1. SHARED QUALITY INITIATIVES IN OBSTETRICAL CARE IN PHILADELPHIA GUIDELINES FOR DRUG SCREENING IN OBSTETRICS Dimitrios S Mastrogiannis MD PhD MBA FACOG Director of Obstetrics and Maternal Fetal Medicine Associate Professor of Obstetrics Gynecology and Reproductive Sciences Temple University School of Medicine

2. NOTHING TO DISCLOSE

3. This presentation is the product of the collaboration of all 6 University Hospitals’ Obstetrical Chairs

4. THE TEMPLE VIEW Collaboration is a substantive idea repeatedly discussed in health care circles The benefits are well validated Yet collaboration is seldom practiced Collaboration is both a process (a series of events) and an outcome (a synthesis of different perspectives) The Philadelphia experience is unique An Example for other Cities

5. OBSTETRICAL CHAIRS MEETINGS Initiated as a result of a crisis with closings of several Ob units Evolved to become a place of sharing information and solutions to various common challenges Increased cooperation among institutions Increase uniformity and patient safety by adopting common minimum guidelines.

6. TEMPLE UNIVERSITY SUPPORTS THE EFFORT OF THE OBSTETRICAL CHAIRS TO REDUCE VARIABILITY IN CARE FROM INSTITUTION TO INSTITUTION Dr. Hernandez Chair of Ob Gyn And The OB team Vow to be an integral part of this process

7. ILLICIT DRUG TESTING IN OBSTETRICAL PATIENTS Why bother? Quite common Illicit Drug use is associated with Medical and Obstetrical complications Management can change based on information Neonatal implications

8. 2010 NATIONAL SURVEY ON DRUG USE AND HEALTH 4.4% of pregnant women reported illicit drug use in the past 30 days http://www.oas.samhsa. gov/NSDUH/2k10NSDUH/2k10Results.pdf

9. URINE DRUG TEST AT TUH 2008-2012 639 PREGNANT PATIENTS TESTED

10. TUH FREQUENCY OF USED DRUGS 639 PREGNANT PATIENTS TESTED 2008-2012 Marijuana 17.5% Cocaine 4.2% Opiates4.1% PCP3.8% Benzodiazepine3.7% Barbiturates1%

11. SELF REPORTED DRUG USE 2008-2011 IN PREGNANCY (QUESTIONNAIRE FROM 3000 PREGNANT PATIENTS TUHS) 47% marijuana use 21% smoking 20% alcohol use Nelson D, Mastrogiannis DS

12. MARIJUANA Antenatal complications Inconsistent effects Neonatal effects Neurobehavioral effects: decreased self-quieting ability, increased fine tremors and startles, increased hand-to-mouth activity, sleep pattern changes SOGC CLINICAL PRACTICE GUIDELINE No. 256, April 2011

13. HEROIN Antenatal complications Premature labor, IUGR, LBW, Preeclampsia, Antepartum and postpartum hemorrhage Neonatal effects Increased perinatal mortality rate Increased inattention, hyperactivity and behavioral problems Difficulty in physical, social, and self adjustment and learning processes SOGC CLINICAL PRACTICE GUIDELINE No. 256, April 2011

14. COCAINE Antenatal complications Spontaneous abortion, PROM, PTL, IUGR, Placental abruption, meconium Neonatal effects ? Congenital anomalies: genitourinary malformations Transient increase in central and autonomic nervous system symptoms and signs Lower birth weight, length and head circumference (dose- dependent) SOGC CLINICAL PRACTICE GUIDELINE No. 256, April 2011 Mastrogiannis DS et al Obstet Gynecol. 1990 Jul;76(1):8-11

15. AMPHETAMINES Antenatal complications Maternal hypertension Fetal demise (at any gestational age) IUGR Neonatal complications Congenital anomalies: central nervous system, cardiovascular, oral clefts, limbs Neurobehavioral effects: decreased arousal, increased stress and poor quality of movement (dose-response relationship)

16. HALLUCINOGENS (MDMA, LSD) Congenital anomalies: cardiovascular, Medullary Sponge Kidney defects SOGC CLINICAL PRACTICE GUIDELINE No. 256, April 2011

17. PCP Antenatal complications Reduces birth weight, Preeclampsia, Preterm labor, PPROM Many times associated with additional drug use Mastrogiannis DS 2013

18. METHADONE Neonatal abstinence syndrome

19. WITHDRAWAL SYNDROMES SOGC CLINICAL PRACTICE GUIDELINE No. 256, April 2011

20. SCREENING FOR SUBSTANCE ABUSE Should be part of complete obstetric care Both before pregnancy and in early pregnancy or women should be routinely asked about the use of alcohol and drugs including prescription opioids Questionnaires 4P’s and CRAFT Signs and Symptoms ACOG Committee Opinion No. 524: Opioid abuse, dependence, and addiction in pregnancy

21. ASSESSMENT FOR SUBSTANCE-RELATED DISORDERS Complete drug history name of drug, amount, frequency, duration, route(s), last use, injection drug use, sharing needles/paraphernalia, withdrawal symptoms Consequences of drug use: medical, social, personal Previous treatment programs, mutual aid groups (e.g., AA )

22. ACOG 1999 educational Slides

23. ROLE OF TOXICOLOGY TESTING Urine, hair, and meconium samples are sensitive biological markers of substance use. Urine drug screening can detect only recent substance exposure, while neonatal hair and meconium testing can document intrauterine use because meconium and hair form in the second and third trimester, respectively

24. DRUG SCREENING Neither hair nor meconium is appropriate for routine clinical use because of the high costs and propensity for false positive results SOGC CLINICAL PRACTICE GUIDELINE No. 256, April 2011

25. LIMITATIONS OF DRUG TOXICOLOGY Women can avoid detection of substances in urine samples through simple measures such as abstaining for 1–3 days before testing, drinking lots of water to lower the concentration of the drug in the urine, or substituting samples of another person’s urine for their own SOGC CLINICAL PRACTICE GUIDELINE No. 256, April 2011

26. ILLICIT DRUG TESTING IN OBSTETRICAL PATIENTS SUGGESTED GUIDELINES Toxicology screening for illicit drugs of Obstetrical patients occurs when patients are admitted to the hospital based on the clinical decision of the physician responsible for patient care SOGC CLINICAL PRACTICE GUIDELINE No. 256, April 2011

27. PATIENTS IN WHOM TESTING IS USUALLY DONE ARE Patients who have no prenatal care or initiate prenatal care after the 20 th week of gestation. Erratic or Bizarre behavior on admission Prior history of drug use during the pregnancy Document the specific drug and when used in pregnancy Suspicion of abruption without evidence of trauma Preterm labor and PPROM of unknown etiology Severe hypertension (160/110) not associated with chronic hypertension or preeclampsia. IUFD unexplained

28. DOCUMENTATION When toxicology screening is done, it is the responsibility of the obstetrical care provider to document in the chart why screening is being done. Toxicology screening can be ordered by the physician caring for the patient based on clinical decision as indicated above or for any other clinical condition in which the care of the patient may be affected by the recent use of illicit drugs. It is the responsibility of the obstetrical physician who orders the toxicology screen or his/her designee to notify the patient of a positive screen, notify the pediatricians of the positive screen and to order a social work consult that indicates the reason for the screening and the drug that the screen detected. Social work will then be responsible for the necessary follow up

29. PERIPARTUM PAIN MANAGEMENT pain management challenges increased pain sensitivity, inadequate analgesia, difficult intravenous access, and anxiety about suffering pain due to their history of addiction Women on MMT should be continued on the same dose of methadone, although this is ineffective for acute pain management Opioids have been found to be safe and effective even in opioid dependent women; higher doses and more frequent analgesics for pain relief ACOG Committee Opinion No. 524: Opioid abuse, dependence, and addiction in pregnancy SOGC CLINICAL PRACTICE GUIDELINE No. 256, April 2011

30. PERIPARTUM PAIN MANAGEMENT Epidural analgesia is an ideal choice Agonist-antagonist medications (e.g., butorphanol, nalbuphine, and pentazocine) should not be used in opioid-dependent individuals because of the risk of precipitating acute withdrawal ACOG Committee Opinion No. 524: Opioid abuse, dependence, and addiction in pregnancy SOGC CLINICAL PRACTICE GUIDELINE No. 256, April 2011

31. OBSTETRIC MANAGEMENT On the basis of gestational age and viability, the fetus should be monitored (watch for signs of abruption, preterm labor, meconium) Infections (HIV Rapid test etc) Management of acute withdrawal, or overdose Withdrawal can precipitate fetal “distress” Co morbidity with Medical conditions Psychiatry/ Psychology ACOG Committee Opinion No. 524: Opioid abuse, dependence, and addiction in pregnancy SOGC CLINICAL PRACTICE GUIDELINE No. 256, April 2011

32. AFTER ACUTE CARE Antepartum Referral to treatment center Methadone or Buprenorphine Mental health Referral for General Medical Ob care, Subspecialty care ACOG Committee Opinion No. 524: Opioid abuse, dependence, and addiction in pregnancy SOGC CLINICAL PRACTICE GUIDELINE No. 256, April 2011

33. POSTPARTUM Support of breastfeeding, as appropriate Follow-up of other medical problems such as liver disease and sexually transmitted infections Discussion of contraceptive needs ?LARC Surveillance and appropriate referral for treatment of postpartum mood and anxiety disorders ACOG Committee Opinion No. 524: Opioid abuse, dependence, and addiction in pregnancy SOGC CLINICAL PRACTICE GUIDELINE No. 256, April 2011

34. POSTPARTUM CONT. Assessment of substance use and encouragement to continue attending drug treatment programs Support with child protection services involvement Assistance with referrals for ongoing primary care and social services ACOG Committee Opinion No. 524: Opioid abuse, dependence, and addiction in pregnancy SOGC CLINICAL PRACTICE GUIDELINE No. 256, April 2011

35. THE LAW

36. PHILADELPHIA

40. CONSENT FOR UDS ACOG suggest that drug screen should only be performed with the patient’s consent Legal opinion Temple Lead counsel Paul Wright Esq. No need for consent if medically indicated Chairs’ discussion Consent desirable but not always possible

41. Thank you Any questions?