I am a
current fourth year medical student at Drexel University College of Medicine
rotating at The Caring Together Program -- a clinic that provides both mental
health and addiction services to women, many of which have been recently
incarcerated. Caring for this unique population has introduced me to a number
of patient circumstances that I could not have previously even imagined I would
encounter. As a student aspiring to go into the field of Obstetrics and
Gynecology, I am particularly drawn to patients at this clinic who are
pregnant, hoping to become pregnant, or are in the postpartum period.
At Caring
Together, we follow the American Committee of Obstetricians and Gynecologists
(ACOG) Committee Opinion number 511 recommendation of obtaining a complete
reproductive history from all patients upon intake to our clinic. This has
shown to be of great importance for women struggling with mental illness and
addiction, as we find many of our patients experience significant mood swings
and irritability in a cyclic pattern prior to their menstrual period. This also
helps us assess the risk of unintentional pregnancy in women, which is of great
importance as we prescribe many psychiatric medications that are labeled as
pregnancy category D (positive evidence of risk) or X (contraindicated in
pregnancy). These categorizations indicate that they carry a significant risk
of adverse perinatal and postnatal outcomes if used during pregnancy.
According to the American Family Physicians
(AAFP), each year an estimated 500,000 pregnancies in the United States involve
women who have or who will develop psychiatric illness during the pregnancy.
The use of previously mentioned category D and X psychotropic medications in
these women is a concern. However, it is not always advisable to abruptly discontinue
these medications in women who become pregnant, and decisions to do so are made
on a case-by-case basis. This issue is particularly worrisome in those with a
history of suicide attempts, significant mania, or psychosis, especially if
they have been stable on a particular medication for some time. Discontinuation
of the medication can result in significant psychiatric morbidity, leading to
poor adherence to prenatal care and ultimately worse outcomes for the mother
and her child. For all of these reasons, we not only attempt to make medication
decisions prior to conception but also assist in providing birth control for
our reproductive age women receiving psychiatric care.
In addition to making decisions
regarding prescription medication, we also screen for illicit drug use in all
of our patients with a thorough history as well as frequent urine drug screens.
Given the potential adverse fetal and maternal effects of drug use, ACOG recommends
screening all pregnant women for drug use at their first prenatal visit.
The NIDA Screen is a quick and effective way to begin the conversation about
substance use with pregnant patients.
Danielle Schenker DUCOM 2020
