Ethical Issues Related to Substance Abuse in Pregnancy ...

Th e Finger Lakes Regional Perinatal ForumToxic Exposures During PregnancyTuesday, June 8, 2010‐ Canandaigua, NYEthical Issues Related to Substance Abuse in PregnancyPresenter: Jane Greenlaw, JDFind presentation at:http://www.urmc.rochester.edu/flrpp/forum/documents/EthicalIssues.pdfCase example: Prenatal clinic in an urban university hospital where workers areconcerned about prenatal cocaine use (based on reports of postnatal observations).Plan is developed to “identify/assist pregnant patients suspected of drug abuse.”Positive results were reported to law enforcement. Women who tested positive were“referred” to substance abuse treatment.• Positive test prenatally – police notified and patient referred to treatment• Positive test postnatally – police notified and patient arrested immediatelyCharges:• 27 weeks or less: simple possession• 28 weeks or more: possession and distribution to “a person under 18”• If positive at delivery: above and unlawful neglect of a childOutcomes: Medical center violated the women’s 4 th Amendment protection againstunlawful searches since they were tested without their knowledge or consent.What Went Wrong: Involvement of law enforcement agencies (creates adversarialsituation between caregivers and patients, changing the normal dynamic)New York State: Prenatal testing should not be done without the woman’s knowledgeand consent.Reminders about pregnant women (generally). They will (are)• try harder than other patients to “follow doctors’ orders”• refrain from smoking, drinking, and try to eat well• accept medical recommendations even when not in their interest• the most compliantEthical stances:• The “patient autonomy” approach• The “save the baby” approach• The “two patient” approachNeed for Intervention:• Medical, not legal, approach• Educate• Refer• Support• Encourage• Expect setbacks• Use established trusting relationship• Don’t judgeFollow up comments/questions included:• Mom, in another county, lost custody of previous child due to substance abuse.Has not abused this pregnancy, yet CPS still says she can’t have custody of child

from current pregnancy. CPS keeps upping the ante to keep mom from havingcustody.• Both drug rehab and jail work as treatment. Drug addicted mom needs to learn tolive with addiction and at the same time learn to parent.• What do you do with mom who totally denies that she uses? Finds those momsvery difficult, frustrating to work with.• Jane Greenlaw: very frustrating stories to tell -- pregnancy after pregnancy --babies born impaired.Managing the Mentally IIl Pregnant PatientPresenter: Beth GoldenbergFind presentation at:http://www.urmc.rochester.edu/flrpp/forum/documents/FAS.perinatalconf.pdfSubstance Abuse and Dependence:• Drug addition is a complex brain disease. It is characterized by compulsive, attimes, uncontrollable, drug craving, seeking and use that persists even in theface of extremely negative consequences.• Drug seeking becomes compulsive, in large part as a result of the effects ofprolonged drug use on brain functioning and, thus, on behavior. For manypeople, drug addition becomes chronic, with relapses possible even after longperiods of abstinence.Disorders with Increased Risks of Drug AbuseDisorderRiskAntisocial personality disorder 15.5%Manic episode 14.5%Schizophrenia 10.1%Panic disorder 4.3%Major depressive episode 4.1%Obsessive-compulsive disorder 3.4%Phobias 2.1%Substance Abuse in Pregnant Mentally Ill Women –Most commonly used drugs in pregnancy:Nicotine 20%Alcohol 19%Marijuana 3%Cocaine 3%(National Institute of Drug Abuse (2002)Substance Abuse in Pregnant Women –Reasons why pregnant women usePrior history of useLimited social supportIntimate partner violenceConcurrent mental illnessCase Study• Courtney, 36 yr. old Caucasian lesbian woman~advanced maternal age~active cocaine use~bipolar disorder• Pregnant as a result of her prostitution

~planned to terminate pregnancy early on but partner, Marie, “talked me out ofit.”~on ultrasound, fetal heart showed Tetrology of Fallot but too late for termination• Attendance at clinic was quite erratic~when she did come, she was typically high and very argumentative• Continued to use cocaine through pregnancy and ended up in the hospital at 33weeks gestation due to premature rupture of membranes.~seen by Psychiatric Consultation Service while inpatient to assist withmanagement of anxiety and demanding behaviors.• Delivered son at 35 weeks gestation (induced)~asked at time of discharge to be referred to outpatient mental health care andchemical dependency treatment.Fetal Alcohol Syndrome and Long Term Developmental EffectsPresenter: Nirupama LaroiaFind presentation at:http://www.urmc.rochester.edu/flrpp/forum/documents/Mentalillnessandsubstanceuse.pdfHistory of Alcohol Consumption and Pregnant Women reviewed• As early as 330 BC Aristotle noted “Foolish drunken and hair brained womenmost often bring forth children like unto themselves, morose and languid.” Inancient Sparta and Carthage, custom prohibited newlyweds from drinking ontheir wedding night in order to prevent conceiving a “damaged” child.• The association of alcohol with poor birth outcomes continued until the end ofprohibition (1920-1933) when some felt that the idea was propaganda circulatedby proponents of prohibition. Mid-1930s -- some doctors reassured pregnantpatients that a drink or two daily was OK as a means of relaxing.• 1950s – Alcohol use among pregnant women rose – few worried about theeffects on the newborn.• 1968 – French scientists tracking 127 children born to alcoholic mothers found aseries of effects that they blame on in-utero exposure to alcohol.• 1973 – Lancet reported the work of scientists from the University of Washingtonwho studied infants born to alcoholic mothers. Named it “fetal alcohol syndrome(FAS).”FAS Diagnostic Criteria• Characteristic pattern of facial anomalies• Growth restriction• Central nervous system neurodevelopmental abnormalities• Known history of maternal alcohol consumptionHow Alcohol Does its Damage• Alcohol passes easily across the placenta• Fetal levels rise above maternal levels• Fetal liver is inefficient, maternal liver must do the work for both• Alcohol is metabolized to acetaldehyde in the liver• Interference with fetal nutritionWhat is Know – What Remains Uncertain?• Incidence 0.5-2.0/1000 births~considerable international variation in estimates• Consistent effects of high dose of alcohol~multiple mechanisms depending on dose, pattern and timing

• Animal models suggest neurologic effects with low to moderate exposure• Tip of the iceberg – alcohol related neurodevelopmental disorder~incident of 10/1000 live births~absent facial features~structural brain abnormalities with confirmed maternal alcohol exposureBarriers to Adequate Counseling• Concern about labeling, difficulties in making a causal attribution to prenatalalcohol• Lack of consensus in the literature, skeptic physicians• Lack of awareness and knowledge among clinicians• Are physicians missing an important diagnosis with important implications forprevention?Important Research Questions• Does the pattern of alcohol consumption matter?• Threshold level of alcohol consumption?• Timing of consumption during pregnancy matter?• Other predictive factors• One or several phenotypes? Associations with other psychiatric disorders?Prevention of Alcohol Induced Fetal Damage• 2000, AAP Committee on Substance Abuse published the followingrecommendations:~abstinence is recommended for pregnant women and for those planningpregnancy~high quality educational programs should be developed for all levels ofsociety regarding the deleterious effects of alcohol on the unborn child.~health care professionals should increase their own awareness of FASand ARND and their prevention~AAP supports federal legislation requiring inclusion of health andsafety messages in all alcohol advertising~parents of affected children should receive appropriate support servicesfor themselves and their childrenNeonatal Alcohol Withdrawal is often overlooked, but importantIs There an Answer?• Abstinence• Discuss risk during pregnancyDaystar – New York State’s First and Only Day and Respite Program for MedicallyFragile InfantsPresenter: Natalie AndersonTo learn more about Daystar: www.daystarsj.orgFounded by the Sisters of St. Joseph in 1988 as a foster home for medically fragileinfants, Daystar fills an unmet need to provide safe, quality care for this population –a need that continues today as medical advances save the lives of children who in thepast would not have survived.In 2001, doctors in the neo-natal intensive care unit at the Golisano Children’s Hospitalat Strong urged Daystar to expand it services to provide medical daycare – first for twobabies, and following an expansion of our current home, for 10 babies per day. As alicensed Group Family Day Care under the NYS Office of Children and Family Services(OCFS), we can serve no more than 10 babies at a time.

Daystar is dedicated to supporting our community’s most vulnerable infants fromnewborns to three-year-olds by providing quality childcare, respite care, advocacy, andfamily support in a safe and stimulating home environment. Daystar is the first and onlyprogram in NYS to offer this type of service. Daystar families receive essentialguidance, education, and support in facing the multiple challenges of raising a child withmedical and developmental complexities. Daystar is a publicly supported non-profitorganization.Awarded a NYS grant through OCFS, Daystar has been able to develop and formalizethe inputs necessary to deliver medical daycare to populations with significant andcomplex medical and developmental factors. Daystar’s comprehensive collaborative,pioneering research and development initiative has yielded the Best Practices ChildCare Program and Environment for caring for medical fragile infants.Please note:• Space is very limited. Interested parents should contact Daystar as soon as needis identified as there is a long waiting list.• Both part time and full time care is offered.