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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 247 - Drug abuse

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		Posted by Zarkoth A. Thu Aug 16, 2007 11:05 pm
a) This is a high risk pregnancy, with increased risk of maternal and fetal morbidity and mortality. From the mother\'s history, it is important to establish what other drugs (if any) the woman is taking as well as the route of administration (as intravenous route is associated with higher risk of infection and thrombosis). She is also at higher risk of acquiring hepatitis B or C and HIV. So she should be enquired about history of infection with these. Her housing and social circumstances need to be ascertained, as well as her sources of income to buy the drugs, as she is more likely to engage into illegal activities. Her nutritional status has to be checked as well, to ensure that she is going to be able to support herself and the fetus during the pregnancy. On examination, her BMI needs to be checked and inspection of infection sites undertaken, in case of intravenous use, to look for signs of thrombosis. b) The fetus would be at higher risk of congenital abnormalities, as well as IUGR, oligohydramnios and preterm delivery, with the associated risk of prematurity. Certain drugs, like cocaine, are also associated with a risk of placental abruption and intrauterine death. Finally, there is increased chance of chorioamnionitis and preterm prelabour rupture of membranes, as a result of maternal infection, with its associated morbidities for the fetus c) The baby is likely to suffer from neonatal abstinence syndrome (NAS), which would exhibit with symptoms such as poor feeding, jittirness and lethargy. It would also be at higher risk of suffering neglect from its mother, as well as non-accidental injuries. A sensitive approach to a woman who uses drugs is necessary, so that she is motivated in the attempt to achieve the best possible outcome for herself and her baby. Support needs to be provided by a multidisciplinary team including the obstetrician, the community midwife, her GP, the paediatrician and possibly a social worker and a psychologist. She needs to be encouraged to enrol into a methadone detoxification programme, as this is associated with reduced maternal, fetal and neonatal risk.
		Posted by Mohammad H. Fri Aug 17, 2007 03:13 am
a-Clinical assessment of the patient should be done sympathetically in anon judgemental manner andI will reassure her that her confedentiality will not be breached.I will ask about the duration of drug use,and the dose taken.I will ask about smoking,alchol intakeand other subtances abuse.History of sexual transmitted infections (STIs).Sexual history and wheather the partner is drug abuser or not .Social historyas these patients may have problems in workwith their families or with police.History of domestic violence and to which extent drug abuse affecting her quality of life. Clinical examination with blood pressure .Local examination for screening for STIs and referral to GUM clinic if positive .Written information leaflets should be provided. b- I will reassure her that her fetus will mostly be normal but he is at increased risk of some problems so, regular ante-natal care is required.the fetus is at increased risk of intrauterine growth restriction (IUGR) and intrauterine fetal death (IUFD) so, serial growth scans and assessment of fetal well being is required.There is increased risk of neurodevelopmental abnormalitiesand facial defects .There is increased risk of fetal distress and low birth weight. Preterm delivery with its risks is more indrug users.I will provide the patient with information leaflets ,giving appointment for antenatal care and anomaly scan.Referral to physician and psycologist for counselling and management may be needed. c- The neonate is at increased risk of drug withdrwal symptomsand this can be minimised by methadone treatment.Breast feeding also reduces the risk of withdrawal symptoms . There is increasaed risk of negligence to the baby by the drug user and this makes the fetus more exposed to malnutrition ,at increased risk of traumatic injuries and this can be minimised by education to the patient and her partner about the care of the baby,helping the patient to stop drugs will also elp her to take care of hre baby.Contact with support groups and providing information leaflets may help the patient to take care of hre baby. Social society can take care of babies that proved to be deprived of being sufficiently cared by their parents .
		Posted by Valerie T. Fri Aug 17, 2007 09:17 am
A 30 year old heroin user attends the antenatal clinic at 14 weeks gestation in her first pregnancy. (a) Logically outline your clinical assessment during the booking visit [8 marks]. (b) What will you tell her about the risks to her fetus? [5 marks] (c) What are the neonatal / infant risks associated with drug abuse and how can these be minimised? [7 marks] a) The general health of this patient is important and a detailed history should be taken to identify the presence of any illnesses such as lung infections. Enquiries should be made about her diet and nutrition. Whether she has commenced folic acid, since this reduces the incidence of neural tube defects. Whether she has been immunized against rubella. The onset and frequency of heroin use, as well as the use of other drugs or alcohol should be noted. This will indicate the severity of addiction, level of drug abuse and degree of fetal risk. Drug abuse is also associated with sexually transmitted infections. Therefore, risk factors should be identified and whether she has had or currently has sexually transmitted infections. This will pose a risk to the fetus as well as to the healthcare workers. Questions should be asked about domestic violence which is also associated with drug abuse. This will allow us to offer her help and protection for her and the baby. A physical examination should be done to assess her general conditon, for example whether she looks well nourished or malnourished. The body mass index should be calculated. These factors may affect the wellbeing of the mother and fetus during pregnancy. Identifying track marks should also be done, since infection and if untreated could lead to generalised septicaemia and cause maternal and fetal morbidity. b) I will tell her that the risks include intrauterine growth restriction and offer serial ultrasound scanning to monitor the growth. In the antenatal period or intrapartum there is a risk of placental abruption which may present with abdominal pain and/ or vaginal bleeding. There is a risk of preterm delivery, low birth weight and stillbirth. . I will provide an information leaflet and inform her of support groups. c) The neonatal risks include neonatal withdrawal syndrome. This may occur in 60% of women with drug abuse. It presents within the first 48 hours of life. It is common for drug abusers to also consume large quantities of alcohol and therefore the neonates are also at risk of fetal alcohol syndrome. Prmaturity may occur. Poor feeding may occur. The neonates or infants may also be at risk of neglect and physical abuse. Risks may be minimized by a sensitive and non judgemental approach. A multidisciplinary approach is also needed with the input of the obstetrician, midwife, neonatologist and the use of a counsellor to provide psycological support. Regular ultrasound monitoring and antenatal clinics. Methadone should be offered. Social worker may be needed to monitor the care of the neonate in it\'s home environment.
		Posted by Saad A. Fri Aug 17, 2007 06:26 pm
The patient is dealt in collaboration with drug specialist,social worker and obstetrician. Her inital assessment at booking needs detailed history including dose,route of administration, quantity of heroin she is taking daily. She is enquired whether she is taking through inhalation or injectables,as venous assess is difficult in I/V drug users. She will also be asked about any other drug she might be using. She will also asked about alcohol usage and smoking.As there is risk of STI she will be asked about detailed sexual history,contraception (as condoms prevent STI). Her LMP will be asked to ascertain the gestational age. She will also be asked about any domestic voilence. Her examination will be carried out including BP and BMI. Her speculum examination is carried out to take swabs for STIs(HIV,gonorrhea,chlamydia), though these will be repeated again later on in pregnancy. She will be advised for anomaly scan at 20 weeks. She will be advised to consult with drug specialist to change drug to methadone for maitenance therapy to prevent withdrawl symptoms. b. I wil tell her that there is risk of IUGR in fetus as drug abuse causes placental venous thrombosis and hence growth retardation,so she will need serial growth scans throughout pregnancy. Then I will tell her that there is increased risk of vertical transmission of STIs if these infections are present,so screening for STIs is carried out. There is also increased risk of intrauterine death. There is also increased risk of preterm delivery and prematurity.There is no proven risk of teratogenic affects of the drug. Written information and hospital contact details are provided. c. There is a risk of withdrawl symptoms in the neonate and should be immediately shown to the neonatologist. There is no need to give drug but only to keep under observation. The withdrawl symptoms are less than with methadone as compared to heroin, so maintanance therapy with methadone is given during pregnancy to the mother. There is also risk of vertical transmission at the time of delivery so if the mother has hepatitis B the neonate should be given active/passive immunisation(immunoglobulin within 12 hrs of birth,active immunisation at 0,1,6 and 18 months of age). If the mother has HIV then PCR technique is used to test the neonate for HIV. Antiretroviral therapy is given to child for 4-6 weeks postnatally. HIV antibody testing is required at 18 months.Breast feeding is not advised if patient is HIV positive and not on methadone maintenance therapy. There is incresed risk of sudden infant death syndrome(SIDs). There is increased risk of non accidental injury and neglect. In order to prevent these risks mother should be properly counselled. There is a need of joint collaboration care of GP,neonatologist, social worker and community midwife in minimising these risks.
		Posted by Sabahat S. Fri Aug 17, 2007 09:20 pm
a) She should be treated in a sensitive & nonjudgmental manner. Duration of heroin use, any other drugs that she may be using e g cocaine, opium etc is elicited. If she is using street heroin also, it is even more harmful, as it is unpredictable in its strength & composition. Any history of smoking & alcohol intake should be taken, and the quantity of such, is important. Her nutritional status should be assessed; as such a patient is prone to malnutrition, due to neglected nutritional intake. Careful note is made of any thrombased veins. Her psycological state & attitude towards this pregnancy should be assessed & she should be offered to be put in contact with support services, detoxification programme (or methadone substitution) if she wishes. History is taken of HIV, syphilis or hepatitis infections, which if negative, she should be offered testing for these after appropriate pretest counseling. Any history of dysuria, unhealthy vaginal discharge may indicate co-existing STD, which should be appropriately investigated & treated in a GUMclinic set up. She should be sympathetically asked about the level of social support she has (single, divorced, homeless, unemployed etc). b) In a sensitive manner she should be told that although majority of such fetuses are unaffected or minimally affected, but her fetus is at risk due to her drug addiction. There is a risk of miscarriage, growth restriction, preterm delivery. The fetus could die in utero & she may have premature separation of the placenta (abruptio placenta) resulting in intra uterine death of the fetus. Due to her intravenous drug intake, she is at high risk of acquiring HIV, hepatitis & other infections & subsequently transmitting it to her fetus c) The neonate is at risk of severe withdrawal symptoms (duration & severity depending the types of drugs she is taking). The baby will have high-pitched cry, jitteriness, poor feeding, floppiness & may have convulsions. The baby is at a high risk of sudden infant death syndrome. Due to the drug addiction of the mother the baby?s nutrition may be neglected, there is also a risk of nonaccidental injury to the baby, which may even be fetal. Such babies are at high risk of neglect & abuse. There is also found to be a high incidence of neurodevelopmental delay & deficits in such children. The above risks could be minimized / avoided by a sensitive joint counseling of both the patient & her partner (if present)with drug counseller,social worker& a neonatologist. Help from social services & support groups could be offered & contacts details should be given along with detailed written information. In case the mother is unable to cut down on her addiction, the baby could be put in foster care or for adoption if she agrees. The mother should be offered a detoxification / deaddiction programme. Community midwife & health visitor should provide home health visits to ensure all is well, when the baby goes home. .
		Posted by Mahmud K. Sat Aug 18, 2007 03:08 am
As an illegal drug user woman has high risk pregnancy . Assessment and management of her pregnancy should be undertaken by multidisciplinary team involvement including social workers, specialist drug addict services, drug-liaison midwives, general practitioners, obstetricians and paediatricians. Assess of the extent of the woman?s heroin use by focused history taking ?including frequency, level, pattern ,method of administration (intravenous route , sharing needles) , and associated confounding factors smoking, alcohol dependency ,poly drug use, should be explored. A systematic enquiry about current and previous psychiatric history, its severity, care received and clinical presentation should be made and need referral to Psychiatrist for further psychiatric assessment or support. History of currently or previously experiences domestic violence should actively sought through questioning as part of the social or family history (unemployed, being single and unsupported , homelessness ). A detailed history and clinical examination should be undertaken for sexually transmitted diseases , endocarditis and tuberculosis, and thrombosis because of needle sharing and chaotic lifestyle .. Booking bloods should be undertaken with testing for hepatitis B and C virus and HIV testing. A vaginal swab is taken to screen for bacterial vaginosis and endocervical swab for gonorrhoea. BMI is taken for measuring of nutritional status .because usually they have a poor diet . Intrauterine growth restriction and stillbirth , miscarriage, congenital anomalies more commonly occur in pregnancy exposed to high opiates. Increase risk of having premature and low birth weight baby which causes respiratory distress syndrome . necrotising enterocolitis and intraventricular brain haemorrhage .Baby may need intensive care unit admission.. Physical and neurological damage to the foetus , particularly if violence accompanies parenteral use of drugs. In newborn period neonate are more likely to suffer low Apgar scores, infectious complications and CNS disturbance, and sudden infant death may occure.In long term learning difficulties and behavioural problems may occure. To minimise these risk she should be strongly encouraged to go onto a detoxification programme with maintenance therapy with methadone. This management should be undertaken by a specialist in addiction medicine . Providing support for reducing alcohol and tobacco consumptions and to stabilize life style. A multidisciplinary planning meeting should be held at 32 weeks of gestation .If there are child protection concerns these should be separately assessed and a child protection case conference held if appropriate. An ultrasound scan is performed to confirm gestation and then foetal anomalies scan at 18-22 weeks followed by serial growth scans are arranged from 28 weeks every fortnight with assessment of liquor volume and umbilical artery Doppler studies from 34 weeks. Continuous intrapartum cardiotocography monitoring may need for early identification of placental insufficiency and foetal compromise. To reduce the risk of vertical transmission of hepatitis?s and HIV avoid as far as possible foetal blood sampling ,scalp electrode and episiotomy. Naloxane should not be given to opiate dependent mother or neonate. It may cause severe withdrawal effect .A neonatologist should be present for the delivery. After birth baby should observed for neonatal narcotic abstinence syndrome which is characterised by hyperirritability, jitteriness, poor feeding and sleeping disturbance. Babies born to hepatitis B positive mothers should be immunised. Breast feeding should be encouraged in most women even those with methadone. Social services should be informed of the delivery and decisions made about the levels of support needed to ensure child safety.
		Posted by Shahla K. Sat Aug 18, 2007 02:30 pm
This is high risk pregnency , I will involve Multidisciplinary team in her care including obstetrician,general practitioner ,paediatrician,drug speciality services ,social worker and drug liaison midwife .During her care confidentiality maintain. non judgemental way to ensure regularity in antenatal clinic. Gestational age should be ascertained by early ultrasound as LMP is usually not correct in drug abuser.Enquiry about duration and dose of heroin use.Rout of drug intake ,weather she is sharing needle.enquiry about smoking , alcohol intake or use of any other drug also made. Enquiry about high risk sexual behaviour, sexual transmitted disease ,and drug being used by partner. Her attitude toward pregnancy should be enquired, and concerns toward safety of her child. Enquiry about her social , financial circumstances and any legal trouble she had should be made. Examination to judge about her nutritional status, BMI, presence of anaemia. Examin injection sites for cellulites and abscess. b)She should be informed clearly about consequences of heroin use as it will help in motivation for treatment.There is high neonatal mortality rate but in multi drug user it rise upto six time. Heroin does not associate with congenital anomalies but its association with vitamin deficiency(folic acid)will lead to structural anomalies,there is increase risk of preterm premature rupture of membrane and delivery. There is increase incidence of placeta praevia and abruption placenta. Her fetus is also at risk of intrauterine fetal death and intra uterine growth retardation.preeclampsia is more common among drug user. Neonatal risk are many due to neutritionl deficiency.Long term effect on general heath of child till adulthood. There is high risk of HIV infection and AIDS. Neonate may acquire hepatitisC and hepatitis B virus infection from mother due to her risky behaviour. c)Neonatal care should be shared with neonatologist. Naloxone to revert the effect of opiate should be avoid as it precipitate withdrawl symptoms Encourage breast feeding (NAS can be avoided)except in HIV infection. But HCV and HBV infected mother can continue breast feeding.Neonate of mother infected with HBV should receive active as well as passive immunization. Neonatal abstinence syndrome is seen in heroin user after 2 days ,but delay of 4 days seen in methadone user.therfore drug speciality services and paediatrician should be involve. Social services should be inform that \'the neonate have born to a heroin user\'. Drug abuse does not equate with child abuse ,level of care by social worker to avoid child abuse need to be individualize.
		Posted by Natalia N. Sat Aug 18, 2007 07:19 pm
A. Clinical assessment should be confedential. It should be done in non-judgemental manner. It is necessary to explore the heroin use, duration of its use, frequency of its use. It is important to find out if she had sharred needles with other people. I will find out if she uses any other ilicit drugs (cocaine, amphetamines, marijhuana). I will find out if her partner uses ilicit drugs. I will ask if smokes, and explore her alcohol consumption. It is necessary to find out if she has issues with law. I will find if she has a safe place to stay. I will check if this pregnancy was planned and she and her partner are happy about the pregnancy. I will check if she has any family or friends support. I will explore her sexual history to establish the risk of sexually transmitted infections (STIs). It is important to get her past medical history as heroin users are at increased risk of hepatitis B and C, CMV, HIV, STIs, cellulitis, osteomyelitis, endocarditis, depression. I will perform clinical examination - check her opusle, BP, examine cardiovascular system (any murmurs suggestive of endocarditis), respiratory system, her abdomen, check for any signs of infection at the injection sites. B. Heroin does not cause congenital abnormalities. However, it increases the risk of perinatal mortality and morbidity. It causes prematurity. It causes growth restriction, e.g. babies born from mother using heroin weigh in average 400 g less. It causes the risk of fetal infection. The main risk is from the fluctuation in blood levels of the drug, so called \"highs\" and \"lows\" whcih increases the risk of adverse perinatal outcome. C. Neonatal and infant risk of heroin are related to prematurity. Babies may develop respiratory distress syndrome and difficulties controling temperature. Babies develop neonatal abstinence syndrome. Infants can be irritable, have high-piched cry, have difficulties breathing and feeding, may have seizures. Heroin increases the risk of neonatal infection. It also increases the risk of sudden infant death syndrome. Heroin use during pregnancy leads to neurodevelopmental delay in children though this is more related to social circumstances and not to heroin itself. Prevention of these risks should include multidisciplinary approach with obstetrician, drug and alcohol specialist, midwife, social worker, and psychiatrist if needed. Child protection service should be involved to assure that baby receives appropriate care. Women should be counselled regarding methadone programme (in cases of heroin use). Change to methadone during prgnancy improves perinatal outcomes,dencreases the rate of neonatal abstinence syndrome by 20%. It allows avoiding the fluctuation of the drug level in blood which is dangerous for fetal development. It improves social situation as women do not need to get involved in illegal activities to be able to get the drug. It encourages regular antenatal visits and, therefore, improves pregnancy outcomes. Women may need to be admitted to start methadone, and to establish an appropriate dose. The low dosage might lead to relapse in heroin use. Only very well-motivated women with a good social support should be encouraged to stop heroin use during pregnancy as the rate of relapse during pregnancy is very high and worsens the perinatal and maternal mortality and morbidity. The risk of threatened preterm labour has been shown to be higher if heroin stopped in the second trimester. Close observation on the baby should be done from the birth time. Baby should be scored on the abstinence scale and given treatment (morphine tencture, barbiturates) if needed. The abstinense symptoms develop later (usually on day 3-7) if mother was using methadone. Breastfeeding is encouraged. Careful monitoring of mother\'s interactions with the baby should be done to assure. Mothers should be counselled regarding of the risks of drug abuse in pregnancy and advised to present for care in case of any problems after the discharge. Mothers should be provided with good social support. Thier psychological status should be closely observed.
		Posted by Jancy V. Sat Aug 18, 2007 09:14 pm
I will adopt a non judgemental, sensitive and confidential approach to her. I will involve the drug laison midwife, specialist drug services if needed. I would ask her menstrual history for dating. I will ask her the type of drugs used, frequency, dose, method of administration as it influences her management. Intravenous drug use has the potential of transmitting HIV, Hepatitis B and C, and can also predispose to endocarditis and septicemia. I would assess if she has fears or concerns of her on about the pregnancy and assess her social and financial background and rule out domestic violence. I will also enquire about her partner, about sex practices because drug abusers tend to be vulnerable to sex abuse and have unsafe sex practices which predispose to STDs. I would also ask history of tobacco smoking and alcoholism as they are commonly associated with drug abuse. I would ask her symptoms of drug overdose or withdrawal. I will examine her for weight, BMI, nutritional status, personal care as drug abusers have lack of personal hygiene and malnutrition. I would do a systemic examination as drug users are at higher risk of CNS manifestations, hepatitis, CVS disease and hypertension. I will also look for signs of pneumonia, tuberculosis, endocarditis as they occur in drug users due to poor immunity and lack of hygiene. I will tell her that there is a higher risk of miscarriage to the fetus in drug users. There is higher risk of congenital anomalies, even though in heroin users it has not been proved conclusively. There is a higher risk of fetal growth restriction due to placental insufficiency; high risk of preterm labour, premature rupture of membranes and abruption placentae. The fetus is also at risk of intrapartum hypoxia . Due to CTG abnormalities produced by heroin, it becomes difficult to have effective fetal monitoring in labour and there is higher chance of operative delivery. These risks can be minimized by cutting down drug use and gradually stopping the drug use by methadone maintenance treatment. The fetus avoids highs and withdrawals and other harmful effects of street drugs if she uses methadone. Compliance to this regimen can reduce perinatal mortality and increase birth weight. Neonates born to drug abusers tend to be low birth weight, hypoxic with low apgar scores and often preterm. They have higher risk of respiratory depression and CNS disturbances . The neonate has withdrawal symptoms to the transplacentally transferred dose of heroin. This is called NAS (neonatal abstinence syndrome) and occurs commonly in the first 24 hours of birth. Neonates are also at high risk of maternally acquired infections- HIV, Hepattis B and C and STDs. Proper antenatal counseling is needed to reduce the dose of heroin used and gradually to stop the use in pregnancy , with the help of methadone regime. It is important to avoid top ups while on treatment. Those who have been on systematic withdrawal from heroin should not be given opiates for pain relief in labour. Naloxonne should be avoided as it precipitates withdrawal. The mother should be given support after delivery as she is likely to have minimal support from home. Breast feeding should be encouraged. The infants are at risk for sudden infant death syndrome, infections, poor nutrition and care. Close liaison with social services, specialist midwife, drug services , pediatrician and community midwife are required.
		Posted by Misbah W. Sat Aug 18, 2007 11:19 pm
A] Her clinical assessment should base on the risk related to drug abuse,her social and sexual behavior, maternal, fetal and neonatal risks and risks to professional careers. The nature of the risk depend on route of administration as intravenous use is associated with sharing of needles and risk of HIV, hepatitis B and C. The dose and pattern of use should be asked as overdose and withdrawal can be fatal to fetus .A detail social and sexual history will reveal her life style, source of income, alcohol abuse ,cigarette smoking and increase risk of sexually transmitted diseases. Her past obstetric history, attitude towards present pregnancy, drug abuse and family life should be assessed in a non judgmental way. Women should be offered screening for STD and immunization if negative for hepatitis B. A general physical examination will help to assess nutritional status and needle marks. She should be booked with MDT including community and social worker. B]?Dependency on narcotics, such as heroine is associated with IUGR, preterm delivery and IUFD due to both overdose and withdrawal. However, heroine-dependent patient should be encourage to enroll in narcotic maintenance programme using methadone since this improve perinatal outcome . She will be monitor for fetal growth with serial scans and Doppler assessments during pregnancy and prompt management of preterm labour. C]-Risks to neonate include neonatal withdrawal syndrome which can be minimized by counseling the women to use maintenance dose of methadone during pregnancy as well as presence of neonatologist at delivery to diagnose and treat early .The neonate is also at risk of vertical transmission of diseases like HIV, hepatitis C and B syphilis and other sexually transmitted diseases. This can be minimized by screening at booking visit and repeating latter in pregnancy. For HIV positive cases in time diagnosis, treatment, delivery by LSCS and avoiding breast feeding can markedly reduce transmission to neonate. Early involvement of community and social worker as well as awareness of mother will help to reduce the incidence of SIDs , neglect and non ?accidental injuries to the babies.
		Posted by Natalie P C. Sun Aug 19, 2007 02:41 am
ESSAY A I would first do a general assessment of her health and nutrition. I would find out if she eats regularly. I would check her BMI. I will check for nutritional deficiencies like iron deficiency anaemia on a FBC and ferritin. I would ask her if she uses any other drugs or substances as she may be a polyuser eg smoking, marijuana or cocaine as risks increase further to her and the pregnancy. I would find out if she knows herself to have or had any infections like HIV, Hepatitis B, other sexually transmitted diseases or contact with someone with tuberculosis. I would offer HIV and Hepatitis B and C screening in the pregnancy and do further tests as directed like Mantoux if contact with TB. I would enquire about her social situation. I would find out if she is or has ever been a sex worker as this increases her infectious risk further. I would enquire as to whether she is in a stable relationship or if there are any domestic violence issues. I would assess her venous access as it may be difficult to take her booking bloods. I would enquire as to whether she is interested in using Methadone especially during the pregnancy and stopping using the heroin. B I would tell her that there is the risk of miscarriage with Heroin use in pregnancy. I would tell her that there are infective risks to her baby of HIV and Hep B if she is a carrier or even more so with HIV if she seroconverts during the pregnancy.. There is an increased risk of preterm prelabour rupture of membranes and preterm labour and delivery with heroin use and especially so during a withdrawal. I would inform her of the increased perinatal mortality. Smoking will increase risk of fetal growth restriction and use of other drugs C The increased risk of perinatal mortality is higher even with methadone (2x) and more so if she uses methadone and heroin (6x). she therefore needs to be encouranged to use the lowest dose of methadone to prevent withdrawal symptoms in herself but also not to use heroin at all. These factors will also reduce the risk of preterm delivery and the associated risks of prematurity ? RDS, intraventricular haemorrhage. Use of methadone instead of heroin will reduce these risks. These risks can also be reduced if she is within a drug service and good contact with her drug liason midwife. This will ensure that she gets the correct dose daily from her appointed pharmacy service. Social worker contact and support will avoid the situations that may drive her to use heroin during the pregnancy.
		Posted by Malar R. Sun Aug 19, 2007 06:40 am
It is important to confirm her dates by checking if her menstrual cycles are regular and offer a USS to accurately date the pregnancy. Her drug use must be explored to check for method of administration if intravenous and use of other drugs in addition to heroin, including cocaine, cannabis, alcohol and smoking.She should be asked if she uses clean needles or shares needles with others.Her past medical history must be enquired specifically to check for endocarditis secondary to IV drug use and any known infections such as HIV, hepatitis B and C.These must be offered if her status is not known. Her social circumstances must be known , including domestic violence, poverty and to see if she has anybody supporting her.She should be asked if the pregnancy was planned or was a result of abuse.Prostitution may also be relevant in drug users and should be asked for and screening for sexually transmitted infections offered. Her BMI should be checked and any malnutrition addressed. She should be asked if she is actively seeking to stop using drugs.She should be offered support from a drug and alcohol specialist midwife if available and the drug and alcohol liaison team. She will be informed that the fetus may demise in utero,may deliver prematurely or may have difficulty in growing inside the womb. The fetus may also be infected secondary to intravenous needles being used if shared.These infections include HIV and hepatitis.Also if she uses additional drugs, there may be other risks such as placental abruption with cocaine potentially resulting in death. The neonate is at risk of low birth weight. This may cause hypothermia, hypoglycaemia and respiratory distress. The neonate is also at risk of withdrawal syndrome. It may be irritable, exhibit poor feeding, have seizures and die as a result. It may also be at risk of abuse and violence depending on the mother\'s circumstances and social support. Low birth weight may be minimised by encouraging the mother to stop smoking, alcohol and gradually reduce the drug intake.Regular growth scans in pregnancy will also help identifying the babies at risk and therefore they can be monitored closely at birth. Withdrawal symptoms can be minimised by monitoring the baby at birth and giving it morphine replacement. The observations should be done by staff trained in recognising the signs.Breastfeeding may also be used as milk will contain the drugs as well. Abuse and violence may be targetted antenatally be identifying the women at risk and involving the social services and the community midwife and having a case conference and a post delivery plan for example if the baby has to be fostered.
		Posted by Idris O. Sun Aug 19, 2007 08:44 pm
a) My clinical assessment would include the dose of heroine, the frequency of its use and the route of administration. I would ask about the missuse of other drugs like cocaine and amphetamine as more likely to be engaged in polysubstance missuse. I would ask about any psychological or health problems which led to or has developed as a consequence of the drug use. History of her use of alcohol or smoking as well as history of the partner also missusing drugs.I would also ask about history of practice of safe sex and sharing of needles . Her examination may show poor personal hygiene and poor nutrition with a low BMI as associated with generalised immunosuppression. I would look for multiple IV sites or collapsed peripheral vein due to multiple injections. Her investigations would include urine for toxicology to determine the current drugs being missused. I would obtain swabs for chlamydia and gonorrhoea due to risk of STI. I would also do bloods for Hep B , C , HIV and syphilis due to increased risk of blood borne infection and STI\'s. She would be offered USS for dating due to increased risk of fetal complications. b) The risk to her fetus include risk of miscarriage and fetal loss. Others include preterm labour with prematurity.There is the risk of placental insufficiency and IUGR with an increased risk of antepartum stillbirth.There is an increased risk of placental abruption. The fetus is also at risk of vertical transmission of infection(HIV,Hepatitis) and risk of chorioamnionitis. c)The neonatal and infant risks includes low apgar scores due to neonatal respiratory depression caused by heroine and infectious complications from the acquired infections from the mother. The neonate is also at risk of neonatal abstinence syndrome causing CNS disturbances of irritability, hyperactivity,tremor and occassionally seizures. Others include abnormal sleep behaviour, high pitched cry and poor feeding with a weak suckling and uncordinated swallowing. The infant risks include child neglect, non-accidental injury and sudden infant death syndrome. This risks can be minimised by a multidisciplinary team approach involving the social worker, drug liason midwive,GP, obstetrician and paediatrician to create a confidential reassuring and non jugdemental environment in which childbirth experience and pregnancy outcome can be optimized. This is to promote a change in the nature of the drug taking, to stabilize lifestyles and reduce criminal behaviour. The patient would be offered methadone treatment as an alternative to heroine if fear of withdrawal symptons. She would be encouraged to exchange her needles or move to non -IV modes of delivery to reduce harm. She would also be counselled to stop or reduce smoking and alcohol intake. The child would be entered into the child protection (at risk) register and in an high risk child with at risk parents the child may be separated from the couple.
		Posted by Parveen Q. Mon Aug 20, 2007 09:16 am
I will enquire her about the dose, duration of herion use, route of administration , and usage of any other drugs. I will also ask her if she is on any detoxification of programme, otherwise will plan for methadone maintainence. History of smoking, and alcohol will be taken as it is seen commonly in drug abusers. Her attitute towards pregnancy , if it was planned or due to missed pills will be ascertained. Any history sexual abuse, relationship problems, use of drugs in the partner will be noted down. Her nutritional status will be assessed as they are mostly nutritionally deprived. There is increase incidence of HIV, Hepatitis B, Hepatitis C in this patients due to their life style, so screening for the same will be undertaken. Her financial status, social support will be enquired. Iwll look for any signs of anaemia, take her BMI, and check her peripheral veins to see if there is good venous access. There is an increase incidence of venous, and arterial thrombosis in this patients. Urine toxicolgy to assess for the amount of drug will be done. Swabs for clamydia, and bacterial vaginosis will be taken. USS for gestational age will be done. (b)Risk to the foetus is due to herion like IUGR, foetal distress, preterm birth and still birth. Herion causes physical addiction, it has no teratogenic effect. If there is concomitant use with drugs like cocaine will cause abdominal wall defects, amphitemines will cause cleft palate, in binge drinkers there is increase risk of structural brain malformation. There are risks due to concomitant infection will lead to miscarriage, preterm delivery, PPROM . There is risk of vertical transmission with HIV. Patient will be provided with information leaflets and support groups. (c)The neonatal /infant risk is mainly due to neonatal abstinence syndrome , leading to hyperactivity, excessive crying, and difficulty in feeding. Mother\'s ability to care for the baby is reduced by the drug, leading to neglect. There is increase risk of SIDS and non accidental injury in this babies. Risk can be minimsed by multidisciplinary team of community midwife, drug liasion service, social workers,named consultant, and infectious disease physician, and GP. Patient will be counselled for detoxification programme, and methdone maintained to a dose of 20mg per day in liasion with the drug liasion service. Set targets and regular urine toxicolgy to assess the success of the programme and will assist in planning for dose adjustment. USS for anomaly at 20- 22 weeks and low threshold for growth scans as they are prone for IUGR.A special planning meeting to be held around 32weeks with the drug committe, partner, patient, health visitor, and social worker to look into the child protection needs. When she is in labour, paediatricia to be alerted, and if there is difficulty with venous access, early referral to anasthetist will be undertaken. Precautions will be taken to prevent vertical transmission in case of HIV, and hapatitis by avoiding FBS, fetal scalp electrode appilication and instrumental delivery. After delivery, immunisation incase of hepatitis, and baby needs to be observed for withdrawl reaction. Admission to special care unit is not routine, can be observed with mother ina transitional unit. Methadone takes time to clear , so observation is essential for 7days. Breast feeding is not contraindicated in heroin addicts.Community midwife, and GP will be informed about the discharge, as the baby needs further follow up at home by health visitor, socail worker to prevent from from violence to the baby.
		Posted by saima gulzar S. Mon Aug 20, 2007 08:48 pm
(a) Clinical assessment should be in a sensitive and non judgemental way.History of dose ,duration and route of administration should be determined as intravenous route of drug administration is associated with risk of thrombosis and infection.Use of other drugs such as cocaine or amphetamines to enhance the effect of heroin should be enquired. Other confouding factors such as alcohol use and smoking should be explored.Her social history need to explore to find out the cause of drug abuse,to rule out domestic voilence or to assess need of social support.Contraception and sexual history should be taken to assess the risk of STDs.History of infection or co morbid illness may point towards acquisition of infections such as HIV ,Hep B or Hep C infection. On examination general nutritional status along with BMI should be assessed as she is more prone to nutritional deficiencies. IV sites should be obsreved for thrombosis as she might need anaesthtic help for IV line siting. Along with routine booking investigations Hepatitis B & C screening should be done and HIV screening should be offered.Urine should be send for toxicology screen and swabs should be collected for chlamydia,gonorrhoea and bacterial vaginosis.Ultrasound should be done to conform ongoing pregnancy and dating of pregnancy. (b) I will tell her that overall there is increase risk of neonatal morbidity & mortality.There is increase risk of miscarriage and preterm labour.Fetus is at increased risk of IUGR due to placental insufficiency and need regular growth scans after 28 weeks .There is increase risk of abruptio placenta with its associated risk of stillbirth.There is increase chance of having low birth weight babies. Fetus is at increase risk of acquiring infection by vertical transmission. (c) Neonatal risks are increase risk of hypoglycaemia,hypothermia and respiratory morbidity due to prematurity,IUGR or low birth weight.Neonate may exihibit signs of neonatal abstinence syndrome 2 -3 days after delivery such as hypotonia,jitteriness,high pitched cry and poor feeding. Infant is at increase risk of nonaccidental injuries and sudden infant death syndrome due to neglect in care. The risk can be minimise by multidisciplinary involvement of obsterician,specialist midwife,drug liaison services ,GP & social srevices.She should be offered methadone maintenance programme and altered accordingly and advised to stop smoking and alcohol use and intavenous route of drug administration.Social support should be provided .A planning meeting at 32 weeks should be arranged with woman ,her partner ,drug team ,health visitor and social worker to assess the need of mother and baby and need for prenatal child protection.Neonatologist should be present at time of delivery and Naloxone should not be given to neonate as it may increase withdrawls effect.Breast feeding should be encouraged except in HIV.Mother is advised to stay in hospital for 4-5 days to obsrve neonatal abstinence syndrome.Social worker should visit regularly to assess child neglect.
		Posted by Reena M. Mon Aug 20, 2007 08:51 pm
Multidisciplinary care is required for this patient involving G.P, community based health care workers, drug abuse counsellors drug dependence nurse/specialist midwife, social workers and social support grousps, drug dependence centres, obstetrician ,paediatrician and anesthetist Assess the patients living environment, determine if she has a partner, whether he is also a drug addict, or hase multiple sexual partners . Any evidence of domestic violence. if so offer help of social support groups and drug dependence counsellors for the partner as well as for herself. Formulate a plan of management after discussion with all health care workers involved in her care and maintain confidentiality Offer antenatal counselling in a non judgemental and sympathetic manner. Provide accurate not alarming information to the patient regarding need for regular and frequent antenatal follow ups, need for serial growth scans as chances of iugr, encourage her to take care of her nutritional status by providing vitamins and iron supplementation. Determine how frequently she uses heroine,route of administration and dosage and from where she acquires the drug .The dose used ,can be found from urine toxicology studies and by assessing the severity of her withdrawal symptoms. Offer substitution therapy with methadone , to reduce the withdrawal symptoms and to use lowest possible dose,with help of drug abuse counsellors. Provision of needles and apropriate disposal if iv use continues. Introduce her to smoking cessation programmes and alocohol reduction programmes. If fails to come for antenatal follow ups arrangements to be made for home visits by community health workers and encourage her for attendance. Screen both partners for STIS, -HIV, HEP B, Hepatitis C, if positive to be referred to GUM clinic , a note made of the same in the case notes for precautions for prevention for vertical transmission of infection to the neonates and transmission to health care professionals involved in her care. Ascertain the gestational age , by ultrasound as chances of IUGR and preterm labour are common. Anesthetist review should be planned as need more analgesia during labour, epidural is preferrable. The patient should be told that heroin is not known to cause teratogenicity, but miscarriage can occur. More chances of intrauterine growth restriction and prematurity,. Risks to the fetus for vertical transmission of STIS , if positive.More incidence of fetal distress during labour, needs continuous fetal monitoring. The neonate can develop severe drug withdrawal syndrome if administered narcan soon after birth. If on methadone this appears after seven days , if not , neonatal withdrawal syndrome appears by the third day. Breast feeding is not contraindicated unless she is HIV positive. Explain the symptoms of withdrawal syndrome such as jitteriness, poor feeding convulsions. Infants cognitive skills affected but no motor deficits noted. Appropriate home environment and support by social workers to the mother and infant can help in a better outcome. Sudden infant deaths are also common. Child protection measures should be taken in case mother reverts back to addiction, in form of rehabilation homes.