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Consider Screening All for Substance Abuse in Pregnancy


 

SAN FRANCISCO — Selectively screening patients for substance abuse in pregnancy is ineffective, Dr. Allison S. Bryant said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

“Everyone should be screened. If you don't want to be screening everybody, then you probably should be screening no one,” said Dr. Bryant, a perinatologist who is also an assistant adjunct professor in the UCSF Department of Obstetrics, Gynecology and Reproductive Sciences.

Universal screening doesn't take much time—perhaps 30 seconds for a woman who is not using alcohol or drugs during pregnancy or 5–10 minutes for patients who are actively using substances, she said.

The first step in screening is to ask every patient about substance use. “It provides an opportunity for a conversation with every patient,” Dr. Bryant said.

Think of potential substance abuse when you see a medical history of frequent hospitalizations, unusual trauma or infections, frequent falls or bruises, chronic mental illness, or diabetes, cirrhosis, hepatitis, or pancreatitis, Dr. Bryant advised.

“I can't tell you how many times during my fellowship I did consults on patients admitted with raging pancreatitis in pregnancy, and they'd had million-dollar work-ups, and nowhere in the medical charts was there documentation about whether they reported using alcohol during pregnancy,” she added.

Some patient behaviors may flag the need for more aggressive screening—behaviors like slurred speech and/or unsteady gait, agitation, disorientation, an appearance of euphoria, or prescription drug-seeking.

Physical clues that should trigger more aggressive screening include tremors, multiple needle marks, inflamed or eroded nasal mucosa, alterations in vital signs, and the dilated or constricted pupils typical of heroin or amphetamine use.

More aggressive screening usually means administering a urine toxicology test, best used after a positive interview screen.

Under most state laws, physicians must obtain consent for a maternal toxicology screen, whereas toxicology screening of infants can be performed without maternal consent.

“Sometimes I see patients who had screening due to acute labor or partial premature rupture of membranes. In our particular setting, I don't think that's warranted,” she said.

“Patients who present with an abruption, on the other hand, probably all should be consented for a tox screen for cocaine use.”

Among pregnant women, approximately 15% abuse alcohol, 20% smoke cigarettes, 2% abuse marijuana, 0.3% abuse cocaine, and 0.7% use other illicit drugs, according to a national survey from 1996 to 1998.

Studies suggest that treatment of substance abuse is as effective as treating other chronic diseases, Dr. Bryant said.

Studies suggest that treatment of substance abuse is as effective as treating other chronic diseases. DR. BRYANT

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