16.1 Substance Misuse
EXPLANATION OF CONDITION
The misuse of drugs during pregnancy encompasses both legal and illegal substances, prescribed and non-prescribed. Nicotine and alcohol are also often overlooked but their detrimental effects on maternal and fetal wellbeing are additive and even in isolation can be considerably harmful.
Women misuse substances for a whole variety of reasons during pregnancy. Some lack awareness of the potential harm it may cause, some are struggling against a psychological or physical dependency, some choose to continue to use substances but many are under pressure to use from their partners and restrictive social network.
Health is also compromised indirectly by the attendant risk-taking behaviour, neglect and adverse socioeconomic factors.
Many will fear stigmatisation from professionals or from family members if the drug use is disclosed. Revealing the extent of substance misuse risks social care involvement which many will simply view as increasing the risk of the baby ‘being taken into care’ after birth. This perception is in stark contrast to the professional’s aim which is that all professionals aim to maximise the chances of the mother and partner safely parenting the child together.
Other barriers to accessing healthcare include:
- Misinterpreting the early symptoms of pregnancy as relating to drug use or withdrawal
- Mistakenly believing pregnancy is not possible due to drug use
- Guilt about current or past substance misuse and many women have used drugs or alcohol before pregnancy is confirmed
- A lack of awareness of the mainstream and specialist services and help available
- Psychiatric co-morbidity and drug-induced mental health problems, depression, psychosis, lethargy
- Arranging child care
- The cost of transport
- Chaotic lifestyle
Nevertheless, many women will be able to stop drug and alcohol use once pregnant and a further proportion will be able to limit their use. Even in those who continue there is often sound, simple and practical advice that can minimise the potential for harm. Pregnancy is seen as a catalyst for change and is a window of opportunity for health professionals. Whilst a minority of women may not be interested in harm reduction for themselves they are still likely to wish to protect their child4.
COMPLICATIONS
- High risk health and social behaviours, whether current or past each contribute to vulnerability
- Injecting drug use can lead to infection, blood-borne viruses, thromboembolism and poor venous access
- Difficulties with informed consent if under the influence of drugs or alcohol at appointments
- Anaemia, malnutrition, under-nutrition and poor dental health
- Co-existing mental health problems particularly anxiety and depression5
- Social problems and housing difficulties with transient lifestyles
- Strong correlation between substance use and domestic abuse both current and historic6–8
- Social exclusion. Saving Mothers Lives 2007 highlighted that socially excluded women are at higher risk of death during or after pregnancy than other women9
- Complications specific to each drug (see later sections)
NON-PREGNANCY TREATMENT AND CARE
Education about the implications of pregnancy for mother and baby made available at various points of contact. Ensure contraceptive needs are met with clear responsibilities agreed and shared between the obstetric team, drug treatment providers and general practioners. Inconsistent or poor engagement with services
Harm minimisation10:
- Accessing any antenatal care
- Stabilising drug use
- Engaging with treatment services
- Where possible arrange for substitute prescribing
- Avoiding the intravenous route
- Using needle exchanges and not sharing needles
- Give contraceptive advice and encourage safe sex practices
PRE-CONCEPTION ISSUES AND CARE
Pregnancy is often unplanned. Consider all contact as an opportunity for pre-pregnancy counselling with harm minimisation as above.
- Offer information about the potential effects of substance misuse on her unborn baby5
- Liaison with specialist midwives if pregnancy planned
- Review prescribed medication with the future pregnancy in mind. Simplify multidrug regimens if possible
- Use open and honest confidential questioning
- Provide regular surveillance with obstetric and midwifery team and assertive follow-up if non-engagement
- Serial scans from 28 weeks for fetal growth
- Information on the potential effects of substance misuse on the unborn baby and what to expect when the baby is born
- Offer referral to a substance misuse programme if indicated
- Offer referral to nutrition worker and consider supplementation of diet
- An empathetic service will enhance attendance11
- Take a comprehensive history to include health and social risk factors
- There should be a dedicated midwifery liaison post for continuity of care
- Work closely with substance misuse teams and community staff
- Offer support and information on the benefits of stability in drug use
- Be realistic about expectations and accept that abstinence does not always immediately improve the maternal situation
- Be aware that withdrawal from drugs can significantly impair capacity to tolerate stress or anxiety12
- Accept that the details given may not be entirely accurate
- Think about domestic violence and the significance of the partner in the women’s ability to engage with services6
- Ensure that the substance use doesn’t become the whole focus of encounters which can deflect from holistic assessment of midwifery care
- Work with local services to deliver a programme of parent education tailored to meet the client’s needs
- Understand that safeguarding the baby begins at conception and early intervention and support is appropriate
- More likely to present in advanced labour or deliver unattended if chaotic drug use
- Less likely to have support for labour
- Fluctuating levels of consciousness depending on recent drug use will impact upon the comprehension of labour events
- Provide clear information in labour as less likely to have planned choices
- Support of clients and use a non-judgemental approach
- Be alert to any child protection concerns and plans
- Ensure informed consent for care planning for labour
- Provide support as often women are ill prepared for labour and birth
- Be sensitive to the woman’s emotional state and potential difficulties in cases where child is to be placed with alternative carers after birth
- Act as woman’s advocate and work on a basis of mutual trust
- Instigate programmes of education and support before the baby is born
- Encourage the future parents to set realistic goals
- Consider the added pressure of being parents on the parent’s ability to remain drug free or stable on substitute medication
- Postpartum relapse rates are high and continuing support is very important
- Not all families need referral to social care but offer support following assessment
- Accurate and timely information and support throughout helps with safe decision-making and engagement with services
- Role of the male partner or absent father can be overlooked to the detriment of the assessment
- Do not presume abstinence will improve parenting skills as some parents use substance to maintain equilibrium12
- For a structured approach to care, use a formal assessment framework (see Appendix 16.1.1)
- Ensure relevant health care professionals are informed once the postnatal care plan is agreed
- Use alternatives to drugs of abuse wherever possible.
- Women who misuse opiates develop tolerance to the analgesic effects rapidly
- Further opiate analgesia can be given postpartum but substitutes can usually be found
- Involve anaesthetic colleagues early for postpartum pain relief advice
- Clear, open discussion about family planning appropriate with follow-up
- Support safe care of the infant
- Encourage the mother to care for baby whenever possible
- Breast-feeding as for all women and babies has many benefits not least the nutritional value, immunological benefits, maternal-child bonding and reduction of SIDS
- In the UK the only absolute contra-indication to breast-feeding is HIV positive status. However, chaotic and persistent drug use will impair conscious levels and affect the mother’s ability to commit to successful breast-feeding
- Encourage breast-feeding if the mother is stable on prescribed medication and abstinent from illicit drug use
- In the immediate hours and days after delivery maternal exhaustion may compromise effective breast-feeding
- Use the full post-natal inpatient stay to teach and assess parenting skills
16.2 Alcohol Addiction
EXPLANATION OF CONDITION
Although legal, the social use of alcohol can evolve into dependency and even moderate levels of drinking in pregnancy may be harmful. Whilst the long -term health risks of alcohol misuse can seem distant, pregnancy can bring the associated risks sharply into focus and provides an opportunity for intervention.
The NHS recommends that non-pregnant women should not drink more than 2–3 alcohol units daily. Fifteen percent regularly drink more than this and overall rates of alcohol use have increased most rapidly amongst women3,4.
During pregnancy the Royal College of Obstetricians and Gynaecologists recommend limiting use to 1–2 units taken 1–2 per week5. Whilst there is no conclusive evidence that drinking alcohol within this limit is harmful there is widespread confusion over the number of units within each drink and the clearest message is to recommend abstinence during pregnancy3.
Box 16.2.1 gives examples of how the number of units of alcohol relates to both the amount and the strength (AbV) of each drink.
COMPLICATIONS
Maternal Complications
- Alcohol intoxification leads progressively to disorientation, loss of consciousness and respiratory depression
- The effects are potentiated if accompanied by illicit drug use
- Vomiting and risk of aspiration
- Impaired fertility
- Obesity
- Domestic violence, social and financial harm
- Sexual risk taking and unwanted pregnancy
- Long-term risks include increased risk of head, neck, throat cancer; breast cancer risk increased up to 50%, liver cirrhosis, and hypertension
Fetal Alcohol Spectrum Disorder
In Western countries fetal alcohol spectrum disorder affects just under 1% of pregnancies and has been reported with apparently moderate amounts of alcohol6. Features include:
- Facial features are characteristic – subtle facial features of the condition such as a smooth philtrum, thin upper lip and flattened nasal bridge2,8. You will see from the list below that these features alone are unlikely to be the main concern and will often go unnoticed
- Disproportionately low height to weight
- Intellectual impairment
- Structural brain anomalies such as agenesis of the corpus callosum and microcephaly
- Poor language and comprehension skills, poor abstraction, memory, attention and judgement
- Structural brain anomalies such as agenesis of the corpus callosum and microcephaly
- Increase rate of cardiac defects
- Behavioural difficulties
- Poor social skills persist and lead to secondary disabilities later in life that include:
- depression
- running away
- anger and aggression
- low self-esteem
- mental health problems (90%)
- disrupted school experience (60% of those over 12 years)
- trouble with crime (60% charged or convicted)
- substance abuse (30% over 12 years)
- dependent living (over 80% 21 years and older are in dependent living situation)
- depression
NON-PREGNANCY TREATMENT AND CARE
- Provide information on long- and short-term effects of alcohol use
- Identify simple measures that can reduce or eliminate intake
- Those who abuse alcohol rarely drink weak alcoholic drinks
- Reduce units by substituting some alcohol for a mixer. e.g. adding soda to wine, lemonade to lager. This will mean the person can still have four ‘drinks’ but the number of units will decrease
- Address behavioural triggers for alcohol use
- Identify whether there is tolerance
- Identify whether there is dependency
- Once dependency has developed there is a risk of withdrawal if alcohol use is stopped suddenly
- Detoxification requires an individualised plan and multidisciplinary involvement with local treatment services. Admission to hospital for detoxification is often necessary
PRE-CONCEPTION ISSUES AND CARE
- Women need to be advised of the long-term health problems caused by alcohol
- The risk of fetal alcohol syndrome is as high as one in three at >18 units alcohol per day5. However, it also occurs with lower consumption: there is no proven safe drinking threshold
- Recognise that many of the children affected by alcohol in pregnancy will not manifest with a complete clinical diagnosis of fetal alcohol syndrome, but will exhibit some of the features particularly learning difficulties, behavioural and psychological symptoms. The broader term fetal alcohol spectrum disorder captures a continuum of permanent birth defects due to alcohol some of which will be quite subtle5,7,8
- Fetal alcohol spectrum disorder affects 1% of all newborns making it the leading cause of ‘preventable’ birth defects
- Binge drinking may be especially harmful as is sustained, regular heavy drinking
- Miscarriage
- Pre-term delivery (doubled by heavy drinking)
- Growth restriction
- Fetal alcohol spectrum disorder
- Consider the partner and who may be a stabilising (or destabilising influence)
- Child protection issues (if any) should be addressed antenatally and a clear postpartum plan devised
- Serial growth scans: note particularly third trimester head circumference
- Gamma-GT (GGT)
- As part of the liver function test serial GGT measurements can be used to monitor alcohol use in much the same way that an HbA1C gives an indication of diabetic control. Measuring GGT is a tangible way of providing feedback to women and demonstrating a positive effect if alcohol consumption is reduced or discontinued. GGT, however, is a relatively insensitive marker and a normal GGT at booking may fail to highlight women who continue to drink
- FBC. Evidence of long-term alcohol misuse may result in a macrocytic anaemia (increased MCV)
- Provide information on the effects of alcohol use in pregnancy to every pregnant woman and be prepared to discuss the impact of alcohol on the unborn baby
- Be alert to making assumptions on alcohol use based on culture, ethnicity or social class
- Assess every pregnant woman for alcohol use in pregnancy and be aware of local referral pathways
- Be alert for any child protection issues
- Prior to labour the birth plan should be reviewed
- It is helpful to discuss views on treatment and investigations antenatally as intoxication may impair consent when labour starts
- Fetal growth restriction may be present and continuous CTG monitoring is warranted
- Anaesthetic review if intoxicated, because of risk of further analgesia and respiratory depression
- Where women have found it difficult to reduce or stop alcohol intake during the pregnancy offer further support and follow-up
- For those at risk of long-term health problems offer hepatitis C and BCG vaccinations
- Neonatal review is indicated but a diagnosis of fetal alcohol spectrum disorder cannot be confidently made in the neonate
- Ideally social, financial and psychological issues will have been identified antenatally and support can continue into the postnatal period
- If a woman is suspected to be withdrawing from alcohol it is important to get a clear sensitive history of how much she has been drinking in order to offer medication and support if appropriate
- An extended postnatal stay offers the chance for parenting skills to be reviewed and supported
16.3 Tobacco and Cannabis Use
EXPLANATION OF CONDITION
Cannabis is the most commonly used illicit drug in pregnancy, estimated at 3.5%4 but under-reporting renders percentage estimates and pattern of use in pregnancy as unreliable.
Cigarette smoking in adults is addictive and while legal and socially acceptable in some communities it remains the greatest single preventable cause of illness and premature death in the UK5.
Smoking amongst women has continued to rise over the last decade and this is reflected in high rates of smoking whilst pregnant despite advice to stop and an increasing awareness of the associated health risks.
Women who use illicit substances are more likely to smoke tobacco. The impact of smoking, however, can easily be overlooked although it has the potential to cause as much direct harm through maternal ill health and placental damage as the illicit substances themselves.
Almost all women who smoke cannabis also smoke tobacco and this is a major confounder when analysing the effects of cannabis on the pregnancy and after birth. Cannabis may be smoked with tobacco as a ‘joint’, or inhaled through a pipe or ‘bong’. Occasionally it may be baked and eaten within cakes or biscuits. Cannabis comes in several forms: a resin (hash or hashish); dried leaves (marijuana, grass or weed); ‘skunk’ is its strongest form. The effects are immediate and last for one or more hours. Cannabis strength has increased over recent years and placental transfer to the fetus of the active cannaboids is one-third that of the maternal plasma levels6.
COMPLICATIONS
Smoking tobacco increases the risk of infant mortality by an estimated 40% due to:
- Fetal growth restriction
- Placental abruption
- Pre-term labour
- Stillbirth
- SIDS
Both SIDS and growth restriction are directly correlated to the amount smoked. The increase of SIDS and neonatal death may be attributed both to smoking in pregnancy but also to exposure after birth by either parent or carer. The Foundation for the Study of Infant Deaths (FSID) estimated that in the UK if no woman smoked in pregnancy over 100 babies each year could be saved7.
Smoking cannabis:
- Cannabis does not appear to increase the risk of low birth weight, pre-term delivery or placental abruption beyond the risk of any concurrent tobacco use8
- Cannabis has been shown to increase anxiety, panic and paranoia and can lead to dependence
- Cannabis increases the likelihood of developing a psychotic illness where there is a family history
Smoking tobacco
- Women who smoke are at increased risk of chest infections, respiratory problems and DVT
- Smoking cigarettes does not alter consciousness. However, smoking cannabis or other drugs does so and needs to be factored in to any assessment of parenting
NON-PREGNANCY TREATMENT AND CARE
The NICE public health guideline on smoking suggests everyone who smokes should be advised to stop unless there are exceptional circumstances9. This guidance may be downloaded at www.nice.org.uk/nicemedia/live/11375/31864/31864.pdf
In the UK the NHS Stop Smoking Service has a comprehensive menu of services and support available to people who wish to stop and the public health guideline outlines the process.
If a woman is smoking cannabis, she should be offered referral to a specialist stop smoking advisor or a substance misuse treatment centre as she may anticipate increased challenges in stopping use.
PRE-CONCEPTION ISSUES AND CARE
- The current UK position is clear and any woman planning a pregnancy should be encouraged and supported to stop smoking
- For women who do not wish to stop smoking advice should be given and appropriate information offered by a specialist advisor
- Nicotine replacement therapy (NRT) is only recommended if other interventions have failed. Evidence surrounding the use of NRT is mixed, but there is currently no convincing evidence that it is effective or improves birth weight
- A 2-week course is prescribed solely for daytime use. The prescription is only repeated if concurrent smoking has ceased10
- The community midwife should follow the NICE guideline in early discussion and appropriately monitor carbon monoxide readings from the first visit and refer to the stop smoking service
- Inform about the risks associated with smoking in pregnancy and exposure to second hand smoke, including the health message to stop rather than cut down
- If a woman is also dependent on other substances, sometimes stopping smoking is the only thing she feels she can do for her baby and the benefits of doing so should be highlighted and encouraged
- Studies have shown that motivational interviewing, structured self-help and support from stop smoking services and cognitive behavioural therapy are all effective interventions in pregnancy
- Evidence also shows that giving pregnant women feedback on the effects of smoking on their health and that of the fetus is not an effective tool in smoking cessation although giving informed choice10
- If a woman is smoking cannabis then safeguarding assessment and information should be available from the outset and safety planning commenced. It needs to be considered that while cannabis use is very common in some communities, use to the point of intoxication when in charge of a child is a safeguarding issue. Use of cannabis is to be discouraged and abstinence encouraged
- Bed sharing should be discouraged due to the increased risk of SIDS11
- All of the advice and the benefits from smoking cessation also apply to partners
- Care should be managed as for any other woman
- Recent cannabis use may impair alertness and concentration and therefore the ability to consent to treatment
- If there is fetal growth restriction then continuous CTG monitoring is appropriate
- All smoking should be discouraged once labour has commenced
- Remain supportive throughout
- Refer to medical staff if concerned about cannabis use and maternal mental health or if evidence of maternal withdrawal
- Milk production may be reduced by smoking12
- If cigarette smoking continues the benefits of breast-feeding still outweigh the potential for harm
- Craving for cigarettes can lead to early mobilisation and this can risk wound breakdown after caesarean section
- Smoking is an independent risk factor for thromboembolism; if immobilisation after operative delivery is expected then thrombopropyhlaxis is indicated
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