New ACOG Guidance Provides Detailed Overview of Treatment Options
Washington DC—Opioid agonist pharmacotherapy, also known as medication-assisted treatment (MAT), continues to be the recommended therapy for pregnant women with an opioid use disorder. However, in newly revised guidance, The American College of Obstetricians and Gynecologists (ACOG) also recognizes that medically supervised withdrawal can be considered under the care of a physician experienced in perinatal addiction treatment and with informed consent if a woman does not accept MAT.
“Concern about medication-assisted treatment must be weighed against the negative effects of ongoing misuse of opioids, which can be much more detrimental to mom and baby,” said lead Committee Opinion author, Maria Mascola, M.D. “Medication-assisted treatment improves adherence to prenatal care and addiction treatment programs and has been shown to reduce the risk of pregnancy complications. And while neonatal abstinence syndrome is often seen in infants who have been exposed prenatally to opioids, it is important to remember that it is an expected and treatable condition that has not been found to have any significant effect on cognitive development.”
The new guidance, “Opioid Use and Opioid Use Disorder in Pregnancy,” provides a detailed and up-to-date overview of the treatment options, such as methadone and buprenorphine, that will allow providers to offer better care for pregnant women with an opioid use disorder. However, there is also an acknowledgement that there may be a select group of women who make an informed decision not to choose that option. In these cases, medically supervised withdrawal under the care of an experienced physician may be considered. If this option is chosen, it is critical that it includes long-term follow-up and support to prevent relapse, which can pose grave risks.
ACOG continues to recommend that screening for opioid use take place during the first prenatal care visit using the appropriate validated clinical screening tools, such as questionnaires. Verbal screening is preferred over urine testing for initial screening because it allows for a more complete clinical assessment of the patient’s substance use disorder and provides an opportunity for conversation that encourages the patient make valuable lifestyle changes. Urine drug testing may also be used as an adjunct to screening, but does not detect all substances and can produce false-positives. Additionally, physicians should be aware of general and state specific reporting mandates for opioid use.
Providers should encourage breastfeeding in women who are stable on their treatment, who are not using illicit drugs and who have no other contraindications. Breastfeeding poses additional benefits for this population, such as decreased severity of neonatal abstinence syndrome, shorter hospital stay, and less need for the baby to receive medication to treat their withdrawal symptoms. Ob-gyns should also discuss the full range of contraceptive options with women suffering from opioid use disorder, as the unintended pregnancy rate among this population—80 percent—far surpasses the national average.
“The postpartum period is already a vulnerable time for new moms, in general, as they face the stresses of sleep deprivation, caring for a newborn, and possibly symptoms of postpartum depression,” said Mascola. “Women with opioid use disorder are dealing with all those things in addition to the challenges of their addiction, which—without treatment and support—can often lead to relapse. These guidelines are meant to help ob-gyns assert themselves in the care of their patients, so that they can make a lasting difference in their lives.”
For more information, visit www.acog.org/opioids.
The Committee Opinion #711, “Opioid Use and Opioid Use Disorder in Pregnancy,” which replaces Committee Opinion #524, will be published in the August issue of Obstetrics & Gynecology.
Other recommendations issued in the August Obstetrics & Gynecology
Committee Opinion #709, “Commercial Enterprises in Medical Practice”
Monetary reimbursement of physicians in exchange for medical advice and treatment is well established and accepted in medical practice. However, financial pressures and the pervasiveness of entrepreneurial values have led some physicians to widen the scope of activities for which they seek reimbursement. Some of these commercial activities are ethically problematic in the clinical setting. Obstetrician–gynecologists should strive to ensure that commercial enterprises in medical practice do not compromise the patient-focused mission of clinical care. In this Committee Opinion, the American College of Obstetricians and Gynecologists’ Committee on Ethics differentiates between commercial activities judged to be generally ethically appropriate for obstetrician–gynecologists and those that are not.
Committee Opinion #710, “Counseling Adolescents About Contraception”
Modern contraceptives are very effective when used correctly and, thus, effective counseling regarding contraceptive options and provision of resources to increase access are key components of adolescent health care. Regardless of a patient’s age or previous sexual activity, the obstetrician–gynecologist routinely should address her contraceptive needs, expectations, and concerns. Obstetrician–gynecologists should be aware of and be prepared to address the most common misperceptions about contraceptive methods in a way that is age appropriate and compatible with the patient’s health literacy. The American College of Obstetricians and Gynecologists recommends that discussions about contraception begin with information on the most effective methods first. Emergency contraception routinely should be included in discussions about contraception, including access issues. Moreover, the American College of Obstetricians and Gynecologists recommends that obstetrician–gynecologists work with their office staff to establish office procedures and routines that safeguard the privacy of adolescent patients whenever possible. Adolescents’ right of refusal for initiating or discontinuing a method should be addressed by obstetrician–gynecologists. At no time should an adolescent patient be forced to use a method chosen by someone other than herself, including a parent, guardian, partner, or health care provider. The initial encounter and follow-up visits should include continual reassessment of sexual concerns, behavior, relationships, prevention strategies, and testing and treatment for sexually transmitted infections per the Centers for Disease Control and Prevention’s guidelines.
Committee Opinion #712, “Intrapartum Management of Intraamniotic Infection”
Intraamniotic infection, also known as chorioamnionitis, is an infection with resultant inflammation of any combination of the amniotic fluid, placenta, fetus, fetal membranes, or decidua. Intraamniotic infection is a common condition noted among preterm and term parturients. However, most cases of intraamniotic infection detected and managed by obstetrician–gynecologists or other obstetric care providers will be noted among term patients in labor. Intraamniotic infection can be associated with acute neonatal morbidity, including neonatal pneumonia, meningitis, sepsis, and death. Maternal morbidity from intraamniotic infection also can be significant, and may include dysfunctional labor requiring increased intervention, postpartum uterine atony with hemorrhage, endometritis, peritonitis, sepsis, adult respiratory distress syndrome and, rarely, death. Recognition of intrapartum intraamniotic infection and implementation of treatment recommendations are essential steps that effectively can minimize morbidity and mortality for women and newborns. Timely maternal management together with notification of the neonatal health care providers will facilitate appropriate evaluation and empiric antibiotic treatment when indicated. Intraamniotic infection alone is rarely, if ever, an indication for cesarean delivery.
Committee Opinion #713, “Antenatal Corticosteroid Therapy for Fetal Maturation”
Corticosteroid administration before anticipated preterm birth is one of the most important antenatal therapies available to improve newborn outcomes. A single course of corticosteroids is recommended for pregnant women between 24 0/7 weeks and 33 6/7 weeks of gestation who are at risk of preterm delivery within 7 days, including for those with ruptured membranes and multiple gestations. It also may be considered for pregnant women starting at 23 0/7 weeks of gestation who are at risk of preterm delivery within 7 days, based on a family’s decision regarding resuscitation, irrespective of membrane rupture status and regardless of fetal number. Administration of betamethasone may be considered in pregnant women between 34 0/7 weeks and 36 6/7 weeks of gestation who are at risk of preterm birth within 7 days, and who have not
received a previous course of antenatal corticosteroids. A single repeat course of antenatal corticosteroids should be considered in women who are less than 34 0/7 weeks of gestation who are at risk of preterm delivery within 7 days, and whose prior course of antenatal corticosteroids was administered more than 14 days previously. Rescue course corticosteroids could be provided as early as 7 days from the prior dose, if indicated by the clinical scenario. Continued surveillance of long-term outcomes after in utero corticosteroid exposure should be supported. Quality improvement strategies to optimize appropriate and timely antenatal corticosteroid administration are encouraged.
Practice Bulletin #181, “Prevention of Rh D Alloimmunization”
Advances in the prevention and treatment of Rh D alloimmunization have been one of the great success stories of modern obstetrics. There is wide variation in prevalence rates of Rh D-negative individuals between regions, for example from 5% in India to 15% in North America (1). However, high birth rates in low prevalence areas means
Rh hemolytic disease of the newborn is still an important cause of morbidity and mortality in countries without prophylaxis programs (1). In such countries, 14% of affected fetuses are stillborn and one half of live born infants suffer neonatal death or brain injury (1). The routine use of Rh D immune globulin is responsible for the reduced rate of red cell alloimmunization in more economically developed countries. First introduced in the 1970s, the postpartum administration of Rh D immune globulin reduced the rate of alloimmunization in at-risk pregnancies from approximately
13–16% to approximately 0.5–1.8% (2, 3). The risk was further reduced to 0.14–0.2% with the addition of routine antepartum administration (2, 3). Despite considerable proof of efficacy, there are still a large number of cases of Rh D alloimmunization because of failure to follow established protocols. In addition, there are new data to help guide management, especially with regard to weak D phenotype women. The purpose of this document is to provide evidence-based guidance for the management of patients at risk of Rh D alloimmunization.
The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 58,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org