SUBSTANCE ABUSE & NEWBORNS

1. SUBSTANCE ABUSE & NEWBORNS

2. Why is this important: • 5.5% of pregnant women in the United States reported using at least one illicit drug during pregnancy. • 21.2% of pregnant women aged 12-44 reported use of alcohol and 21.5% use of cigarettes during the past month.

3. Drug Abuse in Pregnancy • National Survey on Drug Use and Health (2002-2003): 4.3% of pregnant women ages 15-44 self-reported illicit drug use in past month, and may actually be as high as 15-30%.16 • Opiate use in pregnant women ranges anywhere from 1% to 21%.1 • Tobacco use in pregnancy: 20.3% 20 • Alcohol use in pregnancy: 14.8% 20

5. Impact on Mom’s Prenatal Care/ Newborn Outcome • Poor Nutrition • Late Prenatal Care • Greater risk for: infectious diseases & Sexually transmitted diseases • Limited financial resources • Increased risk: premature birth, abruptio placenta, and fetal demise.

6. Pathophysiology of Fetal Alcohol Syndrome: Symptoms of a baby with fetal alcohol syndrome • Poor growth while the baby is in the womb and after birth • Decreased muscle tone and poor coordination • Delayed development and significant functional problems in three or more major areas: thinking, speech, movement, or social skills (as expected for the baby's age) • Heart defects such as ventricular septal defect (VSD) or atrial septal defect (ASD) Structural problems with the face, including: • Narrow, small eyes with large epicanthal fold • Small head • Small upper jaw • Smooth groove in upper lip • Smooth and thin upper lip

7. Alcohol • Associated with16: • Teratogen • IUGR • Fetal alcohol spectrum disorder • Postnatal growth deficiency • Cranial dysmorphology • Mental retardation • Acute neonatal withdrawal20

8. Fetal Alcohol Syndrome

9. Fetal Alcohol Syndrome

11. Fetal Alcohol Syndrome: Tests • Blood alcohol level in pregnant women who show signs of being drunk (intoxicated) • Brain imaging studies (CT or MRI) shows abnormal brain development • Pregnancy ultrasound shows slowed growth of the fetus • Toxicology screen

12. Cocaine Abusing Pregnant Women • Increase the risk of miscarriage • When the drug is used late in pregnancy, it may trigger premature labor • It also may cause an unborn baby to die or to have a stroke, which can result in irreversible brain damage • More likely to have a low birth-weight baby • More likely to have babies born with smaller heads and smaller brains proportionate to body size • Twice as likely to have a premature baby • Placental abruption • Baby with a malformation of the urinary tract • Feeding difficulties and sleep disturbances in newborn

13. Smoking while Pregnant • Lower the amount of oxygen available to you and your growing baby • Increase your baby's heart rate • Increase the chances of miscarriage and stillbirth • Increase the risk that your baby is born prematurely and/or born with low birth weight • Increase your baby's risk of developing respiratory (lung) problems • Elevates the risk of having a child with excess, webbed or missing fingers and toes

14. Drug Abuse in Pregnancy • No consistent pattern of congenital anomalies has been found with illicit substances (excluding EtOH, barbiturates, and maybe tobacco) in large-scale epidemiologic studies.

15. Tobacco • Associated with16: • IUGR • Behavioral problems via nicotine disruption of CNS development • May affect NAS • Placental abruption20 • PROM20 • Placenta previa20 • PTB20 • Up to 20-30% of all LBW infants20

16. Tobacco • No increased RATE of congenital anomalies in smokers, but may contribute to RISK of anomalies associated with vascular disruption20: • Cleft lip with/without cleft palate • Gastroschisis • Anal atresia • Digital anomalies

17. Tobacco • Two to four fold increased risk of SIDS20 • Smoking also increases risk of PTB & LBW, which are independent risk factors for SIDS • Four fold increased risk of DM II with maternal smoking >10 cig/d20 • Inconsistent results from studies on cognitive ability

18. Tobacco • Smoking cessation • Meta-analysis of RCT showed increased BW and decreased LBW and PTB16. • But if that’s not good enough evidence to stop smoking…

19. Tobacco “Effects of cocaine use were NO DIFFERENT than those observed from cigarette smoking” on gestational age-adjusted BW, HC, and length16

20. Marijuana • Mechanism unknown as to how it may effect neonatal outcomes16 • Proposed theory: reduced fetal oxygenation causing diminished fetal growth.16

21. Marijuana Inconclusive data on birth weight (BW)16or gestational age20 • Full gamut: associated with LBW, no difference in BW among controls, & increased BW (up to 142 gm over controls). • 1997 meta-analysis of 10 studies: inadequate evidence that marijuana is associated with LBW in the amount typically consumed by pregnant women, but associated with 131 gm decrease in BW if used >4 times/wk.*

22. Opioids • Few studies have controlled for concomitant drug use, social, or psychosocial factors. • Among most studies, illicit opiate use is associated with LBW, PTB, and reduced fetal growth parameters.16 • Opiates are not teratogens in humans3

23. Opioids • Obstetric complications increase up to six fold1,11: • SAB • LBW • IUGR • Preeclampsia • Placental abruption • PROM • PTB • Fetal distress • Fetal demise • Malpresentation, Low APGAR scores, PPH, septic thrombophlebitis, Meconium aspiration, Chorioamnionitis

24. Opioids • Proposed Mechanisms: • Anorexic effect on maternal nutrition16 • Placental insufficiency11

25. Opioids • Neonatal complications3,1: • Prematurity • Low birth weight • Postnatal growth deficiency • Microcephaly • Neurobehavioral problems* • Increased neonatal mortality • 74-fold increase in sudden infant death syndrome (SIDS) • Neonatal abstinence syndrome (NAS)

26. Opioids • Heroin8 • Passage through placenta to fetus within 1 hour of administration • Accumulates in amniotic fluid • Limited fetal detoxification due to immature tissues • Fluctuation in drug levels causes placental changes*  placental insufficiency and IUGR • More significant placental change and LBW than methadone or buprenorphine.8

27. Central Nervous System Dysfunction Autonomic Dysfunction Respiratory Dysfunction Gastrointestinal Dysfunction CLINICAL SIGNS associated with Opiate Withdrawal in Newborns

28. Risk Factors for Newborns of Substance Abusers • FEEDING PROBLEMS • Suck-swallow incoordination • Tongue thrust during feedings • Poor formula intake • Failure to thrive • SLEEP • Sleep-wake cycles disorder • ATTENTION • Difficulty with reactivity to stimuli

29. Risk Factors for Newborn of Substance Abusers • HYPERTONIC BABIES • Also known as “stiff babies” • Brief deep tendon reflexes • Persistence of primitive infant reflexes • IRRITABILITY • Neurological fragility • Difficulty managing day-to-day stimuli • Jerky movements

30. Screening • Every infant born to a substance abuser should be evaluated for HIV infection. • Signs of neonatal abstinence syndrome • Small head size (brain size) • Newborns who are underweight • Stroke in the newborn • Intestinal blood flow compromise (NEC) • Positive drug screen in mother

31. Opioid Maintenance • Methadone • Subutex (Buprenorphine) • Suboxone (Buprenorphine/Naloxone) • Oral slow release morphine 1 g heroin ~ 8 mg buprenorphine ~ 80 mg methadone

32. Methadone • Pregnancy Category C • Full mu opioid agonist • First-line treatment of opioid addiction in pregnancy in the US2,5,6, UK, and Australia1. • Requires daily visits to methadone clinic.*

33. Methadone • Higher infant BW and less IUGR than seen in heroin-addicted moms.1,8 • NAS in 60-100% of neonates • Longer duration of NAS treatment vs. buprenorphine & heroin • 30 days vs. 11-12 days tx8 • Likely due to long t1/2

34. Methadone • However, some experts believe that, when compared to buprenorphine, methadone is the preferred medication: • They report buprenorphine has a “ceiling” dose, which is surpassed by some woman…thus they require higher levels of opioid maintenance that can only be reached with methadone.10 • Less structured regimen of buprenorphine tx vs. daily methadone dosing may lead to gaps in prenatal care, in addition to diversion or IVDA of buprenorphine.8

35. Subutex • Buprenorphine (Category C) • Long-acting partial mu opioid agonist & kappa antagonist • While approved in the US for opioid detox & maintenance, is not FDA-approved for use during pregnancy.7 * • However, is considered safe in pregnancy.9,15,11 • First choice for opioid maintenance programs & in pregnant women in Finland3since 1996.14

36. Subutex • May have less placenta exposure than methadone1 • Partial agonist profile may lower liability for NAS6 • Cochrane Review6 favored buprenorphine over methadone in regards to: • Higher infant BW* • Shorter hospital stay

37. Subutex • Low rates of prematurity2 (ave 39.2 wks3) • NAS occurs in 62%, but only half require treatment2 • Less severe NAS than methadone2,3,5,6,8,11 (though no RCTs yet*) with ↓ incidence3,6 and ↓ need for pharmacologic treatment vs. methadone.6 * • Shorter duration of NAS treatment vs. methadone8

38. Subutex • Preliminary MDFMR stats show: • None were low BW • All had APGARS of 8 or greater at 1 and 5 minutes • Possible dose-dependent relationship • Unable to draw conclusions about when babies may develop withdrawal symptoms • High degree of variability in the frequency of NAS scoring

39. Suboxone • Buprenorphine (Category C) + Naloxone (Category B) • Limited studies in pregnant women. • US DHHS Center for Substance Abuse Tx: • cautious use of naloxone in opioid-addicted pregnant women  may precipitate withdrawal in both mother & fetus.2 • Recommends buprenorphine monotherapy, though admit it has great potential for abuse & diversion.2

40. Oral slow release morphine • Used in Austria since 1998 for treatment of opioid dependence.9 • One study showed better success over methadone in helping pregnant women abstain from illicit substances.1

41. Opioid Maintenance – Monitoring in pregnancy • UDS, UDS, UDS • At increased risk for: anemia, malnutrition, HTN, hyperglycemia, STDs, TB, hepatitis, and preeclampsia.11 • Regular Prenatal panel • LFTs, Renal function, PPD, glucose intolerance, anti-HCV antibody3,11 • Consider repeat CBC, serology at 24-28 wks.11

42. Opioid Maintenance dosing in pregnancy • Varied opinion on monitored detoxification & abstinence during pregnancy. • If attempt to wean, suggested in 1st vs. 2nd Trimester • 1st – theoretical risk of miscarriage11 • 3rd – risk of premature labor or fetaldeath11 • Generally not recommended • Higher methadone doses related to increased BW, prolonged gestation11 • Attempt to decrease incidence of NAS by weaning may cause continued substance abuse11

43. Opioid Maintenance dosing in pregnancy • In fact, increased dosage of maintenance therapy may be required in 2nd-3rd trimester: • Increased maternal fluid volume + altered opioid metabolism in placenta & fetus  same dose produces lower blood level of particular drug11

44. Pain Management during Labor & Delivery • Opioid-dependent patients may require higher and more frequent doses of opioid analgesics to maintain pain control. • Methadone & buprenorphine suppress opioid withdrawal for 24-48 hours, but only provide analgesia for 4-8 hours.4

45. Pain Management during Labor & Delivery • NO Stadol or Nubain! • Opioid agonist-antagonists, thus can displace the maintenance opioid from the mu receptor, precipitating acute withdrawal4 • Epidural use reported in 73% of deliveries to opioid-dependent mothers.8

46. Impact on Baby • 60-90% of opiate exposed infants develop neonatal abstinence syndrome (NAS). • Symptoms will • manifest within • 48 to 72 hours after birth

47. S&S of Neonatal Abstinence Syndrome • Withdrawal • Irritability • Tremors • High-pitched cry • Diarrhea & Vomiting • Respiratory Distress • Abrasions • Weight loss • Aberrant temp control • Lack of sucking • Sneezing

48. Signs of Neonate Withdrawl • Irritability • Tachypena • Tremors • Shrill Cry • Mottling • Hypertonicity of muscles • Frantic Sucking of hands • Temperature instability • Loose diarrheal stools • Seizures • Nasal stuffiness • Sleep Disturbances Which leads to: “Unlovable Infant…

49. Baby Outcomes • Guilt and Denial from the mother contribute to a poor communication/ connection between mom and baby • Leads to impaired language development, social-emotional problems, and/ or neglect and abuse. • Increased risk for medical, emotional/ behavior, and developmental difficulties.

50. Haven House and CAP • Most drug treatment programs cater to male clients • Those who accept women will often rescind treatment to women who become pregnant while in program • Provision of child-care for existing children is also vital to most women… high risk of relapse during immediate postpartum period. • So….