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

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

Issue Date: October 15, 2019

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.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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