Protocols for High-Risk Pregnancies. Группа авторов
have birth outcomes that are more like those without addiction than those with untreated disease.
Labor and delivery
Upon presentation to labor and delivery units, medication for opioid use disorder should be continued. People with opioid addiction may have greater analgesic needs due to both tolerance and prior negative experiences with the healthcare system. Analgesia should be multimodal. People with addiction often experience discrimination from friends and family as well as from providers. It is therefore essential that all staff treat pregnant and parenting people with opioid addiction with dignity and respect.
Postpartum
Neonatal abstinence syndrome is an expected and treatable outcome of in utero opioid exposure. Opioids are an essential but insufficient cause of NAS in part because maternal medication dose is not related to likelihood of developing NAS. Risk and protective factors for NAS are listed in Table 3.3.
Postpartum, or the fourth trimester, is a period of increased vulnerability to addiction recurrence, compounded by insurance churn, noncontinuation of medication, maternal mood changes, and withdrawal of care from prenatal care providers following delivery. For reasons that are unknown, people with opioid use disorder have almost four times the odds of death during the delivery hospitalization and overdose is one of the leading causes of maternal mortality in the US today.
Table 3.3 Risks and protective factors for neonatal abstinence syndrome (NAS)
| Factors which increase likelihood, severity, and duration of NAS | Factors that decrease likelihood, severity, and duration of NAS |
|---|---|
| Maternal medications Gabapentin Benzodiazepines Selective serotonin reuptake inhibitorsMaternal smoking Fetal methylation of the mu‐opioid receptorNeonatal intensive care unit admission | Smoking cessation Rooming‐in BreastfeedingSkin‐to‐skin contact Preservation of the maternal–infant dyad |
Conclusion
Although there has been an increase in the availability of addiction treatment in the past decade, there remains a large unmet treatment need, with only 30–70% of pregnant women with opioid addiction reporting any treatment during pregnancy. Universal assessment during prenatal care with early medication initiation with either methadone or buprenorphine are recommended. In general, women do well during pregnancy, but disease recurrence is common postpartum. Therefore, continuing care postpartum is essential. Providers need to be sensitive to the discrimination that pregnant and parenting people with opioid addiction face.
Suggested reading
1 Haight SC, Ko JY, Tong VT, Bohm MK, Callaghan WM. Opioid use disorder documented at delivery hospitalization – United States, 1999–2014. MMWR 2018; 67:845–9.
2 Kotelchuck M, Cheng ER, Belanoff C, et al. The prevalence and impact of substance use disorder and treatment on maternal obstetric experiences and birth outcomes among singleton deliveries in Massachusetts. Matern Child Health J 2017; 21(4):893–902.
3 Ondersma SJ, Chang G, Blake‐Lamb T, et al. Accuracy of five self‐report screening instruments for substance use in pregnancy. Addiction 2019; 114(9):1683–93.
4 Schiff DM, Nielsen T, Terplan M, et al. Fatal and nonfatal overdose among pregnant and postpartum women in Massachusetts. Obstet Gynecol 2018; 132(2):466–74.
5 Substance Abuse and Mental Health Services Administration. Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants. HHS Publication No. (SMA) 18‐5054. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2018.
6 Terplan M. Women and the opioid crisis: historical context and public health solutions. Fertil Steril 2017; 108(2):195–9.
7 Terplan M, Kennedy‐Hendricks A, Chisolm MS. Prenatal substance use: exploring assumptions of maternal unfitness. Subst Abuse 2015; 9(Suppl 2):1–4.
8 Vowles KE, McEntee ML, Julnes PS, Frohe T, Ney JP, van der Goes DN. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain 2015; 156(4):569–76.
9 Wachman EM, Hayes MJ, Lester BM, Terrin N, Brown MS, Davis JM. Epigenetic variation in the mu‐opioid receptor gene in infants with neonatal abstinence syndrome. J Pediatr 2014; 165(3):472–8.
PROTOCOL 4 Depression
Kimberly Yonkers
Departments of Psychiatry, Obstetrics, Gynecology and Reproductive Sciences and School of Public Health, Yale University School of Medicine, New Haven, CT, USA
Clinical significance
Approximately 20% of women suffer from a depressive disorder at some point in their lives. The risk of being depressed is greatest for women during their reproductive years and thus clinicians may encounter a pregnant woman with preexisting depression or a woman who becomes depressed during her pregnancy. The potentially devastating toll that a major depressive episode (MDE) has on a mother and the relatively low risk associated with treatment underscore the need to treat depressed pregnant women.
Some women may experience improvement or remission with evidence‐based psychotherapy. However, some women may require pharmacotherapy. This may lead to additional concerns because the antidepressants and anxiolytics, that are often used concurrently, are linked to adverse perinatal and fetal outcomes. Researchers note an increased risk of fetal malformations although the magnitude of this risk is small and largely centered on atrial and ventricular septal defects. Moreover, such risks are only associated with certain antidepressants (e.g., paroxetine). Other worrisome associations include delivery of an infant who is preterm or small for gestational age, as well as a very small increased likelihood of persistent pulmonary hypertension. The evidence for a number of these outcomes among women treated with antidepressants in pregnancy is mixed, with the strongest support for an increased risk of preterm birth. However, even the smallest risk can lead to apprehension on the part of patients and uneasiness for their prescribing physicians.
Pathophysiology
As with many psychiatric disorders, the pathophysiology of a depressive disorder is unknown, although evidence suggests that underlying risk is determined by biology (e.g., genetic factors), stress, and trauma. Co‐occurring general medical conditions and exposure to selected medications and other substances can also lead to development of depressive symptoms or an MDE. Brain imaging studies show that individuals with depression have changes in neurocircuitry and volume reductions in critical brain areas such as anterior cingulate cortex, amygdala, and hippocampus. These regions are also affected by elevations in glucocorticoids and there are long‐standing theories that implicate dysregulation of the hypothalamic–pituitary–adrenal axis in depression. For example, the introduction of stress leads to secretion of cortisol. The integrity of the feedback systems between cortisol, adrenocorticotrophic hormone, and corticotrophin‐releasing hormone (CRH) is compromised in many individuals, with depression leading to overexpression of these hormones. Ongoing exposure to these hormones can lead to anatomic and dynamic (signaling) changes in the aforementioned brain regions.
Diagnosis
There are several mood disorders that fall under the category of “depression” and they are outlined in the Diagnostic and Statistical Manual (DSM) version 5 (American Psychiatric Association 2013). The prototypic depressive