Letters to the Editor

Postpartum Relapse Prevention: The Family Physician's Role


Am Fam Physician. 2020 Apr 15;101(8):452-453.

Original Article: Postpartum Care: An Approach to the Fourth Trimester

Issue Date: October 15, 2019

Available at: https://www.aafp.org/afp/2019/1015/p485.html

To the Editor: I enjoyed the article on postpartum care written by Drs. Paladine, Blenning, and Strangas. I would add to it the need to anticipate the possibility of a patient's postpartum relapse to drugs. Between 50% and 75% of women who used drugs before pregnancy will completely stop using drugs during pregnancy,1 and it is easy for a physician to miss the diagnosis of substance use disorder or to become complacent about the disease. However, most of these women relapse postpartum,1 which has a significant effect on the woman's health and affects her ability to parent her newborn adequately.

At least four states have found that postpartum overdoses contribute substantially to maternal mortality. In a Maryland Maternal Mortality Review, substance use was the leading cause of pregnancy-associated deaths, with the numbers increasing.2 In a Colorado study, 30% of maternal deaths from 2004 to 2012 resulted from accidental overdose or suicide.3 Substance use disorder contributed to 33% of all maternal deaths in 2017 in Tennessee.4 Massachusetts noted 11 fatal overdoses among 4,154 women with opioid use disorder who delivered a child from 2012 to 2014. The rate was lower in women receiving pharmacotherapy for their opioid use disorder.5

Postpartum relapse is often accompanied by shame and fear of losing custody of the newborn. As family physicians, we can identify women with a history of substance use disorder who may be at risk of relapse and hopefully get them into treatment before this happens. Also, we can be alert to any signs of relapse and respond compassionately and appropriately, making sure that mothers and babies get the care they need.

Author disclosure: No relevant financial affiliations.

This letter was sent to the authors of “Postpartum Care: An Approach to the Fourth Trimester,” who declined to reply.


show all references

1. Helmbrecht GD, Thiagarajah S. Management of addiction disorders in pregnancy. J Addict Med. 2008;2(1):1–16....

2. Maryland Department of Health and Mental Hygiene: Prevention and Health Promotion Administration. Maryland Maternal Mortality Review. 2014 Annual Report. Accessed January 16, 2020. https://phpa.health.maryland.gov/documents/Health-General-Article-%C2%A713-1207-2018-Annual-Report-Maryland-Maternal-Mortality-Review.pdf

3. Metz TD, Rovner P, Hoffman MC, et al. Maternal deaths from suicide and overdose in Colorado, 2004-2012. Obstet Gynecol. 2016;128(6):1233–1240.

4. Tennessee Maternal Mortality. Review of 2017 maternal deaths. Accessed January 16, 2020. https://www.tn.gov/content/dam/tn/health/documents/mch/MMR_Annual_Report_2017.pdf

5. Schiff DM, Nielsen T, Terplan M, et al. Fatal and nonfatal overdose among pregnant and postpartum women in Massachusetts. Obstet Gynecol. 2018;132(2):466–474.

Send letters to afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680. Include your complete address, e-mail address, and telephone number. Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors.

Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.

This series is coordinated by Kenny Lin, MD, MPH, Associate Deputy Editor for AFP Online.



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