Perinatal morbidity and mortality in substance using families: effects and intervention strategies

Sections

ABSTRACT
Social and medical characteristics of pregnant substance-dependent women that influence the intrauterine milieu
Impact of maternal substance abuse on foetal welfare
Infant morbidity
Infant mortality
Behaviour of drug-exposed infants in the neonatal period
Interventions to improve stability and perinatal outcomes

Details

Author: L. P. FINNEGAN
Pages: 19 to 43
Creation Date: 1994/01/01

Perinatal morbidity and mortality in substance using families: effects and intervention strategies

L. P. FINNEGAN Senior Adviser on Women's Issues, Office of the Director, National Institute on Drug Abuse, National Institutes of Health, United States Department of Health and Human Services, Bethesda, Maryland, United States of America

ABSTRACT

The epidemic of drug abuse has overwhelmed men, women and children and caused incalculable damage to an honoured structure in human civilization - the family. Moreover, during the past decade, increasing numbers of pregnant drug-dependent women have been presenting themselves to medical facilities, some to receive ongoing prenatal care, but others only to deliver their babies with - out the benefit of any medical services. The present chapter reviews the current literature, as well as the experiences of the author, with regard to the sociomedical characteristics of pregnant, drug -dependent women. The effects of substances of abuse on pregnancy, the foetus and the newborn with respect to morbidity and mortality are presented. Recommendations for management of both the pregnant drug -dependent women and her child, on the basis of clinical research, are also outlined. Although overall medical advances have escalated during the past three decades, there is still much to learn with regard to the effects of drugs of abuse upon families. Moreover, methods of prevention and treatment still need consider- able study. By re-evaluating the areas of strength and weakness in the body of available knowledge, future research will be able to enhance the ability to help those unfortunate families that are effected by substance abuse.

Social and medical characteristics of pregnant substance-dependent women that influence the intrauterine milieu

The use of psychoactive substances has led to an ongoing and increasing number of individuals suffering from the chronic, relapsing disease of addiction. It affects all sectors of the world population and it is widely recognized that millions of individuals use illicit drugs regularly. Many millions more are addicted to nicotine, alcohol or both. Large numbers of people die every day as a result of nicotine's role in heart disease, lung disease and cancer. The effects of alcoholism have wreaked incalculable damage across generations throughout societies. The epidemic of drug abuse has overwhelmed men, women and children and caused incalculable damage to an honoured structure in human civilization - the family. Moreover, during the past decade, increasing numbers of pregnant drug -dependent women have been presenting themselves to medical facilities, some to receive ongoing prenatal care, but others only to deliver their babies without the benefit of any medical services prenatally.

The present chapter reviews the current literature, as well as the experiences of the author, with regard to the sociomedical characteristics of pregnant, drug-dependent women. In addition, the effects of sub- stances of abuse on pregnancy, the foetus and the newborn with respect to morbidity and mortality are presented. Recommendations for management of both the pregnant drug-dependent woman and her child, on the basis of clinical research, are also outlined.

Because of the high incidence of polysubstance use, it is essential to remember the inherent difficulties involved in ascribing any individual perinatal effect to one specific substance. However, because of space limitations, the present chapter can only deal with opiates (primarily heroin and methadone) and the stimulant cocaine. It must be realized that use of the latter agents is frequently augmented by excessive use of the licit drugs alcohol and nicotine, both of which have been found to have a profound effect on pregnant women and their offspring.

As a result of pre-existing conditions and ongoing active drug use, the narcotic-dependent woman frequently suffers from chronic anxiety and depression. Social problems such as poverty, hopelessness, involvement in an abusive relationship and alcoholism may overwhelm coping mechanisms. She usually lacks confidence and hope for the future, and has extreme difficulty with interpersonal, especially heterosexual, relationships. Over 80 per cent of addicted women were raised in house - holds marked by parental chemical abuse, 67 per cent of those women had been sexually assaulted, 60 per cent had been physically assaulted, and almost 100 per cent of the women wished that they were someone else as they were growing up [ 1] . In addition to those problems, the treatment and possible resolution of the superimposed addiction is complicated and requires understanding and patience. Addiction is a chronic, progressive, relapsing disease, and a smooth and rapid recovery cannot be expected. It should not be surprising, therefore, that the lifestyle of the pregnant addict has a profound influence upon her psychological, social and physiological well-being and that of her child and the family relation- ships.

It is well known that medical complications compromise many drug- involved pregnancies. The most frequently encountered complications of injecting drug users are listed in table 1. The human immunodeficiency virus (HIV) has been linked increasingly with drug use. The practices of sharing contaminated needles to inject heroin or cocaine, engaging in prostitution to buy drugs, or conducting the direct sex-for-drugs transaction associated with "crack" smoking have all contributed to this serious international health crisis. Currently, the spread of HIV disease is linked less to homosexual than to heterosexual transmission. Although the exact risk of an infected mother's passing the disease to her offspring is not precisely known, it is estimated that approximately 25 to 30 per cent of infants exposed in this fashion will actually contract the acquired immunodeficiency syndrome (AIDS). AIDS prevention counselling forms an essential part of services that must be offered to pregnant substance- abusing women or women involved in close relationships with addicted men. In addition, recent studies have shown that the use of zidovudine in pregnant HIV-positive women can reduce perinatal transmission from 25 per cent to 8 per cent.

The drug-dependent pregnant woman may also develop anaemia as a result of iron and folic acid deficiency. Nutritional deficiencies associated with drug addiction are due largely to the lack of proper food intake because of inhibition of the central mechanism that controls appetite and hunger. Furthermore, toxic responses to narcotics may contribute to malnutrition by interfering with the absorption or utilization of ingested nutrients. Absorption abnormalities are common among drug addicts because of the high incidence of lesions of the intestine, liver and pancreas; malnutrition is often related to the presence of liver disease. Sometimes, in the chronic drug addict, peripheral neuritis due to thiamine depletion is seen, although a deficiency of vitamin B6, pantothenic acid or nicotinic acid may produce identical signs. Hypoglycaemia, vitamin B6 deficiency, thiamine depletion or magnesium deficiency may cause seizures in both alcoholics and drug addicts. Hepatitis, a frequent complication of abuse of injectable drugs, is nutritionally depleting because it causes a loss of protein, vitamins, minerals and trace elements. Intensive dietary therapy is desirable in drug and alcohol addiction, and parenteral therapy may be necessary to correct fluid, mineral and vitamin deficits in acutely ill patients [ 2] .

Cocaine is known to cause many medical complications in adult users. These complications may include acute myocardial infarction, cardiac arrhythmias, rupture of the ascending aorta, cerebrovascular accidents, hyperpyrexia, seizures and infections, as well as a range of psychiatric disorders such as dysphoric agitation [ 3] . Table 2 elaborates upon the medical complications.

Table 1. Medical complications of intravenous drug users

Type and description

INFECTIONS
CARDIOVASCULAR
GASTROINTESTINAL
Bacterial endocarditis
Arrhythmia
Constipation
Pneumonia
Mycotic aneurysm
Diarrhoea
Cellulitis
Thrombophlebitis
 
Cutaneous abscesses
 
MISCELLANEOUS
Osteomyelitis
PULMONARY
Anaemia
Septic arthritis
Pulmonary oedema
Overdose
Sexually transmitted
Pneumothorax
Allergic reaction
diseases
Pneumomediastinum
Pyrogenic reaction
Tuberculosis
 
Trauma
Tetanus
NEUROMUSCULAR
Needle embolus
HIV infection
Stroke
Amenorrhoea
HTLV-I/HTLV-II
Brain abscess
Hormonal abnormalities
infection
Epidural or subdural
Thrombocytopaenia
Hepatitis A, B, C and D
abscess
Needle embolus
viruses
Anoxic encephalopathy
 
 
Peripheral neuropathy
 
IMMUNOLOGICAL
Horner's syndrome
 
Generalized
Mitosis
 
lymphadenopathy
   
Elevated serum
HEPATIC
 
immunoglobulins
Acute and chronic
 
False-positive serologic
hepatitis
 
tests
Cirrhosis
 
Lymphocytosis
   
Increased lymphocyte
RENAL
 
subset cell numbers
Glomerulonephritis
 
Reduced responsiveness of
Renal failure
 
lymphocytes to mitogens
   
Reduced natural killer cell activity
   
Source:Adapted from J. Lowinson, J. Ruiz and R. Millman, eds., Substance Abuse: A Comprehensive Textbook (Baltimore, Maryland, Williams and Wilkins, 1992), pp. 657-674.

In addition to the vast numbers of medical complications that pregnant substance-using women are predisposed to, a number of obstetrical complications are seen. Table 3 outlines the most common disorders. Because of the lack of prenatal care, many women are more apt to develop pre-eclampsia or eclampsia. Addicted women should also be closely observed for postpartum haemorrhage.

Table 2. Medical complications seen in cocaine abusers

Type and description

CARDIOVASCULAR
MISCELLANEOUS
Myocardial infection
Acute hepatic necrosis
Arrhythmia
Hyperpyrexia
Aortic rupture
Loss of sense of smell
Hypertension
Perforated nasal septum
Cardiomyopathy
Loss of eyebrows, eyelashes
PULMONARY
Sexual dysfunction
Decreased diffusing capacity
Motor vehicle accidents
Pneumomediastinum
Trauma
Pulmonary oedema
Sudden death
NEUROLOGIC
Endocarditis
Stroke
HIV infection
Subarachnoid haemorrhage
PSYCHIATRIC
Seizures
Psychosis
Fungal meningitis
Depression
Headache
Personality changes
GASTROINTESTINAL
Delusions of paranoia
Intestinal ischaemia
 
Colitis
 
Source:Adapted from J. Lowinson, J. Ruiz and R. Millman, eds., Substance Abuse: A Comprehensive Textbook (Baltimore, Maryland, Williams and Wilkins, 1992), pp. 657-674.

Table 3. Obstetrical complications associated with substance abuse

Type and description

Foetal wast-age result-ing in
Spano-aneous abortion
Intra-uterine death
Amnio-nitis
Chorio-amnio-nitis
Gest-ational diabetes
Pre-mature rupture of mem-branes and septi-caemia
Pla-cental dis-orders
Abrup-tion
Infarc-tion
Insuffi-ciency
Foetal growth retard-ation
Pre-mature labour with or without breech presen-tation

In addition to the many potential medical and obstetrical problems, the lifestyle of the addict is also detrimental to herself, her family, and to society. To meet the high cost of maintaining a drug habit, the pregnant drug-dependent woman must often indulge in robbery, forgery, the sale of drugs and prostitution. Because most of her day is consumed by the two activities of either obtaining drugs or using drugs, she spends most of her time unable to function in the usual activities of daily living. The opiate addict will have intermittent periods of normal alertness and well-being, but for most of the day she will either be "high" or "sick". The "high", or euphoric state, will keep her sedated or tranquillized, absorbed in herself, and incapable of fulfilling responsibilities. The "sick" stage, or the state during which she is going through abstinence, generally is characterized by craving for narcotics accompanied by malaise, nausea, lachrymation, perspiration, tremors, vomiting, diarrhoea and cramps. As a result of such a lifestyle and because she may fear calling attention to her drug habit, the pregnant addict often does not seek prenatal care. There may be no experiences of prenatal care, either in a hospital setting or in the office of a private physician. The woman may be unmarried and have venereal disease. Tattoos or self -scarring of the forearm to disguise needle marks may be evident. Due to the diminished pain perception when smoking while "high", burns of the fingertips and cigarette burns of the clothes may be found. The use of poorly cleaned needles or shared needles predisposes the women to serum hepatitis, and jaundiced skin or sclera may be evident.

Examination of her personal history may reveal several other aspects of the pregnant heroin addict's life. She may have several other children who are currently not living with her but with a relative, or who have been placed in care. Drug-dependent women frequently are intelligent, although in a Philadelphia survey the average level of high school achievement was the eleventh grade [ 1] . Housing situations frequently are chaotic, and plans for the impending birth of the child often have not been considered.

Therefore, when assessing the impact of addiction on the pregnant woman, one must put into perspective the milieu within which she must survive. The cycle of addiction not only includes illicit and licit drug use, but also medical and obstetrical complications, family dysfunction, psychiatric disorders, physical and sexual abuse, social issues, legal problems and educational deficits, followed by employment failure and economic loss. Figure I further elaborates on the tragic problems that drug-affected families encounter.

In the United States, alcohol and illicit drug use is frequently associated with tragic fatalities, drownings, suicides, assaults, rape, manslaughter charges and murders. The above stressors have tremendous impact on family integrity.

Figure 1. Drug-affected families

Full size image: 1 kB, Figure 1. Drug-affected families

Impact of maternal substance abuse on foetal welfare

Because of the obvious lack of quality control seen in street drugs, the pregnant woman frequently may experience repeated episodes of withdrawal and overdose. Maternal narcotic withdrawal has been associated with the occurrence of stillbirth [ 4] . Severe withdrawal is associated with increased muscular activity, thereby increasing the metabolic rate and oxygen consumption in the pregnant woman. During maternal withdrawal, foetal activity also increases, and the oxygen needs of the foetus can be assumed to increase. The oxygen reserve in the intervillous space of the placenta may not be able to supply the extra oxygen needed by the foetus. During labour, contractions further compromise the blood flow through the uterus. If labour coincides with abstinence symptoms in the mother, the increased oxygen needs of the withdrawing foetus coincide with a period of variable uterine blood flow, leading to foetal hypoxia and possibly foetal death. As the foetus grows older, its metabolic rate and oxygen consumption increase; therefore, a pregnant woman undergoing severe abstinence symptoms during the latter part of pregnancy could be less likely to supply the withdrawing foetus with the oxygen it needs than would an addict in the first trimester of pregnancy [ 4] . Many other effects upon the foetus exposed to narcotics include: acute infection, intrauterine growth retardation and congenital anomalies. A more extensive description of these effects is found in reviews by Finnegan and Kandall [ 5] .

Various parameters to assess foetal welfare have been studied in the drug-abusing pregnant woman, including: content of amniotic fluid, prostaglandins, corticosteroid production, oestriol excretion, heat-stable alkaline phosphatase enzyme levels, liver function studies, serum immunoglobulin M levels and lecithin/sphingomyelin ratios in amniotic fluid. In comparing the content of amniotic fluid prostaglandins with that of normal, diabetic and drug-abuse-associated human pregnancies, Singh and Zuspan [ 6] did not find any significant differences; however, variable effects have been reported concerning the other parameters [ 5] .

The low molecular weight and high solubility of cocaine in both water and lipids allows this drug to cross the placenta easily and enter foetal compartments. This transplacental passage is enhanced with intravenous or freebase use of cocaine. In addition, the relatively low pH of foetal blood (cocaine is a weakbase) and the low foetal level of plasma esterases, which usually metabolize this drug, may lead to accumulation of cocaine in the foetus. Furthermore, the "binge" pattern commonly associated with cocaine use may lead to even higher levels of cocaine in the foetus. Transfer of cocaine appears to be greater in the first and third trimesters of pregnancy. Because cocaine has such potent vasoconstrictive properties, the constriction of uterine, placental and umbilical vessels may retard somewhat the transfer of cocaine from mother to foetus. A deleterious effect of this vasoconstriction, however, is a concomitant foetal deprivation of essential gas and nutrient exchange resulting in foetal hypoxia [ 7] . In addition to an acute hypoxic insult, cocaine use of long duration may produce a chronic decrease in transplacental nutrient and oxygen flow, leading to intrauterine growth retardation. Although the relationship of cocaine use to congenital malformations is still controversial, a decrease in foetal blood supply during critical periods of morphogenesis and growth may result in organ malformations [ 8-13] .

Studies in sheep have also shown that maternal cocaine administration results in a dose-dependent catecholamine-mediated increase in maternal blood pressure and a decrease in uterine blood flow, with a significant reduction in uterine blood flow for at least 15 minutes [ 14-15] . The, course of labour may also be affected by maternal cocaine use. Intravenous administration of a local aesthetic such as cocaine may cause a direct increase in uterine muscle tone. "Crack" also appears to directly increase uterine contractility and may thus precipitate the onset of premature labour. Higher rates of early pregnancy losses and third- trimester placental abruptions appear to be major complications of maternal cocaine use. Several investigators have reported increased stillbirth rates among cocaine-using women [ 11,16,17,18] . It is currently postulated that increased levels of catecholamines, increased blood pressure and increased body temperature all may play aetiologic roles in early foetal loss and later abruptio placentae. Wang and Schnoll [ 19] have suggested that cocaine-induced down-regulation of placental beta-adrenergic receptor sites may be linked with release of endogenous opiate peptides.

With regard to the teratogenic potential of cocaine in humans, there are conflicting results in the literature. Animal studies have helped to provide some answers regarding the effects of cocaine by controlling many of the confounding variables found in the human literature. The animal studies, like the human literature, has produced evidence of growth retardation, placental abruption, cerebral infarctions, increased prenatal and postnatal mortality, limb/digit reductions and eye anomalies. But like the human literature, the teratogenic risk seems low in animal models, and seems to require high doses and individual susceptibility [ 20] .

The potential teratogenic effects of cocaine have been extensively reviewed, and a meta-analysis has been published by Lutiger and others [ 21] . Koren proposes a hypothesis regarding maternal-foetal toxicology of cocaine [ 22] . It is based on his analysis of published data and experimental laboratory evidence. Cocaine is used by pregnant women in two distinct modes. The social cocaine users consume cocaine as part of a mixed socio - economic class, maintain reasonable medical care, and tend to discontinue cocaine use once pregnancy is detected. There is no evidence that this mode of exposure increases the reproductive risk of such pregnancies in terms of either perinatal complications, dysmorphology or neurobehavioural development [ 23] . Addicted women use cocaine throughout pregnancy and, in addition to cocaine, they have clustering of other reproductive risk factors, some of which include cigarette smoking, alcohol consumption, tendency to belong to low socio- economic classes, shorter education, poor prenatal and medical care, use of other drugs of abuse, young age, single parenthood and sexually transmitted diseases. Analysis of all available studies conducted with this population suggests that cocaine is not a major human teratogen, and that most children are likely to be normal both morphologically and neuro- developmentally. However, it has been hypothesized that there is a subgroup of foetuses susceptible to the adverse effects of cocaine because of the following: variability in maternal pharmacokinetics of cocaine; variability in placental transfer of cocaine; variability in placental- vascular response to cocaine; and foetal pharmacodynamic variability.

Infant morbidity

Because of the extremely high risk environment from which the pregnant drug-dependent woman comes, her infant is predisposed to a host of neonatal problems. In heroin -dependent women, a significant part of the medical complications seen in their neonates is due to low birth weight and prematurity. Therefore, such conditions as asphyxia neonatorum, intracranial haemorrhage, hyaline membrane disease, intrauterine growth retardation, hypoglycaemia, hypocalcaemia, septicaemia and hyperbilirubinaemia may be commonly seen in opiate-exposed, low- birth-weight babies. Because infants born to women who receive methadone maintenance are more apt to have higher birth weights and a decreased incidence of premature birth, medical complications generally reflect:

  1. The amount of prenatal care that the mother has received;

  2. Whether she has suffered any particular obstetrical or medical complications, including toxaemia of pregnancy, hypertension or infection;

  3. Most importantly, multiple drug use that may produce an unstable intrauterine milieu complicated by withdrawal and overdose.

The last-mentioned situation is extremely hazardous, since it predisposes the neonate to meconium staining and subsequent aspiration pneumonia, which may cause significant morbidity and increased mortality [ 24] .

Although many reports expound on the detrimental effects of cocaine on infant morbidity, many have not been substantiated by repeated studies. Assessments of the organic impact of cocaine on human pregnancy have not always considered confounding drug-use-associated variables such as poverty, hopelessness, inadequate prenatal and postnatal care, deficient nutrition, varying types of cocaine use, multiple drug use, sexually transmitted diseases and the possible presence of toxic adulterants that are mixed with or used to process cocaine.

Consistent findings include the impact of maternal morbidity upon the neonate (i.e. infections), impaired growth, smaller head circumference and prematurity. Inconsistent findings include the occurrence of con- genital abnormalities and abnormal neurobehaviour. Transient findings include electroencephalographic abnormalities [ 25] and tortuous iris vasculature in the eye grounds [ 26] . Additional reports concerning infant morbidity related to cocaine are elaborated elsewhere. [ 27-33]

Narcotic abstinence contributes considerably to neonatal morbidity. However, not all infants born to drug-dependent mothers show withdrawal syrnptomatology. Several investigators have reported that between 60 and 90 per cent of infants show symptoms [ 34-36] . Because the biochemical and physiologic processes governing withdrawal are still poorly understood, and because of polydrug abuse, erratic drug-taking, and vague and inaccurate maternal histories, it is not surprising to find varying descriptions and experiences in reports from different centres.

Neonatal narcotic abstinence syndrome is described as a generalized disorder characterized by signs and symptoms of hyperirritability of the central nervous system, gastrointestinal dysfunction, respiratory distress and vague autonomic symptoms that include yawning, sneezing, mottling and fever [ 37-39] . These infants initially develop mild high- frequency, low-amplitude tremors that progress in severity. A high-pitched cry, increased muscle tone, irritability, increased deep tendon reflexes and an exaggerated Moro reflex are all characteristic of this syndrome. The rooting reflex is increased and sucking of fists or thumbs is common, yet when feedings are administered the infants have extreme difficulty and regurgitate frequently. The feeding difficulty occurs because of an uncoordinated and ineffectual sucking reflex. The infants may develop loose stools and therefore are susceptible to dehydration and electrolyte imbalance. Time of onset of symptoms is variable. Once the infant is delivered, serum and tissue levels of the drugs used by the mother begin to fall. The newborn infant continues to metabolize and excrete the drug, and withdrawal or abstinence signs occur when critically low tissue levels have been reached.

Because of the variation in time of onset and in degree of severity, a spectrum of abstinence patterns may be observed. Withdrawal may be mild and transient, delayed in onset or characterized by a stepwise increase in severity. It may be intermittently present, or have a biphasic course that includes acute neonatal withdrawal followed by improvement and then an exacerbation of acute withdrawal [ 40] .

More severe withdrawal seems to occur in infants whose mothers have taken large amounts of drugs for a long time. Usually, the closer to delivery a mother takes a narcotic, the greater the delay in the onset of withdrawal and the more severe the symptoms in her baby. As noted, the maturity of the infant's own metabolic and excretory mechanisms plays an important role after delivery. Because of the variable severity of the withdrawal, the duration of symptoms may be anywhere from six days to eight weeks. Although the infants are discharged from the hospital after drug therapy is stopped, their symptoms or irritability may persist for more than three to four months [ 41] .

The final impact of prenatal drug exposure has many ramifications when the pharmacologic agents are complemented by the severity of the various above-mentioned maternal complications and the environment into which the infant is born. Without comprehensive services to mother, infant and family, some or many of the problems illustrated in figure II may occur.

Infant mortality

Among the major causes of infant mortality in drug-exposed infants are low birth weight, prematurity, birth defects, sudden infant death syndrome (SIDS), or cot-death, and child abuse. Given the increase in obstetrical and medical complications, the lack of prenatal care, and the increase in low-birth-weight infants, it is not surprising to find that the mortality rate in infants born to drug-dependent women is markedly increased. With the advent of newer techniques forthe care of sick new- born infants, however, mortality rates in the 1980s decreased markedly. It has been shown that mortality can be reduced if prenatal care and comprehensive substance abuse services are provided for pregnant substance-abusing women [ 42] .

SIDS is defined as the sudden and unexpected death of an infant between one week and one year of age, whose death remains unexplained after a complete autopsy examination, full history and death site investigation. Compared with an incidence of approximately 1.5 per 1,000 live births in the general population, a number of studies have found increased rates of SIDS in opiate-exposed infants [43-48]. It is critical to remember that other high-risk factors for SIDS such as low socio-economic status, low birth weight, young maternal age, black ethnic background and maternal smoking are all overrepresented in the drug-using group. The most extensive study has been done by Kandall and others [ 49] , who studied SIDS rates in 1.21 million births in New York City from 1979 to 1989. Maternal opiate use increased the risk of SIDS about sixfold; after control for high-risk variables, the risk of SIDS was still three to four times that of the general population. An extensive review of maternal drug use and subsequent SIDS has been published recently by Kandall and Gaines [ 50] .

Figure II. Drug-exposed children

Full size image: 0 kB, Figure II. Drug-exposed children

Previous maternal and paternal physical and sexual abuse as children, the lack of being parented themselves, the continued use of psychoactive agents, the concomitant occurrence of physical and medical illness with irritability and lack of responsiveness by the baby, all create the potential for abuse by drug-using mothers of the drug-exposed infant. Since child abuse is a preventable phenomenon, professionals in the field of substance abuse and paediatrics must be aware of its potential occurrence and provide appropriate assessments of the family and psychological support systems to protect the infant at risk.

Behaviour of drug-exposed infants in the neonatal period

Neurobehavioural adaptation in neonates born to narcotic - dependent mothers has been studied by several investigators [51-54]. The Brazelton Neonatal Assessment Scale has been used extensively for evaluating newborn behaviour. This instrument assesses habituation to stimuli such as the light and bell, responsivity to animate and inanimate stimuli (face, voice, bell, rattle), state (sleep, alertness, crying) and the requirements of state change (irritability, consolability), and neurologic and motor development. Soule and others [ 53] found that methadone -exposed babies were restless, tended to be in a neurologically irritable condition, cried more often and were state-labile. The infants were also more tremulous and hypertonic, and manifested less motor maturity than did the control group. In addition, although quite available and responsive auditorially, the methadone-exposed subjects responded poorly to visual stimuli. These babies seemed to be uncomfortable when opening their eyes and attempting to focus (pupil size was within normal limits).

Strauss and others [ 54] also studied the behaviour of narcotic- exposed newborns and non-drug-exposed controls in the first two days of life using the Brazelton Scale. In addition to the classic signs of narcotic abstinence, the narcotic-exposed infants were less able to be maintained in an alert state and to orient to auditory and visual stimuli, signs that were most pronounced at 48 hours of age. Drug-exposed infants were as capable of self-quieting and responding to soothing intervention as normal neonates, although they were substantially more irritable. These findings have substantial implications for caregivers' perceptions of infants, and thus may have long-term impact on the development of infant-caregiver interaction patterns. These implications have been further developed by Kaltenbach, Graziani and Finnegan [ 55] , who found that infants born to methadone-maintained women showed deficiencies in their attention and social responsiveness during the first few days of life; these abnormalities persisted during the infants' course of abstinence and treatment. Fitzgerald and others [ 56] found that the interaction of drug-dependent mothers and their infants showed abnormalities on measures of social engagement. This dyadic interaction was explained by less maternal affection and attachment as well as by infant behaviour impeding social involvement. Many of the interactive abnormalities normalized by four months of age, but the need for parenting training is obvious.

Studies reporting effects of cocaine on behaviour are variable, and perhaps reflect a dose-response effect as speculated by Hutchings [ 57] . There appears to be no observable effect at low doses on neonatal behaviour [ 58] . Higher doses may be associated with symptoms of hyper- arousal (i.e. tremulousness, irritability) during the early neonatal period [59-62]. It has been suggested that these symptoms are more likely the result of persistent, pharmacologically active levels of cocaine in the newborn central nervous system, and do not represent a cocaine withdrawal syndrome. Studies using the Brazelton Neurobehavioral Scale in cocaine-exposed infants are very inconsistent [ 59, 62-65] . It can be concluded that even though behavioural effects of prenatal cocaine exposure are biologically plausible by direct or indirect mechanisms, currently available research is limited by methodological weaknesses, and no independent effects are credibly established [ 62] .

From the foregoing, it may be seen that the physical and behavioural response of the drug-exposed infant can have a destabilizing effect on the family. Stresses encountered in dealing with a difficult, irritable, non- responsive, poor- feeding, non-sleeping baby cannot only have an effect upon parent-child attachment, but also an adverse effect on the parents' relationship. Figure III shows how the sense of security of the infant can be disrupted with the potential for an adverse behavioural outcome if maternal lifestyle is influenced by addiction. With the above postnatal maternal-infant dyadic interactions, appropriate assessments and interventions must be provided for both mother and child.

Interventions to improve stability and perinatal outcomes

Appropriate interventions for the substance-abusing family have been researched and utilized by many throughout the world [ 66-69] . The essentials are the combination of traditional substance abuse counselling with primary health care, mental health services and prevention, assessment and treatment of HIV disease. Table 4 lists the schema of services that have been recommended [ 67] . Medications for addictive diseases have been used, and more are expected to become readily available as a result of ongoing research. Methadone for opiate dependence has been highly researched and its efficacy substantiated. However, for opiate- addicted patients in general and for pregnant women in particular, there are many prejudices concerning the use of this safe and efficacious medication. Most of those attitudes stem from a lack of knowledge concerning the pharmacology and the appropriate prescribing instructions for methadone. Specifics concerning treatment of opiate dependent pregnant women have been described elsewhere [ 5] [ 69] .

Figure III - Impact of substance abuse on infants

Full size image: 0 kB, Figure III - Impact of substance abuse on infants

Table 4. Schema of services for drug-abusing families

Type and description

OUTREACH
MEDICAL
PSYCHOLOGICAL / BEHAVIOURAL
DEMOGRAPHIC / SOCIOCULTURAL
Community liaison
For potential infections
Life-skills management
Survival management
indigenous workers
assess complications of drug
defining and accessing
housing
mobile van
abuse and HIV infection:
problems associated
clothing
distribution of prevention and
tuberculosis, hepatitis, CMV
with addiction
food
educational information
assess various organ systems:
attitudes, beliefs
financial and budgetary
work with community organ-
hepatic, renal, cardiovascular,
knowledge and
Sociological consideration
izations, churches,
pulmonary, GI, CNS
expectation
gender
recreational centres etc.
assess for STDs
modification
race
Immediate access to treatment
assess immunologic status
problem-solving
social class
provide transportation
Pharmacological
coping mechanisms
economics
coordinate intake
methadone maintenance
relapse prevention
culture
medical
psychotropic medication
social skills competence
 
drug-abuse treatment
antibiotics for bacterial
Psychological
 
psychiatric evaluation
infections
psychiatric assessment and
 
 
HIV drug treatment
treatment
 
PRENATAL
MOTHER-INFANT RELATIONSHIPS
EARLY CHILDHOOD INTERVENTION
 
Prenatal examination
Assess caregiver infant dyad
Intervene in unresponsive and dysfunctional
 
HIV counselling/testing
Intervention strategies to
maternal behaviours
 
Nutritional counselling
meet individual mother-
Encourage optimal social, emotional and
 
Antenatal testing
infant needs
cognitive development of children
 
 
Facilitate caregivers' needs in
born to drug-dependent mothers
 
 
relation to environmental
Promote parenting skills
 
 
realities
Provide child rare
 
Note: STD = sexually transmitted disease; GI = gastrointestinal; CMV = cytomegalovirus; CNS = central nervous system.

Research has shown that a significant number of women who have enrolled in comprehensive treatment services during pregnancy can be rehabilitated, and that maternal and infant morbidity can be reduced. When maternal medical and obstetrical complications are treated, a similar outcome has been seen in drug-dependent mothers as in drug-free mothers of the same socioeconomic and ethnic class. Moreover, the incidence of low-birth- weight infants can be reduced from nearly 50 per cent to less than 20 per cent, which is a significant reduction in terms of neo- natal morbidity, mortality and medical costs.

Addiction must be recognized as a chronic, relapsing disease. Because each addicted woman is different from all others, treatment plans should be individualized. Comprehensive services must include high- risk prenatal care, and clinics must be staffed by obstetricians specifically trained in the field of addiction and high-risk pregnancy. Additional treatment modalities should include individual, group and family therapy.

For maximum recovery rates, dedicated clinicians who realize the need to coordinate such services for addicted women are needed. Since the medical needs of these women are so overwhelming, a perinatologist, in conjunction with a neonatologist and psychiatrist, should lead the team of professionals necessary to encompass, in addition to the physiological and psychological effects of substance abuse, the tremendous sociological issues that exist. Women will not recover if their co -morbidity issues are not identified and treated.

The families of drug-addicted women have higher levels of conflict and physical violence and lower levels of cohesion. Treatment must therefore respond to each of the medical and social variables that complicate addiction issues and recovery. The women have problems associated with support issues, food, access to housing and day care, all of which are clearly overwhelming to the recovering female addict. Relapse is imminent when daily survival is at risk.

AIDS prevention, counselling and testing, as well as educational services in the form of prenatal and parenting classes, must be available. Services should be aimed at eliminating drug use, developing personal resources, improving family and interpersonal relationships, reducing and eliminating socially destructive behaviour and facilitating maximum obtainable adaptation for new parents within their environment.

In spite of the definition of specific intervention strategies for the substance-abusing woman and her family, as well as those used for similarly troubled individuals, the required services have not been available, understood or adequately supported. Negative attitudes exist about maternal drug abuse. Many professionals who could provide appropriate services refuse to do so, and others lack adequate training in the identification of substance -abusing individuals and the effects of drug abuse on pregnancy and the family. As a result of the lack of provision of such services for drug-abusing families, the escalation of the numbers of individuals and families affected has been dramatic. With intergenerational transmission of the disease of addiction, perinatal transfer of HIV and other infectious diseases, as well as perinatal complications, families are being devastated throughout the world.

Drug abuse is not a new phenomenon. It has existed for centuries, and in the last three decades it has reached epidemic proportions. While overall medical progress has been great during this time, there has been a failure to give appropriate attention to resources for research, treatment and education concerning the effects of drug abuse and potential intervention strategies. The result has been the devastation of families suffering from drug abuse and the associated adverse effects on society. The devastation has reached uncontrollable heights, and many children and their families are suffering today because of the unwillingness of society to act with urgency in the past. There must be an end to the physical, psychological and sociological disabilities that have resulted from the neglect of issues confronted by families affected by substance abuse. In 1994, the International Year of the Family, the people of all nations must stand united to avoid the further destruction of the fibre that holds society together - the family.

References

01

T. A. Hagan, "A retrospective search for the etiology of drug abuse: a background comparison of adrug-addicted population of women and a control group of non -addicted women", NIDA Research Monograph Series (Rockville, Maryland, National Institute on Drug Abuse, 1987).

02

J. Jones, "Nutrition, drugs and their interrelations", Pennsylvania Health, vol. 35, No. 3 (1974).

03

L. L. Cregler and H. Mark, "Medical complications of cocaine abuse", New England Journal of Medicine, No. 315 (1986), p. 1495.

04

J.L. Rementeria and N. N. Nuang, "Narcotic withdrawal in pregnancy: stillbirth incidence with a case report", American Journal of Obstetrics and Gynecology, No. 116 (1973), p. 1152.

05

L. P. Finnegan and S. R. Kandall, Maternal and Neonatal Effects of Alcohol and Drugs, Substance Abuse: A Comprehensive Textbook, J. H. Lowinson, P. Ruiz, R. B. Millman, eds. (Baltimore, Maryland, Williams and Wilkins, 1992), p. 628.

06

E. J.Singh and F. P. Zuspan, "Content of amniotic fluid prostaglandins in normal, diabetic and drug-abuse human pregnancy", American Journal of Obstetrics and Gynecology, No. 118 (1974), p. 385.

07

J. R. Woods, M. A. Plessinger and X. E. Clark, "Effect of cocaine on uterine blood flow and fetal oxygenation", Journal of the American Medical Association, No. 257 (1987), p. 957.

08

H. E. Hoyme, K. L. Jones, S. D. Dixon and others, "Prenatal cocaine exposure and fetal vascular disruption", Pediatrics,No. 85 (1990), p. 743.

09

M. P. Mahalik, R. F. Gautein and D. E. Mann, "Teratogenic potential of cocaine hydrochloride in CF-1 mice", Journal of Pharmaceutical Sciences, No. 69 (1980), p. 703.

10

S. E. Lipshultz, J. J. Frassica and E. J. Orav, "Cardiovascular abnor- malities in infants prenatally exposed to cocaine", Journal of Pediatrics, No. 118 (1991), p. 44.

11

N. Bingol and others, "Teratogenicity of cocaine in humans", Journal of Pediatrics, No. 110 (1987), p. 93.

12

I. J.Chasnoff, G. M. Chisum and W. E. Kaplan, "Maternal cocaine use and genitourinary malformations", Teratology,No. 37 (1988), p. 201.

13

A. G. Fantel and B. J.MacPhail, "The teratogenicity of cocaine", Teratology,No. 26 (1982), p. 17.

14

L. V. Baxi and R. Petrie, "Pharmacologic effects on labor: effect of drugs on dystocia, labor and uterine activity", Clinical Obstetrics and Gynecology, vol. 30, No. 1 (1987), p. 19.

15

T. T. Moore, "Hemodynamic effects of intravenous cocaine on the pregnant ewe and fetus", American Journal of Obstetrics andGynecology, No. 155 (1986), p. 883.

16

D. Acker, "Abruptio placentae associated with cocaine use", American Journal of Obstetrics and Gynecology, No. 146 (1983), p. 220.

17

I. J. Chasnof f and others, "Cocaine use in pregnancy", New England Journal of Medicine, No. 313 (1985), p. 666.

18

A. J. Hadeed and S. R. Siegel, "Maternal cocaine use during pregnancy: effect on the newborn infant", Pediatrics, No. 84 (1989), p. 205.

19

C. H. Wang and S. H. Schnoll, "Prenatal cocaine use associated with down regulation of receptors in human placenta", Neurotoxicology and Teratology, No. 9 (1987), p. 301.

20

M. W. Church, "Does cocaine cause birth defects?", Neurotoxicology and Teratology, No. 15 (1993), p. 289.

21

B. Lutiger and others, "Relationship between gestational cocaine use and pregnancy outcome: A meta-analysis", Teratology, No. 44 (1991), p. 405.

22

G. Koren and others, "Perception of teratogenic risk by pregnant women exposed to drugs and chemicals in early pregnancy" American Journal of Obstetrics and Gynecology, No. 160 (1989), p. 1190.

23

K. Graham and G. Koren, "Characteristics of pregnant women exposed to cocaine in Toronto between 1985 and 1990", Canadian Medical Association Journal, No. 144 (1991), p. 563.

24

J. F. Connaughton and others,"'Perinatal addiction: outcome and management," American Journal of Obstetrics and Gynecology, No. 129 (1977), p. 679.

25

T. M. Doberczak and others, "Neonatal neurologic and encephalographic effects of intrauterine cocaine exposure", Journal of Pediatrics, No. 113 (1988), p. 354.

26

S. J. Isenberg, A. Spierer and S. H. Inkelis, "Ocular signs of cocaine intoxication in neonates", American Journal of Ophthalmology, No. 103 (1987), p. 211.

27

I. J. Chasnoff and others, "Temporal patterns of cocaine use in pregnancy", Journal of the American Medical Association, No. 261 (1989), p. 1741.

28

L. D. Kramer and others, "Neonatal cocaine-related seizures", Journal of Child Neurology, No. 5 (1990), p. 60.

29

S. D. Dixon and R. Bejar, "Echoencephalographic findings in neonates associated with maternal cocaine and methamphetamine use: incidence and clinical correlates", Journal of Pediatrics, No. 115 (1989), p. 770.

30

A. Salamy and others, "Brain-stem transmission time in infants exposed to cocaine in utero", Journal of Pediatrics, No. 117 (1990), p. 627.

31

L. Shih, B. Cone-Wesson and B. Reddix, "Effects of maternal cocaine abuse on the neonatal auditory system', International Journal of Pediatric Otorhinolaryngology, No. 15 (1988), p. 245.

32

M. van de Bor, F. J. Walther and M. E. Sims, "Increased cerebral blood flow velocity in infants of mothers who abuse cocaine", Pediatrics,No. 85 (1990), p. 733.

33

M. P. Teske and M. T. Trese, "Retinopathy of prematurity-like fundus and persistent hyperplastic primary vitreous associated with maternal cocaine use", American Journal of Ophthalmology, No. 103 (1987), p. 719.

34

R. W. Cobrinik, T. R. Hood and E. Chusid, "The effect of maternal narcotic addiction on the newborn infant; review of the literature and report of 22 cases", Pediatrics,No. 24 (1959), p. 288.

35

R. M. Hill and M. M. Desmond, "Management of the narcotic withdrawal syndrome in the neonate", Pediatrics Clinics of North America, No. 10 (1963), p. 67.

36

C. Zelson, E. Rubio and E. Wasserman, "Neonatal narcotic addiction: 10 year observation", Pediatrics,No. 48 (1971), p. 171.

37

L. P. Finnegan, "Neonatal abstinence syndrome; assessment and pharmacotherapy", in Neonatal Therapy: an Update, F. F. Rubaltelli and B. Granati, eds. (New York, Elsevier Science Publishers B. V. (Biomedical Division), 1986).

38

L. P. Finnegan and K. Kaltenbach, "Neonatal abstinence syndrome", in Primary Pediatric Care, 2nd ed., R. A. Hoekelman and N. Nelson, eds. (St. Louis, Mosby Year Book, 1992).

39

L. P. Finnegan and S. M. Ehrlich, "Maternal drug abuse during pregnancy evaluation and pharmacotherapy for neonatal abstinence", Modern Methods in Pharmacology. Testing and Evaluation of Drugs of Abuse, No. 6 (1990), p. 255.

40

M. M. Desmond and G. S. Wilson, "Neonatal abstinence syndrome: recognition and diagnosis", Addictive Diseases, No. 2 (1975), p. 113.

41

G. S. Wilson, M. M. Desmond and W. M. Verniaud, "Early development of infants of heroin addicted mothers", American Journal of Diseases in Children, No. 126 (1973), p. 457.

42

L. P. Finnegan, D. S. Reeser and J. F. Connaughton, "The effects of maternal drug dependence on neonatal mortality", Drug and Alcohol Dependence, No. 2 (1977), p. 131.

43

C. J. Chavez and others, "Sudden infant death syndrome among infants of drug dependent mothers", Journal of Pediatrics, No. 95 (1979), p. 407.

44

L. P. Finnegan, "In utero opiate dependence and sudden infant death syndrome", Clinics in Perinatology, No. 6 (1979), p. 163.

45

R. Harper, G. S. Concepcion and S. Blenman, "Observations on the sudden death of infants born to addicted mothers", in Proceedings of the Fifth National Conference on Methadone Treatment (New York, National Association for the Prevention of Addiction to Narcotics, 1973), p. 1122.

46

T. S. Rosen and H. I. Johnson, "Drug-addicted mothers, their infants, and SIDS", Annals of the New York Academy of Sciences, No. 533 (1988), p. 89.

47

S.L.D. Ward, D. Bautista, L. Chan and others, "Sudden infant death syndrome in infants of substance-abusing mothers", Journal of Pediatrics, No. 117 (1990), p. 876.

48

B. K. Rajegowda, S. R. Kandall and H. Falciglia, "Sudden unexpected death in infants of narcotic dependent mothers", Early Human Development, No. 2/3 (1978), p. 219.

49

S. R. Kandall and others, "Maternal substance use and sudden infant death syndrome (SIDS) in offspring", Pediatric Research, No. 29 (1991), p. 92A.

50

S. R. Kandall and J. Gaines, "Maternal substance use and subsequent sudden infant death syndrome (SIDS) in offspring", Neurotoxicology and Teratology, No. 13 (1991), p. 235.

51

R. E. Kron and others, "Neonatal narcotic abstinence: effects of pharmacotherapeutic agents and maternal drug usage on nutritive sucking behavior of neonates", Journal of Pediatrics, No. 88 (1976), p. 637.

52

A. Lodge, M. M. Marcus and C. M. Ramer, "Neonatal addiction: a two-year study, Part II, Behavioral and electrophysiological characteristics of the addicted neonate", Addictive Diseases, No. 2 (1975), p. 235.

53

A. B. Soule III and others, "Clinical uses of the Brazelton Neonatal Scale", Pediatrics, No. 54 (1974), p. 583.

54

M. E. Strauss and others, "Behavioral concomitants of prenatal addiction to narcotics", Journal of Pediatrics, No. 89 (1976), p. 842.

55

K. Kaltenbach, L. J. Graziani and L. P. Finnegan, "Methadone exposure in utero: effects upon developmental status at 1 and 2 years of age", Pediatric Research, No. 13 (1979), p. 332.

56

E. Fitzgerald, K. Kaltenbach and L. P. Finnegan, "Patterns of interaction among drug-dependent women and their infants", Pediatric Research, No. 24 (1990), p. 44.

57

D. E. Hutchings, "The puzzle of cocaine's effects following maternal use during pregnancy: are there reconcilable differences?", Neurotoxicology and Teratology, No. 15 (1993), p. 281.

58

G. A. Richardson and N. L. Day, "Maternal and neonatal effects of moderate cocaine use during pregnancy", Neurotoxicology and Teratology, No. 13 (1991), p. 455.

59

I. J. Chasnoff and others, "Cocaine use in pregnancy", New England Journal of Medicine, No. 313 (1985), p. 666.

60

I. J. Chasnoff and others, "Perinatal cerebral infarction and maternal cocaine use", Journal of Pediatrics, No. 108 (1986), p. 456.

61

S. N. MacGregor and others, "Cocaine use during pregnancy: Adverse perinatal outcome", American Journal of Obstetrics and Gynecology, No. 157 (1987), p. 686.

62

D. R. Neuspiel and S. C. Hamel, "Cocaine and infant behavior", Development and Behavioral Pediatrics, No. 12 (1991), p. 55.

63

I.N. Eisen and others, "Perinatal cocaine effects on neonatal stress behavior and performance on the Brazelton Scale", Pediatrics,No. 38 (1991), p. 477.

64

C. D. Coles and others, "Effects of cocaine and alcohol use in pregnancy on neonatal growth and neurobehavioral status", Neurotoxicology and Teratology, No. 14 (1992), p. 23.

65

K. Graham and others, "Pregnancy outcome and infant development following gestational cocaine use by social cocaine users in Toronto, Canada", Clinical and Investigative Medicine, No. 15 (1992), p. 384.

66

L. F. Finnegan and R. J. Wapner, "Narcotic addiction in pregnancy", in Drug Use in Pregnancy, J. R. Neibyl, ed. (Philadelphia, Lea & Fegiger, 1987).

67

L. P. Finnegan, T. Hagan and K. Kaltenbach, "Opioid dependence: scientific foundations of clinical practice, pregnancy and substance abuse; perspective and directions", Bulletin of the New York Academy of Medicine, No. 67 (1991), p. 223.

68

M. J. Kreek, "Methadone in treatment: psychological and pharmacological issues", in Handbook on Drug Abuse, R. I. Dupont, A. Goldstein and J. O'Donnell, eds. (Rockville, Maryland, United States National Institute on Drug Abuse, 1979).

69

L. P. Finnegan, "Treatment issues for opioid dependent women during the perinatal period", Journal of Psychoactive Drugs, No. 23 (1991), P. 191.