Substance Use and Other Psychiatric Disorders in Pregnancy
Pregnancy is a unique time of change in an individual’s family, social, medical, and interpersonal support systems as well as the pregnant woman’s physiology. This convergence of internal and external motivators and mediators can result in both stress and positive impetus for change with effects on psychiatric conditions including substance use. The issues of substance use disorders (and any substance use) in pregnancy as well as other psychiatric disorders seen during pregnancy are the focus of this review. Substance use in pregnancy, including alcohol, benzodiazepines, and opioids, is presented in the first part of this review. Other preexisting or new psychiatric disorders that are often evaluated in an obstetric triage or emergency setting include depression, anxiety, panic attacks, and insomnia. These topics encompass the remaining portion of the chapter.
Substance use in pregnancy prevails when a woman with a preexisting drug or alcohol use problem becomes pregnant and continues using. Pregnant women are aware that these substances are not healthy for fetuses, and almost no woman initiates drug or alcohol use in pregnancy. Yet, even infrequent or light substance use (that may not meet the criteria for a substance use disorder) may represent a danger to the pregnancy.
Often before problematic substance use is identified by a medical care provider, women may use a range of strategies to decrease or change substance intake to reduce potential harm to the fetus. Such changes include decreasing or stopping usage, switching the drugs used, and entering prenatal care or a substance treatment program. Substance use in pregnancy decreases for all substances, both spontaneously and with treatment, as pregnancy progresses. Muhuri and Gfroerer (2009) used epidemiologic data to show that this is true for multiple substances. This change reverses during the postpartum period, but does not return to preparenting levels. For example, in this sample, daily cigarette use was 20.1% in nonparenting and nonpregnant women. The percentage subsequently decreased to 12.4% in the first trimester and to 9.3% by the third trimester of pregnancy. Binge alcohol use decreased from 25.8% to 7.6% in the first trimester and 1% in the third trimester of pregnancy.
308The etiology of substance misuse is both genetic and environmental. Associations with substance use in pregnancy include missed or inadequate prenatal care; recurrent somatic complaints (chronic pain, nausea, sleep, etc.), which may in turn result in multiple visits to obstetric triage; history of substance misuse and/or treatment; active psychiatric diagnosis; and a psychiatric history and/or history of trauma (including intimate partner violence), prior unexplained fetal death, and a previous child with alcohol-exposure related disorders.
Smoking nicotine cigarettes and alcohol use during pregnancy have well-defined risks. Smoking increases the risk of low birth weight and prematurity. No amount of alcohol is considered safe in any stage of pregnancy, and there appear to be differences in individual fetal vulnerability to the toxic effects. Alcohol exposure in the first trimester is associated with low birth weight, decreased birth length and head circumference, minor physical abnormalities, and neurodevelopmental disorders. Second- and third-trimester exposure can lead to developmental abnormalities such as intellectual deficits and behavioral abnormalities. The full constellation of effects is called fetal alcohol syndrome (FAS). However, fetal alcohol spectrum disorders (FASD) not meeting the full criteria for FAS are common.
HISTORY AND DATA COLLECTION
Universal screening for pregnant women is recommended by many professional organizations (Wright et al., 2016). However, the substance use screening questions developed for the general population are not as accurate among reproductive-aged and pregnant women. The screening tool for drug use, The 4 Ps Plus© (Chasnoff, Wells, McGourty, & Bailey, 2007), consisting of Parents, Partner, Past, and Pregnancy, has been validated for drug use (alcohol, cannabis, heroin, cocaine, and methamphetamines) in pregnant women. T-ACE© (Sokol, Martier, & Ager, 1989) and TWEAK© screening tools (Russell et al., 1994) have been validated for alcohol use in pregnant women. See Exhibit 26.1 for these screening tools.
Some experts encourage the use of the National Institute on Drug Addictions (NIDA) Quick Screen, three open-ended questions regarding use of tobacco, alcohol, and other drugs:
1. In the past year, how many times have you drunk more than 4 alcoholic drinks per day?
2. In the past year, how many times have you used tobacco?
3. In the past year, how many times have you taken illegal drugs or prescription drugs for nonmedical reasons?
This approach is useful because women are more likely to report lifetime use or use of substances before pregnancy than use during pregnancy, given the stigma and risks of such use (Wright et al., 2016). Women who screen positive on any of these screens require further assessment for current use and possibly intervention and treatment, as indicated.
Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a public health-based approach to identify those with substance use disorders, provide early intervention, and, when appropriate, offer referral to treatment services. It is used in emergency settings and obstetric and primary care settings for alcohol and tobacco use and has been endorsed by the United States Preventive Services Task Force as well as the American College of Obstetricians and Gynecologists (ACOG). No past or current use or low use that stopped immediately before pregnancy or immediately following knowledge of pregnancy is considered low risk. Brief advice, and possibly a written pamphlet on the risks of substance use, is given to low-risk patients. Moderate risk is defined as having used heavily in the past, recent treatment for substance use disorder, stopping use later in pregnancy, and/or continued low use. These women should have a brief intervention such as motivational interviewing in the obstetrical triage setting. When permission is given, this moderate level of risk is also communicated to the obstetrical care provider and more frequent prenatal and postpartum visits are recommended. High-risk patients currently meet substance use disorder criteria and are to be referred to specialized treatment programs when available. More frequent prenatal and postpartum visits are also recommended (Wright et al., 2016). In order to facilitate care, obstetric triage units should maintain a list of regional treatment programs able to accommodate pregnant women.
Screening Tools for Tobacco, Alcohol, and Drugs in Pregnancy
4 Ps Plus© Verified for any substance in pregnancy
Parents: Did either of your parents have a problem with alcohol or drugs?
Partner: Does your partner have a problem with alcohol or drugs?
Past: Have you ever drunk beer, wine, or liquor?
Pregnancy: In the month before you knew you were pregnant, how many cigarettes did you smoke?
In the month before you knew you were pregnant, how many beers/how much wine/how much liquor did you drink?
Scoring: Women who acknowledge any use of tobacco or alcohol in the month before pregnancy have a positive screen and need further assessment for current substance use.
T-ACE© Verified for alcohol in pregnancy
Tolerance: How many drinks does it take to make you feel high?
Have people annoyed you by criticizing your drinking or drug use?
Have you ever felt you ought to cut down on your drinking or drug use?
Eye-opener: Have you ever had a drink or drug first thing in the morning to steady your nerves or get rid of a hangover?
Scoring: A score of 2 or more is considered positive, and these patients need further assessment for current substance use.
A, C, E = Affirmative answers are 1 point each.
T = Reporting tolerance to more than 2 drinks = 2 points.
TWEAK© Verified for alcohol in pregnancy
Tolerance: How many drinks can you hold (positive if ≥6 drinks)? or How many drinks does it take before you begin to feel the first effects of alcohol (positive if ≥3 drinks)?
Have close friends or relatives worried or complained about your drinking in the past year?
Eye-opener: Do you sometimes take a drink in the morning when you first get up?
Amnesia: Has a friend or a family member ever told you about things you said or did while drinking that you could not remember?
Do you sometimes feel the need to cut down on your drinking?
Scoring: A score of more than 2 is positive; these women need further assessment for current substance use.
E, A, K = Affirmative answers are 1 point each.
T, W = Affirmative answers are 2 points each.
Sources: Adapted from Chasnoff et al. (2007); Reis et al. (2014); Russell et al.(1994); Sokol et al. (1989).
310Assessing Current Drug Use and Drug History
All questions must be asked in a private and nonjudgmental manner, including questions about drug usage in pregnancy. Each common and suspected substance needs to be questioned specifically, beginning with those perceived as the most common and least harmful and progressing to more stigmatized substances. For example, one can begin with caffeine or cigarettes and proceed through alcohol and marijuana, then nonprescribed pills and other drugs (cocaine, heroin, methamphetamine, etc.). Many people do not think of beer and wine as alcohol, so it is important to ask about these specifically. Likewise, many people do not think about marijuana and nonprescribed pills when asked about drugs, so these need to be specifically noted as well. The language women use to describe drug names and quantities can be unfamiliar and can change rapidly. Either asking the woman to describe what she means, or doing a fast online search for “street drug names” or “street drug amounts,” can provide more detailed information. Sites kept updated include drugabuse.com (drugabuse.com/library/list-of-street-names-for-drugs) and addictionresource.com (addictionresource.com/drugs/street-names).
Physical and behavioral indicators of possible substance misuse include a woman who smells of alcohol or chemicals and inappropriate behavior such as quick or unfocused anger. Changes in mental status such as extreme mood lability and mood extremes, disorientation, somnolence, and loose associations can be due to intoxication and/or withdrawal.
Physical signs of substance abuse or withdrawal vary by substance. They can include increased pulse and blood pressure, increased body temperature, low body weight (failure to gain weight in pregnancy), dilated or constricted pupils, rapid eye movements, nystagmus, inflamed or eroded nasal mucosa, nose bleeds, gum or periodontal disease (meth mouth), hair loss, track marks, injection sites, abscesses, and skin sores.
Maternal–fetal abnormalities associated with substance use in pregnancy include intrauterine growth restriction, failure to gain adequate weight, placenta abruptio, preterm labor, and nonreassuring fetal status. Both maternal and infant withdrawal symptoms can occur in the peripartum period.