October 31, 2013 — Summary of "Identification of the Pregnant Woman Who Is Using Drugs: Implications for Perinatal and Neonatal Care," Casper/Arbour, Journal of Midwifery & Women's Health, September 9, 2013.
Neonatal abstinence syndrome (NAS) -- classified as "a set of drug withdrawal symptoms that affect the central nervous, gastrointestinal, and respiratory systems in the newborn when separated from the placenta at birth" -- is a "significant problem" affecting women, children, health care providers and financial resources in the U.S., according to Tammy Casper, an education specialist at Cincinnati Children's Hospital Medical Center, and Megan Arbour, a clinical assistant professor of nursing and coordinator at the University of Cincinnati College of Nursing.
From 2000 to 2009, NAS increased from 1.2 per 1,000 U.S. hospital births to 3.39 per 1,000. During the same time, total hospital charges for newborns experiencing NAS increased from $190 million to $720 million, "with 78% of total charges from state Medicaid programs," according to Casper and Arbour.
In the article, the authors describe "resources for the identification and management of drug use during pregnancy for midwives who provide care not only during the prenatal period but also during the intrapartum and postpartum periods."
Identifying Women at Risk
According to the authors, "NAS occurs in 55% to 94% of neonates born to women who consumed illicit drugs during their pregnancies." They note that women who use illicit drugs tend to be white and/or Hispanic; young; and lacking adequate or timely prenatal care. Such women usually use opiates, heroin, methadone or prescription pain medications, although concurrent use of nicotine, alcohol or benzodiazepines "is quite common" as well, the authors note. Women in this population are more likely to experience miscarriage, preeclampsia, premature rupture of membranes, placental abruption, fetal restriction and stillbirth.
As such, "[i]t is critical to identify drug use as soon as possible to lower the risk of infant and maternal morbidity and mortality," the authors write. They stress the importance of midwives and other maternal health care providers working to identify pregnant women who are using drugs and guiding them toward treatment options.
Treatment goals for pregnant women should be to "prevent withdrawal signs and symptoms, provide a comfortable transition to medication, and block the euphoric effects of illicit drugs while also reducing the drive to use them," in addition to the "postdischarge care of the newborn," Casper and Arbour write.
Screening for Drug Use During Pregnancy
According to the authors, "[p]renatal screening for alcohol and drug use is widely promoted but often falls short of practice recommendations." They explain that doctors and advanced practice nurses are legally obligated to ask patients universal screening questions and "provide brief interventions and referrals for pregnant women in order to optimize care outcomes at affordable costs."
One of the ways providers can screen for drug use is by using the "4 P's Plus" tool, which includes questions regarding "parents, partner, past and pregnancy." The questions are specifically aimed at discovering whether a patient's parents or partner have had or currently have issues with alcohol or drugs, in addition to the patient's past alcohol use and certain behaviors -- like tobacco use -- in the month prior to the pregnancy.
The authors note that it is important for providers to use standard screening tools for all pregnant women, as risk-based screening methods mainly target women who have histories of drug use, child protection agency involvement or positive drug tests.
Another way to screen for maternal drug use is by urine testing, but the authors note that such tests should only be used in compliance with state laws, with patient consent and as a means of confirming suspected or reported drug use. Because of these parameters, it is important that providers know the laws and policies in their place of practice.
The authors acknowledge that caring for pregnant women who are using drugs can be challenging because of "late presentation to care and undisclosed drug use" among such patients. However, they explain, "If a woman who is using drugs does present for prenatal care, this time may be a window of opportunity to reach her and assist her with understanding the far-reaching ramifications of drug use, as well with referrals leading to management or cessation of use of her substance(s) of choice."
The authors also note that midwives should not manage such patients' care on their own and should instead seek "[e]xpert assistance ... because the effects of all drugs are not equal." Midwives also should notify "the collaborating physician after the drug use is identified," the authors write, adding that the American College of Obstetricians and Gynecologists recommends "that a comprehensive package of prenatal care, drug therapy counseling, family therapy, and nutrition education is important for pregnant women with illicit drug dependence."
After birth, providers should conduct neonatal toxicology testing, such as urine, meconium, umbilical cord, and maternal and newborn hair tests. If results are positive, providers should alert a pediatrician or neonatologist that the infant is at risk of NAS so treatment can begin. A social worker should be consulted to ensure the newborn's care once released from the hospital is "adequate and appropriate based on the Child Abuse Prevention and Treatment Act," the authors add.
According to the authors, "Universal drug-screening and follow-up urine toxicology screens" of pregnant women using drugs "following state and practice protocols are critical during the prenatal care period." It is vital that maternal care providers coordinate with each other, as well as with social workers and neonatal care providers, to achieve the best care outcomes.
"A collaborative, educational approach can yield the best care for mothers and infants alike," Casper and Arbour conclude.