Illicit Drugs. It is estimated that 10 percent of fetuses are exposed to one or more illicit drugs. Agents may include heroin and other opiates, cocaine, amphetamines, barbiturates, and marijuana (American Academy of Pediatrics, 2017; merican College of Obstetricians and Gynecologists, 20 15a, 2017 d). As discussed in Chapter 12 (p. 247), chronic use of most of these in large quantities is harmful to the fetus (Metz, 2015). Well-documented sequelae include fetal-growth restriction, low birthweight, and drug withdrawal soon ater birth. Adverse efects of marijuana are less convincing. Women who use such drugs frequently do not seek prenatal care, which in itself is associated with risks for preterm and low-birthweight newborns (EI-Mohandes, 2003; Eriksen, 2016).
For women who abuse heroin, methadone maintenance can be initiated within a registered methadone treatment program to reduce complications of illicit opioid use and narcotic withdrawal, to encourage prenatal care, and to avoid drug culture risks (American College of Obstetricians and Gynecologists, 2017£). Available programs can be found through the treatment locator of the Substance Abuse and Mental Health Services Administration at ww.samhsa.gov. Methadone dosages usually are initiated at 10 to 30 mg daily and titrated as needed. In some women, careful methadone taper may be an appropriate option (Stewart, 2013). Although less commonly used, buprenorphine alone or in combination with naloxone may also be ofered and managed by physicians with specific credentialing.
Intimate-Partner Violence. his term refers to a pattern of assault and coercive behavior that may include physical injury, psychological abuse, sexual assault, progressive isolation, stalking, deprivation, intimidation, and reproductive coercion (American College of Obstetricians and Gynecologists, 2012). Such violence has been recognized as a major public health problem. Unfortunately, most abused women continue to be victimized during pregnancy. With the possible exception of preeclampsia, domestic violence is more prevalent than any major medical condition detectable through routine prenatal screening (American Academy of Pediatrics and the Ameri can College of Obstetricians and Gynecologists, 2017). The prevalence during pregnancy is estimated to range between 4 and 8 percent. Intimate-partner violence is associated with an increased risk of several adverse perinatal outcomes including preterm delivery, fetal-growth restriction, and perinatal death (Chap. 47, p. 925).
The American College of Obstetricians and Gynecologists (2012) has provided methods for domestic violence screening and recommends their use at the irst prenatal visit, then again at least once per trimester, and again at the postpartum visit. Such screening should be done privately and away from family members and friends. Patient self-administered or computerized screenings appear to be as efective for disclosure as clinician-directed interviews (Ahmad, 2009; Chen, 2007). Physicians should be familiar with state laws that may require reporting of intimate-partner violence. Coordination with social services can be invaluable in these cases. The National Domestic Violence Hotline (l-800-799-SAFE [7233]) is a nonprofit telephone referral service that provides individualized information regarding city-speciic shelter locations, counseling resources, and legal advocacy.