Pregnant, Substance-Using Women
Treatment Improvement Protocol (TIP) Series 2

Procedures at the Time of Admission

1 Obtain a detailed health history, including alcohol and other drug use and arrangements for prenatal care.

2 Conduct a comprehensive physical examination, including weight, vital signs, and an obstetrical evaluation.

3 Obtain laboratory tests, including

a) Initial blood workup that includes, but is not limited to

• Blood group, Rh factor determination, and antibody screen
• Serological test for syphilis
• Hepatitis B and C screens
• Complete blood count with indices

b) Other initial laboratory tests that include, but are not limited to

• Cervical cytology smear (Pap smear), unless the provider has results of a test performed within the past 3 months
• Cervical culture for gonorrhea
• Urine screen for urinary tract infection, kidney disease, protein, and glucose
• Chlamydia screen

4 Obtain purified protein derivative of tuberculin (PPD) test with antigen panel.

5 Obtain urine and/or blood toxicologies (see Guideline 15 -- Urine Toxicology Considerations).

6 Provide for HIV antibody counseling and testing.

7 Obtain baseline sonogram if appropriate.

Dosing Strategy

Determine the amount of drug being used and follow the dosing strategy listed below.

1 Evaluate the pattern of drug use, route of administration, and frequency and amount of drug use.

2 Obtain a detailed history of drug use within the past 24 hours.

To withdraw a pregnant woman dependent on cocaine, the following are options.

1 No medications. Pregnant patients who are withdrawing from cocaine should not be medicated except in cases of extreme agitation and by individual order of the health care provider.

2 Anxiolytics. If medication is needed, low doses of diazepam (Valium) or chlordiazepoxide (Librium) (25 mg by mouth, 4 times a day, x 6 doses) may be used.

3 Antidepressants. A typical withdrawal guideline for cocaine-dependent women uses doxepin (Sinequan) or desipramine (Norpramin). For example,

• Days 1-2: Doxepin 25 mg (one tablet) by mouth 2 times a day, 50 mg maximum.
• Days 3-5: Doxepin 25 mg (one tablet) by mouth 2 times a day, then discontinue.
• Further therapy should be determined by the treating physician after an initial period of observation.
• No drug therapy is usually indicated after the first 5 days.

4 Barbiturates. For cocaine withdrawal symptoms:

• Days 1-2: Phenobarbital 30 to 60 mg every 4 hours as needed.
• Days 3-4: Phenobarbital 30 to 60 mg every 6 hours as needed.

5 Bromocriptine. Bromocriptine, a drug used to treat menstrual abnormalities and infertility in women, has provided striking and consistent relief from cocaine craving among inpatients.

Research indicates that cocaine, when used by the first-time user, seems to stimulate dopamine and also blocks the reuptake of dopamine, which produces the cocaine high. The brains of regular users of cocaine cannot make dopamine as quickly as the cocaine demands; the result is an eventual depletion that creates the crashing and craving effects.

The use of bromocriptine in pregnancy is not recommended because of the lack of proven efficacy and unknown effects, both short and long term, on the fetus.

6 Acupuncture. Acupuncture has been used in the treatment of cocaine addiction. Traditional use of acupuncture for other disorders has usually been contraindicated in pregnancy. At the time of publication, the National Institute on Drug Abuse has not concluded its evaluation of the efficacy of this treatment.