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Library of Congress Cataloging‐in‐Publication Data
Names: Queenan, John T., editor. | Spong, Catherine Y., editor. | Lockwood, Charles J., editor.
Title: Protocols for high-risk pregnancies : an evidence-based approach / edited by John T. Queenan, Catherine Y. Spong, Charles J. Lockwood. Description: Seventh edition. | Hoboken, NJ : Wiley-Blackwell, 2021. | Includes bibliographical references and index.
Identifiers: LCCN 2020024021 (print) | LCCN 2020024022 (ebook) | ISBN 9781119635260 (paperback) | ISBN 9781119635284 (adobe pdf) | ISBN 9781119635291 (epub)
Subjects: MESH: Pregnancy, High-Risk | Pregnancy Complications | Evidence-Based Medicine
3 Opioid Use, Misuse, and Addiction in Pregnancy and Postpartum, 15
Mishka Terplan
4 Depression, 21
Kimberly Yonkers
Part 2 Antenatal Testing
5 Prenatal Testing for Chromosomal Abnormalities, 29
Mary E. Norton
6 Fetal Echocardiography, 41
Joshua A. Copel
7 Clinical Use of Doppler, 49
Henry L. Galan
8 Antepartum Testing, 61
Michael P. Nageotte
9 Fetal Blood Sampling and Transfusion, 69
Patricia Santiago‐Munoz
10 Preconception Genetic Screening, 77
Lauren Sayres and Jeffrey A. Kuller
Part 3 Maternal Disease
11 Maternal Anemia, 89
Elaine Duryea
12
Hemoglobinopathies in Pregnancy, 97
Bradley Sipe and Judette Louis
13 Fetal and Neonatal Alloimmune Thrombocytopenia, 105
Russell Miller and Richard Berkowitz
14 Rheumatological Disorders, 113
Lisa R. Sammaritano and Bonnie L. Bermas
15 Antiphospholipid Syndrome, 125
Robert M. Silver
16 Inherited Thrombophilias, 131
Andra H. James and Jerome J. Federspiel
17 Valvular Heart Disease in Pregnancy, 141
Blake Zwerling and Afshan B. Hameed
18 Peripartum Cardiomyopathy, 165
Sarah Rae Easter and Carolyn M. Zelop
19 Thromboembolism, 181
Michael J. Paidas
20 Renal Disease, 201
Shivani Patel
21 Obesity, 209
Patrick S. Ramsey
22 Diabetes Mellitus, 219
Mark B. Landon and Steven G. Gabbe
23 Thyroid Disorders, 231
Elizabeth O. Buschur and Stephen F. Thung
24 Hepatitis in Pregnancy, 241
Andrew Myers, Asa Oxner, John Sinnott, and Christian Brechot
25 Asthma, 253
Michael Schatz
26 Epilepsy, 263
Thomas McElrath
27 Chronic Hypertension, 273
Michal Fishel Bartal and Baha M. Sibai
28 Cytomegalovirus, Genital Herpes, Rubella, and Toxoplasmosis, 285
Kerry E. Drury and Brenna L. Hughes
29 Syphilis, 293
Emily H. Adhikari
30 Vector‐Borne Diseases in Pregnancy: Zika, West Nile, and Chagas Disease, 301
Karin Nielsen‐Saines and Tara Kerin
31 Influenza, 317
Amanda C. Zofkie and Vanessa Rogers
32 Malaria, 323
Blair J. Wylie
33 Human Immunodeficiency Virus Infection, 333
Emily H. Adhikari
34 Parvovirus B19, 343
Kathy C. Matthews, Emilie L. Vander Haar, and Laura E. Riley
35 Group B Streptococcus, 351
Caitlin A. MacGregor and Mara J. Dinsmoor
36 Biliary, Liver, and Pancreatic Disease, 361
Vic Velanovich, Elizabeth Hoover, and Stephanie Ros
Part 4 Obstetric Problems
37 Cervical Insufficiency, 375
Rupsa C. Boelig and Vincenzo Berghella
38 Nausea and Vomiting, 387
Jared T. Roeckner and Haywood L. Brown
39 Fetal Death and Stillbirth, 397
Alexander M. Saucedo and Robert M. Silver
40 Abnormal Amniotic Fluid Volume, 407
Christina M. Ackerman, Thomas R. Moore, and Heather S. Lipkind
41 Fetal Growth Restriction, 421
Jodi S. Dashe and Anne M. Ambía
42 Rh and Other Blood Group Alloimmunizations, 431
Kenneth J. Moise Jr
43 Preterm Labor, 443
Hyagriv N. Simhan
44 Prevention of Preterm Birth, 449
Anna King and Sarah J.E. Stock
45 Premature Rupture of the Membranes, 461
Brian M. Mercer
46 Indicated Late‐Preterm and Early‐Term Deliveries, 475
Catherine Y. Spong
47 Chorioamnionitis, 481
Catalin S. Buhimschi and Irina A. Buhimschi
48 Third‐Trimester Bleeding, 493
Ilina D. Pluym and Christina S. Han,
49 Amniotic Fluid Embolism, 507
Irene A. Stafford and Michael A. Belfort
50 Preeclampsia, 517
Michal Fishel Bartal and Baha M. Sibai
Part 5 Labor and Delivery
51 Elective Induction of Labor, 531
Rachel G. Sinkey
52 Electronic Fetal Heart Rate Monitoring, 539
David A. Miller
53 Breech Delivery, 555
G. Justus Hofmeyr and Mercy‐Nkuba Nassali
54 Vaginal Birth After Cesarean, 563
James R. Scott
55 Placenta Accreta Spectrum, 571
Robert M. Silver and Deirdre J. Lyell
56 Shoulder Dystocia, 581
George A. Macones and Robert B. Gherman
57 Twins, Triplets, and Beyond, 587
Mary E. D’Alton
58 Postpartum Hemorrhage, 601
David B. Nelson
Appendix A: Evaluation of Fetal Health and Defects, 613
Lynn L. Simpson Index, 629
Preface
The current acceleration in medical discoveries parallels Moore’s law for computer chips. In the 1950s, medical knowledge doubled every 50 years, by the 1980s it doubled every seven years, and now medical knowledge is estimated to double about every two months (Densen 2011). How can busy obstetricians keep pace? Through seven editions, Protocols for High‐Risk Pregnancies has helped address this exact challenge. Providing just‐in‐time content, its focus on protocols and guidelines helps organize medical thinking, avoid heuristic errors of omission and commission, and optimize maternal and fetal outcomes.
As with the prior six editions, we have once again assembled some of the world’s top obstetrical and medical experts. Concomitantly, the seventh edition adds a number of new features including protocols on opioid use, misuse and addiction in pregnancy and postpartum, noninvasive prenatal diagnosis of aneuploidy, periconceptional genetic screening, and expanded protocols on maternal valvular heart disease and cardiomyopathies; we have also added protocols on arboviruses including Zika, and malaria, to reflect new technologies, changing clinical disease patterns, and emerging global pathogens.
As in prior editions, our focus has been on conducting a comprehensive survey of recent relevant literature to extract the most current evidence‐based practices and then presenting them with concise, focused text and crystal‐clear clinical paradigms. In areas where there are reasonable clinical alternatives, where no single compelling randomized clinical trial or a clear metaanalytical preference is available, we have again asked the authors to use their best judgment to make recommendations.
We are deeply indebted to our common mentor, Dr John T. Queenan, who conceived of this text to help “clinicians in the trenches” and hope we have been faithful to his vision. We also appreciate the help of our editorial team at John Wiley & Sons, Deirdre Barry and Anupama Sreekanth.
Catherine Y. Spong, MD
Charles J. Lockwood, MD, MHCM
Reference
Densen P. Challenges and opportunities facing medical education. Trans Am Clin Climatol Assoc 2011;122:48–58.
List of Contributors
Christina M. Ackerman
Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Maternal Fetal Medicine, Yale School of Medicine, New Haven, CT, USA
Emily H. Adhikari
Department of Obstetrics and Gynecology, Division of Maternal‐Fetal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
Anne M. Ambía
Department of Obstetrics and Gynecology, Division of Maternal‐Fetal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
Michal Fishel Bartal
Department of Obstetrics and Gynecology and Reproductive Sciences, The University of Texas Medical School at Houston, Houston, TX, USA
Michael A. Belfort
Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
Vincenzo Berghella
Department of Obstetrics and Gynecology, Division of Maternal‐Fetal Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
Richard Berkowitz
Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, USA
Bonnie L. Bermas
Division of Rheumatic Diseases, University of Texas, Southwestern Medical Center, Dallas, TX, USA
Rupsa C. Boelig
Department of Obstetrics and Gynecology, Division of Maternal‐Fetal Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
Christian Brechot
Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
Haywood L. Brown
Department of Obstetrics and Gynecology, University of South Florida, Tampa, FL, USA
Catalin S. Buhimschi
Department of Obstetrics and Gynecology, University of Illinois College of Medicine at Chicago, Chicago, IL, USA
Irina A. Buhimschi
Department of Obstetrics and Gynecology, University of Illinois College of Medicine at Chicago, Chicago, IL, USA
Elizabeth O. Buschur
Department of Internal Medicine, Division of Endocrinology, Metabolism, and Diabetes, The Ohio State University Wexner Medical Center, Columbus, OH, USA
John Byrne
Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
Joshua A. Copel
Departments of Obstetrics, Gynecology and Reproductive Sciences, and Pediatrics, Yale School of Medicine, New Haven, CT, USA
Mary E. D’Alton
Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York Presbyterian Hospital, New York, USA
Jodi S. Dashe
Department of Obstetrics and Gynecology, Division of Maternal‐Fetal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
Mara J. Dinsmoor
Department of Obstetrics and Gynecology, NorthShore University Health System, Evanston, IL, USA
Department of Obstetrics and Gynecology, Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
Kerry E. Drury
Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
Elaine Duryea
Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
Sarah Rae Easter
Departments of Obstetrics and Gynecology, and Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
Jerome J. Federspiel
Department of Obstetrics and Gynecology, Division of Maternal‐Fetal Medicine, Duke University Medical Center, Durham, NC, USA
Steven G. Gabbe
Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH, USA
Henry L. Galan
Department of Obstetrics and Gynecology, Division of Maternal‐Fetal Medicine, University of Colorado School of Medicine, Colorado Fetal Care Center, Aurora, CO, USA
Robert B. Gherman
Division of Maternal Fetal Medicine, WellSpan Health System, York, PA, USA
Afshan B. Hameed
Division of Obstetrics and Gynecology, Irvine School of Medicine, University of California, Irvine, CA, USA
Christina S. Han
Department of Obstetrics and Gynecology, Division of Maternal‐Fetal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
Center for Fetal Medicine and Women’s Ultrasound, Los Angeles, CA, USA
G. Justus Hofmeyr
Effective Care Research Unit, Universities of the Witwatersrand and Fort Hare, Bhisho, South Africa
Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
Elizabeth Hoover
Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
Brenna L. Hughes
Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
Andra H. James
Department of Obstetrics and Gynecology, Division of Maternal‐Fetal Medicine, Duke University Medical Center, Durham, NC, USA
Tara Kerin
Department of Pediatrics, David Geffen School of Medicine at UCLA/UCLA Mattel Children’s Hospital, Los Angeles, CA, USA
Anna King
Department of Obstetrics and Gynaecology, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
Jeffrey A. Kuller
Department of Obstetrics and Gynecology, Division of Maternal‐Fetal Medicine, Duke University School of Medicine, Durham, NC, USA
Mark B. Landon
Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH, USA
Heather S. Lipkind
Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Maternal Fetal Medicine, Yale School of Medicine, New Haven, CT, USA
Judette Louis
Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
Deirdre J. Lyell
Department of Obstetrics and Gynecology, Division of Maternal‐Fetal Medicine, Stanford University Medical Center, Stanford, CA, USA
Caitlin A. MacGregor
Department of Obstetrics and Gynecology, NorthShore University Health System, Evanston, IL, USA
Department of Obstetrics and Gynecology, Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
George A. Macones
Division of Maternal Fetal Medicine, Dell Medical School‐University of Texas at Austin, Austin, TX, USA
Kathy C. Matthews
New York Presbyterian–Weill Cornell Medicine, New York, USA
Thomas McElrath
Division of Maternal‐Fetal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
Brian M. Mercer
Department of Obstetrics and Gynecology, Case Western University–MetroHealth Medical Center, Cleveland, OH, USA
David A. Miller
Department of Obstetrics, Gynecology and Pediatrics, Keck School of Medicine, University of Southern California, Children’s Hospital Los Angeles, Los Angeles, CA, USA
Russell Miller
Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, USA
Kenneth J. Moise Jr
Departments of Obstetrics, Gynecology and Reproductive Sciences, and Pediatric Surgery, McGovern School of Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA
Thomas R. Moore
Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Perinatal Medicine, University of California San Diego, San Diego, CA, USA
Andrew Myers
Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
Michael P. Nageotte
Miller Children’s and Women’s Hospital, Long Beach, CA, USA
Department of Obstetrics and Gynecology, University of California, Irvine, CA, USA
Mercy‐Nkuba Nassali
Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
David B. Nelson
Department of Maternal‐Fetal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
Karin Nielsen‐Saines
Department of Pediatrics, David Geffen School of Medicine at UCLA/UCLA Mattel Children’s Hospital, Los Angeles, CA, USA
Ruta M. Nonacs
Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
Mary E. Norton
Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA, USA
Asa Oxner
Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
Michael J. Paidas
Department of Obstetrics, Gynecology and Reproductive Sciences, Miller School of Medicine, University of Miami, Miami, FL, USA
Shivani Patel
Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
Ilina D. Pluym
Department of Obstetrics and Gynecology, Division of Maternal‐Fetal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
Patrick S. Ramsey
Department of Obstetrics and Gynecology, Center for Pregnancy and Newborn Research, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
Laura E. Riley
Department of Clinical Obstetrics and Gynecology, Weill Cornell Medicine, New York, USA
Jared T. Roeckner
Department of Obstetrics and Gynecology, University of South Florida, Tampa, FL, USA
Vanessa Rogers
Department of Obstetrics and Gynecology, Division of Maternal‐Fetal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
Stephanie Ros
Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampla, FL, USA
George Saade
Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Texas Medical Branch, Galveston, TX, USA
Lisa R. Sammaritano
Division of Rheumatology, Hospital for Special Surgery – Weill Cornell Medicine, New York, NY, USA
Patricia Santiago‐Munoz
Department of Obstetrics and Gynecology, Division of Maternal‐Fetal Medicine, University of Texas Medical Center, Dallas, TX, USA
Alexander M. Saucedo
Department of Obstetrics and Gynecology, Division of Maternal‐Fetal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
Lauren Sayres
Division of Maternal Fetal Medicine, University of Colorado, Aurora, CO, USA
Michael Schatz
Department of Allergy, Kaiser Permanente Medical Center, San Diego, CA, USA
Department of Medicine, University of California San Diego School of Medicine, San Diego, CA, USA
James R. Scott
Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
Baha M. Sibai
Department of Obstetrics and Gynecology and Reproductive Sciences, The University of Texas Medical School at Houston, Houston, TX, USA
Robert M. Silver
Department of Obstetrics and Gynecology, Division of Maternal‐Fetal Medicine, University of Utah Health Sciences Center, Salt Lake City, UT, USA
Hyagriv N. Simhan
Department of Obstetrics and Gynecology, Division of Maternal‐Fetal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
Lynn L. Simpson
Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, USA
Rachel G. Sinkey
Department of Obstetrics and Gynecology, Division of Maternal‐Fetal Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
John Sinnott
Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
Bradley Sipe
Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
Catherine Y. Spong
Department of Obstetrics and Gynecology, Division of Maternal‐Fetal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
Irene A. Stafford
Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
Sarah J.E. Stock
Department of Maternal and Fetal Medicine, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
Mishka Terplan
Friends Research Institute, Adjunct Faculty, Clinical Consultation Center, University of California, San Francisco, CA, USA
Stephen F. Thung
Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH, USA
Emilie L. Vander Haar
New York Presbyterian–Weill Cornell Medicine, New York, USA
Vic Velanovich
Department of Surgery, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
Blair J. Wylie
Department of Obstetrics and Gynecology, Division of Maternal‐Fetal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
Kimberly Yonkers
Departments of Psychiatry, Obstetrics, Gynecology and Reproductive Sciences and School of Public Health, Yale University School of Medicine, New Haven, CT, USA
Carolyn M. Zelop
Department of Obstetrics and Gynecology, NYU School of Medicine, New York, USA
Amanda C. Zofkie
Department of Obstetrics and Gynecology, Division of Maternal‐Fetal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
Blake Zwerling
Division of Obstetrics and Gynecology, Irvine School of Medicine, University of California, Irvine, CA, USA
Concerns in Pregnancy
Alcohol Use in Pregnancy and Lactation
Ruta M. Nonacs
Department
of Psychiatry,
Massachusetts General Hospital, Boston, MA, USA
Overview
According to data collected in the 2015–2017 Behavioral Risk Factor Surveillance System conducted by the Centers for Disease Control and Prevention (CDC), 11.5% of pregnant women in the United States reported consuming at least one alcoholic drink during the past 30 days, and 3.9% reported binge drinking (five or more drinks during one episode). Among pregnant women who reported binge drinking, the average frequency of binge drinking was 4.5 episodes during the past 30 days. The highest prevalence of alcohol use during pregnancy was observed in older (ages 35–44 years), college educated, and unmarried women. According to the same surveillance, the prevalence of any alcohol use was 53.6% among nonpregnant reproductive age women, indicating that pregnancy may be a time of increased motivation to decrease or stop drinking. Even among women with heavy alcohol use or patterns of use consistent with alcohol use disorder, 70–90% abstain from alcohol during pregnancy. Although many women achieve abstinence during pregnancy, studies have noted high rates of relapse during the postpartum period.
Alcohol use during pregnancy
Alcohol use during pregnancy has been associated with an increased risk of fetal death in some, but not all, studies. For example, an increased risk of miscarriage was reported in women who consumed more than three drinks per week (adjusted odds ratio 2.3; 95% confidence interval [CI] 1.1–4.5), compared to women who reported no alcohol consumption. In a Danish study of nearly 90 000 pregnant women, a higher risk of fetal death after
22 weeks’ gestation (adjusted hazard ratio 2.20; 95% CI 1.73–2.80) was observed in pregnant women who reported either three or more drinks per week or two or more binge‐drinking episodes, compared to women who did not drink.
Alcohol exposure during pregnancy also increases the risk of low birthweight and extreme preterm birth (<32 weeks’ gestation), factors which may contribute to higher rates of neonatal morbidity and mortality and may have long‐term neurodevelopmental consequences.
Most studies have focused on the negative effects of alcohol on fetal development. Alcohol is a known teratogen and exposure early in pregnancy, during the period of organogenesis, has been associated with growth restriction and a constellation of physical abnormalities, including dysmorphic facial features, microcephaly, cardiac defects, and eye and ear abnormalities. Exposure to alcohol at any point during the pregnancy can compromise development of the fetal brain. Prenatal alcohol exposure is one of the leading causes of mental retardation and may result in long‐term deficits in cognitive, behavioral, and emotional functioning.
Fetal alcohol spectrum disorders (FASD) encompass several diagnostic subtypes. Children with fetal alcohol syndrome (FAS) are the most severely affected and present with characteristic facial features (e.g., thin upper lip, small, wide‐set eyes, upturned nose), microcephaly, small stature, and cognitive deficits, including developmental delays and lower IQ, as well as emotional and behavioral problems. Children with alcohol‐related neurodevelopmental disorder (ARND) lack the characteristic facial defects and growth retardation seen in children with FAS but have alcohol‐induced mental impairment.
The effects of alcohol exposure on the developing fetus are variable. While any amount of alcohol consumption may have adverse effects, binge drinking is especially concerning as it has been associated with higher risk of FASD. Children born to women of lower socioeconomic status appear to be more susceptible to the effects of alcohol in utero, a finding which suggests that other factors, including nutritional status and environmental exposures, may contribute to the pathophysiology of FASD. Currently, there is no known amount of alcohol consumption during pregnancy which is considered to be safe.
Prevalence estimates of FAS have varied widely from 0.5 to 3 per 1000 live births; however, studies using in‐person assessments of school‐aged children report higher estimates of FAS: 6–9 per 1000 children. Few estimates for the full range of FASDs are available; the most current estimate of the prevalence of FASD among US children is approximately 1%.
Alcohol use during lactation
Approximately half of all breastfeeding women in the US report consuming alcohol; however, relatively little is known about the consequences of
alcohol intake in breastfeeding women and their infants. Alcohol consumed by the mother passes into the breast milk, with levels peaking 30–60 minutes after an alcoholic beverage is consumed. While the alcohol from one drink can be detected in breast milk for about 2–3 hours, alcohol is detectable in the breast milk for about 4–5 hours if the mother consumes two drinks and for about 6–8 hours if she consumes three drinks, and so forth. Other factors influencing the amount of alcohol in breast milk include how fast it is consumed, whether it is consumed with food, the mother’s body mass index (BMI), and how quickly she metabolizes alcohol.
It has been demonstrated that alcohol inhibits the release of oxytocin, the hormone which stimulates milk ejection, an effect which decreases the amount of milk available to the nursing infant. Higher amounts of alcohol intake appear to have a greater effect; however, one study noted that drinking as little as 0.3 g alcohol per kg (a little more than a 12‐ounce beer or mixed drink) may reduce milk production by about 10%. Other studies have observed that the infants of mothers who consume alcohol tend to take in less breast milk per feeding and may also have disrupted sleep patterns.
The long‐term effects of alcohol delivered to infants via breast milk have not been well studied. In a study of 400 infants born to women in a health maintenance organization, motor development, as measured by the Psychomotor Development Index (PDI), was significantly lower in infants exposed regularly to alcohol in breast milk (even after controlling for prenatal alcohol exposure), with an inverse dose–response relationship noted between frequency of maternal alcohol consumption and scores on the PDI. In a similar study from the same group, however, there was no association between alcohol exposure and scores on the Griffiths Developmental Scales in 18‐month‐old children.
Breastfeeding while consuming alcohol may carry some neurodevelopmental risk for the infant; however, of greater concern is the impact alcohol may have on childcare and safety. Parental use of alcohol is considered a risk factor for sudden infant death syndrome and other infant sleep‐related deaths. Maternal alcohol use disorder (AUD) is associated with poor parenting skills, inadequate supervision, family disruption and conflict, family mobility, and increased risk for child abuse and neglect.
Screening for alcohol use
The US Preventive Services Task Force recommends that all adults seen in a primary care setting, including women seen annually by OB‐GYNs, should be screened for alcohol use and counseling should be provided when there is evidence of risky or harmful drinking. Referral to a specialist for treatment should be considered when there is evidence of an AUD. There is evidence that routine screening and brief behavioral counseling
interventions in women who engage in at‐risk drinking reduce the incidence of alcohol‐exposed pregnancies.
All women seeking obstetric care should be screened for alcohol use within the first trimester of pregnancy and again during the postpartum period; however, screening for alcohol use in an obstetric setting can be more complicated. Many women fear that disclosure of their alcohol use may have negative consequences, such as criminal or civil penalties or the loss of custody of their children. Therefore, it is crucial that, when screening for substance use, clinicians must assure their patients that the information disclosed is privileged and confidential.
Many validated screening tools for AUDs are available, including the CAGE, Alcohol Use Disorders Identification Test (AUDIT), and the revised AUDIT‐C; however, most of these commonly used tools have not been validated in pregnant populations. The American College of Obstetricians and Gynecologists (ACOG) and the National Institute on Alcohol Abuse and Alcoholism recommend using the T‐ACE or revised TACER‐3 (T‐tolerance, A‐annoyance, C‐cutting down, and E‐eye Opener) screening tools which have been specifically validated for use in pregnant women. Because T‐ACE/T‐ACER‐3 define risky drinking as the consumption of one ounce or more of alcohol per day and identify patterns of use suggestive of AUD, additional questions must be used to assess for the use of any alcohol.
Another option is the Substance Use Risk Profile–Pregnancy (SURP‐P), which was designed specifically to screen for alcohol and other illicit/recreational drug use in pregnancy. The SURP‐P is easily administered and consists of three questions: 1) Have you ever smoked marijuana? 2) In the month before you knew you were pregnant, how many beers, how much wine, or how much liquor did you drink?, and 3) Have you ever felt that you needed to cut down on your drug or alcohol use? Scoring requires tallying the number of affirmative responses (0 = low risk, 1 = moderate risk, 2–3 = high risk).
Screening for alcohol use during pregnancy allows clinicians to stratify risk in women according to their patterns of use. It is recommended that women at low risk should receive brief counseling regarding the risk of alcohol use during pregnancy. Women classified as moderate risk should receive a brief intervention (described below), and women at high risk should be referred for specialized substance abuse treatment.
Providers must also be aware of the possibility of concurrent psychiatric illness, as women with risky alcohol use are more likely to suffer from psychiatric illness, and women with untreated psychiatric illness are more likely to use alcohol (and other substances) during pregnancy. Consultation with mental health professionals is indicated and attending to co‐morbid
psychiatric illness can increase the likelihood of abstinence during pregnancy and improve compliance with prenatal care.
Intervention and referral to treatment
Screening, brief intervention, and referral to treatment (SBIRT) is a comprehensive, integrated public health approach used to identify and deliver services to those at risk for substance use disorders and has the potential to reduce the burden of substance use in pregnancy. SBIRT may be implemented in a variety of healthcare settings and adapted for culturally diverse populations. The Department of Health and Human Services Substance Abuse and Mental Health Services Administration (SAMHSA) provides many useful materials to facilitate implementation of SBIRT which consists of three basic components.
1 Screening by a health professional using validated instruments can quickly assess the severity of substance use and identify the appropriate level of care.
2 Brief intervention focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change.
3 Referral to treatment provides those identified as needing more extensive treatment with access to specialty care.
After screening, women at moderate risk should receive a brief intervention which typically involves counseling sessions, approximately five minutes in length, tailored to the severity of the identified alcohol problem. During the
Raise subject “Thank you for answering my questions – is it OK with you if we talk about your answers?”
“Can you tell me more about your past/current drinking or drug use? What does a typical week look like?”
Provide feedback“Sometimes patients who give similar answers are continuing to use drugs or alcohol during their pregnancy.”
“I recommend all my pregnant patients not to use any alcohol or drugs, because of the risk to you and to your baby.”
Enhance motivation“What do you like and what are you concerned about when it comes to your substance use?”
“On a scale of 0–10, how ready are you to avoid drinking/using altogether? Why that number and not a lower number?”
Negotiate planSummarize conversation. Then: “What steps do you think you can take to reach your goal of having a healthy pregnancy and baby?”
“Can we schedule a date to check in about this next time?”
first meeting, the provider should state her/his concerns and help to set goals. Educational materials should be provided. Routine follow‐up is essential; subsequent visits should involve encouragement, information, and reevaluation of goals. Wright and colleagues (Table 1.1) have modified SBIRT for use in pregnant women, leveraging the motivation inherent in the desire to have a healthy pregnancy.
Women who are unable to reduce or eliminate consumption of alcohol during pregnancy should be referred for more intensive intervention.
Conclusion
Alcohol consumption during pregnancy is relatively common, with the most recent surveys indicating that 11.5% of pregnant women in the US report consuming alcohol during pregnancy. While heavy alcohol use and binge drinking pose the greatest risk to the fetus, lower levels of exposure to alcohol have been associated with birth defects, neurodevelopmental deficits, and fetal alcohol spectrum disorders. OB‐GYNs are ideally positioned to screen women for risky alcohol use both before and during pregnancy and can educate women regarding the risks of alcohol use during pregnancy and initiate interventions which significantly decrease the use of alcohol during the perinatal period.
Suggested reading
American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved Women. Committee Opinion No.654: Reproductive Life Planning to Reduce Unintended Pregnancy. Obstet Gynecol 2016;127(2):e66–9.
Brown RA, Dakkak H, Seabrook JA. Is breast best? Examining the effects of alcohol and cannabis use during lactation. J Neonatal Perinatal Med 2018;11(4):345–56.
Denny CH, Acero CS, Naimi TS, Kim SY. Consumption of alcohol beverages and binge drinking among pregnant women aged 18–44 years – United States, 2015–2017. MMWR 2019;68(16):365–8.
DeVido J, Bogunovic O, Weiss RD. Alcohol use disorders in pregnancy. Harv Rev Psychiatry 2015;23(2):112–21.
Subramoney S, Eastman E, Adnams C, Stein DJ, Donald KA. The early developmental outcomes of prenatal alcohol exposure: a review. Front Neurol 2018;9:1108.
Wright TE, Terplan M, Ondersma SJ, Boyce C, Yonkers K, Chang G, Creanga AA. The role of screening, brief intervention, and referral to treatment in the perinatal period.
Am J Obstet Gynecol 2016;215(5):539–47.
PROTOCOL 2
Smoking, Vaping, and Nicotine Exposure
John Byrne1 and George Saade2
1Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
2Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Texas Medical Branch, Galveston, TX, USA
Clinical significance
Although cigarette smoking rates have continued to decline since the turn of the century, approximately 8% of women will smoke cigarettes sometime during their pregnancy in the US.
Tobacco exposure in pregnancy is associated with an increased rate of adverse outcomes such as fetal growth restriction, preterm birth, placenta previa, abruptio placentae, congenital anomalies such as cleft lip/palate, and perinatal mortality. It is estimated that up to 8% of preterm births, 19% of term deliveries of low‐birthweight infants, and 7% of preterm‐related infant deaths can be attributed to smoking during the pregnancy. The effects are not limited to cigarette smoking, as researchers have identified infants born to mothers who use smokeless tobacco, have similar levels of nicotine exposure, low birthweight, and preterm birth as the infants whose mothers smoked during pregnancy. Lastly, there has been a recent emergence of the use of electronic nicotine delivery systems or e‐cigarettes (also known as vaping), shifting many cigarette smokers to the use of e‐cigarettes. This electronic delivery system aerosolizes nicotine, releasing a vapor similar to traditional cigarette smoke, and 7% of women “vape” around the time of pregnancy, with 1.4% using during the pregnancy. Though the aerosol may contain fewer chemicals than cigarette smoke, it does contain other substances such as lead, benzene, and diacetyl.
There are several mechanisms which have been identified and proposed to explain adverse obstetrical and fetal outcomes associated with maternal nicotine exposure through cigarette smoking, e‐cigarette use or other smokeless routes. Nicotine crosses the placenta and can be detected in the fetal circulation at levels that exceed maternal concentrations by 15%, while amniotic fluid concentrations of nicotine are 88% higher than maternal plasma. Nicotine has been identified to impair uterine vascular function during pregnancy, by increasing vascular resistance and decreasing uterine artery blood flow. Carbon monoxide is also released during smoking and can be detected in the fetal circulation at levels that are 15% higher than maternal levels. It has a higher affinity for hemoglobin than oxygen to form the compound carboxyhemoglobin that shifts the oxygen dissociation curve to the left. Consequently, the availability of oxygen to fetal tissues is decreased. Beyond nicotine and carbon monoxide, tobacco smoke contains thousands of compounds that may have adverse effects on the developing fetus. For example, levels of cyanide in the circulation are higher in smokers, a substance that is toxic to rapidly dividing cells. In addition, nicotine can affect long‐term function through epigenetic changes
Nicotine replacement therapies such as gum, lozenges, patches or inhalers provide a sustained, yet lower level of nicotine compared to cigarettes. Similar effects of stillbirth, preterm birth, and low birthweight have been documented with use of these therapies, which can be attributed to impaired uterine vascular function due to the nicotine exposure. Vaping or e‐cigarette aerosol may also expose the user to volatile organic compounds and heavy metals, in addition to the nicotine or other substances commonly delivered. More research is needed regarding the effects of e‐cigarette on the developing fetus.
Screening for tobacco, nicotine, and vaping exposure
Identifying pregnant women who use tobacco, specifically cigarettes, e‐cigarettes and smokeless tobacco, is critical to the cessation and reduction of morbidity. Ideally, this would be identified prior to the pregnancy, when the risks associated with smoking in pregnancy could be discussed and the benefits of smoking cessation emphasized. Screening at prenatal visits using biochemical markers of tobacco exposure may have some utility in identification and cessation of tobacco use. Cotinine, a metabolite of nicotine, is an accurate assay for nicotine exposure when measured in urine and can be part of a cost‐effective cessation program. Studies indicate higher success rates when participants are aware that compliance is measured with biochemical tests. However, this has not been accepted into routine clinical practice at this time.
Interventions
Smoking cessation interventions for pregnant women result in fewer low‐birthweight newborns and perinatal deaths, fewer physical, behavioral and cognitive problems during infancy and childhood, and important health benefits for the mothers. Women who discontinue smoking even as late as 30 weeks of gestation have infants with higher birthweight than those who continue smoking. In contrast, “cutting down” seems to improve fetal growth only slightly.
Smoking cessation interventions, whether it be for cigarette or e‐cigarette smoking, should be included as part of prenatal care. Women are more likely to quit smoking during pregnancy than at any other time in their lives. An office‐based cessation counseling session of 5–15 minutes, when delivered by a trained provider with the provision of pregnancy‐specific educational materials, increases rates of cessation among pregnant smokers. Trials have shown that a five‐step intervention program (the 5 As) is effective.
1 Ask pregnant women about smoking status using a multiple‐choice question method to improve disclosure.
2 Advise women who smoke to quit smoking, with unequivocal, personalized and positive messages about the benefits for her, the baby, and family.
3 Assess the woman’s willingness to try to quit smoking within the next 30 days. If the woman wants to quit, the provider should move to the next step, Assist. For women who are unwilling to attempt cessation, the advice, assessment and assistance should be offered at each future visit.
4 Assist women who are interested in quitting by encouraging use of problem‐solving methods and skills for cessation and addressing issues that the woman believes might adversely influence her attempt to quit. Provide self‐help smoking cessation materials that contain messages to build motivation and confidence in support of a cessation attempt. Avoid “trigger situations.” Arrange social support in the smoker’s environment by helping her identify and solicit help from family, friends, co‐workers, and others who are most likely to be supportive of her quitting smoking. Provide social support as part of the treatment.
5 Arrange follow‐up. Smoking status should be monitored throughout pregnancy, providing opportunities to congratulate and support success, reinforce steps taken toward quitting, and advise those still considering a cessation attempt.
Pharmacotherapy
Pharmaceutical tobacco smoking cessation aids such as nicotine replacement therapy (NRT), varenicline, or bupropion SR are efficacious as first‐line agents in the general nonpregnant population. The use of these medications is
not yet routinely recommended in pregnancy, as there are inconclusive data on their effectiveness and safety. NRT is available as transdermal patch, inhaler, nasal spray, chewing gum, or lozenge. Most existing data for smoking cessation in pregnancy are based on NRT delivery methods such as patches, but a randomized clinical trial (RCT) comparing nicotine inhalers and placebo for pregnant smokers was recently published. This RCT showed no benefit of nicotine inhalers for smoking cessation in pregnancy, although there was notably a lower rate of preterm birth if the woman used the nicotine inhaler compared to placebo. In general, NRT should be used with extreme caution and women should be warned of uncertain side effects in pregnancy.
Bupropion SR is an atypical antidepressant that has been approved by the FDA for use in smoking cessation. It is contraindicated in patients with bulimia, anorexia nervosa, use of MAO inhibitors within the previous 14 days, or a known or history of seizure disorder. It carries a black box warning due to an association of antidepressant medications with suicidality in children, adolescents, and young adults under the age of 24 years. Varenicline is approved for smoking cessation in the general population. Serious neuropsychiatric symptoms have been associated with its use including agitation, depression, and suicidality. Although there have been several small studies performed evaluating the safety of varenicline in pregnancy with no evidence of teratogenicity documented, these data must be interpreted with caution.
To date, contingency management, or the use of tangible reinforcement to promote desired behaviors, is the most promising technique to achieve smoking cessation and has been shown to be an effective motivational tool for overcoming other addictions, including alcohol and substance abuse.
An increasing proportion of smokers are now using e‐cigarettes, either for nicotine delivery or as a measure to assist with smoking cessation. Although e‐cigarettes may contain fewer harmful substances than cigarettes, they are not considered safe to use during pregnancy. In addition to the impact of the nicotine administered, there are some flavorings that may be harmful to the developing fetus. It should be noted that at this time, the Centers for Disease Control and Prevention (CDC) recommend against the use of e‐cigarette products given the risks associated with such use.
Complications
Tobacco use not only impacts the health of the mother and fetus but carries over into the postnatal period. Pregnancies among women who smoke cigarettes have been associated with increased risks for miscarriage, ectopic pregnancy, fetal growth restriction, placenta previa, abruptio placentae, preterm birth, premature rupture of the membranes, and low birthweight. In a recent metaanalysis reviewing 142 studies, any smoking during the
pregnancy increased the risk of stillbirth by approximately 50% and risk of neonatal death by 20%. There appears to be a dose–response relationship, with heavy smokers having the greatest risk.
The offspring of smoking mothers face additional risks during childhood. There is a strong association between maternal smoking and sudden infant death syndrome, and again, a clear dose–response relationship has been demonstrated. Prenatal and postnatal tobacco smoke exposure has also been associated with increased risk of reduced lung function, respiratory infections, and asthma in the children. Recent studies suggest that infants born to women who smoke during pregnancy may be at increased risk for childhood obesity, as well as other metabolic dysfunctions, likely through a developmental programming effect. In addition, there is evidence suggesting a neurotoxic effect of prenatal tobacco exposure on newborn behavior, i.e., being more excitable and hypertonic. The behavioral and cognitive deficits associated with in utero exposure to tobacco seem to continue into late childhood and adolescence with increased risk for attention‐deficit hyperactivity disorder and conduct disorder.
In addition to nicotine exposure, e‐cigarette use has been associated with an additional risk. An acute, severe respiratory distress syndrome has been identified in individuals using e‐cigarette products. Over 2000 e‐cigarette or vaping product use‐associated lung injury (EVALI) events were reported by the CDC in the US in 2019. The exact etiology of the lung injury is unknown but vitamin E acetate exposure may play a role in the development of EVALI. Pregnant women are at higher risk for severe outcomes with EVALI, therefore these products should not be used in pregnancy.
Follow‐up and prevention
Many pregnant women can remain smoke free during their pregnancy but postnatal relapse rates are high. The Pregnancy Risk Assessment Monitoring System reported relapse rates as high as 67% at greater than six months postpartum. Counseling should be continued at each postpartum visit including unequivocal, personalized and positive messages about the benefits to the patient, her baby and family resulting from smoking cessation. Although available data are limited, pharmacotherapy can be considered for the lactating woman. Any potential risk for the nursing infant from passage of small amounts of the medications through breast milk should be weighed against the increased risks associated with second‐hand exposure to smoking such as sudden infant death syndrome, respiratory infections, asthma, and middle ear disease.
Suggested reading
American College of Obstetricians and Gynecologists. Smoking cessation during pregnancy. Committee Opinion No. 721. Obstet Gynecol 2017;130:e200–4.
Blunt BC, Karwowski MP, Shields PG, et al. Vitamin E acetate in bronchoalveolar‐lavage fluid associated with EVALI. N Engl J Med 2020;382:697–705
Curtin SC, Matthews TJ. Smoking prevalence and cessation before and during pregnancy: fData from the birth certificate, 2014. Natl Vital Stat Rep 2016;65:1–14.
Jatlaoui TC, Wiltz JL, Kabbani S, et al. Update: interim guidance for health care providers for managing patients with suspected e‐cigarette, or vaping, product use – associated lung injury – United States, November 2019. MMWR 2019;68:1081–6.
Kapaya M, d’Angelo DV, Tong VT, et al. Use of electronic vapor products before, during, and after pregnancy among women with a recent live birth – Oklahoma and Texas, 2015. MMWR 2019;68;189–94.
Layden JE, Ghinai I, Pray I, et al. Pulmonary illness related to e‐cigarette use in Illinois and Wisconsin – final report. N Engl J Med 2020;382:903–16.
Likis FE, Andrews JC, Fonnesbeck CJ, et al. Smoking Cessation Interventions in Pregnancy and Postpartum Care. Evidence Report/Technology Assessment No. 214. (Prepared by the Vanderbilt Evidence‐based Practice Center under Contract No. 290‐2007‐10065‐I.)
AHRQ Publication no. 14‐E001‐EF. Rockville, MD: Agency for Healthcare Research and Quality, 2014. www.effectivehealthcare.ahrq.gov/reports/final.cfm
Shahab L, Goniewicz ML, Blount BC, et al. Nicotine, carcinogen, and toxin exposure in long‐term e‐cigarette and nicotine replacement therapy users: a cross‐section study. Ann Intern Med 2017;166:390–400.
Tong VT, Dietz PM, Morrow B, et al. Trends in smoking before, during, and after pregnancy – Pregnancy Risk Assessment Monitoring System, United States, 40 sites, 2000–2010. MMWR Surveill Summ 2013;62:1–19.
Tran T, Reeder A, Funke L, Richmond N. Association between smoking cessation interventions during prenatal care and postpartum relapse: results from 2004 to 2008 multi‐state PRAMS data. Matern Child Health J 2013;17:1269–76.
US Department of Health and Human Services Substance Abuse and Mental Health Services Administration Center for Behavioral Health Statistics and Quality. National Survey on Drug Use and Health, 2013. Inter‐University Consortium for Political and Social Research (ICPSR) [distributor].
US Department of Health and Human Services. The Health Consequences of Smoking: 50 Years of Progress. A Report of the Surgeon General. Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.
World Health Organization. WHO Recommendations for the Prevention and Management of Tobacco Use and Second‐Hand Smoke Exposure in Pregnancy. Geneva: World Health Organization, 2013.
Opioid Use, Misuse, and Addiction in Pregnancy and Postpartum
Mishka Terplan
Friends Research Institute, Adjunct Faculty, Clinical Consultation Center, University of California, San Francisco, CA, USA
Overview
Opioids have been part of human culture and healing for millennia. Initially cultivated and distributed throughout the ancient world, opioids are described in Sumerian, Egyptian, Greek, Islamic, and Chinese medical treatises. Whereas opioid use is ancient, problematic use and, specifically, addiction are more modern phenomena. The first opioid crisis, which dates to the latter half of the 18th century, was iatrogenic in origin. This was an epidemic overwhelmingly of women, who had initially been exposed to opioids through a prescription for the treatment of “female ailments.”
The current opioid crisis in the US is arguably the most severe in history and, like the first, features a large proportion of women. Overdose deaths have become one of the leading causes of mortality and, along with hepatitis C and suicide, have contributed to a decrease in life expectancy especially among white, middle‐aged Americans. The current crisis consists of three related phases. The first began with a marked increase in opioid prescribing starting in the mid‐1990s and peaked in 2010. The second was driven by illicit heroin distribution while the third phase began in 2016 powered by fentanyl and other illicitly manufactured synthetic opioids. Opioid‐related drug deaths may have plateaued nationally in 2019, but a fourth wave of stimulant‐related mortality (both amphetamine and cocaine) is now emerging.
The current crisis has changed the demographics of substance use and addiction. Whereas less than 20% of people who used heroin in the 1970s were women, today roughly 50% are women. Although more men have addiction than women, for opioid use disorder at least half of people presenting for treatment are female.
Opioid use, misuse, and addiction have increased in pregnancy and postpartum, in parallel with the overall crisis. Rates of opioid use disorder assessed at the time of delivery more than quadrupled between 1999 and 2014, as have rates of neonatal abstinence syndrome (NAS), and, in many states, overdose is the leading cause of maternal death.
Opioid use and misuse
Opioids are a class of substances which bind to the opioid receptor. They are commonly utilized in anesthesia, prescribed as analgesics, employed for the treatment of opioid use disorder, and available in illicit economies (heroin and both diverted and counterfeit pills). Although data support the use of opioids for acute pain, their effectiveness for chronic pain management is limited. Details regarding opioid prescribing for pain are beyond the scope of this Protocol though general principles of care include (i) treating pain with combination therapies (both opioid and nonopioid pharmaceuticals and nonpharmacologic management), and (ii) when opioids must be used, employ the lowest dose for the shortest duration.
Risks associated with opioid use include (i) tolerance (dose increase needed to maintain effect), (ii) dependence (withdrawal symptoms upon cessation), and (iii) overdose‐related morbidity and mortality. The risk of overdose is related not just to the opioid dose, but also to the concomitant use of other central nervous system (CNS) depressants (both prescribed and not prescribed) such as benzodiazepines, zolpidem and other sleep aids and alcohol. Therefore, individuals prescribed opioids for both chronic pain and addiction treatment should be co‐prescribed naloxone and instructed in its use. Naloxone is an opioid antagonist, most often administered via an intranasal route, which reverses opioid overdose.
A third of individuals prescribed opioids for chronic pain report misuse. Symptoms of misuse can include taking extra medication because of the effect, running out of prescriptions early, and crushing and snorting or injecting the medication. At most, 12% of individuals prescribed opioids for chronic pain develop an opioid use disorder. Opioid misuse can be a risk factor for the development of opioid addiction. Validated instruments, such as the Opioid Risk Tool, should be utilized when initiating opioid prescribing to assess and communicate misuse and addiction risk to patients.
Screening and diagnosis
Pregnancy is an opportune time to assess behavioral health conditions in general, and substance use and addiction in particular. Universal screening with a validated instrument is recommended as a routine part of prenatal
care. The following instruments have been studied in a comparative study design: the Substance Use Risk Profile‐Pregnancy (SURP‐P), CRAFFT, 5Ps (parents, peers, partner, pregnancy, past), Wayne Indirect Drug Use Screener (WIDUS) and the National Institute on Drug Abuse (NIDA) Quick Screen. All perform with similar efficacy though none has both high sensitivity and high specificity. Screening should occur at the first prenatal care visit, every trimester, and, especially, postpartum. Urine drug testing is not a substitute for screening. Urine drug tests, especially point‐of‐care tests, do not capture certain substances (such as alcohol, nicotine and many synthetic opioids including fentanyl) and are plagued by false‐positive results due to medications commonly utilized in pregnancy and during labor and delivery. Most people who use substances quit or cut back during pregnancy. However, some people cannot, most likely because they have an addiction. While it is very rare for a woman to develop an addiction during pregnancy, some people with addiction get pregnant and may initially present for care during pregnancy. Opioid addiction (also termed opioid use disorder) is a chronic and treatable disease. Symptoms of addiction include inordinate amount of time spent craving, obtaining, using, and recovering from a substance; compulsive use; use that interferes with school, job, family, and other aspects of social life; and continued use despite harms to self and others. Opioid addiction should be diagnosed with the framework detailed in the DSM‐5.
Management
Individuals with addiction need treatment. The core component of opioid addiction treatment is medication. There are three FDA‐approved medications for opioid use disorder: methadone, buprenorphine, and naltrexone. Evidence for naltrexone in pregnancy is limited and therefore it is not recommended at this time. Methadone, a full opioid agonist, has been used in pregnancy since the 1960s and buprenorphine has been available in the US since 2002. Randomized trial and systematic review data demonstrate that both are safe and effective. Methadone must be dispensed from an opioid treatment program (OTP) and carries a small risk of overdose primarily during the initial phase of treatment. Buprenorphine can be dispensed from an OTP but is more often prescribed by providers who have obtained an “X waiver” from the Drug Enforcement Administration (DEA). Buprenorphine is a partial agonist and can precipitate withdrawal if given to a patient who is not already in withdrawal. Neonatal abstinence syndrome (NAS) is a possible side effect of both methadone and buprenorphine, although the severity and duration of NAS are less with buprenorphine.
Patients can be initiated on medication in either inpatient or outpatient settings at any gestational age. Both methadone and buprenorphine can be
administered in inpatient settings by providers without DEA X waivers and by health systems without attached OTPs. Details regarding medication choice are detailed in Table 3.1. However, the hospital care team must ensure presence and availability of outpatient providers for continuing care. Initial clinical assessment should include a Clinical Opiate Withdrawal Scale (COWS), other substance use history, and HIV and HCV testing. COWS is an 11‐item scale administered by a clinician which provides a summary measure of withdrawal. (There is a helpful online tool to assess COWS available at: www.mdcalc.com/cows‐score‐opiate‐withdrawal).
Medication dosage is first titrated to treat withdrawal (see Table 3.2 for draft induction protocol). Stabilization occurs within days. Further dose increases may be needed to control craving. A goal of medication‐assisted treatment for opioid addiction is a clinically meaningful opioid “blockade”: the degree to which medications block the reinforcing effects of other self‐administered opioids. In other words, if a patient feels an effect from an
Table 3.1 Medication choice for treatment of opioid use disorder in pregnancy and postpartum
Benefit
MethadoneNo need for withdrawal for initiation
May have better treatment adherence
BuprenorphineCan be prescribed by waivered provider
Newborns may have less severe neonatal abstinence syndrome
Consideration
Must be dispensed from an opioid treatment program
