Mental Health Disorders and Substance Abuse in Pregnancy Fall 2024 PDF

C Mental Health Disorders and Substance Abuse in Pregnancy Acquired Problems of the Newborn-Substance Abuse Professor Kara Shiner MSN, RNC-NIC, PHN, ICCE Fall 2024  IT IS SAD TO HAVE TO MAKE THIS INTRODUCTION SLIDE; HOWEVER, WE HAVE BEEN...

C Mental Health Disorders and Substance Abuse in Pregnancy Acquired Problems of the Newborn-Substance Abuse Professor Kara Shiner MSN, RNC-NIC, PHN, ICCE Fall 2024  IT IS SAD TO HAVE TO MAKE THIS INTRODUCTION SLIDE; HOWEVER, WE HAVE BEEN FINDING OUR CONTENT SHARED ON OTHER SITES OR EDITED AND USED WITHOUT OUR PERMISSION. THANK YOU FOR YOUR UNDERSTANDING AND COMPLIANCE. ¢ The following content is protected and may not be shared, edited, or distributed. This PowerPoint Presentation is protected by U.S. copyright law. IMPORTANT ¢ I am the exclusive owner of the copyright in the course materials PRIVACY that I create. You may not reproduce, distribute, display, post, or upload my course materials or recordings or course materials in INFORMATION any other way without my express written consent, whether a fee is charged or not. It is for your personal educational use in this course only. ¢ The following Textbook is used throughout this presentation: Perry, S., Lowdermilk, D., Cashion, K., Alden, K., Olshansky, E., Hockenberry, M. (2023). Maternal child nursing Care (7th ed.). Elsevier 2 Reading for the objectives is scattered throughout the text. Each slide will give you the chapter numbers to review, and you can do a word search in the e- book to find the specific topic in the slides Pay attention to the informational boxes For objectives 1-3, most of the information is in Chapters 20 and 21; however, small sections can be found in Chapters 8, 19, and 25 For Objectives 4 & 5, information is in Chapters 3, Ch. 10, Ch. 11 & Ch. 25 3  Mental OBJECTIVES: Health 1. Describe mental health disorders occurring in the perinatal Disorders period, including mood disorders, anxiety disorders, posttraumatic stress disorder, and bipolar disorder and 2. Compare postpartum blues, postpartum depression, and postpartum psychosis including risk factors, assessment, and Substance management Abuse 3. Evaluate the role of the nurse in caring for patients with mental health disorders during pregnancy and the in the postpartum period Pregnant 4. Examine substance abuse during pregnancy, including prevalence, barriers to treatment, legal considerations, and commonly abused drugs Woman 5. Discuss the care of pregnant people who use, abuse, or are dependent on alcohol or illicit or prescription drugs 4  Perinatal Mental Health According to the American College of Obstetricians and Gynecologists (ACOG), perinatal mental health disorders affect up to 15% of all pregnancies Antidepressant use doubled in the last 15 years: 6%- 13% prescribed while pregnant 1 in 7 will experience Postpartum Depression Affects pregnant people worldwide from all backgrounds Implications for the pregnant person, infant, and family 5 Perinatal Mood Disorders PMDs occur anytime during pregnancy up to one year postpartum and include: → still consider perinatal even tho 1 year PP Perinatal or Postpartum Depression (PPD) Anxiety Bipolar disorder Posttraumatic stress disorder (PTSD) Postpartum psychosis 6  Perinatal or Postpartum Depression (PPD) PPD R/T significant drop in estrogen and progesterone levels Day 3 PP = huge drop in hormone increase risk for mom who has NICU admit baby Most significant risk for PPD: History of anxiety or mood disorder Onset of depression during pregnancy 70% recurrence with previous PPD diagnosis Rule out medical issues → run labs before prescribe meds Anemia Thyroid disorders 7  Perinatal Depression Other PPD risk factors Trauma Pregnancy and birth complications Hx of severe premenstrual dysphoria → horrible issues with menstruation growing up Preterm/ill newborn Substance Abuse Intimate partner violence Socioeconomic Inequality Big trigger Young age Stressful life events Homeless 8 Postpartum Mood Disorders: Baby Blues Baby Blues 85 % of postpartum people will experience baby blues Less pervasive Lasts < 2 weeks Signs of Baby Blues Sad Overwhelmed Loss of appetite Difficulty sleeping Crying spells → very similar to PPD n could happen to dads too 9  → these can come at any point PP and rapidly w/out Postpartum Mood Disorders: any pre-existing risk factors or expose environments Postpartum Depression Category 1 Category 2 Postpartum Depression without Postpartum Depression with psychotic features: psychotic features: More persistent than baby blues Auditory and visual hallucinations Lasts > 2 weeks Paranoid or grandiose delusions, delirium, disorientation Pervasive sadness Extreme deficits in judgement and high Severe labile mood swings levels of impulsivity Feelings of guilt & inadequacy May include intense fears, anxiety, PP psychosis is a psychiatric and despondency emergency, likely requiring inpatient care → could kill baby dlt hearing voices Disinterest in baby Bipolar disorder commonly preexisting Thoughts of harming self/ baby with both types of PPD 10 Edinburgh Postnatal Depression Scale (EPDS) → initial assessment before refer to psychiatrist Commonly used on postpartum floor before discharge This assessment is not enough Postpartum depression typically occurs four weeks post birth Follow-up assessment should be done at infant’s 1, 2, and 4-month follow-up EPDS Maximum score is 30 12 or higher will need follow-up for possible depression Any response other than “never” to question #10 needs immediate social work consult 11 Postpartum Mood Disorders: Postpartum depression (PPD) Often underreported D/t societal expectations Guilt and shame Denial Untreated PPD associated with detrimental infant outcomes: → long term factors Difficult infant/childhood temperament Developmental delays Lower infant/child IQ 12  PPD is not the same for everyone Talk about any changes you or family Postpartum may notice Depression Help clients understand guilt and seek support Three Women Discuss Post Partum Depression 13  POSTPARTUM BLUES, → big factor but there are some cultures that are distance from the baby but there will be interest at some level DEPRESSION, C → fear of sth not in the room AND PSYCHOSIS 14  CLIENT TEACHING FOR PREVENTION OF C POSTPARTUM DEPRESSION "The dish need to be done, the house need to be clean, etc" → avoid regimen schedule → can try to put baby on schedule but expect things will change unexpectedly 15 Perinatal Mood Disorders: Anxiety Disorders Characterized by prominent symptoms of anxiety that impair functioning Obsessive-compulsive disorder (OCD) Bipolar disorder (BPD) Generalized anxiety disorder (GAD) Panic disorder Phobias most common = severely scared that the baby will die Post Traumatic Stress Disorder (PTSD) L&D can trigger PTSD if hx of traumatic birth or sexual violence perinatal loss emergency C/S w/out anesthesia (initial cut) sexual abuse → ask for permission before assessment 16 Perinatal Mood Disorders: PPD Management Cognitive-behavioral therapy (CBT) or interpersonal psychotherapy (IPT) ECT can be safely used during pregnancy as an alternative to medication If inpatient psychiatric hospitalization is required, then the baby should be reintroduced in the hospital, if possible, at the woman’s pace in a supervised and guided environment. → never give the baby w/out supervising or checking safety 17 Perinatal Mood Disorders: Management Medications during pregnancy: risk/benefit analysis Risks with treatment (all cross the placenta and in breastmilk) Paxil= possible cardiac defects For newborns 18 https://www.cdc.gov/pregnancy/meds/treatingfortwo/index.html Selective Serotonin Reuptake Inhibitors → just know there could be some cardiac defects and if they are having any kind of med then higher risk to have withdrawal symptoms Most common: Citalopram, Escitalopram, Fuoxetine, Fluvoxamine, and Sertraline Known to cross placenta and transfer to breastmilk in small amounts SSRI’s used in 3rd trimester may mimic Neonatal Abstinence Syndrome (NAS), but usually last only 2-3 days 19  Perinatal Mood Disorders: Management Medications during pregnancy: risk/benefit analysis Risks without treatment: Continued/worsening depression Inability to prepare for parenthood Preterm birth Suicide 20  When to Call a Healthcare Provider Baby Blues continue for more than two weeks Depression symptoms get worse Difficulty performing tasks at home or work Inability to do self care Thoughts of harming self or baby 21 Perinatal Mood Disorders: Final Words on Care and Management People often do not seek help until at a crisis point Caregivers must be active listeners with a non-judgmental attitude Anticipatory guidance and education for triggers Help clients understand they are not alone Ongoing assessment Referrals to mental health services when necessary 22  PERINATAL SUBSTANCE C ABUSE “National and global substance use have reached epidemic proportions” (Wallen & Gleason, 2018) 23 Perinatal Substance Abuse Women are more likely to seek treatment during pregnancy than at any other time in their lives! Prenatal care, childbirth education, and parenting classes are important educational opportunities to curb substance use/abuse Commonly a dual diagnosis: Coexistence of substance abuse and another psychiatric disorder. Fetal effects: Teratogenic, abnormal growth, placental insufficiency, Central Nervous System (CNS) effects Barriers to treatment: Guilt, fear of CPS, lack of education or resources 24 Perinatal Substance Abuse BE AWARE OF COMMON ADDICTION BEHAVIORS ALL PREGNANT WOMEN INCLUDING: MANIPULATION, SHOULD BE SCREENED AT DEMANDING, POOR THEIR FIRST PRENATAL VISIT BEHAVIOR CONTROL, AND LOW THRESHOLD FOR PAIN DEVELOP A STANDARDIZED PROMOTE MOTHER-INFANT CARE PLAN FOR BOTH ATTACHMENT BY HELPING MOTHER AND BABY BEFORE THE MOTHER IDENTIFY HER DELIVERY STRENGTHS 25 Perinatal Screening Note: opiates don't see withdrawal until after DC since it take 48-72 hrs until seeing symptoms so mom can stop taking it 2-3 days before labor then baby born with perinatal withdrawal syndrome → baby will be taken away if suspect! Assessment Maternal history Family assessment Chapter 11 Box 11.4 26 Substance Abuse: Effects on Pregnancy Alcohol- Teratogen- found in maternal and fetal blood. Altered nutrition, preterm birth, intrauterine fetal death (IUFD) → one of the worst but the most use! Tobacco- Blood clots, respiratory complications, miscarriage, preterm, placenta previa, Intrauterine growth restriction (IUGR) → Dlt decrease in oxygen level n the availability to the baby Cocaine and Methamphetamine-Teratogen- cross placenta and blood-brain barrier, miscarriage, preterm, placental abruption, low birth weight, IUFD → cocaine stimulate the contractions so much that could cause abruption Opioids- Rapidly cross placenta, attach to neuro receptors causing withdrawal after birth. Associated with IUGR, placental abruption, preterm, meconium aspiration, IUFD. 27 Acquired OBJECTIVES: Problems of the Newborn: 1. Analyze fetal and neonatal effects of commonly abused substances during pregnancy. Substance Abuse 2. Describe concerns for fetal and neonatal well-being related to perinatal use of tobacco and caffeine during pregnancy 3. Describe concerns for fetal and neonatal well-being related to perinatal use of selective serotonin reuptake inhibitors during pregnancy 4. Discuss the assessment and care of the newborn experiencing drug withdrawal (neonatal abstinence syndrome) during pregnancy 5. Explain the nursing care and interventions for a family of an infant experiencing drug withdrawal 28 Substance Abuse: Effects on The Newborn Adverse effects for fetus range from transient to permanent Outcomes dependent upon: Specific drug Dosage Route IV or oral or smoking Timing of drug exposure Poly-drug use → usually there is cross over so hard to monitor Variations in street drugs → use accross 10 years or longer State to state variation in child-welfare laws/reporting → marijuana is not required to report any more in CA 29  Tobacco Nicotine is a vasoconstrictive agent that decreases blood flow to the placenta and umbilical vessels: fetal hypoxemia preterm birth, low birth weight, harmful effects on brain development Remains in the breastmilk for up to two hours after smoking: decreased milk supply poor weight gain 2nd hand smoke More damage Increased ear infections, respiratory illnesses, asthma, bronchitis Sudden Infant Death Syndrome (SIDS) new set of clothes that doesn't have smoke when around baby smoke outside 30 Caffeine Readily crosses the placenta Irritability and insomnia Chronic use may reduce iron content in breastmilk Recommended daily dose less than 200mg/day Ahhh... Coffee → small amount is fine Don’t forget about caffeine in tea, chocolate, and even the ”healthy” energy- boosting drinks 31  Alcohol Ethanol easily crosses the placenta; no known amount is considered safe Signs & symptoms of withdrawal after birth: Jitteriness → baby Increased tone and reflexes Irritability Pharmacological treatment is reserved for the most severe symptoms Seizures Vomiting 32 Alcohol Fetal Alcohol Syndrome-3 characteristics: Growth restriction CNS malfunction Craniofacial features → will see the most Epicanthal folds Small eye openings Thin upper lip Low Nasal Bridge Underdeveloped jaw Prenatal exposure to alcohol is the most preventable cause of newborn cognitive disability 33  Cocaine & Amphetamines Cocaine is commonly used with tobacco, marijuana, and other drugs. Strong association with perinatal morbidity Placental abruption → it affect newborn n maternal mortality IUGR Low birth weight Prematurity 34 Cocaine & Amphetamines Infants exposed to cocaine typically experience symptoms until the drug clears: Irritability Hypertonicity Tremors Transient tachycardia and bradycardia Associated with: Frequent infections Emotional disturbances Attention Deficit, Language Development, Information Processing Note: show symptoms and clear out of the system pretty quickly = night see right after birth not associate with a lot of long term affect but might see language development delay or infection 35  Marijuana Second recording Cannabis use on the rise with legalization Older research does not include today’s potent THC THC crosses the placenta Remains in the body for 30 days Association with growth restriction and preterm birth Memory, attention, and cognitive function deficits are suspected, but more studies are necessary Difficult to study due to common poly-drug use 36  Marijuana and Pregnancy American College of Obstetricians and Gynecologists (ACOG ): → consider pregnant of bible Researchers are still learning about the effects of marijuana during pregnancy. Studies are not always clear, but researchers and doctors think the following: Marijuana exposure may disrupt normal brain development of a fetus. Babies whose mothers used marijuana during pregnancy may be smaller at birth. Research suggests an increased risk of stillbirth. It is not known if this is only because of marijuana use or due to use of other substances. Some studies suggest that using both marijuana and cigarettes during pregnancy can increase the risk of preterm birth. There is no evidence to support marijuana is helpful in managing morning sickness ACOG website: https://www.acog.org/womenshealth/faqs/marijuana-and-pregnancy 37 This Photo by Unknown Author is licensed under CC BY-SA-NC Marijuana: Different Perspectives Mom describes Marijuana Use for CDC Marijuana Use and Pregnancy N/V But it associate with worsening of symptoms and it is subjective → hyperemesis gravidum American College of Obstetricians Growing Number of Pregnant and Gynecologists (ACOG) Women Using Marijuana NBC Nightly Marijuana and Pregnancy FAQs New What You Should Know About Using Kaiser Health News Pediatricians Put Cannabis, Including CBD, When It Bluntly: Motherhood And Marijuana Pregnant or Breastfeeding Don’t Mix 38 Opiates Significant rise in opiate use Cross the placenta → bond tightly to neuro Maternal withdrawal can lead to fetal withdrawal and Neonatal Abstinence Syndrome (NAS) Most severe neonatal withdrawal symptoms Risks for: Meconium aspiration Microcephaly Neurobehavioral problems IUGR Increased risk of exposure to Hepatitis B, C & HIV → if using it via IV 39 Opiates Opiate receptors in CNS and GI tract = NAS Infant Pharmacologic Treatment: Depends on the severity of symptoms Morphine Phenobarbital Clonidine Nonpharmacologic Interventions for NAS → try to do these first Breastfeeding → goal is to help both mom and baby withdraw slowly since abrupt stop could worsen s/s but can still breastfeed Skin to skin → encourage Rooming in with infant if in NICU Use of cuddlers in NICU 40  Perinatal Substance Abuse: Opiate Dependency Comprehensive treatment programs for addiction during pregnancy shown to be effective Medication Assisted Treatment (MAT) is the standard of care for opioid use disorders (heroin or other morphine-like drugs) Methadone improves perinatal outcomes Started during pregnancy but methadone is also opiate receptor so will cause withdrawal symptoms as well Buprenorphine (Subutex) or Buprenorphine with Naloxone (Suboxone) becoming more popular treatment for heroin/opiate addiction Better prenatal care and lifestyle choices with MAT 41  Physiologic Signs of Withdrawal Neonatal Abstinence Syndrome (NAS) CNS irritability → screaming even with interventions Respiratory distress GI dysfunction → diarrhea Autonomic dysfunction → tremors when laying down n severely with touch Withdrawal symptoms related to exposure Type of drug Opiates, barbiturates, alcohol, SSRI’s, amphetamines to some degree Amount Time (duration) Timing (in relation to birth) How close to the actual birth did they last use 42 37  Signs of Neonatal Abstinence Syndrome SYSTEM SIGNS Respiratory Irregular respirations, tachypnea, apnea, nasal flaring, chest retractions, intermittent cyanosis, rhinorrhea, nasal congestion → sneezing count too Neurologic Irritability, tremors, shrill cry, incessant crying, hyperactivity, disturbed Biggest thing you will see sleep pattern, seizures, hypertonicity, increased deep tendon reflexes, exaggerated Moro reflex Autonomic dysfunction Frequent yawning, frequent sneezing, tearing, excessive generalized sweating, mottling of skin, fever Gastrointestinal Abnormal feeding pattern, uncoordinated and ineffectual sucking and swallowing reflexes, incessant hunger, frantic sucking, refusal to feed, vomiting, regurgitation, diarrhea 43 NAS Scoring 44 The Reality of Infant Opiate Withdrawal Drug-Dependent Infants Detox at Tenn. NICU- ABC special https://www.verywellmind.com/guidelines-updated-for-treating-drug-addicted-newborns-67819 45  Care of Infant Experiencing NAS Skin to Skin is the best intervention to calm infants experiencing NAS Swaddle Feed Introduce Calm Stress Rock → tight hug Swaddle the Feed infant in Introduce Reduce Stress signals= When the infant with upright one stimulus stimuli (lights, gaze infant is the legs position to at a time noise) Private room aversion, distressed, flexed and avoid when the Use calming yawning, rock in a slow, the infant’s choking, infant is in a music sneezing, rhythmic Very slow hands midline avoid eye quiet, alert hiccups, fashion contact or state arching, talking during mottled feeding color, stop sign 46 Care of Infant Experiencing NAS New Research for caring for infants experiencing NAS=Try“ESC” before using pharmacology Eat Sleep Console Regular on-demand Sleeping for regular Infant can be feeds, small amounts intervals without consoled within 10 Goal frequently to reduce interrupting symptoms minutes of crying regurgitation, Organize care to encouraging mother reduce interruptions and baby to stay → Don't put them on the schedule n do more on demand together https://www.nichq.org/insight/mother-centered-approach-treating-neonatal-abstinence-syndrome 47 Care and Management Develop a plan of care prenatally if possible Education Social support Pharmacological treatment as needed Breastfeeding when appropriate 48 Nursing Diagnoses for Infant Experiencing Drug Withdrawal Risk for Injury related to hyperactivity, seizures secondary to passive drug addiction resulting from maternal substance abuse during pregnancy Imbalanced Nutrition: Less than Body Requirements related to increased basal metabolic rate, CNS irritability, poor suck reflex, vomiting, and diarrhea Risk for Deficient Fluid Volume related to diarrhea and vomiting Ineffective Maternal Coping, Anxiety, Powerlessness related to drug use, infant distress during withdrawal 49 Final Non - judgemental Words… RESPECT COMPASSION SUPPORT 50  THANK YOU FOR HANGING IN C THERE WITH THESE INTENSE TOPICS!!! 51  References Kharbanda, E. O., Vazquez-Benitez, G., Kunin-Batson, A., Nordin, J. D., Olsen, A., & Romitti, P. A. (2020). Birth and early developmental screening outcomes associated with cannabis exposure during pregnancy. Journal of Perinatology, 40(3), 473–480. https://doi.org/10.1038/s41372-019-0576-6: Perry, S., Lowdermilk, D., Cashion, K., Alden, K., Olshansky, E., Hockenberry, M. (2023). Maternal child nursing Care (7th ed.) Oei, J.L. (2020). Alcohol use in pregnancy and its impact on the mother and child. Addiction., 115(11), 2148–2163. https://doi.org/10.1111/add.15036 Stewart, D. E., & Vigod, S. N. (2019). Postpartum depression: Pathophysiology, treatment, and emerging therapeutics. Annual Review of Medicine, 70, 183– 196. https://doi.org/10.1146/annurev-med-041217-011106 Substance Abuse and Mental Health Services Administration Center for Behavioral Health Statistics and Quality (SAMHSA). (2018). The American College of Obstetrics and Gynecologists (ACOG). Marijuana and pregnancy. (2021). https://www.acog.org/womens- health/faqs/marijuana-and-pregnancy The American College of Obstetrics and Gynecologists. (2022). Tobacco, alcohol, drugs, and pregnancy. https://www.acog.org/womens- health/faqs/tobacco-alcohol-drugs-and-pregnancy U.S. Department of Health and Human Services: Office on Women’s Health. (2021). Depression during and after pregnancy. https://www.womenshealth.gov/a-z-topics/depression-during-and-after-pregnancy U.S. Department of Health and Human Services. (2019). U.S. surgeon general’s advisory: Marijuana use and the developing brain. https://www.hhs.gov/surgeongeneral/reports-and-publications/addiction-and-substance-misuse/advisory-on-marijuana-use-and-developing- brain/index.html U.S. Food and Drug Administration. (2019). FDA approves first treatment for post-partum depression. https://www.fda.gov/news-events/press- announcements/fda-approves-first-treatment-post-partum-depression Viswasam, K., Eslick, G. D., & Starcevic, V. (2019). Prevalence, onset and course of anxiety disorders during pregnancy: A systematic review and meta analysis. Journal of Affective Disorders, 255, 27–40 https://doi.org./10.1016/j.jad.2019.05.016 Wallen, L., & Gleason, C. (2018). Prenatal drug exposure. In Avery's Diseases of the Newborn (10th ed., pp. 126-144). Elsevier. https://doi.org/10.1016/B978-0-323-40139-5.00013-9. 52