Protocols for High-Risk Pregnancies. Группа авторов
risk of stillbirth by approximately 50% and risk of neonatal death by 20%. There appears to be a dose–response relationship, with heavy smokers having the greatest risk.
The offspring of smoking mothers face additional risks during childhood. There is a strong association between maternal smoking and sudden infant death syndrome, and again, a clear dose–response relationship has been demonstrated. Prenatal and postnatal tobacco smoke exposure has also been associated with increased risk of reduced lung function, respiratory infections, and asthma in the children. Recent studies suggest that infants born to women who smoke during pregnancy may be at increased risk for childhood obesity, as well as other metabolic dysfunctions, likely through a developmental programming effect. In addition, there is evidence suggesting a neurotoxic effect of prenatal tobacco exposure on newborn behavior, i.e., being more excitable and hypertonic. The behavioral and cognitive deficits associated with in utero exposure to tobacco seem to continue into late childhood and adolescence with increased risk for attention‐deficit hyperactivity disorder and conduct disorder.
In addition to nicotine exposure, e‐cigarette use has been associated with an additional risk. An acute, severe respiratory distress syndrome has been identified in individuals using e‐cigarette products. Over 2000 e‐cigarette or vaping product use‐associated lung injury (EVALI) events were reported by the CDC in the US in 2019. The exact etiology of the lung injury is unknown but vitamin E acetate exposure may play a role in the development of EVALI. Pregnant women are at higher risk for severe outcomes with EVALI, therefore these products should not be used in pregnancy.
Follow‐up and prevention
Many pregnant women can remain smoke free during their pregnancy but postnatal relapse rates are high. The Pregnancy Risk Assessment Monitoring System reported relapse rates as high as 67% at greater than six months postpartum. Counseling should be continued at each postpartum visit including unequivocal, personalized and positive messages about the benefits to the patient, her baby and family resulting from smoking cessation. Although available data are limited, pharmacotherapy can be considered for the lactating woman. Any potential risk for the nursing infant from passage of small amounts of the medications through breast milk should be weighed against the increased risks associated with second‐hand exposure to smoking such as sudden infant death syndrome, respiratory infections, asthma, and middle ear disease.
Suggested reading
1 American College of Obstetricians and Gynecologists. Smoking cessation during pregnancy. Committee Opinion No. 721. Obstet Gynecol 2017; 130:e200–4.
2 Blunt BC, Karwowski MP, Shields PG, et al. Vitamin E acetate in bronchoalveolar‐lavage fluid associated with EVALI. N Engl J Med 2020; 382:697–705
3 Curtin SC, Matthews TJ. Smoking prevalence and cessation before and during pregnancy: fData from the birth certificate, 2014. Natl Vital Stat Rep 2016; 65:1–14.
4 Jatlaoui TC, Wiltz JL, Kabbani S, et al. Update: interim guidance for health care providers for managing patients with suspected e‐cigarette, or vaping, product use – associated lung injury – United States, November 2019. MMWR 2019; 68:1081–6.
5 Kapaya M, d’Angelo DV, Tong VT, et al. Use of electronic vapor products before, during, and after pregnancy among women with a recent live birth – Oklahoma and Texas, 2015. MMWR 2019; 68;189–94.
6 Layden JE, Ghinai I, Pray I, et al. Pulmonary illness related to e‐cigarette use in Illinois and Wisconsin – final report. N Engl J Med 2020; 382:903–16.
7 Likis FE, Andrews JC, Fonnesbeck CJ, et al. Smoking Cessation Interventions in Pregnancy and Postpartum Care. Evidence Report/Technology Assessment No. 214. (Prepared by the Vanderbilt Evidence‐based Practice Center under Contract No. 290‐2007‐10065‐I.) AHRQ Publication no. 14‐E001‐EF. Rockville, MD: Agency for Healthcare Research and Quality, 2014. www.effectivehealthcare.ahrq.gov/reports/final.cfm
8 Shahab L, Goniewicz ML, Blount BC, et al. Nicotine, carcinogen, and toxin exposure in long‐term e‐cigarette and nicotine replacement therapy users: a cross‐section study. Ann Intern Med 2017; 166:390–400.
9 Tong VT, Dietz PM, Morrow B, et al. Trends in smoking before, during, and after pregnancy – Pregnancy Risk Assessment Monitoring System, United States, 40 sites, 2000–2010. MMWR Surveill Summ 2013; 62:1–19.
10 Tran T, Reeder A, Funke L, Richmond N. Association between smoking cessation interventions during prenatal care and postpartum relapse: results from 2004 to 2008 multi‐state PRAMS data. Matern Child Health J 2013; 17:1269–76.
11 US Department of Health and Human Services Substance Abuse and Mental Health Services Administration Center for Behavioral Health Statistics and Quality. National Survey on Drug Use and Health, 2013. Inter‐University Consortium for Political and Social Research (ICPSR) [distributor].
12 US Department of Health and Human Services. The Health Consequences of Smoking: 50 Years of Progress. A Report of the Surgeon General. Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.
13 World Health Organization. WHO Recommendations for the Prevention and Management of Tobacco Use and Second‐Hand Smoke Exposure in Pregnancy. Geneva: World Health Organization, 2013.
PROTOCOL 3 Opioid Use, Misuse, and Addiction in Pregnancy and Postpartum
Mishka Terplan
Friends Research Institute, Adjunct Faculty, Clinical Consultation Center, University of California, San Francisco, CA, USA
Overview
Opioids have been part of human culture and healing for millennia. Initially cultivated and distributed throughout the ancient world, opioids are described in Sumerian, Egyptian, Greek, Islamic, and Chinese medical treatises. Whereas opioid use is ancient, problematic use and, specifically, addiction are more modern phenomena. The first opioid crisis, which dates to the latter half of the 18th century, was iatrogenic in origin. This was an epidemic overwhelmingly of women, who had initially been exposed to opioids through a prescription for the treatment of “female ailments.”
The current opioid crisis in the US is arguably the most severe in history and, like the first, features a large proportion of women. Overdose deaths have become one of the leading causes of mortality and, along with hepatitis C and suicide, have contributed to a decrease in life expectancy especially among white, middle‐aged Americans. The current crisis consists of three related phases. The first began with a marked increase in opioid prescribing starting in the mid‐1990s and peaked in 2010. The second was driven by illicit heroin distribution while the third phase began in 2016 powered by fentanyl and other illicitly manufactured synthetic opioids. Opioid‐related drug deaths may have plateaued nationally in 2019, but a fourth wave of stimulant‐related mortality (both amphetamine and cocaine) is now emerging.
The current crisis has changed the demographics of substance use and addiction. Whereas less than 20% of people who used heroin in the 1970s were women, today roughly 50% are women. Although more men have addiction than women, for opioid use disorder at least half of people presenting for treatment are female.
Opioid use, misuse, and addiction have increased in pregnancy and postpartum, in parallel with the overall crisis. Rates of opioid use disorder assessed at the time of delivery more than quadrupled between 1999 and 2014, as have rates of neonatal abstinence syndrome (NAS), and, in many states, overdose is the leading cause of maternal death.
Opioid use and misuse
Opioids are a class of substances which bind to the opioid receptor.