Drug and Alcohol Review (i99o) 9, 3°3-3 I°

Practical issues in the methadone management of pregnant heroin users

ROBERT G. BATEY, TRUDY PATTERSON & FRANCES SANDERS

Dru~ and Alcohol Unit, Department of Medicine, I~estmead Hospital, l#'estmead, New South l~ales, Australia

Abstract

Methadone management of pregnant heroin-using patients has become a standard approach to this particular population of patients. This paper discusses the establishment and running of an out-patient stabilization programme and highlights areas of difficulty experienced in this exercise. Guidelines are suggested for those who wish to establish such a service in the future.

Introduction

The management of pregnant heroin-using patients is a demanding process as these patients present complex and difficult problems, often not encountered in standard obstetric and medical practice. International experience has highlighted these difficulties and resear- chers in these projects have indicated that progress towards a drug-free state is often slow and erratic and that recidivisim rates are high in this population Ix-6]. This aspect of the management of these patients alone can lead to frustration and anger in staffused to dealing with more compliant patients.

Not only do pregnant heroin users face the difficulties of the non-pregnant addict, they also have additional pressures associated with the pregnancy. These indivi- duals need to consider the effect of their drug use on the developing foetus and they need to make appropriate arrangements for the baby's arrival. The pregnant heroin user often appears to lack a commitment to the usual obstetric management programmes and this lack of commitment is often seen by staff as indicating a lack of insight and care for the developing foetus.

Many attempts have been made to define an ideal programme for the pregnant heroin user and in recent years many groups have published data suggesting that

methadone programmes are an appropriate option for these women [i-12]. A number of these programmes have described an in-patient stabilization regime for establishing patients on methadone during their preg- nancy [6, 8-1i]. Whilst these programmes are effective, not all hospitals have access to beds to allow immediate admission of patients requesting methadone during their pregnancy. The Drug and Alcohol Unit at Westmead Hospital faced this difficulty. The Unit is based in a large teaching hospital in the Western Metropolitan Region of Sydney, a city with a population of 3.7 million. The hospital serves as the only teaching hospital for *.7 million of the city's population and the Obstetric Unit has an annual delivery rate exceeding 400o. Westmead Hospital was involved in treating a small number of pregnant heroin users in the period x982 to i984 and in i986 a research programme was established to examine the safety and efficacy of an Out- patient Methadone Stabilisation Programme for the pregnant heroin users. A report of the obstetric outcome of these patients has been published and the results show that our experience differs little from that of another major Sydney teaching hospital [I4, 15].

It is emphasized here that the service provided

Robert G. Batey, MB, FRACP, Trudy Patterson, BSc, Frances Sanders, BSc, Drug and Alcohol Unit, Department of Medicine, Westmead Hospital, Westmead, NSW 2x45, Australia. Correspondence and requests for reprints to Dr R. Batey.

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304 Robert G. Bate_? et al.

differed from 'in-patient' programmes in that patients were commenced on methadone as out-patients and were only admitted to hospital for obstetric complica- tions. Other strategies employed are similar for in- and out-patient approaches to management. In-patient stabilization may only require 4-5 days in-patient stay but even this can be difficult to arrange in busy obstetric units. This paper describes the practical establishment and running of the out-patient methadone stabilization programme as it is believed that a detailed survey of the practical aspects of this programme will provide insight to those wishing to commence similar services.

Establishing the programme

Patients

Heroin dependent women presenting themselves to Westmead Hospital were studied during the period February x986 to December 1988 Ix4]. A comprehensive care programme was offered to these patients and this service included management of their drug dependence, obstetric, paediatric and psychosocial needs.

Referral

The programme was not advertised widely but the existence of the new service became known quite quickly via the network that exists in a Drug and Alcohol Clinic Community. Over the study period, referral sources included local medical practitioners, staff of methadone maintenance units in the Western Area of Sydney, obstetricians, and social service organisations in the same region of the city. The majority of the women who entered the study pro- gramme were self-referred. Entry was via the Drug and Alcohol Unit or the Obstetric Antenatal Clinic.

Study population

The group entered into the methadone study comprised all pregnant heroin or methadone-dependent women in the Western Metropolitan Health Region, presenting themselves to Westmead Hospital requesting manage- ment of their obstetric and/or drug problems in the period February x986 to June i988. Three major groups of drug using patients were identified and included in the study:

*. Women having a heroin problem who requested treatment with methadone at the Westmead Hospital Drug and Alcohol Unit and who became part of the comprehensive management programme (46 patients).

2. Women who were already on methadone from outside prescribers who presented themselves to the hospital requesting obstetric management at the Antenatal Clinic (x2 patients).

3. Women who used heroin until their presentation for delivery were included in a third study group. This population was further divided into two, a division being determined by the frequency of their use of heroin (26 patients).

Nature of the programme

A comprehensive service which included steps to address their drug dependence, obstetric, neonatal, counselling and social welfare needs was provided to the group of patients placed on methadone at Westmead Hospital. This programme involved a number of staff and these included: the prescriber, a physician in the Drug and Alcohol Unit, a research nurse with paedia- tric, midwifery and counselling skills, a part-time welfare officer with counselling and welfare work skills, and an obstetrician who saw all of the pregnant heroin- using patients. A special antenatal clinic for high risk pregnancies was established and all patients were seen in this clinic at routine visits. A neonatologist was involved in the Special Care Nursery Management with the majority of the babies born to women in this study population. A specific management protocol for these was designed by the neonatologist and the staff of the Special Care Nursery and this will be described in a separate publication. In addition to these specifically identified personnel, nursing staff on the obstetric ward, nurses in the outpatient department and members of the department of Clinical Psychology, Psychiatry, Phar- mac,/" and Social Work were intermittently involved in the management 9 f many of these patients.

A management protocol for these patients was prepared by the Research Officers involved in the project in consultation with the Obstetric Department staff, the Special Care Nursery staff and the Child at Risk Committee, all of whom were involved in the patient's care. The policies contained in the protocol were communicated to members of the Obstetric Team through repeated inservice teaching sessions. With significant staff turnover being a feature of any major hospital it is important that staff are continually being made aware of management policies. Protocol was seen as highly important for maintaining the cohesion within a multi-disciplinary team working with the patient throughout the pregnancy.

Assessment

On presentation to the Drug and Alcohol Service, patients were advised of the research nature of the programme and informed consent was obtained from all patients entering the study. Normally patients would need to be advised of the Unit policies relating to the methadone programme. After obtaining consent, patients underwent an initial assessment conducted

alternately by the research nurse or the welfare officer. At this initial interview, data was collected to cover a range of factors deemed important in determining the patient's suitability for treatment and to define areas of immediate need. Information was also obtained for the Department of Health Pharmaceutical Services Branch which re- quired a specific application form to be completed for approval for methadone treatment. A very large data base was collected from patients during the study period and this questionnaire is available from the authors on request. At the first visit to the Unit a urinary drug screen was taken and blood was collected for hepatitis B and HIV serology, liv/~r function tests, full blood count and ESR. Following the initial assessment the patient was given an appointment for a medical assessment by the Drug and Alcohol medical officer and the patient was booked into the Obstetric Antenatal Clinic if this had not already been done.

A general and medical assessment followed the initial assessment by the research officer. The research officer responsible for the first interview attended the medical assessment so that the facts given by the patient could be confirmed and any discrepancies discussed in full with both members of the managing team. At the medical assessment the patient was advised of the consequences of methadone use for the newly born child and questions relating to medical complications of the drug use were dealt with. A repeat drug screen was collected at the time of the medical assessment and at this visit the patient was advised of the results of the blood test taken in the previous week. Following a physical examination to determine if there were any complications of regular intravenous drug use, a methadone dosage was determined for that patient and therapy with methadone commenced. Factors influenc- ing the dosage of methadone provided included the length and extent of the patient's heroin habit and the nature of the physical signs present. Signs of significant liver disease or of nutritional impairment were an indication for a lower starting dose (20-25 mg metha- done). In general, patients were in reasonable health. For practical reasons, patients were never commenced on methadone on a Friday because of the real difficulty of arranging follow-up visits over the weekend. The majority of patients had their medical appointment on a Wednesday and commenced their dosage on that day or on the subsequent Wednesday. Patients were seen daily (Monday to Friday) for one week following commence- ment on the methadone programme and the dosage of methadone was modified according to their response to the initial dose. Dispensing of methadone occurred in the Out-patient Pharmacy on weekdays. Weekend doses were provided in the Accident and Emergency Depart- ment and when patients were stabilized, take-away rights for weekend doses were sought from the Department of Health.

Methadone management of pregnant heroin users 3o 5

Exclusion criteria

Women were not accepted into the Out-patient Metha- done Programme if they were:

x. Under i8 years of age; 2. Using heroin intermittently (i.e. less than three times

per week)~ 3" Using intravenous heroin for a period of less than six

months; 4. Using less than AUS$z 5 worth of heroin per day.

Patients were excluded if their urine tests were negative for heroin. Regular street methadone use was not regarded as a contraindication to entry to this study. Our present practice would include patients under i8 years of age if the patient fulfilled criteria for a regular heroin habit.

Once a patient had proceeded through the initial assessment, the medical assessment and the routine testings associated with this, approval to commence methadone was obtained by telephone contact with the New South Wales Department of Health, Pharmaceuti- cal Services Branch and the dose was commenced.

Often this period of assessment took up to three weeks and this is now regarded as an inappropriately long delay. Patients in the study who presented themselves later in their pregnancy (after 28 weeks) often had the assessment process facilitated so that they could commence on the drug and stabilise well before delivery was expected.

Methadone prescribing schedule

An initial dose, ranging between 2o and 40 mg was prescribed for all patients in the Westmead treatment group. The dose chosen was dependent on the patient's drug history and, in particular, the length of the habit and the claimed daily expenditure on heroin. Medical factors did influence the dosage prescribed (see above). Having commenced treatment, patients were observed daily as they presented themselves for their medication and they were asked additionally to report any symp- toms or signs that they may have experienced which may have suggested withdrawal from opiates or over- dosage by the methadone. Doses were able to be adjusted on a daily basis for these patients in the first week of treatment. Following stabilization, changes in dosage were only implemented if patients made a formal request to discuss the matter with the prescriber or with one of the counsellors.

Rapid, effective stabilisation is imperative in an out- patient programme and staff must be available for daily contact during this stabilization. Failure to achieve effective stabilization quickly will be associated with continued drug use and an increased risk of foetal harm associated with 'double dosing', i.e. methadone plus other drugs.

306 Robert G. Batey et a l .

Dosage reduction protocol

All patients entering the study were advised at assess- ment that it would be most appropriate for them to consider withdrawing from their methadone prior to the birth of the child. Most patients chose not to reduce their dose to zero prior to delivery and a number of patients presented themselves at greater than 3 ° weeks of pregnancy, making it almost impossible to implement a stabilization and withdrawal regime in the time available. These patients remained on a stable dosage.

The rules relating to dosage reduction were estab- lished at the commencement of this project and were as follows:

I. No dosage reduction was implemented during the first trimester of pregnancy.

2. Dosage reductions of between 2. 5 and 5 mg per week were possible during the second and early third trimester.

3. As the date of delivery drew closer, it was felt inappropriate to initiate any significant reduction in dosage schedules. Patients who were already with- drawing and showing no stress from this were continued in a withdrawal regime up until the time of delivery.

4. Any reduction programme was premised by the fact that the dosage reductions could be suspended at any point if the patient requested this course of action.

Patients undertaking a reduction programme were seen on a four to six weekly basis by the prescriber and, as with all patients, they were able to be seen daily by the research officers. Complex requests which did not relate specifically to drug doses were taken to a full Drug and Alcohol Unit Staff Intake Meeting for discussion. Simple requests and problems were dealt with immedi- ately by the research team.

Treatment of drug using partners

Experience at Westmead Hospital prior to the com- mencement of these studies suggested that it was appropriate to offer methadone to the heroin-using partners of pregnant women. Failure to provide the drug to a partner frequently led to significant conflict between the two individuals. The New South Wales Department of Health facilitated the process of having the partner placed on methadone even though this policy at times meant that the partner 'jumped the queue' for other non-pregnant individuals. Experience during the study added strength to the belief that it is important to have both members of a partnership on the same treatment.

Continuing management

Having stabilized patients on methadone they, and their partner (if appropriate), were managed according to the

rules of the New South Wales Methadone Programme. They were additionally managed by the Obstetric Out- patient Clinic at the In-patient Services where required. Liaison between the obstetric team and the Drug and Alcohol Unit was maintained by the research team attending the Tuesday Antenatal Clinic on a weekly basis to see those patients who were on the programme, and to discuss with them and the obstetric team any difficulties that were being experienced.

Patients in the programme had a random urine sample collected on a weekly basis. Results of these urine screens were available within eight days. Use of illicit drugs identified by the urine screening was discussed with the patient at the regular visits to the prescriber.

Patients and their partners were expected to comply with the state government rules and regulations relating to the programme. In this group of pregnant patients the penalties for breaking the guidelines were not adhered to as rigidly as they might have been in a Unit dealing with non-pregnant patients, e.g. intermittent use of heroin even on five or more occasions was not an automatic indication for withdrawal from the metha- done programme. The reason for allowing a little leeway in this aspect of the programme related quite specifically to the fact that the patient taken off a methadone programme frequently continues to use heroin and often increases the use of heroin significantly. This behaviour increases the risk to the developing foetus.

It is imperative to stress that if any patient continued to use heroin on a regular (greater than three times per week) basis despite discussion of this difficulty she was withdrawn from methadone by reducing the dosage at a rate of 2.5- 5 mg per week. The rationale for this response relates to the fact that patients continuing to use heroin were receiving two sources of opiates, often on a daily basis. The risk associated with the double- dose of opiates was considered to be significant enough to withdraw methadone. Ultimately only two patients were withdrawn throughout the study period.

Obstetric management

Ante-natal care

The majority of patients were managed obstetrically at Westmead as indicated above. A small number were managed at other hospitals in the State and these hospitals adhered to the Westmead Hospital manage- ment protocol.

With the exception of two privately insured patients, all the Westmead patients were treated at the public antenatal out-patient clinic by one obstetrician and his affiliated registrar and nursing team. The management of the pregnancy in the out-patients followed routine

obstetric guidelines. The patients were initially seen in Clinic at the same frequency as non-drug users. If they showed signs of developing specific complications they were seen more frequently. Attendance at clinics was not always reliable even if complications were present. These patients did, on occasions, request to see the obstetrician at times other than the formal clinic time and the need for an urgent consult was determined by the research staff in consultation with the obstetric registrar. In addition to routine screening these patients were tested for sexually transmitted diseases and ultrasound examinations were more closely monitored to determine the rate of growth of the foetus. All patients in the study were screened for hepatitis B virus infection and HIV infection at entry to the study and again at 36 weeks because of the risk these patients have of contracting these illnesses at any time during their drug career.

Electrotochographs were performed at 32, 34, 36 and 38 weeks and at term. Referral for placental flow studies was made by the obstetric staff if these were indicated by the other investigations or by clinical signs.

Delivery

These patients were treated as routine obstetric eases and during labour, patients were admitted to the Delivery Suite where they underwent routine assessment and routine management of their subsequent labour and delivery. Foetal heart rate was monitored continuously once labour was fully established, to assess foetal wellbeing. Methadone dosage on the day of labour was not witheld unless surgery was considered highly likely. Analgesics were provided for all these patients as for any other non-drug using patient. Epidural anaesthesia was encouraged but not utilised in all cases. It was found that this approach to the management of these women led to minimal problems during their labour and in the post partum period. Analgesia prescribed, in addition to their routine methadone, was found to be efficacious. There is no indication for witholding analgesia in these patients although there is often a tendency for staff to use opiates sparingly in these patients.

The on-call paediatrician was present for every delivery in the Westmead stabilized group of patients. Heroin-using groups were at a disadvantage in that they usually presented themselves late in pregnancy and did not give a full history of their drug use to the attending staff. In these cases the paediatrician was called when signs of foetal distress appeared, or when evidence of drug use by the mother became apparent. Narcan was not given to any of the newborn babies. Its use is quite inappropriate as it may induce severe withdrawal symptoms that will require sedative therapy to control them.

Methadone management of pregnant heroin users 307

Postnatal management of mother and baby

Postnatal management of all of the drug-using patients followed routine management patterns established within the Westmead Hospital Obstetric Unit. Patients on methadone were given their dose on a daily basis and at no stage was the dose withheld unless the mother requested this. Breastfeeding was encouraged if the woman was not using heroin or drugs, other than the prescribed methadone. Methadone therapy is not a contraindication to breastfeeding. Patients were visited by either one of the research workers on a daily basis during the hospitalization. The aim of the visits was to provide support and to liaise between the patient and the ward staff if problems arose. The number of visits increased if the patient was particularly dependent on the research staff but the development of their own independence was encouraged.

The neonates were admitted to the Special Care Nursery of the hospital under the care of one neona- tologist and his affiliated registrar. Babies were observed for 72 hours post delivery for signs and symptoms of opiate withdrawal. All babies were placed on a Neonatal Abstinence Score Chart and this was found to be efficacious in assessing the severity of the opiate withdrawal. If withdrawal symptoms and signs became evident, medication was given according to the severity of the withdrawal and the neonate's response to the treatment. In the early phase of the study, Paragoric was administered but in the latter i2 months of the study Phenobarbitone became the drug of choice for the management of withdrawal.

Child 'At Risk' notification

State Youth and Community Services Authority was notified only if the child was considered to be At Risk. In the majority of cases in the methadone-treated group notification was not made, although cases were dis- cussed at the hospital Child At Risk Committee. Even in the group of heroin-using mothers, risk was not considered great enough to justify routine notification to Youth and Community Services. The factors that were considered in determining an At Risk Classifica- tion included:

i. Heroin use up until delivery; 2. Ongoing drug use despite methadone therapy; 3. Poor antenatal clinic attendance; 4. Past history of child abuse; 5. Inability to provide accommodation for the newborn

baby.

It is emphasized that one of these factors alone was not seen as grounds for automatic notification of a patient. During the study, a total of three heroin users were notified and only one baby was in care at the completion of the study.

308 Robert G. Batey et al.

Conclusions

In that this paper reports the establishment of a programme for managing patients there are no statis- tical results presented for discussion. The obstetric outcome of the patients has already been reported [I4]. The programme established at Westmead has now continued beyond the research state to a routine service for drug-using pregnant women and the discussion highlights the difficulties that have had to be overcome in developing this permanent service.

Management problems

A number of problems were experienced in the overall management of the methadone programme in this group of patients. Pregnant women often came with a complex variety of specific problems that needed relatively urgent attention because of the patient's tendency to present themselves late in pregnancy. Further, problems were experienced by the Unit in achieving a wholistic approach to the patient and often to her drug-using partner. It became evident that a lot of energy and attention to detail was needed to keep all those involved in the care of these patients working towards the one goal rather than different goals. Management of these patients was further complicated by the fact that methadone therapy itself is a treatment option that needs to be closely supervised.

Patient's problems

Problems experienced by a pregnant intravenous drug user on or off methadone include the drug dependence state itself, sociological, psychological and physical distress secondary to the drug usage and additionally they" do experience obstetric problems [I4].

Drug dependence problems in these patients were real and difficult to address. The foetus does influence how one responds to the needs and behaviours of the pregnant female. Repeated drug use or the missing of occasional doses of methadone were excused in the pregnant group, whereas this behaviour would have led the non-pregnant patient to have been withdrawn from many methadone programmes. The pregnant patient's behaviour tends to reflect their level of dependence rather than their awareness of the pregnant condition and the responsibilities attendent on being pregnant. Unfortunately methadone, the drug, does not address many of the factors influencing the life and behaviours of the dependent individual. Patients remain dependent, unemployed, in need of accommodation, out of touch with non-drug using individuals and quite different energies need to be employed to achieve change in these areas. Attention to these details by the Drug and Alcohol Team sometimes led to conflict with the

obstetric staff. It seemed, at times, that the research team were more inclined to condone or accept maternal drug use in addition to methadone if the patient was making progress, solving some of her other problems rather than to care 'for the developing foetus' by withdrawing the patient from the methadone pro- gramme.

Drugs were used by patients in the study including heroin, benzodiazepines and amphetamines, a pattern similar to that seen in non-pregnant methadone patients. It is of note that a higher percentage of women stabilized during their pregnancy used other drugs (3o%) than did those who had been on methadone when they first presented themselves to the Unit (less than 20%).

Obstetric complications and management strategies

Pregnancies in drug-using women are normally consi- dered to be 'high-risk' with an increased incidence in maternal and foetal complications including miscarri- age, placental abruption, intrauterine infection, prema- ture delivery, antepartum and postpartum haemorrhage, intrauterine hypoxia or anoxia and small gestational weight for age, stillbirth and neonatal withdrawal syndromes [9, x6].

This significant list of possible complications does, and did, raise the anxiety level of all staffinvolved in the management of these patients. It is of interest that the obstetric outcome data from the study indicates that whilst babies were born at a younger age than the control patients' children, and although they were significantly lighter than the control patients' babies, their overall outcome was good [I4]. As indicated in the Methods section, many of these patients did not present themselves until much later in their pregnancy than the control patients and the average number of attendances at the Antenatal Clinic was significantly lower than that of the non-drug using women. This again~ placed some stress on the managing teams and raised the possibility of conflict between the team and the pregnant women. The need for a Drug and Alcohol staff member to attend the Antenatal Clinic was very evident throughout the study. Patients were able to discuss their frustrations and difficulties with this staff member.

Psychological and sociological needs and their management

Drug-dependent patients present themselves with significant psychological difficulties and with a back- ground often including criminality, drug and/or alcohol dependence, psychiatric illness, little education and poor parenting skills [17]. Many of the women in our population have significant issues of unresolved loss or grief due to the death, divorce or separation of family

members, or their own personal experiences of the legal and welfare system. Many of these patients had lost children into custody from previous pregnancies and this led them to be anxious about the outcome of the pregnancy they presented with prior to entry into the study. It is important to stress that all of these experiences make the patient both difficult to manage and suspicious of people seeking to get close to them. Their experience of ' the system' in general has often left them cynical and doubtful as to its ability to really meet their individual needs. Many of these patients played on their difficulties in non-constructive ways by speaking briefly to the research team members about particular problems but then failing to follow through recommen- dations that were made. This capacity of the patient to consume a lot o f staff time led to a decision part way through the project to enforce an appointment system for most patients and to indicate that only absolute emergencies would be dealt with on an adhoc basis. The mere process of asking patients to keep appointments significantly decreased the number of non-specific requests made by them.

These patients often presented themselves with sociological problems that required specific attention. The need for the attention was often relatively urgent, e.g. housing situations had to be resolved prior to the arrival of the baby. Many of the patients in this group claimed to be homeless, without a regular income, heavily in debt with legal charges pending. The time of the welfare workers was often very fully committed dealing with issues such as these. A policy was taken by the research t eam early in the project, following discussions within the Unit, that patients with many of these needs would be encouraged to work through to a full resolution of their problems using their own resources. Patients were given advice on appropriate ways of dealing with their issues and were then encouraged to follow-up on these courses of action.

Our own unit tried to address the needs of the group of patients in a variety of ways, one of these including a regular group meeting held on a weekly basis. The two research officers in the project coordinated the meeting which revolved around a morning tea discussion programme. Agendas for the meetings were never rigidly set and if clients wished to bring up particular problems these were dealt with by the group. Over a period of months, interest in the group waned and it was finally discontinued. The role of a group meeting for patients remains unclear but the value of the group in providing an opportunity for several individuals to be attended to at once remains very real and new programmes need to consider the need for and viability of such a group in future programmes.

Our previous publication Ix4] indicates that it is quite appropriate to consider managing pregnant heroin- using patients on an out-patient basis during stabiliza-

Methadone management of pregnant heroin users 3o9

tion of their methadone dosages and their subsequent withdrawal to a safe level of treatment. This paper has sought to outline some of the daily issues associated with the treatment of this particular group of patients. Experience at the Westmead Unit indicates that a high degree of communication is required to ensure that such a programme functions efficiently. Our own research staff acted as the coordinators of this project largely because of the need for trained Drug and Alcohol workers to encourage ongoing change in these patients. Any clinical unit established to care for these patients should appoint one or two individuals to the team who will deal with the Drug and Alcohol problems and coordinate the overall management of the patients. Members of the obstetric, neonatal, social work and drug and alcohol units of each hospital involved in the provision of these services need to be identified as having a particular interest in the management of these patients, and this group needs to meet on a regular basis to ensure that the practical management steps are all continuing to function well. The hospital Child at Risk Committee should be involved in the management of these patients. Such Committees are often linked into the service through the Social Work Department and/or the Drug and Alcohol Service. Decisions are made at this Committee as to whether patients ultimately have to be identified to the government Youth and Commu- nity Services.

Whilst many practical difficulties can arise in the management of the pregnant heroin-using patient, it is possible to provide management for them which will assist them through their pregnancy and which will result in the delivery of a child that is likely to be healthy and to develop normally post partum. One of the keys to an effective management programme for this group of patients is the recognition that all those involved in the care of the patient need to meet regularly to discuss the progress of the individual through the programme.

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