Ethical Issues Related to Substance Abuse in Pregnancy ...

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from current pregnancy. CPS keeps upping the ante to keep mom from havingcustody.• Both drug rehab and jail work as treatment. Drug addicted mom needs to learn tolive with addiction and at the same time learn to parent.• What do you do with mom who totally denies that she uses? Finds those momsvery difficult, frustrating to work with.• Jane Greenlaw: very frustrating stories to tell -- pregnancy after pregnancy --babies born impaired.Managing the Mentally IIl Pregnant PatientPresenter: Beth GoldenbergFind presentation at:http://www.urmc.rochester.edu/flrpp/forum/documents/FAS.perinatalconf.pdfSubstance Abuse and Dependence:• Drug addition is a complex brain disease. It is characterized by compulsive, attimes, uncontrollable, drug craving, seeking and use that persists even in theface of extremely negative consequences.• Drug seeking becomes compulsive, in large part as a result of the effects ofprolonged drug use on brain functioning and, thus, on behavior. For manypeople, drug addition becomes chronic, with relapses possible even after longperiods of abstinence.Disorders with Increased Risks of Drug AbuseDisorderRiskAntisocial personality disorder 15.5%Manic episode 14.5%Schizophrenia 10.1%Panic disorder 4.3%Major depressive episode 4.1%Obsessive-compulsive disorder 3.4%Phobias 2.1%Substance Abuse in Pregnant Mentally Ill Women –Most commonly used drugs in pregnancy:Nicotine 20%Alcohol 19%Marijuana 3%Cocaine 3%(National Institute of Drug Abuse (2002)Substance Abuse in Pregnant Women –Reasons why pregnant women usePrior history of useLimited social supportIntimate partner violenceConcurrent mental illnessCase Study• Courtney, 36 yr. old Caucasian lesbian woman~advanced maternal age~active cocaine use~bipolar disorder• Pregnant as a result of her prostitution
~planned to terminate pregnancy early on but partner, Marie, “talked me out ofit.”~on ultrasound, fetal heart showed Tetrology of Fallot but too late for termination• Attendance at clinic was quite erratic~when she did come, she was typically high and very argumentative• Continued to use cocaine through pregnancy and ended up in the hospital at 33weeks gestation due to premature rupture of membranes.~seen by Psychiatric Consultation Service while inpatient to assist withmanagement of anxiety and demanding behaviors.• Delivered son at 35 weeks gestation (induced)~asked at time of discharge to be referred to outpatient mental health care andchemical dependency treatment.Fetal Alcohol Syndrome and Long Term Developmental EffectsPresenter: Nirupama LaroiaFind presentation at:http://www.urmc.rochester.edu/flrpp/forum/documents/Mentalillnessandsubstanceuse.pdfHistory of Alcohol Consumption and Pregnant Women reviewed• As early as 330 BC Aristotle noted “Foolish drunken and hair brained womenmost often bring forth children like unto themselves, morose and languid.” Inancient Sparta and Carthage, custom prohibited newlyweds from drinking ontheir wedding night in order to prevent conceiving a “damaged” child.• The association of alcohol with poor birth outcomes continued until the end ofprohibition (1920-1933) when some felt that the idea was propaganda circulatedby proponents of prohibition. Mid-1930s -- some doctors reassured pregnantpatients that a drink or two daily was OK as a means of relaxing.• 1950s – Alcohol use among pregnant women rose – few worried about theeffects on the newborn.• 1968 – French scientists tracking 127 children born to alcoholic mothers found aseries of effects that they blame on in-utero exposure to alcohol.• 1973 – Lancet reported the work of scientists from the University of Washingtonwho studied infants born to alcoholic mothers. Named it “fetal alcohol syndrome(FAS).”FAS Diagnostic Criteria• Characteristic pattern of facial anomalies• Growth restriction• Central nervous system neurodevelopmental abnormalities• Known history of maternal alcohol consumptionHow Alcohol Does its Damage• Alcohol passes easily across the placenta• Fetal levels rise above maternal levels• Fetal liver is inefficient, maternal liver must do the work for both• Alcohol is metabolized to acetaldehyde in the liver• Interference with fetal nutritionWhat is Know – What Remains Uncertain?• Incidence 0.5-2.0/1000 births~considerable international variation in estimates• Consistent effects of high dose of alcohol~multiple mechanisms depending on dose, pattern and timing
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