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Perinatal Substance Abuse

Perinatal Substance Abuse. Denice Gardner, MSN, NNP-BC. Objectives. Discuss Perinatal Substance Abuse and its affect on the newborn. Pictures used in this presentation were obtained from the Mosby’s Nursing Consult web site. Categories of Drugs. Tobacco/Nicotine Alcohol Stimulants

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Perinatal Substance Abuse

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  1. Perinatal Substance Abuse Denice Gardner, MSN, NNP-BC

  2. Objectives • Discuss Perinatal Substance Abuse and its affect on the newborn

  3. Pictures used in this presentation were obtained from the Mosby’s Nursing Consult web site

  4. Categories of Drugs Tobacco/Nicotine Alcohol Stimulants Narcotics & Opioids Sedatives/Hypnotics Antidepressants

  5. Effects of Drugs on Pregnancy • Spontaneous abortion • Placenta previa • Placental abruption • Preterm labor • Premature rupture of membranes • C-Section delivery • Precipitous delivery • Hypertension

  6. Tobacco & Nicotine • Tobacco is a CNS stimulant • Active components of cigarette smoke • Nicotine • Tar • Carbon monoxide • Cyanide • Plus, thousands of other compounds

  7. Tobacco & Nicotine Nicotine-water & fat soluble; cross the placenta Carbon Monoxide- combines with hemoglobin & impairs oxygenation for mother & fetus; causes placental vasoconstriction & vasospasm Dose/Response relationship- the higher the number of cigarettes smoked – the greater the effect on the fetus

  8. Tobacco & Nicotine • Fetal/ Newborn Effects • Intrauterine growth restriction • Slight increase in risk for congenital malformations • Neurobehavioral effects • Sudden Infant Death Syndrome • Increased cost of hospitalization & medical care • Increased perinatal mortality

  9. Tobacco & Nicotine • Nursing Considerations • EDUCATION • Follow infant’s growth • Provide information regarding smoking cessation programs & encourage participation

  10. Alcohol CNS depressant Absorbed rapidly through the stomach & intestines; metabolized by the liver; excreted through the kidneys & lungs Fetal alcohol is eliminated only after being broken down in the maternal liver Diffuses across the placenta & impairs flow of nutrients to the fetus

  11. Alcohol Broken down into acetaldehyde & acetate. (Acetaldehyde is MORE toxic than alcohol). Is a known teratogen Fetal effects are directly related to dose, chronicity of use, gestational age, & duration of exposure

  12. Alcohol • Fetal Alcohol Spectrum Disorder (FASD) • Fetal Alcohol Syndrome (FAS) • Partial Fetal Alcohol Syndrome • Alcohol-Related Birth Defects (ARBD) • Alcohol-Related Neurodevelopmental Disorder (ARND)

  13. Fetal Alcohol Syndrome • Most severe form of FASD • Most common identifiable cause of mental retardation (also is a preventable cause) • Abnormalities in 3 domains • Poor growth • CNS abnormalities (developmental delays, impaired brain growth, abnormal structure, etc.) • Dysmorphic facial features (thin, upper lip; smooth philtrum; short palpebral fissures, etc.) • Alcohol exposure may or may not be confirmed

  14. Fetal Alcohol Syndrome

  15. Partial Fetal Alcohol Syndrome • Typical dysmorphic facial features • Abnormality in one of the domains • CNS abnormality • Growth • Behavioral or cognitive ability • Confirmed prenatal alcohol exposure

  16. Alcohol-Related Birth Defects (ARBD) Typical dysmorphic facial features Normal growth and brain function/structure Congenital anomalies in other organs (cardiac, skeletal, renal, eyes, ears) Confirmed prenatal alcohol exposure

  17. Alcohol-Related Neurodevelopmental Disorder (ARND) • Absence of typical dysmorphic facial features • Normal Growth • CNS abnormalities: • Decreased cranial size at birth • Structural brain abnormalities • Impairment of neurologic status in relation to age • Behavioral or cognitive abnormalities inconsistent with age/developmental level • Confirmed prenatal alcohol exposure

  18. Fetal Alcohol Syndrome

  19. Withdrawal from Alcohol • Begins anytime between birth & 12 hours after birth • Symptoms • Tremors • Hypertonia • Opisthotonos • Weak suck & poor feeding • Sleeplessness • Excessive crying • Excessive mouthing behavior

  20. Stimulants Cocaine Amphetamines Cannabinoids

  21. Cocaine One of most powerful addictive substances Is fat-soluble with low molecular weight so readily crosses blood-brain barrier & placenta Rarely used alone Long half-life (can be present in infant’s urine for up to 7 days of age)

  22. Cocaine • Fetal/Newborn Effects • No increase in congenital malformations • Multi-organ dysfunction • CNS: abnormal sleep pattern, EEG, & cry; seizures/tremors; cerebral infarctions • Sensory organs: increased auditory startle response; abnormal ABR • Cardiac: arrhythmias; hypertension; decreased cardiac output

  23. Cocaine • Fetal/Newborn Effects • Multi-organ dysfunction (cont.) • Respiratory: apnea; periodic breathing • Renal: ectopia • GI: intestinal perforation; early-onset NEC • Eye: vascular, disruptive lesions; retinal hemorrhage

  24. Withdrawal from Cocaine • Felt to be due to CNS irritability from effects of cocaine rather than from withdrawal • Initial period of hyperirritability followed by drowsiness &/or lethargy • Changes in behavioral state • Difficulty responding to human voice/face, comforting, &/or environmental stimuli • Difficulty maintaining alert states or rapid change is states • Hyperactive startle

  25. Amphetamines • Used medically for treatment of narcolepsy, depression, weight loss, hyperactivity • Neurotoxic • Fetal/Newborn effects: • IUGR

  26. Withdrawal from Amphetamines • Abnormal sleep patterns • Diaphoresis • Vomiting after birth • Agitation alternating with lethargy • Constriction of pupils • High-pitched cry • Loose stools • Yawning • Fever • Hyperreflexia

  27. Cannabinoids CNS- both depressant & mild hallucinogenic effects High affinity for lipids & accumulates in fatty tissue of body Placental transfer is greatest during first trimester of pregnancy Results in increased carbon monoxide levels in blood causing hypoxia

  28. Narcotics & Opioids • Natural Opioids • Morphine & Opium • Semi-synthetic Opioids • Heroin & methadone • Synthetic Opioids • Oxycodone, hydromorphone, oxycodone, Fentanyl, etc.

  29. Narcotics & Opioids • Fetal/Newborn Effects • Readily crosses placenta • Lower Apgar Scores • Do NOT use naloxone for with known/suspected narcotic & opioid dependence due to creation of rapid withdrawal & seizures • Meconium aspiration • IUGR • Lower incidence of RDS

  30. Narcotics & Opioids Congenital infections Increased incidence of SIDS Low birth weight Microcephaly Increased chromosomal abnormalities in heroine-exposed infants

  31. Sedatives/Hypnotics Barbiturates Benzodiazepines

  32. Sedative/Hypnotics Readily crosses placenta Fetal blood levels are similar to maternal blood levels Accumulate in adipose tissue High concentration also present in brain, lungs, & heart Fetuses exposed to long-term benzodiazepines may have hypotonia, feeding difficulty, & withdrawal symptoms

  33. Antidepressants • Selective Serotonin Reuptake Inhibitors (SSRIs) • Sertaline (Zoloft), Fluoxetine (Prozac), Escitalopram (Lexapro), Paroxetine (Paxil), etc. • Tricyclic Antidepressants (TCAs) • Amitriptyline (Elavil), Nortriptyline, etc. • Monoamine Oxidase Inhibitors (MAOIs) • Phenelzine (Nardil), Isocarboxazid (Marplan), etc.

  34. Neonatal Abstinence Syndrome Onset may vary from shortly after birth to 2 weeks Duration may range from 8 to 16 weeks Severity of presentation varies Infants of chronic drug abusers usually have more severe withdrawal The closer to delivery the drug is taken, the later the signs of withdrawal appear & the more severe the symptoms will be

  35. Neonatal Abstinence Syndrome • Multiorgan/System Disorder • Most common symptoms • Neurologic • Increased tone • Tremors • Exaggerated reflexes • Irritability/restlessness • High-pitched cry • Difficulty sleeping • Seizures

  36. Neonatal Abstinence Syndrome • Most common Symptoms • Autonomic • Yawning • Nasal stuffiness • Sweating • Sneezing • Low-grade fever • Mottling

  37. Neonatal Abstinence Syndrome • Most Common Symptoms • GI • Loose stools • Vomiting/regurgitation • Poor feeding • Difficulty swallowing • Excessive sucking

  38. Neonatal Abstinence Syndrome • Most Common Symptoms • Respiratory • Tachypnea • Others • Skin excoriation

  39. Neonatal Abstinence Syndrome • Onset of withdrawal symptoms • Alcohol- usually 3-12 hours after delivery • Narcotics- usually 48-72 hours after delivery, but may be as long as 4 weeks • Barbiturates- usually 4-7 days after delivery but can occur 1-14 days after delivery • Cocaine- usually 48-72 hours after delivery

  40. Neonatal Abstinence Syndrome • Severity of NAS depends on • The type of drug used • Half-life of the drug • Time of last exposure before delivery • Dose taken • Quality of labor

  41. Neonatal Abstinence Syndrome • Severity of NAS depends on • Type of analgesia/anesthesia used during labor • Maturity & status of infant • Gestational age • Nutritional status of mother

  42. Neonatal Abstinence Syndrome • Scoring Systems • Modified Finnegan Scoring Tool • Gold Standard*** • Neonatal Drug Withdrawal Scoring System • Neonatal Withdrawal Inventory

  43. Neonatal Abstinence Syndrome • Screening Tools • Maternal • Thorough history & assessment • Drug testing (urine is most commonly used) • Infant • Thorough assessment • Urine Drug screen • Meconium Drug Screen • Newer testing: hair and umbilical cord testing

  44. Neonatal Abstinence Syndrome • Nursing Management • Accurate assessment, evaluation, & use if institution’s screening tool • Comfort measures (swaddling, holding, cuddling, response to stress cues, etc.) • Assessment & encouragement of mother/infant interaction • Maternal/family support

  45. Neonatal Abstinence Syndrome • Pharmacologic management • Tincture of opium • Camphorated Tincture of Opium (Paregoric) • Morphine (most common) • Methadone • Clonidine • Chlorpromazine (Thorazine) • Phenobarbital • Diazepam

  46. Neonatal Abstinence Syndrome • Breastfeeding • Cigarettes: • not contraindicated • encourage decreasing numbers of cigarettes smoked & smoking cessation • Smoke after breast feeding • Alcohol: use should be discouraged

  47. Neonatal Abstinence Syndrome • Breastfeeding • Cocaine: contraindicated during active use • Marijuana: contraindicated • Heroin: contraindicated • Methadone: not contraindicated; should not be stopped abruptly • Sedatives/Hypnotics: dose-dependent; discontinue with signs of lethargy &/or weight loss

  48. References Chang, G., Lockwood, C.J., & Barss. (2012). Substance Use In Pregnancy. Retrieved from www.uptodate.com on 8/17/2012. Sielski, L.A., Garcia-Prats, J.A., & Kim, M.S. (2012). Infants of Mothers with Substance Abuse. Retrieved from www.uptodate.com on 8/17/2012.

  49. References Sielski, L.A., Garcia-Prats, J.A., & Kim, M.S. (2012). Neonatal Opioid Withdrawal (Neonatal Abstinence Syndrome). ` Retrieved from www.uptodate.com on 8/17/2012. Verklan, M.T. & Walden, M. (2009). Core Curriculum for Neonatal Intensive Care Nursing (4rd Edition). Elseiver Saunders: St. Louis. Retrieved from Mosby’s Nursing Consult web site on 6/16/2012.

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