Prenatal Followup Care for Pregnant, Substance-Using Women
1 Visits to identify and address medical and psychosocial problems, as well as health education considerations
2 Random urine and/or blood toxicologies
3 Encouragement to continue treatment and establish ongoing relationships with other service providers
4 Written release from the patient to enable service providers to exchange information
5 Discussion of reproductive options
6 Management of common complications
7 Encouragement to involve the father of the baby and other persons the woman considers significant, where appropriate
1 Schedule visits to identify medical and psychosocial problems, as well as health education considerations.
Prenatal followup visits should be determined by the woman's individual needs and risk assessment.
Recognizing that the majority of substance-using women have high-risk pregnancies, it is desirable to see them every 2 to 3 weeks, up until 28 weeks, then weekly thereafter.
It may not be necessary for all contacts to be with a physician; some contacts may be handled by a nurse or by the case manager.
In some instances, a woman should be seen weekly throughout her pregnancy, particularly if she is not enrolled in a therapeutic alcohol and other drug treatment program.
A woman with active medical or obstetric problems should be seen more frequently, at intervals to be determined by the nature and severity of her problems.
Up to 28 weeks, the following should be done at each visit:
Measure weight and blood pressure; obtain urine dipstick for sugar, protein and ketones; test for nitrites and leukocyte esterase; obtain urine and/or blood toxicologies in accordance with the guidelines of the program.
Assess for evidence of edema, abdominal pain, abnormal vaginal discharge, bleeding, headache, visual disturbances, nausea, vomiting, signs and symptoms of urinary tract infection, uterine contractions, pregnancy-induced hypertension, and common discomforts.
Perform abdominal examination.
Review the chart to compare weeks by date and weeks by examination.
Auscultate fetal heart tones.
Obtain sonograms as needed.
Repeat blood work as needed.
Provide for health education about the signs and symptoms of pregnancy, sexual intercourse, breast feeding, preterm labor precautions, common complaints of pregnancy, childbirth, and parenting.
From 28 to 34 weeks, in addition to the above, the following should be done when appropriate:
Obtain diabetes screen.
Administer RhoGAM, if indicated.
Repeat blood work as needed (syphilis, complete blood count [CBC], antibody screen, repeat screens for gonorrhea and chlamydia, and HBsAg if initially negative).
Repeat sonogram for growth or detection of other abnormalities.
Initiate preterm labor precautions.
Provide for antepartum testing, if indicated.
Provide for health education and parenting considerations, including preterm labor precautions and early infant care.
From 35 weeks on, the following should be done at each visit
Repeat blood work as needed.
Provide for antepartum fetal monitoring, if indicated.
2 Obtain random urine and/or blood toxicologies.
The purposes of these screens are to
Establish the extent of recent alcohol and other drug use.
Identify alcohol and other drug use and the need for early preventive interventions.
Identify crises or coping difficulties in the woman.
For additional information and guidance, see Guideline 15 -- Urine Toxicology Considerations.
3 Encourage treatment and ongoing relationships with other service providers, including the patient's therapeutic alcohol and other drug program or support groups. Some patients need education and support to ready them for participation in a treatment program or support group, and to prepare them for change.
Provide direct support or referral for pre-treatment intervention.
If a patient is already involved in an alcohol and other drug treatment program or support group, establish a relationship with that provider after written informed consent is obtained from the patient.
Methadone maintenance: Methadone maintenance has proved effective in the treatment of pregnant, opioid-dependent women.
Participation in an alcohol and other drug treatment program is also important for those women using and abusing other drugs, such as alcohol, cocaine, amphetamines, benzodiazepines, cannabinoids, barbiturates, and hallucinogens.
Service provider communication: It is important that the alcohol and other drug treatment provider and the prenatal health care provider have access to information about the progress of treatment in both disciplines.
4 Obtain written release of information to enable service providers to exchange information.
Release forms, giving permission for the exchange of infor- mation, must be signed by the patient in accordance with Federal confidentiality laws and regulations (see Chapter 3 -- Legal and Ethical Guidelines for the Care of Pregnant, Substance-Using Women). Multidisciplinary case conferences and communication between disciplines are essential.
Meetings of the prenatal care provider, alcohol and other drug counselor, child protective service worker, probation officer, case manager, outreach worker, and social worker can help facilitate optimal prenatal care for the patient.
5 Conduct an initial discussion of reproductive options.
Beginning in the prenatal period, ethnically and culturally sensitive education on birth control and family planning should be provided and emphasized.
Several routine methods of birth control are not optimal choices for the woman who uses alcohol and other drugs.
An individual evaluation is required to determine the best methods for each patient.
Condoms can be used in combination with other methods for birth control and for prevention of sexually transmitted diseases.
Termination of pregnancy, adoption, and foster care are other options.
Oral estrogen-progestin (contraceptive pill): Oral estrogen-progestin, preferably given in low doses, should be prescribed with care, as many substance- using women have vascular disease secondary to prolonged abuse of alcohol and other drugs.
They also may not be conscientious in taking prescribed medication as indicated.
Intrauterine devices (IUDs): These devices may be considered only if the patient's past history does not include pelvic infections.
An additional complication with IUDs is the possibility of exposure to sexually transmitted diseases.
Barriers: Barrier-type contraceptive methods, while the safest medically, are not the most effective and require consistent use.
These methods include condoms -- which also reduce the risk for HIV and other sexually transmitted diseases -- and diaphragms.
Subcutaneous implants: Norplant is an example of a long-acting, reversible contraceptive method.
Sterilization: Permanent sterilization may be introduced as an option.
The procedure can be completed before discharge postpartum.
The need for appropriate family planning must be stressed, because an unwanted pregnancy may add unnecessary anxiety to an already precarious situation.
Counseling should be readily available and, at the discretion of the mother, should include significant others.
6 Manage common complications.
Some prenatal complications are sufficiently common among substance-using women to warrant specific comment.
These complications include preterm labor, intrauterine growth retardation, hepatitis B, and HIV.
Substance-using women are at risk to deliver prematurely.
Pertinent risk factors for preterm delivery, aside from the use of alcohol and other drugs, include preterm and premature rupture of membranes, placental abruption, and stress.
Due to the anesthetic/analgesic properties of most drugs of abuse, the patient may not perceive the early signs and symptoms of preterm labor and present too late to benefit from tocolytic therapy.
Due to late initiation of prenatal care, it is sometimes difficult to distinguish true PTL from labor at term with a growth-retarded fetus.
Substance-using patients should be educated about their increased risk for preterm labor.
Preterm labor precautions should be reviewed at each prenatal visit, especially between the 26th and 36th week.
These patients often confuse symptoms of PTL with those of drug withdrawal.
Screen for and treat infections that predispose to PTL, such as gonococcal or chlamydial infections.
Some patients may benefit from serial cervical exams and/or antepartum fetal heart rate/uterine activity testing to rule out PTL, especially if they have a multiple gestation or a previous history of PTL or preterm delivery (PTD).
A complete history of alcohol and other drug use and a urine and/or blood toxicology screen should be obtained on any patient presenting in PTL and/or with preterm and premature rupture of membranes.
Betamimetic tocolytics, such as ritodrine or terbutaline, should be used with great caution in stimulant-abusing patients.
Alternative tocolytic agents, such as magnesium sulfate, may be preferable.22
Assessment of fetal lung maturity may be helpful in distinguishing between PTL and labor at term with a growth-retarded fetus.
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