Managing the Cardiovascular Complications of Substance Use Disorders During Pregnancy
Key findings
- Substance use during pregnancy can cause significant changes to maternal cardiovascular function that contribute to adverse maternal and fetal outcomes during pregnancy, at the time of delivery and in the postpartum period
- Universal screening for substance use should take place preconception, during the initial obstetric visit, in the third trimester and at presentation for delivery
- If SUD is identified during pregnancy, a multidisciplinary team approach is optimal for management
- All pregnant women with SUDs should be counseled about family planning, with special attention to long-acting reversible contraception
Substance use disorders (SUDs) of all kinds are on the rise in the United States, including among pregnant women. For example, opioid use by pregnant women increased 333% between 2004 and 2017. The normal physiologic changes in pregnant women can be rapidly accelerated or blunted in the setting of active substance use, potentially leading to catastrophic cardiac effects in the mother.
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In Current Treatment Options in Cardiovascular Medicine, P. Kaitlyn Edelson, MD, a maternal-fetal medicine fellow at Massachusetts General Hospital, and Sarah N. Bernstein, MD, a specialist in the Maternal-Fetal Medicine Division and obstetrical director for the HOPE Clinic, which provides multidisciplinary care for pregnant women and their families during pregnancy and the first two years postpartum, review management considerations for pregnant women with substance use disorders.
Prenatal Care
The writers make general recommendations around prenatal care. Universal screening for SUDs, using any of the many validated screening tools available, should take place at three points:
- Preconception
- During the initial obstetric intake visit
- In the third trimester or upon presentation to labor and delivery
Once a SUD is identified in a pregnant woman, a multidisciplinary team should be assembled when possible. The obstetrician should either provide primary management or consult with a maternal–fetal medicine (MFM) physician. Other team members ideally include an addiction medicine physician, psychiatrist and social worker.
If an underlying cardiovascular disease is suspected, baseline maternal EKG and echocardiography should be ordered. Close co-management with a cardiologist and MFM specialist is warranted. Anesthesia and neonatology consults can be helpful when preparing for delivery.
Fetal Risk Assessment
The fetal risk assessment should consider the following:
- Exposure to illicit substances during pregnancy increases the risk of congenital malformations
- All pregnant women, including those with SUD, should be offered a complete fetal anatomic survey between 18 and 22 weeks of gestation. Depending on the results, fetal echocardiography or MRI may be indicated
- Fetuses exposed to substances should be screened for growth restriction in the third trimester
- Additional fetal surveillance may be warranted in the setting of ongoing use
Recommendations by Substance Type
- Alcohol: Pregnant women who use alcohol chronically should be screened for hepatic dysfunction early in pregnancy, and a low threshold should be applied to investigate alcohol withdrawal in pregnant women presenting with withdrawal symptoms
- Cocaine: Pregnancy appears to exacerbate the direct cardiovascular toxicity of cocaine (progesterone causes increased metabolism of cocaine to norcocaine). Even small quantities of cocaine ingestion have been associated with catastrophic maternal and fetal events in the peripartum period
- Opioids: Referral for treatment with methadone or buprenorphine is standard of care. Methadone can prolong the QT interval, so patients should have an EKG with each dose increase and avoid additional QT-prolonging medication if possible. It's also reasonable to offer a prescription for naloxone for home treatment of accidental opioid overdose
- Intravenous Use - In women who have used cocaine or an opioid intravenously, consider infective endocarditis, most commonly of the tricuspid valve. In addition, evaluate the peripheral vasculature and inquire about any history of difficulty with intravenous access. A positive history should be well documented in the patient's chart, and there should be a plan for IV access
Postpartum Care
Within the first 24 hours of delivery, large volume shifts occur, along with a sudden increase in intravascular volume. In a patient with valvular disease or cardiomyopathy, close attention must be paid to volume status, intravenous fluid administration and urine output.
Monitoring of electrolytes is also crucial during this period, particularly in patients who may have recently used drugs that provoke arrhythmia.
Counseling About Contraception
The American College of Obstetricians and Gynecologists recommends offering contraception to all pregnant women. Patients should be counseled about the full range of options with special attention to long-acting reversible contraception, including IUDs and progesterone implants.
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