Guidance for the care of pregnant women who have an alcohol misuse problem

Transcription

1 Document level: Clinical Service Unit (CSU) Code: DA1 Issue number: 2 Guidance for the care of pregnant women who have an alcohol misuse problem Lead executive Lead Clinical Director (Not for TW documents) Author and contact number Clinical Director, Drug & Alcohol Services Type of document Target audience Document purpose Guidance Drug & Alcohol Medical Officers / Clinical Staff To provide accessible, non-judgmental and holistic care which will enable this patient group to access antenatal services early, help stabilise their alcohol use and have healthy babies that can be breastfed unless contra-indicated. Document consultation Clinical Standards Approving meeting Medicines Management Group 9-Jun-11 Ratification Document Quality Group (DQG) 8-Sep-11 Original issue date Sep-11 Implementation date Sep-11 Review date Sep-16 CWP documents to be read in conjunction with HR6 Trust-wide learning and development requirements including the training needs analysis (TNA) Drug Misuse & Dependence UK Guidelines on Clinical Management DoH 2007 Training requirements Financial resource implications There are no specific training requirements for this document. Yes - Any identified financial pressures will be reported to local PCTs and DAATs Equality Impact Assessment (EIA) Initial assessment Yes/No Comments Does this document affect one group less or more favourably than another on the basis of: Race No Ethnic origins (including gypsies and travellers) No Nationality No Gender Yes Pregnant women Culture No Religion or belief No Sexual orientation including lesbian, gay and bisexual people No Age No Disability - learning disabilities, physical disability, sensory impairment and mental health problems No Is there any evidence that some groups are affected differently? No If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable? Yes Is the impact of the document likely to be negative? No If so can the impact be avoided? No Page 1 of 10

2 What alternatives are there to achieving the document without N/A the impact? Can we reduce the impact by taking different action? N/A Where an adverse or negative impact on equality group(s) has been identified during the initial screening process a full EIA assessment should be conducted. If you have identified a potential discriminatory impact of this procedural document, please refer it to the human resource department together with any suggestions as to the action required to avoid / reduce this impact. For advice in respect of answering the above questions, please contact the human resource department. Was a full impact assessment required? What is the level of impact? No Low Monitoring compliance with the processes outlined within this document Is this document linked to the No NHS litigation authority (NHSLA) risk management NB - The standards in bold above are those standards which are standards assessment? assessed at the level 2 and 3 NHSLA accreditation. Who is responsible for undertaking the monitoring? How are they going to monitor the document? What are they going to monitor within the document? Where will the results be reviewed? When will this be monitored and how often? If deficiencies are identified how will these be dealt with? Who and where will the findings be communicated to? How does learning occur? How are the board of directors assured? Clinical Director Monitoring of clinical incidents related to non-adherence of this policy document. Review and update policy in line with national guidance and changes in clinical practice. CWP Drug & Alcohol Serivce Management Meetings and consultation with Medical Staffing. Yearly Any deficiencies identified from internal audits or incidents would trigger an action plan that would be monitored by the Clinical Director. Feedback through Clinical Director to all service units. It is the duty and responsibility of all CWP Drug and Alcohol Services Specialist Team's to keep up to date with this policy. Line Managers have the responsibility to cascade information on the revised policy, ensuring any training needs are identified. All action plans are registered via the Trust compliance and performance sub-committee which reports to the Board via the Quality committee. There is also an annual medicines management report to the Board that gives assurances of the work completed in each 12 month cycle on medicines management. Document change history Changes made with rationale and impact on practice 1. Page 2 of 10

3 External references References 1. American Hospital Formulary Service - Drug information 1997, Bethesda, MD: American society of Health systems Pharmacists: 1997: Bamji MS- Enzymic Evaluation of Thiamine, Riboflavin and Pyridoxine Status of Parturient Women and Their Newborn Infants : BR J Nutr 1976; 35: Department of Health (2007) - Drug Misuse and Dependence: UK Guidelines on Clinical Management, 7.4 Pregnancy and Neonatal Care. 3. Dostalova L Correlation of The Vitamine Status Bewtween Mother & Newborn During Delivery. DeV Pharmacol Ther 1982;a(suppl1): Plant M (2001) - FAS info: Drinking in Pregnancy, uwe.ac.uk accessed on 5th April Royal College of Obstetricians and Gynaecologists. Alcohol Consumption and the outcome ROCG statement No 5 March Sign (Scottish Intercollegiate Guidelines Network) Guidelines (2003) - The Management of Harmful Drinking and Alcohol Dependence in Primary Health Care: National Clinical Guidelines. 7. Stockwell T, Murphy D, Morgan R, (1983) - The Severity of Alcohol Dependence Questionnaire: its use, reliability and validity. British Journal of Addiction 78 pg Taylor DJ, (2003) - Alcohol Consumption in Pregnancy, Guidelines and Audit Sub committee of the Royal College of Obstetricians and Gynaecologists 9. Cooper J.R and Pincus J.H (1979) The role of Thiamine in nervous tissue. Neurochemical Research 4, Aboulaye BA*, Bialli V. Seri and Sun Heat Han Alcohol & Alcoholism, Vol. 31, No.1 pp , Butterworth R.F (1993) Maternal thiamine deficiency. A factor in intrauterine growth retardation. In Maternal nutrition and pregnancy outcome. Annals of the New York Academy of Sciences 678, Content 1. Introduction Background Pre-conception Prescribing issues during pregnancy Vomiting in pregnancy Duties and responsibilities Clinical Director Line Managers Lead Nurse Trust Staff... 6 Appendix 1 - Alcohol Use Disorders Identification Test (Audit)... 7 Appendix 2 - Severity of Alcohol Dependence Questionnaire... 8 Appendix 3 - Prescribing for alcohol dependence... 9 Appendix 4 - Severity of Withdrawal Chart Page 3 of 10

4 1. Introduction Pregnant alcohol misusing women should be regarded as pregnant women who have an alcohol problem rather than alcohol misusers that happen to be pregnant. Our aim is to provide accessible, non-judgmental and holistic care which will enable this patient group to access antenatal services early, help stabilise their alcohol use and have healthy babies that can be breastfed unless contra-indicated. Women with an alcohol misuse problem have potentially higher risk pregnancies. A multi disciplinary, community based care plan which looks at both medical and social problems on a one stop basis is important. The main aim must be for stability and the whole plan should be realistic and achievable, with abstinence being the ideal outcome. 2. Background The models of care for alcohol use Department of Health (DOH) 2006 states: Pregnant women and those who are trying to become pregnant should be informed of the current advice on alcohol and its effects on conception and during pregnancy. This includes advice that if they do drink, they should not get drunk and should not consume more than one or two units once or twice per week during pregnancy. Women who are dependent on alcohol and are pregnant, or currently trying to become pregnant, should receive immediate treatment for their alcohol problems. Royal College of Obstetricians and Gynaecologists: No5. March 2006 states: There is an increased incidence in both the number of women using alcohol, their duration of alcohol use and increased risk to pregnancies. Alcohol use is common throughout all social strata, and more associated with medical and social problems in deprived groups and their associated lifestyles. 3. Pre-conception Approximately 40-60% of women consume alcohol during their pregnancy. Services should address each woman s needs with regards to her sexual health. Alcohol use may be associated with loss of menstrual function, and reduction or abstinence may lead to a restoration of menstrual function. It is therefore important to encourage women to take the necessary steps to prevent an unplanned pregnancy and for alcohol using women to maximise their health before becoming pregnant. Issues around lifestyle, diet, stabilising / stopping of alcohol use [Taylor 2003], screening for sexually transmitted infections, contraception, cervical cytology and street working may need to be addressed. If pregnancy is planned it is important to prescribe the recommended folic acid supplements, 400 micrograms per day. Thiamine is water soluble, and can not be stored in the body. Maternal deficiency is common during pregnancy without the added problems of alcohol usage [Bamji 1976, Dostalova 1982]. As a result it is important that stores are regularly replenished with supplements, especially in the presence of alcohol and smoking. Thiamine is essential for the building and functioning of nerves, brain and muscles in the mother and demand is increased during pregnancy. It is actively transported to the foetus which requires higher levels than that required by the mother, allowing for the optimum growth of bodily organs and its nervous system. It is recommended that the dose is between 200mgs and 1.4g daily dependent upon the level of alcohol usage and dietary intake, with a multiple pregnancy requiring higher doses than a single pregnancy. If Disulfiram is being prescribed for the maintenance of abstinence in alcohol dependence in a potentially fertile woman then the woman must be informed on commencement that it is not licensed in pregnancy and that it can lead to high concentrations of acetaldehyde which could be teratogenic. Once a pregnancy has been confirmed Disulfiram will be discontinued. There is no evidence of adverse effects from Acamprosate during pregnancy, but the manufacturers recommend that it is not used in pregnancy or breastfeeding. Continuation will be at the discretion of the Obstetrician once full counselling has taken place around potential risks. Page 4 of 10

5 If a woman becomes pregnant whilst being prescribed Disulfiram / Acamprosate a discussion must take place to inform her that treatment would be stopped. All this information must be documented in the case notes. 4. Prescribing issues during pregnancy Prescribing for alcohol withdrawal during pregnancy may be monitored in an in-patient setting [Plant 2001, SIGN 2003] by a medical officer, with the support of an alcohol specialist practitioner. This patient group is not suitable for detoxification in a community setting, due to the increased risks to both the woman and the foetus. The woman should also be informed of the risks to herself and the possible teratogenic effects on the foetus. All information must be documented in the woman s notes. Those professionals involved in the woman s pregnancy must be prepared to see the woman much more frequently once the detoxification has been completed, to reduce the risk of relapse. A woman who presents with harmful or dependent alcohol use at the maternity service, following screening using Alcohol Use Disorders Identification Test (AUDIT) (appendix 1), must be referred to an alcohol specialist service within 7 working days. Liaison should take place immediately between the alcohol specialist and the midwifery specialist. Vitamin B and thiamine is recommended for women who are harmful and dependent drinkers, neither are contraindicated in pregnancy. Excellent communication with the obstetric and gynaecology team is essential to provide a coherent package of care. The greatest risk of teratogenesis to the foetus and the development of the foetal alcohol syndrome occurs during the first trimester. However, ongoing consumption in the second and third trimester can potentially damage the developing brain, impair foetal growth and result in foetal alcohol spectrum disorder. There is evidence that alcohol consumption is associated with increased risk of miscarriage. Alcohol detoxification can occur at any time in pregnancy. It is common when a woman finds she is pregnant that her immediate goal is to become alcohol free. This can often lead to an unplanned withdrawal which will have adverse effects on the woman and the foetus wellbeing. This should be discouraged and an appointment arranged with the obstetrician. A referral to alcohol specialist services should be made as soon as pregnancy is diagnosed. The obstetrician can then discuss the risks of alcohol in pregnancy and to the foetus and go through possible treatment options, the best point in the pregnancy to undertake a detoxification and any associated risks. The alcohol specialist services can provide information around safe reduction, cognitive/behaviour links associated with alcohol intake, undertake work towards detoxification and support post detoxification. A reducing chlordiazepoxide regime should be kept to the lowest possible amount due to the possible teratogenic effect on the foetus (appendix 3). It should be set at the level that best corresponds with their Severity of Alcohol Dependency Questionnaire [SADQ Stockwell1983] (appendix 2) that should be completed prior to the detoxification taking place. A pregnant woman s care plan should be reviewed. It is important that care plans are realistic and achievable and they should involve the woman s partner and family whenever possible. Liaison arrangements between Alcohol Services (Drug Services if involved) and the four Trust Maternity Services (Wirral University Teaching Hospital NHS Foundation Trust, Countess of Chester, Leighton and Macclesfield District General) have not been standardised. The referral of pregnant women to maternity services and ongoing liaison communication between the Alcohol Service (Drug Service if involved) and Maternity Services will need to follow the agreed procedures in each of the four areas. At around the 28 th to 32 nd week of pregnancy a planning meeting should be held with the pregnant woman and relevant professionals involved in her care, including those from maternity, paediatrics, primary care (especially the health visitor), alcohol and drug services, using the common assessment framework. At the meeting any possible child protection risks need to be considered and a referral to social services made if the woman s drinking poses a risk of significant harm to the unborn /new born baby. At this meeting goals will be set, risks considered and the decision will be made whether a predischarge meeting should be held. The patient s partner is often not involved in these meetings at present, but should be encouraged to attend. Page 5 of 10

6 Undertaking an alcohol detox at the 28 th week and above should only be considered when the obstetrician deems it is in the best interest of the woman and foetus, to maintain their well being. It will be necessary for the detox to be undertaken as an inpatient and under medical supervision. Due to the action of progesterone on the oesophageal sphincter and the slowing down of gastric emptying, the stomach contents become more acid based. There is a possibility if the woman needs to be placed in a recumbent position i.e. if fitting occurs, that silent regurgitation will occur, which could lead to Mendelson s Syndrome. Metabolism of alcohol in pregnancy is increased around the 28 th week and the woman risks going into withdrawal 12 hours after the last drink of alcohol. To maintain the woman s and foetus well being a reducing dose of chlordiazepoxide should be commenced. If a woman presents with alcohol dependency in labour, once reviewed by the obstetrician, a chlordiazepoxide reducing regime should be commenced. The paediatrician should be present at delivery as the baby may be flat as a result of the chlordiazepoxide given in labour. Once admitted to the ward post delivery the neonate will need to be monitored for withdrawal of alcohol or for the presence of respiratory depression due to the chlordiazepoxide given in labour, in the first 72 hours. Alcohol misuse must be treated and advised on with a plan for cessation as urgently as possible. However, retention and care planning is just as important. 5. Vomiting in pregnancy Vomiting, particularly, in early pregnancy can cause difficulties with women who are on higher levels of alcohol as withdrawal may be triggered or the woman may become dehydrated. It may be necessary to have the woman admitted to a ward and a reducing chlordiazepoxide regime commenced on admission. Ideally pregnant alcohol using women should receive care under one roof via a multi-disciplinary team. The normal pregnancy advice, sexual health, blood borne virus testing, harm reduction and brief intervention around alcohol should be provided. The opportunity to detoxify from long term alcohol use during pregnancy, should involve a full assessment, care planning and co-ordination of services, and form the basis for good care. All professionals involved with pregnant women should have a sound knowledge of the risks of alcohol use in pregnancy, offer early screening, brief interventions and early sign posting to specialist services. Services should be easily accessible and women should feel the attitude of the service providers is non judgmental and both positive and motivational in its approach. 6. Duties and responsibilities 6.1 Clinical Director Clinical Director is responsible for development, implementation and review of the approved document which falls within their remit. The Clinical Director will take a uniform approach towards the complex issues in this guidance. They will ensure training is implemented across CWP Drug & Alcohol services through their managers meeting. 6.2 Line Managers Line Managers have the responsibility to highlight the guidance to all trust staff and to ensure that they have received adequate training. 6.3 Lead Nurse Lead Nurse is responsible for communicating and coordinating detoxification after medical officer discussion. 6.4 Trust Staff It is the responsibility of trust staff to keep up to date with the approved document relevant to their working environment. CWP Drug & Alcohol clinical staff are required to attend required training. Page 6 of 10

7 Appendix 1 - Alcohol Use Disorders Identification Test (Audit) Clients Name: DOB: Date: How often do you have a drink containing alcohol? How many standard drinks containing alcohol do you have on a typical day when you are drinking? How often do you have 6 or more standard drinks on one occasion? How often during the last year have you found that you were not able to stop drinking once you had started? How often during the last year have you failed to do what was normally expected from you because of your drinking? How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? How often during the last year have you had a feeling of guilt or remorse after drinking? How often during the last year have you been unable to remember what happened the night before because you had been drinking? Have you or someone else been injured as a result of your drinking? Has a relative or friend, doctor or other health worker been concerned about your drinking or suggest you cut down? 1 or 2 or less 3 or 4 Page 7 of 10 2 to 4 Times month 5 or 6 Yes, but not in the last year Yes, but not in the last year 2 to 3 times a week 7 or 9 4 or more times a week (4) 10 or more (4) Yes, during the last year (4) Yes, during the last year (4) Scoring The scores for each question are shown under each response. The minimum score: (for non-drinkers) is 0 and the maximum possible score is 40 Audit total score 0-7 Low risk 8-15 Increasing Higher risk 20+ Possible Dependence

8 Appendix 2 - Severity of alcohol dependence questionnaire Name No Date INSTRUCTIONS: The following questions cover a wide range of topics to do with drinking. Please read each question carefully but do not think too much about exact meaning. Think about your MOST RECENT drinking habits and answer each question by placing a tick under the MOST APPROPRIATE heading. If you have any difficulties ASK FOR HELP. Questions Sometimes Often Nearly always 1. Do you have difficulty in getting the thought of drinking out of your mind? 2. Is drinking more important than your next meal? 3. Do you plan your day around when & where you can drink? 4. Do you drink in the morning, afternoon & evening? 5. Do you drink for the effect of alcohol without caring what the drink is? 6. Do you drink as much as you want regardless of what you are doing the next day? 7. Given that many problems might be caused by alcohol do you still drink too much? 8. Do you know that you won t be able to stop drinking once you start? 9. Do you try to control your drinking by giving it up completely for days or weeks at a time? 10. First thing in the morning after drinking do you need a first drink to get yourself going? 11. First thing in the morning after drinking do you wake up with a definite shakiness of your hands? 12. First thing in the morning after drinking do you wake up retching or vomit? 13. First thing in the morning after drinking do you go out of your way to avoid people? 14. After a drinking session do you see frightening things or hear things that later you realise weren t real? 15. After drinking, do you find you have forgotten what happened the night before? 16. First thing in the morning after drinking alcohol, do you wake up sweating? 17. First thing in the morning after drinking alcohol, do you have a strong craving for drink? 18. First thing in the morning do you need to gulp your first few drinks down to get you sorted? 19. First thing in the morning after drinking does your whole body shake? 20. First thing in the morning do you need to drink more to get rid of the shakes? Scoring: The 20 items summed for a total score that can range from 0 to 60. Scale totals are interpreted as follows: medium dependence and 20 or greater high dependence. Scoring as follows: = 0 Sometimes = 1 Often = 2 Nearly always = 3 Note. Reprinted with permission from D. Raistrick (1991) & Alcohol Concern Page 8 of 10

9 Appendix 3 - Prescribing for alcohol dependence Alcohol withdrawal Alcohol dependence and withdrawal may be treated in inpatient settings. Alcohol dependence may occur in combination with dependence on other classes of drugs. Where there is a history of alcohol and benzodiazepine use, a benzodiazepine withdrawal schedule as outlined below may be used. The Severity of Alcohol Dependence Questionnaire (SADQ) (Stockwell et al 1979) can be helpful in measuring the severity of alcohol dependence. Alcohol withdrawal regimes: Dosages of chlordiazepoxide SADQ Moderate (SADQ 20-30) Severe (SADQ 30-40) Very Severe (SADQ 40-60) Day 1 10mg 15mg 20mg 30mg 40mg 50mg Qds Qds Qds Qds Qds Qds Day 2 10mg 10mg 15mg 25mg 30mg 40mg Qds Day 3 5mg 10mg 10mg 20mg 25mg 30mg Tds Day 4 5mg 5mg 10mg 15mg 20mg 25mg bd Tds Day 5 5mg 5mg 5mg 10mg 15mg 20mg nocte Bd Day 6 5mg 5mg 10mg 10mg 15mg Nocte bd Day 7 5mg 5mg 10mg 10mg nocte Day 8 5mg 5mg 10mg bd Day 9 5mg 5mg 5mg nocte bd Day 10 5mg 5mg nocte bd Day 11 5mg nocte Qds = 4 x daily Tds = 3 x daily Bd = 2 x daily Nocte = at night Page 9 of 10

10 Appendix 4 - Severity of withdrawal chart Client name Date of birth Client No Starting date of detox Please score one number in each case Day 1 Day 2 Day 3 Day 4 Day 1 Day 2 Day 3 Day 4 Orientation 0-Fully orientated 1-Mildly disorientated 2-Obviously disorientated 3-Totally disorientated Level of consciousness 0-Fully alert 1-Slightly drowsy 2-Very drowsy 3-Roused with difficulty Hallucinations 0-No hallucinations 1-Unstructured 2-Intermittent structure 3-Frequent structure Agitation 0-No sign of agitation 1-Slightly restless 2- Moderate restlessness 3- Constantly restless Mood 0-Cheerful / appropriate 1-Sometimes low 2-Often low 3-Constantly low Anxiety 0-Finds it easy to relax 1-Finds it difficult to relax 2-Hardly ever relaxed 3- Cannot relax A score of 18+ indicates concern consult the doctor Sleep 0-Sleeps well 1-Broken sleep 2-Difficulty in getting to sleep 3-Insomnia Appetite 0-Good appetite 1-Fair appetite 2-Poor appetite 3-No appetite Sweating 0-No sweating 1-Slight sweating 2-Moderate sweating 3- Profuse sweating Tremor 0-No tremor 1-Slight tremor 2-Moderate tremor 3- Marked tremor GI Disturbance 0-No abnormalities 1-Mild nausea 2-Persistent nausea 3-Vomitting 2 or more times Commitment to Detox 0-Strong 1-Moderate 2-Slight 3- None Total score Day1 Day2 Day3 Day4 BP Pulse Foetal heart rate Comment >15 mmhg from booking contact doctor 3 <79 = = =2 >120 = 3 (contact Dr) <120bpm >160bpm PV loss If yes inform doctor Page 10 of 10