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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
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 2008-2012
639 PREGNANT PATIENTS TESTED
TUH FREQUENCY OF USED DRUGS
639 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 GUIDELINE
No. 256, April 2011
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
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 (dosedependent)
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
SOGC CLINICAL PRACTICE GUIDELINE
No. 256, April 2011
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
SOGC CLINICAL PRACTICE GUIDELINE
No. 256, April 2011
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
SOGC CLINICAL PRACTICE GUIDELINE No. 256, April 2011
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
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
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 pregnancy
SOGC 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 pregnancy
SOGC 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
ACOG Committee Opinion No. 524: Opioid abuse, dependence, and
addiction in pregnancy
SOGC CLINICAL PRACTICE GUIDELINE No. 256, April 2011
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
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
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
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?