A 34 YEARS OLD PRIMIGRAVIDA REMAINS UNDELIVERED AND IS EXHAUSTED AFTER 2.5 HOURS OF FULL DILATATION
Posted by
Aroosha B.
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 .
