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MRCOG PART 2 SBAs and EMQs

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notes	336
EMQ	1502
SBA	2115

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ESSAY 196 - Drug abuse in pregnancy

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		Posted by QWE Q. Thu Jul 6, 2006 05:22 pm
Multidisplinary team work is required ie - psychiatrist; GUM; obstetrician; drug worker to try and improve pregnancy outcome. Pregnancy is associated with PPROM; preterm labour; IUGR, still birth; probable impaired neurological outcome. Drug use is associated with multifactorial co morbidities; smoking; drinking; high risk sexual behaviour; poor nutrition and poor clinic attendance. These contribute to adverse outcome. Principle of therapy include risk minimisation. Ie - cutting down smoking; drinking. Using clean needles instead of dirty needles; using oral instead of IV drugs. Telling a user to stop taking heroine is unlikely to be effective Allow multiple channels to access health care; deal with health issues as opportunity arises (ie when ever they turn up - how ever this is) Assessment of STD\'s, HEP B,C, HIV. These should be repeated Advice and supply of free condoms to minimise std aquisition in pregnancy. These need rechecking at 36 wks. STD\'s carry risk of adverse outcome and fetal anomaly (eg syphilis) and should be treated. Identification of HIV/HEP b allows interventions that either help prevent transmission and /or improve maternal outcome. Assessment of conditions associated with drug use - CXR for TB; echocardiogram for endocarditis and valve disease. Appropriate physician input required. Consideration of methadone replacement treatment. This may improve outcome by preventing need for street crime to fund addiction; and improve clinic attendance. Benefit is lost if illegal IV drugs are used as top up. Identification and treatment of co - morbidities associated with srom - ie asymptomatic bacteriuria. Poor clinic attendance and adverse social circumstances are hard to address. Fetal surveillance - these pregnancies are associated with IUGR; and may require earlier delivery - monthly growth scans. Drug use (apart from alcohol) has not clearly been linked to teratogenicity. But encouragement given to avoid poly pharmacy. Awareness of patient of delivery suite; anaesthetic considerations include tolerance to anaesthetic agents; paeds should be present at delivery. Delivery should have continuous CTG Baby should be observed 2 to 4 days post delivery for withdrawl syndrome. Oppotrunity to immunise against Hep B; Hep B IVg if necessary. Social worker input; there may be increased need to watch the child in the community and ensure ongoing protection.
		Posted by Balakrishnan V. Thu Jul 6, 2006 08:05 pm
Drug abuse in pregnancy is associated with fetomaternal morbidity and mortality. The principles of her management should include care of her social problems, health problems and drug abuse poblem. She should be cared in non judgemental and sensitive mannar by health personnal who are familiar with her problem and have been trained to tackle them. She should be cared by a multidisciplinary team involving obstetrician, neonatologist, drug specialist, social worker and community midwives. In her booking visit detailed history is taken to findout about what drug/drugs she takes, through which route/routes, dose and for how long she has been taking them. How severe are the withdrawal symptoms and any other associated problem of alcohol abuse, smoking, malnutrition. What is her attitude towards her pregnancy and future plan of care of the baby. Is she financially stable, have family or friends. Is she a victum of domestic violance. Whether she is in a stable relationship and is her partner is also a drug abuser. In such case her partner also needs counselling to make home environment not encouraging for drug abuse. All this information will help to make a care plan of her pregnancy and to address her needs. Booking bloods are taken to test for hepatitis B, C and HIV . She should have an appointment with genitourinary specialist to screen for sexual transmitted diseases which are more common in drug abusers due to their life style. She should be stressed upon maternal risks of drug abuse, which are preeclampsia, abruption, preterm labour, arteriovenouse thrombosis and fetal risks are IUGR, IUD, and withdrawal symptoms. She should be strongly encouraged to go onto methadone detoxification programme if she is a heroin addict. Methadone is slowly metabolised and remains at more stable levels than opioids thus less risk of fetal distress and preterm labour.The dose of methadone is gradually reduced to the minimum dose and maintained as long as required. She should be advised not to share needles. She should have a dating scan and as the fetus is at increased risk of small for gestational age she should have monthly and after 32 weeks fortnightly growth scans. A care plan of the baby is made by social worker, health visitor, drug team and the patient at 32 weeks. If she is not compliant with her antenatal followup, she should have home visits. In labour dose of opioid analgesics has to be increased. Epidural analgesia is safe and prefrred choice. Paediatrician should be present at delivery and baby should be monitord for neonatal narcotic abstinence syndrome. The breast feeding is encouraged as severity of withdrawal symptoms are reduced. She should be given proper contraception before her discharge. A community midwife and social worker should care for her at home postnatally as she will need more support and baby is at increased risk of SIDS, negligence and non accidental injuries.
		Posted by Ebeinheizer S. Thu Jul 6, 2006 08:27 pm
Underlying principle would be to reduce and prevent maternal and fetal morbidity and mortality. A multidisciplinary approach should be taken right from the beginning involving the GP, Community Midwife, Social Worker, Obstetrician and in some cases Genito-Urinary Medicine Clinic, Psychological Medicine Specialist. When management involve potentialy criminal activities like stealing to finance drug abuse, the police might have to be involved. A specialist team in substance abuse (in my hospital consists of specialist midwives under consultant supervision) would take the lead in identifying the appropriate rehabilitation programme. \"Cold turkey\" approach is not suitable in pregnancy. Methadone replacment programme has shown to have a greater success rate. In the event of co-existing smoking problem, nicotine patches can be offered as well. Affect of intra-venous substance abuse on the mother would underlie maternal management. Generaly, IVDA are nutrition depleted, have underlying psychological problem, poorly compliant to drugs or appointments and have other social problems as well. They are also at greater risk for needle/serum transmitted infection such as Hepatitis B/C, HIV and sexually transmitted diseases such as syphillis and gonorrhoea. Screening, contact tracing and treatment would be necessary if any diagnosed. Undeniably, intra-venous substance abuse would affect the fetus/pregnancy. In the first trimester, there is a great risk of tetratogenicity from the drugs. As she is already 14 weeks, detailed anomaly ultrasound would give a lot of information on subsequent management. If there is maternal HIV, vertical transmission is a potential problem and the mother would need anti-retroviral (AZT) treatment. In second trimester,potential risk of IUGR would mandate regular 3-4 weekly growth scan after 24 weeks. In the third trimester, there would be higher risk of placental abruption and precipitate labour. The mother should be advised to come to the hospital at the earliest signs. Labour might pose challenges in analgesia and anaesthesia as IVDA might need higehr dosage of drugs and intra-venous access would be difficult. Senior anasthetist would need to be involved for this. Puerperium would need thromboprophlaxis per protocol, anti-D if Rhesus negative and contraceptive advice with written information. Pre-pregnancy Folic Acid 5mg before next pregnancy would also be advised.
		Posted by Remi A. Fri Jul 7, 2006 05:06 am
The woman\'s recreational behaviour is associated with increased maternal/perinatal morbidity and mortality.It also put Healthworkers caring for her at risk of violence and transmision of infection. She is at risk of Hepatitis B,C,HIV[and other STIs],abruptio[if taking cocaine]. Fetal risks are vertical transmission of infection,IUGR,preterm delivery,and neonatal withdrawal syndrome. The approach to this woman should be sensitive and non-judgemental.The management should be multidisciplinary involving the obstetrician,General practitioner,Specialist midwife,Drug Dependence Physician,Health visitor and social worker. Its important to enquire about the drug[s] she abuses and the source,as these would help to tailor her rehabilitation. Its may be difficult to stop her from the drug abuse-proactive measures like putting her on methadone program,and provision of sterile needles and syringes would be more productive.This should be done in close liason with Drug Dependence Physician. The treatment program should invovle the partner/husband,as these may help with compliance. She should be counselled and offered screening for Hepatitis B,C,HIV and other sexually transmitted infections.If she screen positive,She should be managed in conjunction with Genitourinary medicine clinic. Joint clinic would be more appropriate,as she is likely to be a poor attendee. She should have serial growth scan[+/- Dopplers],because of increased risk of IUGR and IUD. She should have anaesthetic assessment as there may be difficulty with venous access in labour. Healthcare workers should take appropriate precautions to avoid violence at each visit. A multidisciplinary conference should be held at 32/40 to determine the care of the baby. Epidural may be a better analgesic option in labour,as there may be opiate dependence. Standard infection control measures should be taken during delivery to prevent transmission of infection to health workers. Breastfeeding is not contraindicated. The baby should have neonatal assessment for withdrawal syndrome. The baby should be screen for infection like HIV,Hepatitis vaccination provided.
		Posted by Tanzeem Sabina C. Fri Jul 7, 2006 06:50 am
The main underlying principles of this lady is to reduce the complications associated with drug abuse and to prevent fetal and maternal morbidity and mortality. Main aspect of her taking care is nonjudgmental approach with involvement a multidisciplinary team including GP, Community midwife, Social worker, Addiction counsellors, Health visitors, Obstetrician, Psychological medicine specialist, Neonatologist and Genitourinary physician, in some cases. A detailed history and clinical examination should be undertaken including the types, quantities, pattern (IV, IM or oral)and duration of drugs used,about nutritional status of the mother with any other associated factors such as alcohol, smoking should also be asked. About socio-economic history, whether she is living alone or has a stable relationship, any relative or friend, any evidence of domestic violence, whether any homelessness or chaotic lifestyle which will help in planning her future care of her pregnancy and any help she needs. An ultrasound scan is performed to confirm the gestation and detailed anomaly scan, as there is higher chance of teratogenicity from the drugs. A vaginal swab is taken to screen for anaerobic vaginosis. Booking blood is taken for Hep B, HepC testing and HIV testing should be offered. A genitourinary physician is involved in her care if positive for any of the above diseases. She should be aware about the maternal risks of drug abuse: preeclampsia, arterial thrombosis, placental abruption (specially cocaine user), and preterm delivery. Fetal risks are IUGR, IUD, and neonatal risk is neonatal withdrawal syndrome, sudden infant death syndrome(SIDS), vertical transmission of disease. If she is on \'street heroin\', she should be strongly encouraged to go onto a detoxification programme with maintenance therapy with methadone. The dose is maintained as long as required and can be slowly reduced, if she is agreeable. In the event of associated smoking problem, nicotine patches can be offered simultaneously. Anti-retroviral Zidavudine) or HAART should be offered if she is HIV positive Serial growth scans are arranged from 28 weeks onwards every 2 weeks as there is chance of IUGR. Umbilical artery Doppler studies with assessment of liquor volume should be undertaken weekly from 34 weeks. A planning meeting is held at 32 weeks with the women, her partner, the community drug team, health visitor and social worker. The needs of the mother and baby during pregnancy and the necessity for a prenatal child protection are discussed. If she is not compliant for antenatal check up, home visit should be arranged, as 31 women had died during the last trennium (CEMACH-2000-02 report) who are drug/alcohol abuser.During labour dose of opiate may have to be increased,specially in IVDA and IV access would be difficult. Senior anaesthesist may need to be involved in this situation. Epidural analgesia may thus be a good idea. Neonatologist should present at delivery and after birth the baby should be observed on the postnatal ward for signs of withdrawal.Postnatal thromboprophylaxis should be given as per local hospital protocol. Anti-D should be given if Rhesus negative. There is contraindication of breast feeding if she is HIV-negative. She needs closed multidisciplinary follow up postnataly and the welfare of the child is ensured. A community midwife and social worker should aware about care and support of the mother and the baby as there are increased risk of SIDS, negligence and nonaccidental injuries. Contraception should be discussed before discharge.
		Posted by Kishor S. Fri Jul 7, 2006 10:22 am
Intravenous drug abuse not only affects the general health of the woman but poses a greater risk to fetus and parenting. The principles of management, therefore, extend beyond the care of pregnancy alone, and should have clear lines of communication, information sharing and multi-agency working in place during all stages of pregnancy and following birth. This will involve the GP, community midwife, obstetric and paediatric staff, health visitor, social worker and drugs worker. All decision-making processes should be clearly documented in the records. A holistic and consistent approach is necessary using an open, honest and non judgmental attitude during history taking and throughout the care. This will help to establish a relationship in which she will come out with all the valuable informations. In general, she is more likely to be receptive and motivated during pregnancy. At booking, a comprehensive assessment of risks should be made regarding the implications of the drug in terms of maternal and fetal risks, and safety and welfare of the newborn baby. Since these risks are dynamic and may change at any stage, all professionals involved need to ensure that they are continuously evaluated. In order to carry out risk assessment, professionals should consider the detailed advice given in Getting Our Priorities Right (Scottish Executive 2003) and this should be available in all clinical areas. Ensure a regular antenatal care as she is likely to be a defaulter. There is evidence that the outcome of pregnancy in such women is not different if she has regular antenatal care. Just like any other normal woman she should be empowered to make decisions about her care and be provided with evidence based information and advice. In addition to routine booking blood testing, screening of blood born virus (BBV) should be done as she is at greater risk for HIV and hepatitis (because of needle sharing) in addition to skin infection. She is also at a greater risk for sexually transmitted diseases. Anomaly scan and fetal growth monitoring should be similar to a care of high risk pregnancy along with intensive psychosocial support. Detoxification and motivation to stop the drug: The common intravenous drugs abused are opioids including heroin. They are associated with increased risk of IUGR, preterm labour and still birth. Use of Methadone should be considered and it will facilitate counselling sessions and reduce drug-seeking behaviours such as prostitution (thereby reducing the risk of hepatitis and HIV/AIDS). Labour and delivery do not differ except that she will require epidural for analgesia as other parenteral drugs will be ineffective. HBV prophylaxis and HIV screening will be done for the neonate as per maternal report. Lastly, try to identify the socio-economic circumstances that led to this abuse and any associated domestic violence. This should be followed by appropriate counseling with evidence and support. This will require appropriate referral criteria and pathways.
		Posted by Kishor S. Fri Jul 7, 2006 01:29 pm
Intravenous drug abuse not only affects the general health of the woman but poses a greater risk to fetus and parenting. The principles of management, therefore, extend beyond the care of pregnancy alone, and should have clear lines of communication, information sharing and multi-agency working in place during all stages of pregnancy and following birth. This will involve the GP, community midwife, obstetric and paediatric staff, health visitor, social worker and drugs worker. All decision-making processes should be clearly documented in the records. A holistic and consistent approach is necessary using an open, honest and non judgmental attitude during history taking and throughout the care. This will help to establish a relationship in which she will come out with all the valuable informations. In general, she is more likely to be receptive and motivated during pregnancy. At booking, a comprehensive assessment of risks should be made regarding the implications of the drug in terms of maternal and fetal risks, and safety and welfare of the newborn baby. Since these risks are dynamic and may change at any stage, all professionals involved need to ensure that they are continuously evaluated. In order to carry out risk assessment, professionals should consider the detailed advice given in Getting Our Priorities Right (Scottish Executive 2003) and this should be available in all clinical areas. Ensure a regular antenatal care as she is likely to be a defaulter. There is evidence that the outcome of pregnancy in such women is not different if she has regular antenatal care. Just like any other normal woman she should be empowered to make decisions about her care and be provided with evidence based information and advice. In addition to routine booking blood testing, screening of blood born virus (BBV) should be done as she is at greater risk for HIV and hepatitis (because of needle sharing) in addition to skin infection. She is also at a greater risk for sexually transmitted diseases. Anomaly scan and fetal growth monitoring should be similar to a care of high risk pregnancy along with intensive psychosocial support. Detoxification and motivation to stop the drug: The common intravenous drugs abused are opioids including heroin. They are associated with increased risk of IUGR, preterm labour and still birth. Use of Methadone should be considered and it will facilitate counselling sessions and reduce drug-seeking behaviours such as prostitution (thereby reducing the risk of hepatitis and HIV/AIDS). Labour and delivery do not differ except that she will require epidural for analgesia as other parenteral drugs will be ineffective. HBV prophylaxis and HIV screening will be done for the neonate as per maternal report. Lastly, try to identify the socio-economic circumstances that led to this abuse and any associated domestic violence. This should be followed by appropriate counseling with evidence and support. This will require appropriate referral criteria and pathways.
		Posted by adnan S. Fri Jul 7, 2006 09:06 pm
The principles of the management are multidisciplinary and non judgemental care involving obstetrician ,specialist drug clinic,GP.drug liaison midwife ,community midwife and socialworker. History is obtained about type of drug used ,quantities of drug and strength of drug used,any needle sharing and associated alcohol intake ,smoking.Social history like poor support ,domestic violence is also enquired.She is likely to be poor attender of antenatal clinic .and there is a potential risk of violence and infection to hospital staff.I will discuss the maternal risk due to drug abuse like poor venous access , APH-especialy abruptio placenta, risk of infections, about intra-partum analgesia and risk of withdrawl in puerparium.Fetal risks are IUGR,pre-term delivery ,vertical transmission of infections like HIV hepatitis B&C infectins neonatal withdrawl syndrome and sudden infant death syndrome. At booking dating scan is done ,blood tests for infection screening is done like hepatitis B &C .syphilis ,HIV,and these tests need to be repeated later in pregnancy.Routine screenining for downs syndrome and fetal anomalies is done .Dietary advice is given as she might be having poor neutrition along with supplementation of iron and folic acid.Cessation of smoking and alcohol is advised.Detoxification is un safe in pregnancy hence convert to safer substitute like methadone in consultation with special drug clinic,and reducing the dose if woman is agreeable.Fetal monitoring is done every two weekly from 26 wks onwords to monitor the growth and umblical artery Doppler studies with liquor assessment weekly from 34 week. A meeting is usually held around 32wks with woman and her partner present along with drug team ,community midwife and social worker to decide the need of the mother and baby and necessity for a prenatal child protection conference. Intrapartum care involves adequate analgesia she may needs higher dose opiates hence apidural analgesia is advisable.there may be difficulty in venous access .Continues fetal monitoring is done .Neonatalogist should be present at the time of delivery as there is risk of respiratory depression and neonatal withdrawl .Breastfeeding is controversial but not adviced if moman is using heroin may be safe in woman using methadone exclusively.If hepatitis B positive baby should be immunized with hepatitis B immunoglobulins within 12hrs of delivery and first dose of vaccine within 7days ,second and third dose at 1 and 6 months,baby is screened at 12-15 months.At the time of discharge about contraception is discussed and adequate social support is given.
		Posted by Aroosha B. Fri Jul 7, 2006 11:29 pm
The principles of management of this woman depends on awareness of maternal and fetal risks associated with drug abuse during pregnancy so that appropriate steps are taken during antenatal ,intrapartum and postanatal period to decrease the subsequent risk of maternal, fetal and neonatal morbidity and mortality. Maternal risks include poor nutrition leading to anemia and increased risk of infections like hepatitis ,endocarditis septicemia and local cellulites. They usually have poor social and economic support leading to non compliance to antenatal care ,theft and prostituition. They are prone to practice unsafe sex and share iv needles which increases the risk of acquiring STDS AND HEPATITIS B , C and HIV infection.they are also indulged in taking other drugs , smoking and alcohol which expose them to high risk of placental abruption , PET, and TED. Fetal risk include miscarriages IUGR,PTL.Neonatal risk involve withdrawl symptoms , vertically acquired infections , neglect and non-accidental injuries.Moreover the hospital staff is at risk of acquiring infections. As regards her antenatal care , I will ensure multidisciplinary approach to create confidential , reassuring and nonjudgemental environmenant.which wil include input from midwife , pedriatition , healthworker , social worker and drug abuse counselor.i will take detaled drug history including type , how often and how much drugs have been used . I will also enquire about consumption of alcohol and smoking. It is also important to explore the reason of why she has been taking theses drugs, that is ,is there any associated health and psychological problems so that appropriate steps are taken . I will also ensure about her social and financial stability so that social and economic support is arranged if required.It is also important to ask about unsafe sex and sharing of iv needles which will put her at high riskof STDS,and infections. I will discuss the risk of drug abuse during pregnancy and steps which might be taken to decrease the risks like decreasing the dose of drugs , change to other routes , compliance to drug detoxification programmes with maintenance therapy in collaboration with drug addict . withdrawl of drugs are not usually advised as it can lead to relapse with severe consequences . anyhow she will be advised to stop smoking and decrease the intake of alcohol. A s this is her booking visist , she will be advised to take good diet and nutritional support and to have regular antenatal visits.In the absence of which home visits might be arranged . Her investigation will include the CBC , to detect anemia , blood serology to detect hepatitis B,C , and HIV infection .If found positive , subsequent care is done with involvement of relevant physician . Screening for sexually transmitted diseases is also performed .And if found positive they are referred to genitourinary physician . urine is also checked for drug profile . USG is done to confirm gestational age and subsequent ultrasound is arranged at 20 weeks to rule out fetal anomaly. I will advise her to have regular antenatal visits to detect complication of PET . IUGR, PLACENTAL ABRUPTION , AND PRETERM LABOUR by clinical assessment supported by labwork.Serial USG is recommended at third trimester to rule out IUGR. Meeting is held at thirty two weeks ,both woman and her partner along with drug team , health and social worker to decide the need for mother and baby and necessity for prenatal child protection . Intara partum care involves continuous CTG as there is risk of fetal compromise .. anasthesist should be informed in case there is poor iv access and if required to give epidural anesthesia. Similarly neonatologist will be involved. Mode of delivery is vaginal and LSCS is reserved for obstetrical reason and those with HIV. If the woman is receiving maintenance dose , it has to be continued .If she is suffering from HIV ,HEPATITIS B AND C , I will avoid doing FBS , internal fetal monitoring , early ruture of membranes and episiotomy.and universal infections control measures are taken. postnatal care babies are observed for neonatal withdrawl symptoms in postnatal wards . Breast feeding is encouraged with exception of HIV positive individuals and also those who consume benzodiazepine and cocaine,If mother is HEP B positive , active and passive immunization is give to neonates . appropriate contraception must be discussed and provided befor discharge,social services are to be informed befor discharge to ensure optimum care .
		Posted by SANGEETA P. Sat Jul 8, 2006 12:23 am
Dug addiction puts the woman on high risk.Principles of her management are antenatal support, psychological support, financial and social support using social services.The detailed history of duration,type of drug,dose,route,if partner is also taking drugs, safe sex practice ad previous obstetrics ooutcome should be taken.Approach to such pregnant women should be sympathetic, in confidence, non judgemental and multidisciplinary involving GPs, obstetricians, drug liasion midwives, social services dealing with the drugs.Patient should be councelled in detail about the risks involved to the pregnancy and the fetus like miscarriage, congenital anamolies(with heavy alcohol),placenta previa, abruptio, preterm labour and its concequences,intra uterine growth restriction and even sill birth.Enquiry about the patient;s view for pregnancy,her willingness to either reduce the drug or giveup or going on methadone programme with the narcotics use should be enquired . Usually these patients are prone for nutritional defeciencies and initial investigations for B1, B6, B12, iron and folate defeciency should be sought and accordingly additional supplement should be provided.She should be scrrened for hepatitis B, C and HIV , STIs as these ptients are at high risk for above.Dating scan will provide accurate dates and viability.Detailed scan should be done, though there is no evidence that drugs can cause any congenital anamolies, only heavy alcohol has been associated with fetal alcohol syndrome.She should be encouraged to have regular antenatal visits as these patients are very poor attenders.In view of risk of IUGR, after 24 weeks she should have regular growth scans+/-doppler/umbilical artery flow velocity.Liasion with the child protection units should be made if there is any question regarding the child\'s safety.She should be given an oppurtunity to see the anasthetist sometime during antenatal period to discuss the pain relief in labour.In view of using drugs, opiates pain relief in labour may not be enough for her and the epidural will provide the best pain relief.A consultation with the paediatrician should be made antenatally to discuss the possible effects on the baby and baby might need to go to special care unit for observation post natally for drugs withdrawl symptoms which may appear with in 24 hours. Intrapartum she should have continuous fetal monitoring.If she is Hep B or HIV positive invasive monitoring, fetal blood sampling should be avoidedand should be offered elective c/section as cesarean section reduces the transmission to fetus. Baby should be attended by senior pediatric staff.Baby may have withdrawl symptoms in form of irritability, jittery, lithargy, respiratory difficulties and need to be monitored for.It is not advisable to give naloxone to such babies postnatally. Social services should be kept informed at every step so that women can be cared after discharge.She is councelled for contraception before discharge and stopping the drugs and importance of taking folic acid before planning the next pregnancy should be emphasized.and her care should continue with drug liasion services and social services to improve her quality of life.
		Posted by SWATI M. Sat Jul 8, 2006 08:46 am
Multidisciplinary care is important in her management which includes obstetrician, drug addiction units, social services ,midwife,dietician, counselor, neonatologist , primary health care team ? community midwife and GP and GUM physician if she has infectious disease. Identify potential problems in her antenatal care such as missing antenatal visits , blood born infections , smoking , alcohol intake, poor nutrition and formulate plan to manage these.Document this plan and disseminate to all health care workers involved in her care and maintain the confidentiality.Counsel woman and her partner about increased risk of blood born infections , risk of drug overdose, increased perinatal morbidity and mortality due to IUGR ,IUD, preterm birth and neonatal withdrawal syndrome. Counseling should be done sensitively and in non-judgmental manner. Proper documentation is important after counseling woman and to maintain confidentiality at all times. Reduction in drug used / substitution with methadone if heroin addict if agreeable to woman with help of drug addiction units. Minimise risk of infection by providing her with disposable syringes and needles .Referral to smoking cessation programme and alcohol dependence units for advice and help if problem is identified. Arrange home visits by involving primary health care team if poor antenatal clinic attender.Provide advice about adequate nutrition and supplementation with iron and vitamins. Screen for blood born infections such as HIV ,HBV ,HCV and partner if positive . Referral to Gum physician for its management and advice about minimizing risk of transmission to fetus / neonate and partner. Monitoring fetal growth by serial ultrasound scan every 2 ? 4 weeks from 24 weeks and Doppler if IUGR. Referral to anaesthesist to discuss labour analgesia and neonatalogist for neonatal care. Provide adequate analgesia during labour preferably with epidural as frequent doses with opiates will be needed.Provide continuous support during labour .Monitor fetus by continuous electronic fetal monitoring. Neonatalogist should to be present at delivery.Neonate should be followed up carefully for withdrawal symptoms and provide supportive care if develops. Contraceptive advice should be provided . Minimise occupational health hazard risk of contacting blood born infections to the staff involved in her care by adequate precautions and units should have protocols for management of such cases.
		Posted by Sreekala S. Sat Jul 8, 2006 10:53 am
IV drug abuse is a high risk during pregnancy . She should receive a multidisciplinary team care involving the consultant obstetrician, midwife, social workers, GP, paediatrician and the anaesthetist. A detailed history should be obtained regarding the type, amount and frequency of the IV drugs. Alcohol consumption and smoking should also be asked. Any psychological or medical problems leading to the drug abuse should be enquired into.. Her social and financial circumstances should be assessed. She should be counselled that there is high risk of IUGR, Premature rupture of membranes, chorioamnionitis, infections, Preterm labour, DVT and Pulmonary embolism. She should be screened for blood borne infections like HIV, Hepatitis B, Hepatitis C and sexually transmitted infections after proper counselling. She should be offered antiretroviral medication, an elective caesarean section and advised to avoid breast feeding to reduce vertical transmission if HIV is detected. She should be informed of the needle exchange programme and should be offered methadone maintenance treatment. Withdrawal symptoms can be very severe if she completely abstains from the IV drugs. She should be encouraged to gradually withdraw from the Methadone maintenance treatment as well. Advice should be given on reduction of alcohol and smoking. Dietary advice should be given as IV drug abusers may not take a balanced diet regularly. A detailed anomaly scan should be performed at 20weeks. Serial Growth scans should be performed as there is a high risk of IUGR. Child protection case conference should be arranged. During labour, a continuous CTG monitoring should be used. A senior obstetrician, anaesthetist and paediatrician should be involved in her care. The CTG may not be reactive due to the drugs and therefore should be interpreted with caution. IV access may be difficult to obtain. Fetal blood sampling should be avoided as far as possible if there is a suspicion about HIV/Hepatitis to reduce vertical transmission. Maintenance dose of methadone should be continued during labour to avoid withdrawal symptoms. Adequate pain relief should be given in labour. Paediatrician should be present at delivery. The baby may need to be observed in the SCBU for withdrawal symptoms. Thromboprophylaxis should be given postnatally. TEDs with/without LMWH should be given postnatally. Child protection issues should be discussed. Breast feeding should be encouraged unless HIV is suspected. Advice should be given on contraception at discharge and should be followed up by the GP and the social workers.
		Posted by Kishor S. Sun Jul 9, 2006 08:23 am
Dear Paul, This question was a difficult one. I have a different view about the comments you made in my answer. I shall be grateful if you please clarify. The underlying principles would be as follows. (How and what is to be done under the principle is not necessary according to the question)  Multi disciplinary and multi agency care sharing all information  Risk assessment to pregnancy and parenting  Screening for blood borne infections  Categorisation as High risk pregnancy (fetal surveillance and labour care are not different in such patients from a high risk pregnancy)  Ensuring regular antenatal visits/care (explaining ?how? does not come under principle)  Detoxification (Changing over to oral e.g methadone is process of detoxification)  Management of withdrawal symptoms in neonate  Child protection during parenting  Establishment of a protocol for referral to appropriate centre for further management that includes rehabilitation I do not think the following (among what you mentiond) are specifically related to drug abusers.  Measures to prevent vertical transmission of infections  Antenatal fetal surveillance  Antenatal anaesthetic assessment ? opiate tolerance / poor venous access  Measures to protect staff from the risk of infection / abusive behaviour These principles apply to the management of any high risk pregnancy. Universal precaution for prevention of infection to staff applies to all patients. When it is not necessary that IV drug abusers will have HIV/HPV, it is not justified to include prevention of vertical transmission as a principle. It will come under the category of screening of BBV.
		Posted by Aroosha B. Mon Jul 10, 2006 01:09 am
DEAR DR PAUL , I POSTED MY REPLY WELL IN TIME .PLEASE CHECK MY ANSWER ON DRUG ABUSE IN PREGNACY.I SHALL BE THANKFUL INDEED.
		Posted by OJO AJIBADE . Tue Jul 11, 2006 03:37 pm
This is a social problem that have significant impact on the paitient and outcome of pregnancy. At booking drug history will reveal the type of drug she is taking;cocaine or heroin.and also other illict drugs; needle sharing and try to explore the reason for indulging in drug abuse eg she is being abused herself. If She on cocaine;the amount of metadone treatment being offered should be checked and modified as necesary.The approach to management should be multidicplinary involving obstetrician;pschologists;member from drug liason team. Routine booking blood will be taken and after counselling will be screened for sexually transmitted infections eg HIV;Hepatitis B and C.If positive she should be refered to GUM clinic for further management.All professionsls involve in her management should be aware about her infectious status so as to take necessary precautions to prevent been infected. Ultrasound scan will be offered for dating and anomaly scan at 20-22 weeks. Intervention will be supportive as advise to stop is difficult and will be counter productive.However adressing a social problem that makes her prone to drug indulgence eg abuse from partner may be helpful. Involvement of parner who may also be an addict may be helpful. Growth scan at 28 week and fortnightly to exclude fetal growth restriction should be done. She need to reviewed by an anaesthetic as pain requirement in labour will be high and siting IV cannula will be difficult. At 32 weeks planned meeting is nessary between herself;the partner ;social worker;drug liason team member to discuss needs of mother and baby for the rest of the pregnancy and child care protection after delivery. One would aim for vaginal delivery except for obstetric reasons. Peadiarician should be present at delivery as the baby need to be monitored for withdrwal syndrome. Social support is important after delivery and contraception will be discussed.and offered.