Pregnancy And Drug Dependence: Opioids And Cocaine

During the 1980s, increasing numbers of pregnant drug-dependent women went to medical facilities—some to receive ongoing prenatal care, but others only to deliver their babies without the benefit of any prenatal care. Such women fear the threat of confrontation with legal authorities. The general lack of women-oriented drug-treatment programs contributes to this major health problem—addiction in pregnancy. It has also contributed to increased medical and social maladies and mortality in such mothers and their infants.

The 1990 NATIONAL HOUSEHOLD SURVEY ON DRUG ABUSE estimated that almost 50 percent, approximately 29 million of the 60 million women of child-bearing age, used an illicit drug at least once in their lifetimes. In 1988, one study reported for the United States an annual occurrence rate (prevalence) of 11 percent, resulting in an estimated 375,000 drug-exposed births; these data cannot be applied to the entire country, since they were collected from a limited number of mainly urban hospitals—and the frequency, amount, type, and duration of drugs used were unavailable. The basis is also unclear for the reported estimates of 50,000 to 100,000 cocaine-exposed babies born each year. The occurrence of drug abuse among pregnant women varies widely in local studies—from 7.5 percent in Rhode Island, to 14.8 percent in Pinellas County, Florida, to 17 to 31 percent in a Boston hospital. These local rates cannot be used to estimate the prevalence of drug abuse among pregnant women in the United States; they can only provide data for averages.

As a result of the uncertainty among data sources, in 1992, the NATIONAL INSTITUTE ON DRUG ABUSE (NIDA) began a national hospital-based study known as the National Pregnancy and Health Survey. This survey collected data on the prevalence of licit and illicit drug use by pregnant women, limited data on infant birth weight, and the duration of hospital stay. The results were released in late 1994 and the summary tables are included here. Additional surveys in progress include the National Maternal and Health Survey conducted by the National Center for Health Statistics, which will collect data on drug-abusing women who had a live birth, stillbirth, or an infant who died before one year of age, and the National Longitudinal Survey, which collects data on the frequency of marijuana and cocaine use during pregnancy by women who have given birth to a child since 1986.

OPIOIDS

Due to preexisting conditions and ongoing active drug use, the opioid-dependent woman frequently suffers from chronic ANXIETY and DEPRESSION. Social problems, such as POVERTY, HOMELESSNESS, involvement in an abusive or battering relationship, and ALCOHOLISM, may overwhelm her ability to cope with life activities. She usually lacks confidence and hope for the future and has extreme difficulty with interpersonal relationships, especially with men. One study found that 83 percent of addicted women were raised in households marked by parental drug or alcohol abuse, 67 percent of those women had been sexually assaulted, 60 percent had been physically assaulted, and almost 100 percent of the women wished that they were someone else as they were growing up. In addition to these problems, the treatment and resolution of their addiction is a complex biopsychosocial matter which requires understanding and patience. Addiction is a chronic, progressive, relapsing disease, and one cannot expect a smooth and rapid recovery. It should not be surprising, therefore, that the lifestyle of the pregnant addict has a profound influence on her psychological, social, and physiological well-being.

She may have several other children who are currently not living with her, but instead with a relative or in placement. Drug-dependent women are frequently intelligent, although the average level of high school achievement is usually at the tenth-grade level. Housing situations are frequently chaotic, and plans for the impending birth of the child may not have been considered.

It is well known that medical complications impact many drug-involved pregnancies; the most frequently encountered complications include anemia, various infections such as pneumonia, hepatitis, urinary tract infections, and sexually transmitted diseases. The women are at risk for human immunodeficiency virus (HIV) disease culminating in acquired immmunodeficiency syndrome (AIDS).

The HIV disease has been increasingly linked to drug usage. The practice of sharing contaminated needles to inject HEROIN or COCAINE, the practice of prostitution to buy drugs, or the direct sex-for-drugs transaction associated with "crack" smoking have all contributed to this serious international health crisis. Currently, the spread of HIV is less linked to homosexual spread and more to heterosexual transmission and intravenous drug abuse. Although the exact risk of an infected mother passing the disease to her offspring is not precisely known, it is estimated that approximately 25 to 30 percent of infants exposed in this fashion will actually contract AIDS. Counseling in an effort to prevent HIV infection, therefore, forms an essential part of services that must be offered to pregnant substance-abusing women or women involved in relationships with addicted men.

Nutritional deficiencies associated with drug addiction are due largely to the lack of proper food intake, which may result in iron and folic-acid deficiency anemias. Toxic responses to narcotics may contribute to malnutrition by interfering with the body's ability to absorb or utilize nutrients. Abnormalities result because of the high incidence of altered function of the intestine, liver, and pancreas; malnutrition is often related to the presence of liver disease (since nausea causes addicts to eat infrequently or to vomit). Low sugar levels in the bloodstream or certain vitamin (B6, thiamine) and mineral (magnesium) deficiencies may cause seizures in both alcoholics and drug addicts. Hepatitis, a viral infection of the liver, often accompanies the abuse of injectable drugs; it causes addicts to eat infrequently—due to fatigue, swollen liver, nausea, and vomiting—which in turn diminishes the intake of nutrients, vitamins, minerals, and trace elements. Consequently, intensive diet therapy is needed in correcting drug and alcohol addiction—to balance fluids, electrolytes, trace elements, minerals, and vitamins—especially in acutely ill patients.

In addition to many potential medical problems, the lifestyle of some pregnant addicts becomes burdensome. To meet the high cost of maintaining a drug habit, she may often indulge in robbery, forgery, the sale of drugs, and/or prostitution. Because most of her day may be consumed by the activities of either obtaining drugs or using drugs, she spends most of her time unable to function in society's usual activities. She may have intermittent periods of normal alertness and well-being, but for most of the day, she will be either "high" or "sick." The high (euphoric) state will keep her sedated or tranquilized, absorbed in herself, and incapable of ful-filling familial responsibility. The sick (withdrawal) state is generally characterized by craving for more drugs, malaise, nausea, tearing, perspiration, tremors, vomiting, diarrhea, and cramps. Since hormonal changes in pregnancy manifest some of these symptoms in nondrug users, the sick state may be more frequent or intensified for addicts.

IMPACT OF MATERNAL OPIOID USE ON FETAL WELFARE

Opioid dependence in the pregnant woman is not only overwhelming to her own physical condition but also dangerous to that of the fetus (and eventually to the newborn infant). Because of her lifestyle, and because she may fear calling attention to her drug habit, the pregnant addict often does not seek prenatal care. Obstetrical complications associated with heroin addiction include miscarriages, premature separation of the placenta, infection of the membranes surrounding the FETUS, stillbirth, retardation of the growth of the fetus, and premature labor.

Because no quality control exists for street drugs, doses and substances used to stretch the dose may cause repeated episodes of underdose, withdrawal, and/or overdose. Maternal narcotic withdrawal has been associated with the occurrence of stillbirth. Severe withdrawal is associated with increased muscular activity, thereby increasing the rates of metabolism and oxygen consumption; during maternal withdrawal, fetal activity also increases, as does the oxygen need of the fetus. The oxygen reserve in the placenta may not be able to supply the extra oxygen needed by the fetus. During labor, contractions further inhibit the blood flow through the uterus. If labor coincides with withdrawal symptoms in the mother, the fetus will also withdraw. Since uterine blood flow will vary at this time, and less oxygen will be delivered to the fetus, fetal death may occur.

COCAINE

Cocaine is known to cause many medical complications in adult users, including heart attacks, irregular heart beats, rupture of major blood vessels, strokes, fevers, seizures, infections, as well as a range of psychiatric disorders. The medical impact of cocaine on human pregnancy must consider all associated variables such as poverty, homelessness, inadequate prenatal and postpartum care, deficient nutrition, varying types of cocaine usage, multiple drug use, sexually transmitted diseases, and the possible presence of toxic chemicals that are mixed with or used to process cocaine.

Suppression of maternal appetite with inadequate nutritional intake is well recognized in cocaine "binging." Many cocaine users admitted for treatment may have at least one vitamin deficiency (B1, B6, C). Correction of these vitamin deficiencies is important during pregnancy so that essential chemicals (neurotransmitters) that transmit messages in the brain can be replenished.

Cocaine's chemical properties (low molecular weight and high solubility) allow it to cross the placenta easily and enter the fetus. The passage from maternal circulation to the fetus is enhanced by the injection or smoking of cocaine. In addition, because of acid/base balance issues and low levels of certain enzymes, which usually metabolize the drug, accumulation of cocaine in the fetus occurs. Furthermore, the "binge" pattern commonly associated with cocaine use may lead to even higher levels of cocaine in the fetus. Transfer of cocaine appears to be greatest in the first and third trimesters of pregnancy. Cocaine has a very potent ability to constrict blood vessels. A deleterious effect of this blood vessel constriction is fetal deprivation of essential nutrients and decreases in the amount of fetal oxygen. In addition to an acute oxygen deprivation, long time use of cocaine may produce a chronic decrease in nutrients and oxygen, leading to diminished growth of the fetus.

The use of cocaine by the mother may also affect the course of labor. CRACK (smokable cocaine in its base form) also appears to increase directly contractions of the uterus and may thus precipitate the onset of premature labor. Higher rates of early pregnancy loss and third-trimester separations of the placenta appear to be major complications of maternal cocaine use. Increased blood pressure and increased body temperature caused by cocaine may be responsible for early fetal loss and later separation of the placenta. The latter is hazardous to the fetus and the mother because of bleeding, shock, and the chance of death for both, if an emergency cesarean section is not performed.

The major fetal effect of cocaine is retardation of growth, resulting in smaller than normal babies at the time of birth. Although animal studies suggest that cocaine may cause malformations of the fetus, data from studies in humans are contradictory. Some reports have shown an increased chance of abnormalities of the heart, limbs, and urinary tract, but others show no differences; studies in humans have not included large populations, and good scientific methods have not been utilized to control for many other factors that may contribute to abnormalities. Studies like these are very difficult to design for human populations.

It is currently thought that the incidence of malformations in infants as a result of cocaine taken by pregnant women is very low and that those that do occur are the result of disruption in the fetal blood vessels due to the constriction that occurs. This vessel constriction diminishes blood supply, which causes organs to malform at varying stages of fetal development. Abnormalities have been observed in the intestines, the kidneys, and the extremities.

RECOMMENDATIONS TO AMELIORATE THE EFFECTS OF DRUGS ON WOMEN AND THEIR CHILDREN

Despite the increased use of other drugs of abuse, such as cocaine, opioid abuse continues to be a major problem in the United States. Numerous investigators have reported the extremely high incidence of obstetrical and medical complications among street addicts, as well as the increase in medical conditions and death among their newborn infants.

Insufficient data exist for measuring the long-term effects of maternal drug usage. Controversy exists on how best to prevent anti treat the adverse effects of addiction. It now seems clear, however, that providing comprehensive multidisciplinary drug-treatment services and prenatal care for addicts will significantly reduce the medical and psychological conditions and the death rate in both mothers and infants. Recommendations for treatment for drug-dependent women are multifaceted. The pregnant woman who abuses drugs must be designated as high risk; she warrants specialized care in a perinatal center where she can be provided with comprehensive addictive and obstetrical care and psychosocial counseling. Care must be provided in a supportive, proactive, and nonjudgmental fashion. The women must know that sharing of confidential information with health-care providers will not render them liable to criminal prosecution under state law statutes that define drug addiction in pregnancy as a form of fetal abuse.

Treatment of addiction in pregnancy may involve voluntary drug-free THERAPEUTIC COMMUNITIES, outpatient or day treatment, and, in narcotic-dependent women, METHADONE MAINTENANCE. The pregnant drug-dependent woman should be evaluated in a hospital setting where a complete history and physical examination may be performed and targeted laboratory tests carried out to evaluate her overall health status. Opioid dependent women should receive appropriate methadone maintenance, with support from an extensive medical and psychosocial network. Psychosocial counseling should be provided by experienced social workers who are aware of the medical needs, as well as the social and psychological needs, of these women. The pregnant woman addicted to BARBITURATES or major tranquilizers along with opioids should be medically withdrawn during her second trimester in a setting that furnishes appropriate monitoring of fetal well-being.

Maternal-infant attachment should have special emphasis. Parenting skills of these women need to be strengthened in an effort to nullify the anticipated (assumed) increase in child neglect and abuse that occurs in this population. Social and medical support should not end with the hospitalization. An outreach program, incorporating public health nurses and community workers, should be established. The ability of the mother to care for the infant after discharge from the hospital should be assessed by frequent observations in the home and clinic settings. Mechanisms by which to follow and supervise the infant's course after discharge from the hospital must be developed.

The major impact of comprehensive care, coupled with methadone maintenance for opioid-dependent women, has been the reduction of perinatal illness and mortality and the reduction of rates of low birthweight in offspring. Increases in birthweights, in themselves, have dramatically reduced illness and mortality for drug-exposed infants and children (mortality rates for low-birthweight newborns are forty times that of the full-term infants of normal weight).

Moreover, it is known that low-birthweight infants contribute greatly to the population of infants who test as mentally retarded (IQ of 70 or below), as well as those who will have great difficulty in school because they are "poor learners." These handicapped individuals will be unable to compete fully in our increasingly complex society. In addition, the incidence of cerebral palsy and lethal malformations are increased in low-birthweight infants. Emotional disturbances, social maladjustments, and visual and hearing deficits are also increased. With the increasing number of addicted women, custodial facilities for their mentally and neurologically deficient infants may be necessary if programs do not deal with prevention and treatment during pregnancy.

(SEE ALSO: Addicted Babies; Complications; Fetal Alcohol Syndrome; Fetus: Effects of Drugs on the; Injecting Drug Users and HIV; Opioid Complications and Withdrawal; Substance Abuse and AIDS)

BIBLIOGRAPHY

FINNEGAN, L. P., & KANDALL, S. R. (1992). Maternal and neonatal effects of drug dependence in pregnancy. In J. Lowinson et al., Comprehensive textbook of substance abuse, 2nd ed. Baltimore: Williams & Wilkins.

HADEED, A. J., & SIEGEL, S. R. (1989). Maternal cocaine use during pregnancy: Effect on the newborn infant. Pediatrics, 84, 205.

KALTENBACH, K., & FINNEGAN, L. P. (1988). The influence of the neonatal abstinence syndrome on mother-infant interaction. In E. J. Anthony & C. Chiland (Eds.), The child in his family: Perilous development: Child raising and identify formation under stress. New York: Wiley-Interscience.

ZUCKERMAN, B., ET AL. (1989). Effects of maternal marijuana and cocaine use on fetal growth. New England Journal of Medicine, 320, 762.

LORETTA P. FINNEGAN

MICHAEL P. FINNEGAN

GEORGE A. KANUCK