Chapter Notes: Miscellaneous medical disorders

Table of Contents
1. Introduction
2. General Considerations
3. Respiratory Disorders
4. Neurological Conditions
5. Rheumatology
6. Liver Disorders
7. Hyperemesis
8. Acute Abdominal Complications
9. Dermatoses of pregnancy
10. Human Immunodeficiency Virus (HIV)
11. Psychiatric Disorders During Pregnancy
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Introduction

• Most medical conditions in this age group are not expected to cause serious health problems, although some, such as epilepsy, asthma, and migraine, have the potential to do so. 
• It is crucial for women to receive proper guidance before pregnancy regarding the possible impacts of their medical conditions.
•  They should enter pregnancy with confidence in their regular medications or specific plans to adjust treatment during the first trimester. This necessitates easy access to specialist support once they become pregnant.
• There may be a decrease in the effectiveness of medical treatments for long-term conditions during pregnancy, so it is important to discuss these issues beforehand.
•  This is particularly relevant for matters such as anticoagulation in high-risk patients or renal protection with angiotensin-converting enzyme (ACE) inhibitors.

Medical Disorders Impacting Pregnancy

• Various medical disorders can influence a mother's health during pregnancy and the postpartum period.
• These disorders can be categorized into two groups:
  • Conditions that are not related to pregnancy, where no deterioration is anticipated.
  • Conditions that are likely to worsen due to pregnancy, which are of particular concern to obstetricians.
• Additionally, incidental issues that may lead to severe health problems require careful management, although the care pathways for these conditions are often less established.

General Considerations

• The average age at which women are having children has been gradually increasing in recent years.
• This trend raises the likelihood of pregnancies being complicated by other medical conditions, which can significantly impact women's health.
• In the United Kingdom, data from 2000 to 2002 indicates that 3% of deliveries are to women aged 40 and older.
• In certain regions, this percentage increases to 6% for women aged 40 and above.
• This shift reflects a substantial change and may contribute to the rise in reported indirect deaths in maternal mortality reviews.

Management of Women with Medical Disorders

• It is often most effective to manage women with medical conditions in clinics that offer expertise in both obstetrics and medicine, along with midwifery support.
• These specialized clinics facilitate outpatient care for patients when issues arise and ensure smooth communication among the involved medical teams.
• Acting as a central point of contact during early pregnancy, these clinics are crucial for women whose treatment needs to be adjusted quickly.
• They also play a vital role later in pregnancy if complications emerge.
• The latest triennial review emphasizes the importance of integrated care plans for women with medical disorders.
• Effective communication among different specialties and early, experienced assessments are essential to ensure that women with complications receive care in centers with the appropriate expertise.

Respiratory Disorders

• Women with respiratory disorders require careful assessment during antenatal care. 
• For those at risk of respiratory issues during pregnancy or delivery, specific tests and evaluations may be necessary.
• Key Points:
  • Pulmonary Function Tests: These tests may be needed to assess lung function in pregnant women with respiratory disorders.
  • Echocardiography: This imaging technique can help rule out related pulmonary vascular disease.
  • Anesthetic Consultation: Obtaining an anesthetic opinion before the third trimester is advisable, especially for individuals with potential respiratory compromise due to musculoskeletal issues.

Breathlessness

• Breathlessness during pregnancy can be difficult to interpret.
• While some level of breathlessness is normal, it may also signify serious conditions such as:
  • Thromboembolism
  • Cardiac disease
  • Worsening of existing respiratory conditions
• Patients experiencing breathlessness should undergo a comprehensive clinical evaluation, including:
  • Medical history and physical examination
  • Measurement of oxygen saturation levels
  • Arterial blood gas analysis to assess respiratory function
  • Chest X-rays to identify any underlying issues
  • It is crucial to seek guidance from experienced medical professionals if there are concerns about potential underlying problems.

Management of Acute Respiratory Compromise

• In certain situations, addressing acute respiratory compromise may necessitate delivery.
• Although the body's adaptations to pregnancy are not critically dependent on respiratory changes, pre-existing conditions can mean:
  • Pregnancy might worsen the condition, including diaphragm splinting.
  • Delivery could be vital for recovery.
• This might result in a Caesarean delivery in complex cases, requiring involvement from:
  • Experienced obstetricians
  • Medical professionals
  • Anesthetists
• Such patients may require general anaesthesia and intensive care following delivery.

Asthma

• Asthma is the most prevalent respiratory condition, impacting 3% of women of childbearing age.
• The effects of pregnancy on asthma can vary, but for the majority of women, there is no significant impact.
• A common reason for the deterioration of asthma symptoms is when patients discontinue their treatment, believing it may be harmful.
• All medications used to manage asthma are safe during pregnancy.
• Patients should be reassured that asthma flare-ups should not be overlooked, and medications such as steroids are safe for both the mother and the baby.
• There is no evidence to suggest that asthma significantly affects fetal growth or outcomes.
• Any patient experiencing worsening asthma, particularly in the third trimester, should seek consultation with an obstetric physician.
• It is crucial to have optimal asthma control before the onset of labor.
• Patients in labor should receive treatment according to an agreed-upon protocol.
• Asthma attacks during labor are rare, likely due to increased levels of cortisol.
• In the event of an attack, standard treatments such as inhaled beta-sympathomimetics can be used to manage the situation.
• Patients on maintenance glucocorticoids, such as Prednisolone at doses over 5 mg daily, require hydrocortisone cover during labor.
• For operative deliveries, epidural anesthesia is preferred over general anesthesia; if general anesthesia is necessary, the care provided is similar to that for non-pregnant patients.
• Patients with severe asthma should plan to deliver in facilities equipped with appropriate support and medical expertise.
• Acute asthma can lead to complications, so it needs to be managed with great care.

Pneumonia

• Pneumonia can pose a serious health risk for women of childbearing age.
• Acute pneumonia necessitates treatment from experienced medical professionals, and imaging should not be overlooked if it is essential for care.
• Most antibiotics are generally considered safe for pregnant women.
• It is crucial to treat infections vigorously rather than holding back due to unfounded concerns about medications.
• Management objectives include:
  • Preventing respiratory complications, especially if delivery is necessary, as this carries a high risk.
  • Preventing the infection from advancing to septicemia, which can lead to unstable blood flow.
• Early involvement of anesthesiology is important if delivery may be required.
• Women with pneumonia are at an increased risk of preterm labor, likely due to fever and the release of prostaglandins.
• Varicella pneumonia is especially worrisome for pregnant women and necessitates intravenous acyclovir treatment.
• This condition may occur in conjunction with encephalitis and hepatitis.
• Up to 10% of women with varicella may develop pneumonia and require hospitalization for intravenous therapy.
• Current studies suggest that acyclovir does not significantly harm the fetus, although further research is needed for confirmation.
• With acyclovir treatment, the case fatality rate has decreased to 1% or lower.

Tuberculosis

• Pulmonary tuberculosis may first be diagnosed during pregnancy.
• Obstetricians should watch for symptoms like cough, malaise, or weight loss in pregnant patients from high-risk groups.
• Most tuberculosis treatments, such as ethambutol, rifampicin, isoniazid with pyridoxine, and pyrazinamide, are generally considered safe during pregnancy.
• However, streptomycin should be avoided as it can harm the VIII cranial nerve.
• There is no strong evidence to suggest that tuberculosis adversely affects pregnancy outcomes if treatment is initiated in the first half of pregnancy.

Post-Birth Treatment

• After birth, neonates typically receive prophylactic isoniazid for 3 months.
• Following this, a BCG vaccination should be given, although its effectiveness remains uncertain.

Cystic Fibrosis

• Cystic fibrosis is a rare condition during pregnancy.
• More women with cystic fibrosis are reaching an age where they can think about getting pregnant.
• Pre-conception counselling is very crucial.
• Important tests include:
  • Pulmonary function tests
  • Echocardiography to check for pulmonary hypertension
  • Arterial blood gases
• These tests help determine if pregnancy is a good idea.
• Chest infections during pregnancy need prompt and expert treatment.
• Other problems, like diabetes, need careful management.
• It is recommended for the patient to consult an anaesthetist during pregnancy.
• This consultation helps evaluate pain relief and anaesthesia options for labour, preferably using an epidural anaesthetic.
• Most women with cystic fibrosis have positive pregnancy outcomes.
• Comprehensive support is essential to tackle the unique challenges these women face.

Respiratory failure postpartum 

• Respiratory failure can manifest for the first time following childbirth.
• Potential causes include:
  • Adult Respiratory Distress Syndrome (ARDS)
  • Pulmonary edema resulting from pre-eclampsia
  • Amniotic fluid embolism
  • Pulmonary embolism
  • Infection
  • Lung collapse
  • Side effects of tocolysis
• A definitive diagnosis is often lacking, leading to the provision of supportive care.
• Clinicians must exclude any undiagnosed cardiac conditions or peri-partum cardiomyopathy.
• It is crucial to protect the patient from thromboembolic complications.
• ARDS continues to be a recognized cause of maternal mortality.

Neurological Conditions

• While serious cases of neurological diseases during pregnancy are rare, cerebral hemorrhage remains a significant cause of maternal death. Conditions like epilepsy and migraine often lead to various health issues.

Epilepsy

• Women of childbearing age with epilepsy on maintenance therapy should have their treatment reviewed.
• Monotherapy is recommended when possible.
• Antiepileptic drugs can cause teratogenicity, so a daily dose of folic acid. 
• Mg is typically prescribed due to the common folate deficiency in mothers on these medications.
• It's essential to control seizures to reduce maternal morbidity, as seizures can be fatal.
• Patients must be monitored during pregnancy for necessary dose adjustments.
• Sodium valproate is particularly concerning in the second and third trimesters, as data indicate increased educational needs in children exposed in utero.
• All patients should undergo an anomaly ultrasoundto check for specific abnormalities linked to their medication, such as:
  • Orofacial clefts
  • Neural tube defects
  • Craniofacial dysmorphism
• Vitamin K is advised from 36 weeks onward to prevent neonatal bleeding disorders.
• Epileptic seizures may happen during labour, which can complicate diagnoses that include eclampsia.
• In such cases, seizures should be treated as usual, and epidural anaesthesia may help reduce their frequency.
• Postpartum drug doses may need adjusting if they were increased during pregnancy.
• Specific guidance must be provided to women with epilepsy regarding childcare, such as avoiding bathing the baby alone.
• Patient organisations offer valuable information leaflets for support.

Migraine

• During pregnancy, headaches are a frequent concern, and individuals with a history of migraines may find their symptoms worsening in the first trimester.
• Many patients who previously relied on ergot alkaloids for migraine relief should avoid these medications during pregnancy.
• Fortunately, migraines often show significant improvement during the second and third trimesters.
• If migraine issues persist, potential treatment options for prevention include:
  • Low-dose aspirin
  • Paracetamol
  • Codeine for pain relief
  • Propranolol if migraines continue to be a problem
• In the case of a new type of migraine developing during pregnancy, it is essential to seek guidance from a qualified professional to rule out any serious underlying conditions.

Cerebrovascular disease

• Cerebral hemorrhage is a major cause of serious illness and death in pregnant women.
• It can occur due to uncontrolled high blood pressure or problems with blood vessels in the brain.
• Pregnant patients with neurological symptoms should be evaluated the same way as those who are not pregnant.
• Ischemic strokes can happen during pregnancy, but there is debate about whether this is linked to the increased blood clotting that occurs during this time.
• It is crucial to check for any underlying thrombophilic conditions and consider additional measures to prevent blood clots.
• The maternal mortality report from 2004 found that 17 out of 21 cases of intracranial hemorrhage were due to subarachnoid hemorrhage, and none of these cases occurred during labor.
• In 7 of these cases, an aneurysm was identified as the cause.

Cerebral Vein Thrombosis (CVT)

• Cerebral vein thrombosis is a rare condition during pregnancy.
• It typically presents with a severe headache.
• Most cases occur after childbirth and are often associated with dehydration.
• Diagnosis requires Magnetic Resonance Imaging (MRI).
• Although Computer Tomography (CT) scans are commonly used, MRI is better for detecting acute intracerebral bleeding.
• There is ongoing debate about treatment options, but anticoagulation is increasingly used, even in patients with a history of bleeding.

Rheumatology

Antiphospholipid Syndrome (APS) and Systemic Lupus Erythematosus (SLE) in Pregnancy

• Systemic lupus erythematosus (SLE) can have a negative impact on pregnancy outcomes.
• Pregnancies that occur during periods of disease stability tend to have better results.
• When SLE is unstable or during flare-ups, the outcomes can be poorer.
• A significant factor contributing to these poor outcomes is secondary antiphospholipid syndrome (APS).
• APS increases the risks of:
  • Intrauterine growth retardation
  • Placental abruption
  • Pre-eclampsia
• It is crucial to monitor immunosuppressive treatment carefully during pregnancy.
• Associated infections and disease flare-ups should be addressed promptly.
• Antiphospholipid Syndrome (APS)is an acquired condition characterized by:
  • Increased risk of thrombosis
  • Recurrent miscarriages
  • Poor pregnancy outcomes
  • Thrombocytopenia (low platelet count)
• Diagnosis is confirmed through laboratory tests measuring:
  • Anticardiolipin antibody levels
  • Lupus anticoagulant
• These tests must be positive on two separate occasions, at least 6 weeks apart, as transient positivity can occur during viral infections.
• Treatment during pregnancy typically includes:
  • Anti-platelet therapy with low-dose aspirin
  • Heparin
• Autoantibodies to Ro and Lacan complicate pregnancies, leading to:
  • Congenital heart block
  • Neonatal lupus syndrome

Rheumatoid Arthritis

• During pregnancy, women with mild rheumatoid arthritis may find that their symptoms improve temporarily. This improvement is likely due to the steroid-like effects of placental hormones.
• An increasing number of women with moderate or severe rheumatoid arthritis are considering pregnancy, thanks to the success of disease-modifying drugs such as methotrexate, leflunomide, and tumour necrosis factor (TNF) antagonists. 
• However, these medications need to be discontinued before or early in pregnancy.
• Pregnancy can be more complicated for women with moderate to severe rheumatoid arthritis. 
• These individuals require close monitoring by a rheumatologist or obstetric physician, and it is advisable to involve an anaesthetist before delivery.
• Women undergoing long-term steroid therapy during pregnancy should be monitored more closely for gestational diabetes.
• The level of disability caused by moderate to severe rheumatoid arthritis can significantly impact a mother's ability to care for her newborn.
• Early referral to an occupational therapist can assist families in preparing for potential challenges related to caring for a newborn.

Scleroderma

• Scleroderma, which is also referred to as systemic sclerosis, is a condition that carries significant risks during pregnancy.
• This condition typically requires management in specialized medical units due to its complexity.
• Before pregnancy, it is crucial to conduct a thorough evaluation of the cardiopulmonary status of women with scleroderma who are planning to become pregnant.
• The severity of hypertension and kidney issues in scleroderma patients can vary; not all patients will experience these complications.
• However, careful management is essential for those who are affected by these issues.
• Mixed connective tissue disorders can pose challenges similar to those encountered with lupus and other rheumatic diseases, complicating the clinical picture.

Liver Disorders

• Liver disorders can complicate pregnancy, but they usually do not lead to long-term health problems.
• Cholestasis of pregnancy is the most common liver condition during pregnancy. 
• It typically leads toRisks associated with cholestasis include:
  • Intrauterine death risk increases from 37 weeks' gestation.
  • Higher likelihood of meconium passage.
  • Increased risk of preterm labour.
• The exact cause of intrauterine death is not clear, but it may be related to a toxic effect on the fetus.
• Tests for cholestasis involve liver function tests and measuring serum bile acids, but it is still uncertain whether bile acids directly cause fetal death.
• Treatment options for cholestasis include:
  • Timely delivery
  • Applying cool aqueous menthol cream to relieve itching
  • Administering Ursodeoxycholic acid and vitamin K
• Ursodeoxycholic acid is the main treatment, starting at 500 mg twice daily, with a possible increase to a maximum of 2 g daily.
• Recurrence rate for this condition is high, around 80%. Some women may have underlying liver disease, especially if they experience early onset or if liver function does not normalize after delivery.
• Acute fatty liver of pregnancy (AFLP) is a serious but rare condition that can initially present with vague symptoms such as
• Diagnosis of AFLP usually shows:
  • Moderately elevated levels of aspartate amino transferase (AST)
  • Absence of signs indicating pre-eclampsia
  • Diagnosis may be supported by imaging showing fatty change in the liver
  • Signs of liver failure in AFLP include:
  • Coagulopathy: Blood clotting issues
  • Haemodynamic instability: Unstable blood circulation
  • Hypoglycemia: Low blood sugar, especially severe cases during labor requiring immediate treatment
• Monitoring blood clotting is crucial in cases of AFLP. 
• Delivery should occur before any coagulation failure, even if it impacts fetal maturity.
• Distinguishing AFLP from HELLP syndrome or pre-eclampsia can be challenging.
• Liver dysfunction during pregnancy can also arise from incidental cases of viral or autoimmune hepatitis. If the cause is unclear, tests for acute hepatitis should be performed, and medical assistance should be sought.
• Determining whether liver dysfunction is due to a pregnancy-related issue or a separate liver problem can be difficult, potentially necessitating consideration of delivery in uncertain cases.
• Liver failure, though rare, can occur during or after pregnancy in certain situations. 
• Common causes include:
  • Paracetamol overdose
  • Viral hepatitis
  • HELLP syndrome
  • AFLP
• Accurate diagnosis is crucial, as early referral to a liver unit for potential transplantation may be necessary. While delivery may not alter the outcome of viral hepatitis, it is likely to benefit the other conditions.
• Referrals to specialist liver units typically occur after delivery if liver function continues to deteriorate, and these decisions should involve input from a specialist unit.

Hyperemesis

• Hyperemesis gravidarum refers to a condition in early pregnancy where vomiting is so severe that it necessitates hospitalization.
• Although vomiting is a common occurrence in early pregnancy, some women experience it to a much greater extent, leading to serious complications such as severe dehydration and an increased risk of thromboembolism.
• Typically, the overall outcome of the pregnancy is not impacted, but there is a heightened risk of intrauterine growth restriction (IUGR) if vomiting results in significant weight loss.
• Treatment options for hyperemesis include:
  • Consuming small, light snacks
  • Intravenous rehydration
  • In some cases, antiemetic medications such as promethazine and metoclopramide may be administered.
• The effectiveness of antiemetics is not well-established, and they are generally avoided unless there is a risk to hydration.
• It is essential to replenish B vitamins to prevent Wernicke's encephalopathy.
• In rare instances, corticosteroids may be beneficial.
• Ondansetron could be considered in exceptional cases, but evidence regarding its safety during the first trimester is still lacking.
• Total parenteral nutrition is seldom required.
• Predicting whether nausea and vomiting will recur in future pregnancies is challenging, but some women do experience these symptoms in each subsequent pregnancy.

Diagnosis Considerations

• Hyperemesis should be considered a diagnosis of exclusion.
• It is important to investigate serious underlying conditions that could be causing persistent vomiting, such as:
  • Central nervous system (CNS) disorders
  • Gastrointestinal diseases
  • Surgical issues
• Although peptic ulcers are uncommon during pregnancy, they can occur.
• In cases of ongoing vomiting, endoscopy may be a suitable option or a trial of treatment.
• Gastro-oesophageal reflux is a more prevalent condition that is easily diagnosed.
• Treatment for gastrooesophageal reflux can involve:
  • Antacids
  • Occasionally metoclopramide
  • H2 antagonists
  • Proton pump inhibitors

Acute Abdominal Complications

• During pregnancy, conditions like appendicitis, pancreatitis, and cholecystitis can arise and need prompt treatment to prevent peritonitis. Peritonitis can trigger premature labor and potentially lead to sepsis, which is a serious infection.
• Diagnosing these abdominal issues in pregnant women can be difficult, so it's important to consult with an experienced clinician. Generally, early surgical intervention for acute appendicitis is recommended to prevent peritonitis and serious complications, including the risk of preterm delivery.

Inflammatory Bowel Disease (IBD)

• Inflammatory bowel disease can complicate pregnancies, but the overall outlook for women with this condition is usually positive. However, certain specific risks need to be managed. Treatment for IBD during pregnancy is generally similar to treatment for non-pregnant patients and often involves the use of steroids and sulfasalazine.
• Pregnant women with IBD may also need supplements of haematinics (iron and related substances) and vitamin D. Additionally, potential complications such as perineal and peri-anal disease and intra-abdominal adhesions should be taken into account when planning the method of delivery.

Dermatoses of pregnancy

• Dermatoses of Pregnancy refers to a group of specific skin conditions that occur only during pregnancy. The most common among these is polymorphic eruption of pregnancy, which affects about 0.5% of pregnancies. 
• This rash typically manifests as a maculo-papular rash on the abdomen and thighs, sparing the umbilical area. 
• While it can be irritating, it is usually treated with:
  • Steroid cream for localized rashes
  • Systemic steroids for more widespread cases
• In some instances, a skin biopsy may be necessary, especially if the rash appears early and causes significant discomfort. 
• This condition generally arises in the late third trimester and does not tend to recur in future pregnancies.
• Pemphigoid Gestationis is a much rarer condition, occurring in about 1 in 60,000 pregnancies. 
• It typically begins around the umbilicus with itchy papules and plaques that can develop into vesicles and bullae over a few weeks. 
• This condition is believed to be of immunological origin and is associated with other autoimmune disorders.
• Severe cases may require treatment with systemic steroids. 
• The rash may take time to resolve after delivery and has a high likelihood of recurring in subsequent pregnancies, often appearing earlier. 
• It can also pose risks to the fetus, such as intrauterine growth restriction (IUGR), necessitating careful monitoring.
• Prurigo of Pregnancy is another type of papular rash that primarily affects the extensor surfaces and abdomen. 
• It may be linked to atopy and can be treated with:
  • Antihistamines
  • Topical steroids
• There are other skin conditions that can specifically develop during pregnancy, but dermatological consultation and biopsy are usually reserved for those that are particularly severe or do not respond to topical treatments.

Human Immunodeficiency Virus (HIV)

• Routine antenatal testing for HIV is now standard in most developed countries. 
• This testing is most effective when an opt-out approach is used. 
• Being infected with HIV presents unique challenges during pregnancy, and any antiretroviral treatment must be managed by skilled doctors. 
• Women who are infected will receive this treatment to help reduce vertical transmission and slow down disease progression.

Antiretroviral Treatment Considerations

• The choice of antiretroviral treatment depends on:
  • Clinical status
  • Viral load
  • CD4 counts
• There is no clear evidence of consistent congenital abnormalities with various antiretroviral agents, but caution should be exercised with newer medications until long-term data is available.

Reducing Perinatal Transmission

• Risks of perinatal transmission can be decreased by:
  • Caesarean delivery
  • Proper intrapartum antiretroviral treatment
  • Avoiding breastfeeding
  • Treating the newborn
• These strategies have successfully lowered mother-to-child transmission (MTCT. rates to 2% .

Psychiatric Disorders During Pregnancy

• It is becoming clear that mental health issues can lead to serious risks for mothers, including death and significant health problems. 
•  The latest report on maternal mortality highlights the important role that mental illness plays in these outcomes. 
•  During pregnancy, it is essential to assess the risk of mental health issues. 
• This assessment should include: 
  • Reviewing any past experiences with psychiatric care
  • Considering any social vulnerabilities the patient may have
• Patients who may face these issues often do not attend antenatal care regularly and are frequently from refugee or ethnic minority groups. 
•  Barriers such as language and culture can prevent these patients from getting the care they need. 
• Health-care workers must be aware of these challenges and ensure that systems are in place to help these patients access the necessary antenatal care.
• Plans should also be created to provide support during the postpartum period.
• Most psychiatric medications are generally safe during pregnancy, with few serious birth defects associated with them.
• However, lithium is an exception, as it is linked to an increased risk of a serious heart defect called Ebstein's anomaly.
• This is particularly important for patients with bipolar disorder, where a careful decision is needed between maintaining psychiatric stability and the 5% risk of this defect.
• For women dealing with anxiety and mild depression, psychotherapy and counseling may be better choices than medication.
• Tricyclic antidepressants, like imipramine or amitriptyline, seem to be safe during pregnancy, but there are reasons to consider lowering the dose or stopping before delivery because of possible side effects for the baby.
• Benzodiazepines might pose some risks to the developing fetus and are best avoided during pregnancy.
• It is reasonable for many women who are on antidepressants when they conceive to try going off the medication, provided they have support from their psychiatrist.
• Manic depressive illness and schizophrenia carry significant risks of worsening after giving birth, so planning for care in the early postpartum phase is crucial.
• Reintroducing medication after delivery should be carefully arranged in advance.
• While antipsychotic medications during pregnancy might have some risks for the fetus, the need for stability often outweighs these concerns.
•  Decisions regarding long-term treatment during pregnancy should involve discussions with a psychiatrist. 
• Substance abuse can also lead to vulnerable mothers missing out on care. It is important to identify substance abuse, as there are specific care programs available based on the type of substance used.