Drug abuse patients are often complex in their presentation and management, but those who are pregnant add distinct elements that increase this complexity. The intent of this article is to further equip EPs with diagnostic and management information in dealing with the pregnant patient who is abusing drugs. The first part focuses on medical issues, and the last part deals with the important ethical and legal aspects.

Table 1 provides a clinical tool covering key principles.

Incidence

Conservative estimates of substance abuse during pregnancy range from 10% to 15%,¹ a marked increase over the last 3 decades. Bottom line: just because she’s pregnant, don’t rule out drug intoxication.

General Principles

Much of the acute care is similar to nonpregnancy management. Concerns regarding teratogenic effects of drugs are highest in the first trimester of the pregnancy. Management of patients with drug toxicity in the second trimester focuses on the support of the mother to ensure the well-being of the fetus. In the third trimester, caution should be taken to avoid precipitating premature delivery or damaging the fetus, such as causing ductal closure with agents like NSAIDs.

For all patients, consider:

• As with most management decisions in pregnancy, maternal stabilization is the priority. While the mother is being stabilized, institute rapid fetal monitoring in the ED for any viable fetus.
• Coordinate with OB, L&D, and pediatrics for any imminent delivery.
• Consider polydrug use, including alcohol, and complications of some kinds of drug use (e.g., HIV, hepatitis).
• Questions regarding teratogenicity and risks to the fetus are often best reserved for the OB department and a genetic counselor. Much of the research in this area has been hampered by the confounding variables of polydrug use, including cigarettes and alcohol. Despite pessimism among many EPs, it may be worthwhile to discuss the dangers to the baby with the mother, while getting social service intervention as described later.

Neonatal Toxicity and Withdrawal

Many drugs of abuse have been associated with neonatal toxicity and withdrawal symptoms.^2,3 Opiates appear to be among the most life threatening. As the EP will be admitting these OB patients who are either in labor or have delivered at home, the babies will be best managed by pediatric specialists. Communicate to the OB and pediatric team all documented or suspected drugs, as well as drugs administered in the ED.

Other Diagnostic Tests

Keep in mind the legal issues (as discussed later) regarding drug screening and other diagnostics that are not directly related to acute care. Life-threatening exceptions would generally justify drug screening to identify the cause of delirium, cardiovascular abnormalities, and so on.

Because of significant implications in pregnancy, consider testing IV drug users for HIV and hepatitis B using the legal principles described below.

With cocaine, if abruptio placentae is in the differential (uterine pain, tenderness, vaginal bleeding may or not be present), order a CBC, type and cross for packed RBCs, DIC profile, and ultrasound. Monitor for uterine contractions and fetal heart rate.

Cocaine and Amphetamines

Clinical Presentation

Cocaine or amphetamine (e.g., meth­amphetamine) intoxication may mimic preeclampsia/eclampsia, with elevated blood pressure, muscle twitching, and hyperreflexia.^4,5 This may progress to grand mal seizures or status epilepticus. After 20 weeks, consider the possible coexistence of intoxication and preeclampsia/eclampsia.

Spontaneous coronary artery dissection is a rare entity leading to acute coronary syndrome and sudden cardiac death, and therapeutic management options are variable. The literature describes a young patient who presented with ST-elevation myocardial infarction (STEMI) due to coronary artery dissection secondary to cocaine abuse.⁶

Cocaine is associated with increased risk of placental abruption. Uterine pain, with or without bleeding, should warrant an OB consult. Order a CBC, type and cross for packed RBCs, DIC profile, and ultrasound (which lacks significant sensitivity). Have L&D staff monitor for uterine contractions and fetal heart rate.

Symptom-Specific Treatment

Hypertension, tachycardia. As in nonpregnant patients, hypertension and tachycardia may often respond to benzodiazepine sedation. Be aware that if delivery is imminent, the neonate may have significant sedation from benzodiazepines, so notify the delivery team if they are used.⁷

For pregnancy beyond 24 weeks, consider that the supine patient may have falsely decreased BP from vena caval compression. Check BP in the left lateral decubitus position to verify numbers. Nitroglycerin can also be used to control hypertension and treat chest pain if needed. This is a reasonable next step after benzodiazepines. After 20 weeks, consider magnesium sulfate to cover preeclampsia/eclampsia.

Nitroprusside is relatively contraindicated secondary to potential fetal cyanide poisoning.

Labetalol, commonly used for hypertension in pregnancy, poses a risk if the patient is cocaine toxic due to more beta- than alpha-adrenergic antagonist effects. The beta-blocking effects should be avoided in this setting.

The role of calcium channel blockers in the treatment of patients with cocaine-associated ACS remains uncertain. Calcium channel blockers should not be used as a first-line treatment but may be considered for patients who do not respond to benzodiazepines and nitroglycerin. Nicardipine is the shortest-acting of the calcium channel blockers.

Phentolamine is an alpha-adrenergic antagonist that may affect vasoconstriction, can be used for severe hypertension, and is considered a second-line agent for chest pain. It appears to increase uterine blood flow.⁸

Hyperthermia. Malignant hyperthermia may occur with cocaine abuse. Mild exposures during the preimplantation period and more severe exposures during embryonic and fetal development often result in prenatal death and abortion. The fetus may be at risk for multiple anomalies.⁹ Treat this aggressively using same interventions as with nonpregnant patients.

Seizures. Patients having seizures or with a decreased level of consciousness generally need to be evaluated by noncontrast head CT scan. Assume that seizures are due to eclampsia after

20 weeks of pregnancy,¹⁰ even if BP is not elevated. Magnesium sulfate is the drug of choice. Benzodiazepines, fosphenytoin, levetiracetam, and propofol can be used for acute seizures, as in nonpregnant patients.^11-13

Mental changes. Combative patients may require sedation. Risk-benefit considerations often favor benzodiazepines for acute management. Some authorities suggest drugs with the longest established safety records, such as diazepam.¹⁴ Haloperidol does not appear to pose any teratogenic risk.¹⁵

Phenothiazines may lead to other complications and are used cautiously.

Designer Drugs

A variety of drugs ranging from K2 (also called spice) to mephedrone (often called bath salts) and MDMA derivatives are available on the Internet and their use is increasing. They are very difficult to identify in the analytical laboratory and produce a range of symptoms from hallucinations to agitation and hypertension. Some substances, such as “bromo-dragonfly,” may induce intense vasospasm. The general approach described for cocaine and amphetamines – starting treatment with benzodiazepines and controlling hypertension and hyperthermia – should be considered.

Opiates

Withdrawal, overdose, and complications are among the main issues in dealing with opioid abuse in pregnancy.

An intrauterine abstinence syndrome (IAS) is a potentially fatal consequence of maternal opiate withdrawal and is associated with developmental problems.¹⁶ Naloxone is safe otherwise,¹⁷ and to prevent maternal mortality or morbidity can be used as in nonpregnancy. Use should be avoided in the opiate-toxic patient who is relatively stable.

Newborn withdrawal from heroin or methadone can lead to sudden death. Heroin withdrawal typically presents within the first 24 hours, while methadone-exposed infants may not show symptoms of withdrawal until 72 hours after birth. Naloxone should be given to the newborn with significant opioid depression.

Alcohol

As in nonpregnancy, thiamine appears to be a safe and reasonable treatment for a suspected alcohol abuser. The issue regarding multivitamin/mineral infusions is more controversial.¹⁸ EPs can approach the pregnant patient as they do their other alcoholic patients.

Other Drugs

Generally, pregnant abusers of other recreational and prescription drugs are managed using the principles already discussed, with the primary issue often being legal and ethical considerations.

Ethical-Legal Issues

Pregnancy complications of drug use, aside from direct toxic effects, result from the lifestyle of the abuser (e.g., smoking, alcohol malnutrition, prostitution). Prenatal care is more likely to be inadequate.¹⁹ Of major concern to the EP in this setting are the ethical and legal responsibilities once drug abuse in pregnancy is identified. This often poses a real dilemma for the EP. Involving social services consultation early on may be helpful.

Drug Testing

Patients should not be screened without their permission, as there are profound legal consequences associated with positive tests. ^20,21 Refusal to allow testing should be documented, and discussion with hospital legal council may be needed in the context of state policies. An exception is during life-threatening events when test results may be needed to guide management.

Urine drug screens may be false positive. Common agents like labetalol or pseudoephedrine may cause drug screens to be positive for amphetamines and methamphetamines.²² Dextromethorphan may show up as PCP. No rapid urine drug screen should be taken as an absolute positive until confirmed by gas chromatography–mass spectrometry.

Medical professionals should be aware that in performing testing for the specific purpose of gathering evidence of criminal conduct by patients, they have an obligation to inform the patients of their constitutional rights to protection from unreasonable search and seizure. Hospitals that fail to inform patients of their rights may be open to civil liability.

Testing policies that are developed with law enforcement agencies, employing their protocols, are more likely to be deemed unrelated to treatment and thus be perceived as being used only to further prosecution. To avoid such categorization, hospitals should develop testing procedures based on medical care and treatment options, independent of police or prosecutors.

No state authorizes or expects physicians to use medical evidence of addiction for criminal prosecution.

Reporting

Some states may require reporting of mothers with drug problems to protective services. One must be aware of how local law and social services approach this issue. This will help avoid conflicts between parental rights and child protection.

The goal is to get these patients into programs that specifically address drug dependency. These programs have demonstrated significant improvement in obstetric outcomes in both health-related parameters and costs of care. An example is the Center for Addiction and Pregnancy.²³

No state specifically criminalizes drug use during pregnancy. Prosecutors have attempted to rely on a host of criminal laws already on the books to attack prenatal substance abuse. Only the South Carolina Supreme Court has upheld such a conviction, ruling in Whitner v. State that a woman’s substance abuse late in pregnancy constitutes criminal child abuse. Meanwhile, several states have expanded their civil child-welfare requirements to include prenatal substance abuse, so that prenatal drug exposure can provide grounds for terminating parental rights because of child abuse or neglect. Further, some states, under the rubric of protecting the fetus, authorize civil commitment (such as forced admission to an inpatient treatment program) of pregnant women who use drugs; these policies sometimes also apply to alcohol use or other behaviors. A number of states require health care professionals to report or test for prenatal drug exposure, which can be used as evidence in child welfare proceedings. In order to receive federal child abuse prevention funds, states must require health care providers to notify child protective services when the provider cares for an infant affected by illegal substance abuse. Finally, a number of states have placed a priority on making drug treatment more readily available to pregnant women.²⁴

References

1. Topics in Brief: Prenatal Exposure to Drugs of Abuse. National Institute of Drug Abuse. Revised May 2011. www.drugabuse.gov/publications/topics-in-brief/prenatal-exposure-to-drugs-abuse.
2. Pediatrics 2009;123:e614-21.
3. Pediatrics 2012;129:e540-60.
4. ACOG Committee on Obstetrics Opinion: (114) Cocaine abuse – implications for pregnancy. 1992.
5. ACOG Committee on Obstetrics Opinion: (479) Methamphetamine abuse in women of reproductive age. 2011.
6. Br. J. Cardiol. 2011;18:142-4.
7. Circulation 2008;117:1897-907.
8. J. Soc. Gynecol. Investig. 2004;11:388-92.
9. Birth Defects Res. A Clin. Mol. Teratol. 2006;76:507-16.
10. Obstet. Gynecol. 2002;99:159-67.
11. Neurology 2009;73:133-41.
12. Epilepsy Res. 2011;94:53-60.
13. JAMA 2011;305:1996-2002.
14. Psychiatr. Serv. 2002;53:39-49.
15. J. Clin. Psychiatry 2005;66:317-22.
16. J. Matern. Fetal Neonatal Med. 2012;25:1197-201.
17. Briggs GG, et al. Drugs in Pregnancy and Lactation. 8th ed. Baltimore: Lippincott Williams & Wilkins, 2008.
18. J. Emerg. Med. 1998;16:419-24.
19. ACOG Committee on Obstetrics Opinion: (321) Maternal decision making, ethics, and the law. 2005.
20. JAMA 2003;289:1697-9.
21. Am. Med. Assoc J. Ethics 2008;10:41-4.
22. Obstet. Gynecol. 2011;117(2 Pt 2):503-6.
23. J. Subst. Abuse Treat. 1996;13:321.
24. Guttmacher Institute. State Policies in Brief. Substance Abuse During Pregnancy. 3/1/12. http://www.guttmacher.org/statecenter/spibs/spib_SADP.pdf.

Dr. Roemer is an Associate Professor in the Department of Emergency Medicine, OU School of Community Medicine, Schusterman Center, in Tulsa, Okla.; Dr. Banner is Medical Director at the Oklahoma Poison Control Center and Pediatric Critical Care Attending at Integris Baptist Medical Center in Oklahoma City, Okla.; Dr. Katz is a Clinical Professor in the Department of Obstetrics and Gynecology at the Oregon Health Sciences University and Medical Director of Women’s Services at Sacred Heart Medical Center, Center for Genetics and Maternal-Fetal Medicine, in Eugene, Ore.; Dr. Plinsky is a Resident in the Department of Emergency Medicine at the OU School of Community Medicine in Tulsa, Okla.