SHARED QUALITY INITIATIVES IN OBSTETRICAL CARE IN PHILADELPHIA GUIDELINES FOR DRUG SCREENING IN OBSTETRICS Dimitrios S Mastrogiannis MD PhD MBA FACOG Director

SHARED QUALITY INITIATIVES IN OBSTETRICAL CARE IN PHILADELPHIA

GUIDELINES FOR DRUG SCREENING IN OBSTETRICS

Dimitrios S Mastrogiannis MD PhD MBA FACOGDirector of Obstetrics and Maternal Fetal MedicineAssociate Professor of Obstetrics Gynecology and

Reproductive SciencesTemple University School of Medicine

NOTHING TO DISCLOSE

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

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

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.

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

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

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

URINE DRUG TEST AT TUH 2008-2012639 PREGNANT PATIENTS TESTED

TUH FREQUENCY OF USED DRUGS639 PREGNANT PATIENTS TESTED 2008-2012

• Marijuana 17.5%

• Cocaine 4.2%

• Opiates 4.1%

• PCP 3.8%

• Benzodiazepine 3.7%

• Barbiturates 1%

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

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 GUIDELINENo. 256, April 2011

HEROIN• Antenatal complications

• Premature labor, IUGR, LBW, Preeclampsia, Antepartum and postpartum hemorrhage


• Increased perinatal mortality rate

• Increased inattention, hyperactivity and behavioral problems

• Difficulty in physical, social, and self adjustment and learning processes


COCAINE• Antenatal complications

• Spontaneous abortion, PROM, PTL, IUGR, Placental abruption, meconium


• ? 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

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)

HALLUCINOGENS (MDMA, LSD)• Congenital anomalies: cardiovascular,

• Medullary Sponge Kidney defects


PCP• Antenatal complications

• Reduces birth weight, Preeclampsia, Preterm labor, PPROM

• Many times associated with additional drug use

Mastrogiannis DS 2013

METHADONE• Neonatal abstinence syndrome

WITHDRAWAL SYNDROMES


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

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)

ACOG 1999 educational Slides

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

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

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


ILLICIT DRUG TESTING IN OBSTETRICAL PATIENTSSUGGESTED 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


PATIENTS IN WHOM TESTING IS USUALLY DONE ARE• Patients who have no prenatal care or initiate prenatal care after the 20th 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

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

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 pregnancySOGC CLINICAL PRACTICE GUIDELINE No. 256, April 2011

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 pregnancyACOG Committee Opinion No. 524: Opioid abuse, dependence, and addiction in pregnancySOGC CLINICAL PRACTICE GUIDELINE No. 256, April 2011

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


AFTER ACUTE CARE• Antepartum

• Referral to treatment center

• Methadone or Buprenorphine

• Mental health

• Referral for General Medical Ob care, Subspecialty care


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


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


THE LAW

PHILADELPHIA

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

Thank you

Any questions?

Documents

SHARED QUALITY INITIATIVES IN OBSTETRICAL CARE IN PHILADELPHIA GUIDELINES FOR DRUG SCREENING IN OBSTETRICS Dimitrios S Mastrogiannis MD PhD MBA FACOG Director