Loretta P. Finnegan

Cocaine abuse in pregnancy: effects on the fetus and newborn.

The outcome of infants born to cocaine-using drug dependent women was compared to that of infants of non-cocaine using drug dependent and non-drug dependent women. The study population included 150 pregnant women: 50 women used heroin and methadone plus cocaine, 50 used heroin and methadone minus cocaine, and 50 were non-drug dependent women. Significant differences were found between the cocaine and drug-free groups in infant birth weight, length, head circumference and Apgar scores, with the cocaine group having lower values for each variable. Average gestational age did not vary between the 3 groups. The cocaine group included 1 spontaneous abortion and 4 fetal deaths; non-cocaine drug dependent women had 2 fetal deaths, with none in the control group. Mean abstinence scores for 19 of the physiological and behavioral parameters were lower in the cocaine group than in the non-cocaine drug dependent women with the exception of vomiting and convulsions. These data suggest that: (1) infants born to drug dependent women have a poorer general outcome than those born to non-drug dependent women; (2) maternal cocaine use does not appear to increase the incidence of severe neonatal abstinence symptomatology; (3) pregnancies complicated by cocaine abuse have a greater chance for fetal loss resulting from both spontaneous abortions and fetal death; (4) infants born to cocaine abusing women had infants with decreased birth weight, head circumference, length and Apgar scores.

Treatment Issues for Opioid-Dependent Women During the Perinatal Period

Opioid dependence has been studied with regard to its effects on the woman, the fetus, and the child for the past three decades, and it continues to be a serious problem that must be recognized and addressed by the health care delivery system in order to provide optimal medical care. The use of pharmacotherapy, such as methadone maintenance treatment (MMT), is only one of a variety of treatment modalities to provide optimal services for opioid-dependent women. The complete schema for treating opioid dependence in the perinatal period is complex and intense, but MMT serves multiple purposes. Primarily, it removes the addicted woman from the drug-seeking environment, eliminates the necessary illicit behavior, and prevents the peaks and valleys in the maternal heroin level that may occur throughout the day. In addition, maternal nutrition is usually improved and MMT patients become amenable to prenatal care and psychosocial rehabilitation. It is evident from the findings of numerous studies that when the physical, psychological, and socioeconomic issues of pregnant opioid-dependent women and their children are coupled with MMT, the potential physical and behavioral effects of psychoactive drugs on the mother, the fetus, the newborn, and the child may be markedly reduced.

Infants of drug addicts: at risk for child abuse, neglect, and placement in foster care

In a methadone maintenance program for pregnant, drug dependent women, an investigation was undertaken (1) to study the occurrence of violence experienced by the women as children and as adults and (2) to lean whether those who report past violence/abuse are more likely to neglect and/or abandon their children to the care of others. Subjects included 178 drug dependent women who completed a Violence Questionnaire and 70 comparable, but drug-free women. Results revealed that a history of violence or abuse is related to drug abuse and also to the placement of ones child(ren) in foster care.

Perinatal and developmental outcome of infants exposed to methadone in-utero

The purpose of this research is to delineate the effects of methadone exposure in-utero. Subjects were 141 infants born to drug dependent women maintained on methadone during pregnancy and 127 non-drug exposed comparison infants matched for race, maternal age, and socioeconomic status. Methadone exposed infants had smaller birth weights than comparison infants. Differences were also found in head circumference. However, this difference was not clinically significant but rather reflects the relationship between birth weight and head circumference. No difference was found between groups in mental development. One hundred and five methadone exposed infants and 63 comparison infants were evaluated with the Bayley Scale of Mental Development at 6 months of age. Mean Bayley Mental Development scores for methadone exposed infants and comparison infants were 103 and 105 respectively. These data suggest that while methadone exposure in-utero is associated with lower birth weight and head circumference, by six months of age, these infants do not exhibit any general developmental sequelae.

MANAGEMENT OF PREGNANT DRUG-DEPENDENT WOMEN

Although many recommendations have been published for management of the pregnant woman on drugs, they vary greatly concerning the specific mode of management during pregnancy, and moreover, the management of the newborn infant. Several options have been described and recommended: 1. Methadone maintenance;- 2. Low-dose methadone maintenance;l,3.4,B 3. Slow detoxification using methadone substitution and later w i t h d r a ~ a l ; ~ . ~ 4. Acute detoxification; lo 5 . Merely supporting the woman prenatally without attempting to alter the addiction pattern, and 6 . Drug-free programs.1*,13 Although admission to a methadone maintenance program requires initial hospitalization for substitution of the heroin habit by methadone, the patient can be stabilized on a daily controlled dose of drug. Advantages include: 1. Better participation in prenatal care; 2. Shorter hospital stay for the newborn; 3. Improved attention by the mother to her health care needs and those of her child; 4. The creation of a more stable social environment for both the mother and the infant, and 5 . The ability to-follow these mothers and infants on a long-term basis in order to evaluate outcome.I4 In contrast, if the patient is merely encouraged to come for prenatal care and permitted to continue her heroin habit through the usual channels, good results cannot be expected. Prenatal care tends to be spotty and erratic since the patient is primarily motivated to the time-consuming activity of supporting her habit. The outcome for the newborn with erratic prenatal care generally involves a high incidence of low birth weight and infant morbidity. Acute detoxification without the use of any other supportive agents is not acceptable to the drug-dependent woman nor is it without medical complications to her infant. The fetus may undergo simultaneous withdrawal and suffer considerable distress. The result may be intrauterine fetal death or the birth of an infant who has a severe meconium aspiration syndrome. If one decides to detoxify the pregnant woman by giving her large doses of tranquilizers or methadone and then slowly withdrawing the substitute medication, this may be uncomfortable for the pregnant woman as well as hazardous to the unborn fetus. It may also require prolonged hospital stays. Withdrawal from methadone is generally more difficult than that of heroin and is particularly hazardous in the first and third trimesters. In the first trimester, abortion may ensue, and in the last trimester, the onset of premature labor with the birth of a low weight infant is common. The objective of this report will be to describe what has recently proven to be an acceptable approach for the management of pregnant, substance-abusing women, an approach which not only meets their addictive problems but also addresses their overwhelming social, psychological and medical needs.

Impediments to comprehensive treatment models for substance-dependent women: treatment and research questions.

A number of factors need to be addressed in order to provide efficacious treatment for drug-dependent women, particularly those who are opioid dependent. If left unaddressed, these factors may reduce the effectiveness of treatment. In addition, evaluation research frequently overlooks the impact of these factors in methodological approaches examining treatment outcomes. This article discusses several of the problems brought to treatment settings by women, considers how these problems impact on current treatment models, examines alternative research approaches to evaluating treatment for women, and focuses on three critical factors regularly overlooked in treatment provision and in research related to women: (1) broader issues of dependency in women; (2) the impact of chaotic early interpersonal relationships on developmental levels; and (3) diagnostic criteria and treatment goals appropriate for women. It attempts to provide an understanding of the impact of these three elements on treatment and on research methodologies in order to provide and evaluate comprehensive and effective treatment for drug-dependent women.

Evaluation of parenting, depression and violence profiles in methadone maintained women

Twenty-one patients of the Family Center Program for pregnant drug dependent women were studied employing tools which indicate potential ability to parent or risk of child abuse. The Profile of Mood States and Beck Depression Inventory were administered, and a Violence Questionnaire was self-administered to ascertain the presence of physical or sexual abuse in the mothers lives. These results were compared to an assessment of parenting ability as well as general demographics and urinalyses which indicate whether the mothers were taking any drugs in addition to their methadone. Results revealed that there were strong relationships between parenting ability and abusive life events, prenatal clinic attendance, use of depressant drugs, number of children, age, and education and/or employment. These variables were also interrelated with depression, abnormal mood states, and general drug abuse. It appears that while polydrug abuse, psychological problems, and stressful life events are strong indicators of poor parenting ability, the successfully methadone maintained woman who does not feel the need to supplement her methadone with other drugs, whose life has stabilized, and who is relatively normal in her affect and mood, has a strong potential for good childrearing ability.

Children Exposed to Methadone in Utero: Assessment of Developmental and Cognitive Ability

The consequences of maternal drug abuse on the fetus, newborn and infant have been an area of special concern for more than a decade. Methadone maintenance is often recommended for the care of the pregnant opiate-dependent woman primarily to prevent erratic maternal drug levels so that the fetus is not vulnerable to repeated episodes of withdrawal. However, the reduced medical risks associated with methadone maintenance during pregnancy do not alter the fact that the infant becomes passively addicted in utero and usually undergoes neonatal abstinence at birth. The consequences of such exposure for the neonate and young infant have been widely investigated. Studies have consistently found infants exposed to methadone in utero to be well within the normal range of development by six months of age, as measured by the Bayley Scale of Infant Development.’ However, there have been few studies to determine if preschool children exposed to methadone in utero have impaired cognitive functioning. The purpose of this study was to evaluate the developmental and cognitive functioning of preschool children born to women maintained on methadone during pregnancy. Forty-four children (27 methadone-exposed children and 17 nondrug-exposed comparison children) participated in a longitudinal study from birth through five years of age. All of the drug-dependent mothers were enrolled in a comprehensive program for drug-dependent women. Nondrug-dependent mothers were from comparable socioeconomic and racial backgrounds. The mean daily maternal methadone dose during pregnancy was 38.42 mg and 92% of the children required pharmacotheraphy for neonatal abstinence. At 6, 12 and 24 months of age infants were evaluated with the Bayley Scale of Mental Development and received a comprehensive neurological exam. At 3 1 / 2 to 4 1 /2 years of age, the children were evaluated with the McCarthy Scale of Children’s Abilities and a neurological exam. The results of the Bayley Scale of Mental Development are presented in TABLE 1, and those of the McCarthy Scales of Children’s Abilities in TABLE 2. The results of the McCarthy assessments differ from those reported by Wilson et aL2 They found differences between

Pregnancy in a Drug-Abusing Population

Substance abuse in pregnancy places both mother and infant at extremely high risk. There is little information, however, about the impact of changing patterns of drug use and improvements in medical technology on pregnancy outcome. The Family Center Program utilizes a team approach to provide counseling, support, and education as well as complete medical care for substance-abusing pregnant women. We reviewed the records of women seen in the Family Center Program from 1981 to 1983 to evaluate the effect of intervention on pregnancy outcome. Complications, including prematurity, growth retardation, intrauterine fetal demise, and neonatal abstinence, were common, although early prenatal care and frequent visits appear to reduce the risk of low birth weight infants. Uncorrected perinatal mortality was 11/163 (67/1,000). Compared to earlier experience in this program, few women delivered with no prenatal care. Thus a program designed specifically for the needs of these women is successful in increasing the number seeking prenatal care and appears to improve pregnancy outcome. Despite this, serious problems are common and further improvement seems unlikely unless such women can be maintained in a stable, drug-free environment during their pregnancies.

The Effects of Opiates, Sedative—Hypnotics, Amphetamines, Cannabis, and Other Psychoactive Drugs on the Fetus and Newborn

Over the past 20 years, the medical and nonmedical use of psychoactive agents has markedly increased in the United States as well as in other countries. Sir William Osler’s statement, made in the 19th century, still seems applicable: “The desire to take medicine is, perhaps, the greatest feature which distinguishes man from animals” (Cushing, 1925).