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UW-Madison SOCWORK 453 - Substance Use and Pregnancy

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Guest LectureSubstance Use and PregnancyRandall Brown MD, PhD, FASAMIClicker questionThe regular use of which of the following substances during pregnancy has the worst effects on the fetus?A. Tobacco/nicotineB. AlcoholC. MarijuanaD. CocaineE. OpioidsIntroductionSubstance use during pregnancy is commonAssociated with adverse maternal and fetal outcomesAssociated with childhood environmental riskAssociated with developmental issues in childhoodThere can be a tension between women’s health and fetus healthDaily and heavy substance use this can have to do with other things like mental illness, problems with poverty, domestic violence, transportation. We have to think about care of someone with a substance use issue…What do we know about effects of fetus later in life from substances?OverviewConceptualize pathways for drug-environment effects on developing fetus and childDiscuss particular substances and associated neonatal and childhood outcomesDiscuss evidence-based screening/assessment and treatmentDiscuss ethical, policy issuesAt what point do we report these activities to child protective services?What Problems do Drugs “Cause?”Answer is tricky because drug use is associated with all kinds of other things. Women that use substances regularly during pregnancy may also be at risk for other mental health issues which can effect parenting skills or engagement with the child and how that child does later in life as they enter school.Can affect: Education attainmentCare tensionsRegular care during the pregnancy, is women being monitored and fetus being monitored?Caregiving function is very important, like how women interact with child.All of these things in pregnancy and childhood can affect child’s way to pay attention or have executive function in school. And also cognitive and language development. And eventually adult function.Many things go together that have to do with substance use and pregnancy.This is a very complicated situation. Do we really know the effects that drugs themselves have on the infant?There are some things…Tobacco – stimulantCan restrict blood flow to blood vesiclesPlacental abruptionIntrauterine deathDecreased birth weightPreterm labor/deliveryRisk of SIDS (sudden infant death syndrome, happens before 9 months)HyperactivityAnti-social behavior, conduct disorderLearning disabilities and lower IQCan lead to death of the fetusWe expect pregnancy to go 40 weeks. 35 weeks infant outcomes usually good. But earlier than that like mid 20’s that early delivery can have serious complications. And this can mean long standing injuries for the infant.No matter what point in the pregnancy you are able to quit it does make it differenceAlcoholThis is about the only substance we know that actually causes actual abnormalities in the anatomy and severe impact on cognitive function as wellGrowth deficienciesCraniofacial abnormalitiesIntellectual disabilityAttention deficitsHyperactivityImpaired motor developmentDifficulty with educationBig problems that alcohol can cause that are identifiable when students reach schoolingCannabisNo fetal growth effects -No physical abnormalitiesSubtle withdrawal (autonomic, state regulation) –may cry more. Don’t feed as well which can interfere with early growth. If marijuana use daily baby may not be able to calm themselves as wellDaily use > 1 joint/day associated with some subtle academic deficits (reading, spelling), but no impact on IQAdolescent depression (?)Questionable between substance links and environment. Could be something else that caused that.In Jamaica study between mother and child if they used cannabis at lower levels. They were actually more interactive with their mothers. It’s an interesting study.-Fussy and difficult to feedStimulantsCocaine and also Methamphetamine and AmphetaminesCocaineLowers placental blood flow and abruption, preterm labor/delivery, intrauterine growth retardation (IUGF)No physical abnormalitiesMild behavioral issues (?)Subtle attentional deficits, impulsivityLikely ameliorated by appropriate care/environmentMethamphetamineLimited knowledge/studiesLow birth weight, increased stress, decreased achievementAmphetamines for ADHDNo known effectsOpioidsIncludes prescription pain meds (oxy, hydrocodone, morphine) and heroinFetal/childhood effectsNo physical deformitiesPossible cognitive/behavioral issuesLower verbal, arithmetic, reading abilities (age 3)Real danger is that if someone using all the time and then stop right away unpleasant withdrawal. Person feels anxious, sweats, vomiting, etc. That is where there is damage to the baby. There is risk for early delivery.Neonatal Abstinence SyndromeNot clearly related to “dose”Onset 48-72 hour and some symptoms last weeksFeatures:Excessive cry/irritabilityErratic sleepStartleTremorIncreased toneYawningVomitingSneezingPoor feedingSeizureInfant will be put into care if born with use withdrawals. They can be given morphine…Injection Drug UseInfectious complicationsHIVHepatitisCutaneous infectionsEndocarditisIf sharing needles or drug filtered through cotton. This can lead to Hepatitis or other viruses. And then this can be passed to the fetus.So what should we do?ScreeningTobaccoAlcoholT-ACETWEAKOther drugs(?)DAST-10CAGE-AIDWe really don’t know what level of alcohol is safe to use during alcohol. So we say to not drink at all during pregnancy.**+ screen ≠ diagnosisA positive screen doesn’t mean the person has an addiction or substance use problem. It means we need to ask more questions and find out what is going on.**remember what you’re screening forWe are looking for risky substance use or an addiction. For pregnancy we don’t know what is safe.For alcohol:Levels of use go from harmful and high-risk use to low-risk use to abstinenceUse disorder is above harmful and high-risk use.For pregnancy we may want to be lower on this pyramid because there are complications with alcohol use and pregnancy.T-ACE(T) Tolerance: How many drinks before you feel high? (≥ 3 is positive)(A) Annoyed: Have you been annoyed by people criticizing your drinking?(C) Cut down: Have you felt you need to cut down on your drinking?(E) Eye opener: Have you had a drink in AM to calm nerves?2+ = positiveFor pregnant women tolerance question is usually asked. If that number is 3 or more that is tolerance and may indicate that there needs to be more assessment.TWEAK(T) Tolerance (2)(W) Worry: Have others worried about your drinking? (2)(E) Eye opener(A)


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UW-Madison SOCWORK 453 - Substance Use and Pregnancy

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