Pregnancy requires less than a year in the lifespan of a woman, but its impact on her future is enormous. Prenatal care is designed to guide women through pregnancy and to identify medical problems early and manage them successfully. All pregnant women can benefit from this care, but it is especially important for women with a history of substance use disorder (SUD).
Studies that demonstrate a close tie between receipt of prenatal care and improved outcomes in the typical pregnancy have been limited; however, a number of studies have found that the connection between prenatal care and resultant improved outcomes is strong for pregnant women with SUD. In a retrospective review from 1992, Broekhuizen et al. demonstrated that a minimum of 5 prenatal visits was associated with better outcomes in patients who used illicit drugs . Berenson et al. found that having more than 3 prenatal visits was associated with better pregnancy outcomes for women using cocaine . El-Mohandes et al. performed an extensive review of a Washington, DC, population in the mid-1990s and found that the highest rates of prematurity and low birthweight occurred in women who had no prenatal care and who used illicit drugs during pregnancy, and that these rates decreased as the number of prenatal care visits increased . Although many of these studies suggest a dose–response curve between the number of prenatal visits and desired outcomes for pregnancy in women with SUD, the content or quality of the prenatal care these women received is largely unaddressed.
This chapter focuses on those elements of prenatal care that our experience suggests might require special attention in the pregnancies of women with SUD. Many elements of care remain constant, but the manner in which prenatal care is provided will differ greatly by circumstance. Not only do individual patient characteristics vary, but also the care women receive in resource-rich suburban settings is likely to be quite different from that provided in rural areas or in large inner-city settings. The literature offers scant support for the best practices suggested here, but they are offered to prompt discussion about how to maximize prenatal care in the office, clinic, or bedside. The goal is to provide the reader with tools that may assist in the care of women with these special considerations.
When care is provided by many individuals and for multiple conditions, there is a danger of missed care, contradictory recommendations, and suboptimal coordination caused by poor communication. All efforts must be made to prevent patients from being lost in a maze of appointments, meetings, and missed telephone calls. For many women with SUD, life is chaotic; pregnancy adds another level of complexity. It is paramount that the patient remains in the center of the care model (Figure 9.1).
Figure 9.1 Patient-centered model of care for pregnant women with SUD
For the obstetric care team and the addiction team, care coordination should occur at the first opportunity. In most pregnancies, the obstetrical care provider (obstetrician, family medicine provider, or nurse-midwife) serves as the coordinator of care. Training or experience in addiction care may vary, but either the obstetrical provider or an addiction provider must possess this competency. It is important to assess patient needs and who might best provide the necessary care. Who will prescribe which medications? Who will coordinate care to make sure she is not lost in the system? How will information be shared and with whom? It is important to have all the necessary release of information forms signed so all parties to the patient’s care can communicate with each other.
The rate of unplanned pregnancy is 50 percent for the general population [4, 5], but for patients with SUD, the rate may be as high as 85 percent . Opioid use may affect ovulation, so irregular menses are more common in women who use them . Contraception is used by approximately 50 percent of women with SUD. Many have a long history of unprotected intercourse without pregnancy , which leads them to believe that they could not conceive. Some early pregnancy symptoms may resemble withdrawal symptoms for some women, which further delays recognition of the pregnancy. Once they are sure they are pregnant, they may worry about how their pregnancy will be received by their partner, family, or treatment team. Some fear being pressured, or even forced, to terminate the pregnancy. Others worry that the pregnancy might require them to discontinue medically assisted treatment (MAT). An important aspect of early prenatal care is to address any patient concerns and expectations.
In our clinic, two-thirds of pregnant patients with SUD are already receiving addiction care when they arrive for their first prenatal visit. Many notify their methadone or buprenorphine clinic providers early in the pregnancy, and we prioritize early access for these patients in order to introduce them to prenatal care, often before 8 weeks gestation. The other third of our patients are actively using drugs at their first prenatal visit and have had limited exposure to health care since childhood. They arrive at unpredictable durations of pregnancy and through multiple points of entry, including emergency services, county health departments, and jail medicine.
A positive pregnancy test may prompt patients to immediately discontinue all medications without consulting a professional. While it is difficult for many professionals to truly know what is safe, it is even more difficult for patients. Even during pregnancy, the need to treat some illnesses outweighs the disadvantages of the medications used to treat them. This complexity is well demonstrated with bipolar disorder in pregnancy. Very few of the medications used to treat bipolar disorder have been well studied in pregnancy; however, the relapse rate for bipolar disorder for patients who discontinue mood stabilization medications may be as high as 70 percent, more than double the rate of those who stay on their medications [9, 10] – and relapse can be deadly for the mother and her fetus, especially if she becomes suicidal.
Because early pregnancy is a time of organogenesis, a review of patient medications should be conducted as early as possible, perhaps even before the initiation of formal prenatal care. We must determine which of those medications she is currently taking are safe to use, which should be discontinued, and which should be started. The obstetrical team, the addiction team, and sometimes the psychiatric care team may share this responsibility, often with the assistance of an experienced pharmacist. Online resources, such as Reprotox (reprotox.org), offer continually updated and concise information about the safety of medications during pregnancy.
Women with SUD are encouraged to begin prenatal care as early as possible. As soon as they become known to the team, they should be seen for initial evaluation and triage to appropriate care – not made to wait for a “new patient” opening on the provider’s schedule.
Early Prenatal Care
Patients should be educated about the benefits of prenatal care, their responsibilities, the frequency of visits, the duration of visits, and tests to be performed during pregnancy. Prenatal care begins with a thorough history of medical and obstetrical concerns, and also with a review of previous addiction and mental health care. Knowledge of the patient’s patterns of use, along with any previous treatment successes and failures, will help the care team individualize the care plan to her advantage. Is she currently using? Does she have an established relationship with an addiction provider?
Does the patient intend to carry the pregnancy? A review of the literature failed to identify studies that investigated the frequency, timing, or complications of abortion in women with SUD. Martino et al. found no association between abortion and subsequent drug use. They concluded that women who used substances were more likely to engage in behavior that led to unplanned pregnancy, but that reducing substance use would not lead to fewer abortions .
Pregnancy may be the patient’s first experience with medical care since childhood and presents an important opportunity to introduce her to substance use treatment. Both pregnancy and addiction care represent major life events, so to face both at once can be challenging. In our experience, treatment-naive women are at increased risk of relapse through the pregnancy and postpartum.
It is important to introduce risk mitigation strategies early in the pregnancy (harm reduction). These strategies should include those intended to reduce exposure to drugs and prevention of overdose, including the prescription of naloxone. Other environmental risks, such as shared needles, should also be considered. Patients should be educated about, and assisted in avoiding, sexually transmitted infections; in this effort, clinics may consider providing condoms. Patients should be screened for a history of domestic abuse or violence. Medications the patients need in early pregnancy (prenatal vitamins with folate and anti-emetics, for example) should be determined.
Social services must be actively involved in early pregnancy to understand the resources needed for the individual patient. For patients already established and stable on MAT, care may not be much different from that of the routine prenatal patient. For many patients, needs assessment focusing on the basics must be a priority: housing, food, security, and a secure legal status. In her review of the relevant literature, Schempf questioned the degree to which poor pregnancy outcomes are related to the drug use itself versus the social, economic, and psychological factors that frequently surround drug use. She concluded that these factors would need to be addressed in order to improve pregnancy outcomes . We agree that these issues must be addressed as early as possible. Furthermore, many of these concerns need to be revisited repeatedly over the course of the pregnancy. An experienced social worker remains an invaluable member of the team throughout pregnancy and the puerperium.
The patient’s initial physical examination should focus on known physical risk factors for patients with opioid use disorder (OUD). Patients who have injected medications may be at risk for hepatitis, cellulitis at injection sites, or even subacute bacterial endocarditis with associated murmurs. Laboratory evaluation should include screening for hepatitis C virus infection. Screening for sexually transmitted infections is also important at initiation of care and during the third trimester.
Prenatal genetic testing should be considered and offered, as would be done in routine prenatal care and for the usual indications. If the patient enters prenatal care early enough, she should be offered nuchal translucency, maternal serum screening, or noninvasive prenatal testing. Other options for genetic testing include chorionic villus sampling and amniocentesis. A fetal anatomical survey at the time of a second-trimester ultrasonographic examination at 18–22 weeks should also be conducted.
Smoking and OUD are both associated with increased risks of premature labor and intrauterine growth restriction (IUGR), so efforts should be made to limit or prevent both activities. Patients will often make a commitment to cut back or quit smoking before the baby is born; however, Burns et al. reported that it was harder for women with SUD to quit smoking . Nurses, doctors, and other providers should utilize frequent visits in early pregnancy to stress the advantages of smoking cessation. Other centers have found that focusing on smoking cessation improves overall addiction treatment success and that this focus is more readily accepted because smoking carries a less severe stigma. Smoking cessation programs with proven success are widespread. Although the US Food and Drug Administration has not approved the use of nicotine substitutes in pregnancy, the treatment team may also consider this tool. Other medications, such as buproprion, have been studied in pregnancy and found to be successful in decreasing cravings . Varenicline has not been well studied in pregnancy.
The rates of premature labor and IUGR for women with SUD are known to be higher than those for the overall population, so accurate pregnancy dating obtained in early pregnancy is vital [15–18]. In our experience, 77 percent of our patients with SUD are unable to date their pregnancy based on last menstrual period or probable date of conception, compared with 36 percent of our patients without SUD (unpublished data). Early ultrasonographic examinations are highly recommended for a number of reasons:
To ensure viability. If a spontaneous abortion (miscarriage) is destined to occur, we believe it is preferable for our team to provide patient-centered care and emotional support, as we have found increased use or relapse to be associated with miscarriage. The pregnancy may be met with ambivalence, and miscarriage may be met with a range of emotions, including relief, grief, or self-blame. Early counseling can help the woman process these emotions and reassure her that she did not cause her miscarriage.
To determine her due date. As stated above, this may prove very useful later in pregnancy, when accurate dating is paramount to diagnosing preterm labor or IUGR.
If the patient plans to terminate the pregnancy, accurate dating must be known prior to referral.
To help the patient gain a perspective on the pregnancy being real. Patients speak positively of the value of visualizing the pregnancy, and we feel that it may help to secure patient buy-in and cooperation. Some literature supports that visualization of the fetus aids in decreasing drug use and improving compliance [19, 20].
We are unaware of any untoward or negative impacts from such an ultrasonographic examination.
Ongoing Pregnancy Care
Late or missed appointments are common among patients with SUD, so obstetric care teams need to be patient, flexible, and forgiving. Some patients may be seen only once, while others have as many as 20 visits over the course of the pregnancy. No appointment should be routine; instead, if possible, pack each encounter with social service visits, patient education, and visits with other people who can add value to her care – whether dermatology, dietary, dentistry, or other specialties – per the patient’s needs. Ideally, the majority of needed services will be co-located, but if not, arranging transportation and coordinating visits can aid with compliance. Goals should be set for each visit. Consider providing healthy snacks. Ease of access to necessary services is key. Providing childcare for the woman’s other children as well as transportation improves attendance at prenatal care as well as drug treatment and should be provided if at all possible.
Throughout the pregnancy, it is important to continue to assess mental health. Zilberman et al. reported that as many as two-thirds of women with SUD also experience mental health disorders, such as depression, anxiety and panic disorders, and posttraumatic stress disorder . Holbrook and Kaltenbach reported that 67.3 percent of women in an SUD program carried a diagnosis of depression, anxiety, or both . Many patients are taking antidepressant, antianxiety, or antipsychotic medications, as is discussed in more detail in Chapter 4. It is critically important to make sure that the medications are safe, effective, and not causing unacceptable side effects. A number of questions concerning the patient’s mental health care must be answered: Who will prescribe any related medications? How will communication be maintained to avoid lapses in treatment or abrupt termination of medications? Is the patient seeing a counselor/therapist? With proper release of information forms signed, communication between the pregnancy team and counselors should provide insight into the patient’s adaptation to pregnancy and treatment for substance use disorders (SUD).
This patient population tends to have high rates of urgent care and emergency service visits . We attempt to minimize these visits by anticipating when patients might seek emergency care and coach them about how to manage specific problems when the clinic is closed. Dental pain is one of the most common reasons for emergency service visits for these patients. Many have decaying or infected teeth caused by inadequate or absent dental care. They often seek emergency care to obtain antibiotics and pain medications. Providing early referrals to dentistry as well as communicating with the dental care providers on safe care of pregnant women can help prevent these emergency visits. Dental colleges, public clinics, or community dentists can be good resources to see these patients. Obstetric teams should also identify oral surgeons and prosthodontists willing to move these patients up their long wait lists to perform extractions and obtain dentures.
Drug testing during routine prenatal care is controversial. Some addiction treatment experts recommend routine testing. However, this can be problematic during pregnancy, as it increases the chance of the woman having child welfare or legal involvement without clear evidence that it improves pregnancy outcomes. With proper consent, patients on MAT are generally recommended to undergo urine drug testing throughout pregnancy. These tests may be random or regular, depending on patient needs. Results should be shared with the addiction care team to minimize excessive screening. If urine drug testing is done, it is imperative to set a proper tone for this testing. It should be done in partnership with the patient; the goal is to demonstrate that she is remaining free of nonprescribed medications or drugs – to build a case for her rather than against her. Interpreting drug testing results can be difficult, all positive screening tests need to be sent for confirmatory testing with GC-MS if they are to be placed in the patient chart. Please see Chapters 2 and 3 for more discussion on drug testing.