the substances abused and the possible side-effects on the foetus have to be explained to the mother. Maintenance medication for foetomaternal risk reduction and maternal stabilisation remains the state-of-the-art treatment. Furthermore, it is important to explain the neonatal abstinence syndrome to the mother as well as the result of breast-feeding in the presence of smoking and/or infectious diseases. DISCUSSION: Professionalism and empathy are needed from gynaecologists in order to achieve risk reduction for mother and child in substance-using pregnancies. However, in spite of close cooperation of all health-care professionals and avoidance of stigma, it will be difficult to offer good obstetric care to the high-risk patients with poly-drug abuse.

Tolerance and addiction; the patient, the parent or the clinician?

Tolerance has been recognized for some time where chronic exposure to certain drugs, particularly benzodiazepines and opioids, is associated with apparent tachyphylaxis. When these drugs are stopped or progressively reduced as in 'tapering', withdrawal symptoms may result. Tolerance and the flip side of the coin, withdrawal, are the determinants of addiction. It is increasingly apparent that tolerance can occur acutely, even within the time span of a single anesthetic for a surgical procedure. Addiction is caused by agents, foreign to the body, that provoke adaptation by homeostatic biological processes. When these agents are withdrawn, the adaptive mechanisms, devoid of substrate, take time to diminish and produce symptoms recognizable under the term of 'withdrawal'. Children may be exposed to these agents in different ways; in utero, as a result of substances that the mother ingests by enteral, parenteral or inhalational means that are transmitted to the infant via the placenta; as a result of an anesthetic for surgery; or as a result of sedation and analgesia administered to offset the stresses and trauma inherent from intensive care treatment in the neonatal intensive care unit or pediatric intensive care unit. Additionally, anesthetic and intensive care staff are exposed to powerful and addictive drugs as part of everyday practice, not simply by overt access, but also by subliminal environmental exposure.

Prenatal cocaine use and maternal depression: effects on infant neurobehavior.

OBJECTIVE: The present study examined the impact of both perinatal maternal depression and cocaine use on infant neurobehavior at 1 month of age in a large, multi-site study. METHODS: Infant neurobehavior was examined in 1053 infants at 1 month of age using the NICU Network Neurobehavioral Scale (NNNS). Mothers were interviewed using The Addiction Severity Index to determine present and past psychiatric history. Four groups were derived from the total sample: 385 prenatally cocaine-exposed infants, 76 whose mothers reported current postpartum depression (DEP/COC) and 309 without current postpartum depression (nonDEP/COC); 668 infants were not exposed to cocaine, 104 whose mothers reported current postpartum depression (DEP/nonCOC), 564 without current postpartum depression (nonDEP/nonCOC). A 2x2 Analysis of Covariance was used with covariates (birthweight, maternal age, SES, nicotine, alcohol, and research site) to examine infant neurobehavior in these four conditions. Secondary analyses were conducted to examine the effects of amount and timing of prenatal cocaine exposure. RESULTS: DEP group by COC exposure status interactions were significant; there was only a DEP effect in the nonCOC infants. Infants in the nonCOC/DEP group had poorer self-regulation and more stress signs, excitability, and arousal than infants in the other groups. CONCLUSIONS: Postpartum maternal depression has negative effects on infant neurobehavior at 1 month of age. Prenatal cocaine exposure may serve to suppress or buffer the effects of postpartum depression on infant neurobehavior. Maternal mood could explain some of the inconsistencies found in the prenatal cocaine exposure literature.

Neurologic manifestations of in utero cocaine exposure in near-term and term infants.

OBJECTIVE: To determine whether the incidence of neurosonographic and neurologic abnormalities is higher in cocaine-exposed infants at birth. METHODS: In utero exposure to cocaine was investigated in 39 term and near-term infants with positive urine screens for cocaine only and 39 matched control infants without drug exposure admitted to the regular term newborn nursery. Serial evaluations were performed on each infant on postnatal days 1 and 2 and included a cranial sonogram, a neurologic and behavioral assessment for drug withdrawal, and Doppler interrogation of the anterior and middle cerebral arteries. RESULTS: There were no differences between groups in neurosonographic abnormalities. Grade I or II intraventricular hemorrhage occurred in 11% of cocaine-exposed and 11% of control infants. There were no cases of grade III intraventricular hemorrhage, cystic periventricular leukomalacia, or neonatal stroke. Head size was smaller in cocaine-exposed infants, ie, 32.7 +/- 0.1 cm versus 33.8 +/- 0.1 cm. The neurologic examination was similar between groups with regard to tone, reflexes, and cranial nerves. Behavioral scores were higher on both days, in cocaine-exposed versus control infants, ie, 4.4 +/- 0.5 versus 2.7 +/- 0.03 on day 1 and 5.0 +/- 0.5 versus 1.71 +/- 0.31 on day 2. Cerebral blood flow velocity measurements in the anterior cerebral artery were similar between groups on both days of examination. However, cocaine-exposed infants demonstrated a significant increase in flow velocity from day 1 to day 2, ie, 0.48 +/- 0.03 to 0.57 +/- 0.04. There was a concomitant decrease in the pulsatility index from day 1 to day 2 in the cocaine-exposed, ie, 0.74 +/- 0.02 to 0.69 +/- 0.02, but not in the control infants. No differences were noted in the flow velocities in the middle cerebral arteries between groups. CONCLUSIONS: Term and near-term infants admitted to a regular nursery who are exposed to cocaine in utero: (1) do not exhibit an increased incidence of neurosonographic abnormalities; (2) do exhibit altered behavior consistent with drug withdrawal; and (3) do demonstrate changes in flow velocity in the anterior cerebral artery consistent with the vasoconstrictive effects of the drug. However, these changes were not accompanied by changes in the neurologic examination or altered care. The long-term neurodevelopmental implications of these subtle abnormalities in the neonatal period remain to be determined.

Common issues for parents in a methadone maintenance group.

Change has been noted in some of the group members. For example, one long-term group member who never spoke when she was in a previous group that focused on addiction-related problems has become the role model for other members. In this group, she says, she feels more competent. She is appropriately outspoken and has established relationships with her children which consistently underpin the parent-child boundaries that need to be drawn. One specific issue she resolved involved her 19-year-old son and his girlfriend who was pregnant with the group member's grandchild. By role playing the different positions that each of these people held in the home (the group member was paying the rent and had the right to set the rules, the girlfriend was feeling unaccepted by the group member and was acting out inappropriately, and the son was caught between trying to please the two females), the group member was able to clarify for herself how to approach future conflicts. A second member has improved her relationship with her youngest son (age 3) but still struggles with her 15-year-old daughter. What has been most effective for her was teaching her to count to 10 before responding to what she considers the goading of both of her children. In addition, she was feeling pressured by her mother, in whose house she lives, to have her son toilet trained.(ABSTRACT TRUNCATED AT 250 WORDS)

Maternal bereavement in the perinatal substance abuser.

Maternal bereavement has been reported in involuntary perinatal loss and voluntary custody relinquishment. Since child custody loss is common among childbearing chemically dependent women, maternal bereavement was investigated in a small pilot sample of obstetric substance abusers. Findings suggest that grief in anticipation of possible postnatal custody loss is common. Unresolved grief from previous custody loss was also common. Clinical features, treatment considerations, and public health concerns are discussed.