Maternal & Newborn Effects of Prenatal Substance Abuse

2. مردم دو دسته اند: دسته اي برادر ديني تو و دسته ديگر همانند تو در آفرينش .اگر گناهي از آنان سر مي زند يا علت هايي بر آنان عارض مي شود، يا خواسته و ناخواسته اشتباهي مرتكب مي گردند آنان را ببخشاي و بر آنان آسان گير. آن گونه كه دوست داري خدا تو را ببخشايد و بر تو آسان گيرد. امام علی(ع)

3. Maternal & Newborn Effects ofPrenatal Substance Abuse Noori-Shadkam M(MD)

4. Objectives • Substance use and pregnancy • Maternal & fetal effects during pregnancy • Withdrawal syndrome • treatment

5. Behavior during pregnancy • Behaviors of drug-using pregnant women contribute to H.R pregnancy • Unsafe sex with risk of violence • Infection from injection • Stimulant abuse may lead to early labor • Poor nutrition • Lack of prenatal care

6. Drug Classes • Alcohol • Opioids • Stimulants • Nicotine • Marijuana

7. Opioids • Morphine • heroin • OxyContin • methadone

8. Effects on mothers Extrauterine pregnancies Premature labor PROM Uterin irritability Breech presentation Antepartum hemorrhage Toxemia

9. Con… Anemia Infections Stillbirth

10. Opioids: Effects on fetus • Hyperactivity • Hypoxia • Meconium passage • No known fetal anomalies • Utero demise

11. Effect on neonate LBW Thrombocytosis & increased circulating platelet aggregation Abnormal thyroid function Decrease HMD Decrease sever hyperbilirubinemia

12. Neonatal withdrawal syn.

13. Follow-up reports Neurobehavioral deficits Decrease visual & auditory orientation Decrease motor maturity More jerkiness Tremulousness Hypertonicity

14. Con… Irritability Increase cry Decrease PDI Increase nystagmus;strabismus & otitis media

15. Stimulants • Cocaine • Crack • Amphetamine • Methamphetamine • MDMA(Ecstasy) • Caffeine

16. Cocaine

17. Pharmacologic effects Norepinephrine effect tachycardia arrhythmias hypertension vasoconstriction diaphoresis mild tremors

18. Pharmacologic effects Dopamin effects increased alertness enhanced sense of well-being & self-stem heightened energy sexual excitement

19. Effects on mother Spontaneous abortion Abruptio placenta PROM STD

20. Effects on fetus & neonate • Fetal hypoxia • Fetal hypertention • Cocaine-Induced ischemia intestinal atresia infarction NEC

21. Con… G.U malformation STD Prematurity IUGR SIDS Diminished alertness Poorer state regulation

22. Con… Abnormal reflex;tone & motor maturity Impaired autonomic control Irritability Poorer orientation Decreased habituation

23. Amphetamine

24. Effects on mother Miscarriage Placental hemorrhage

25. Effects on fetus Prematurity IUGR Congenital anomaly cardiovascular musculoskeletal

26. Complication Cardiac arrhythmia ARF DIC Rhabdomyolysis Learning & memory damage

27. Con… Loss of sexual pleasure Effect on cognitive;sleep;appetite death

28. Nicotine • Cigarettes • pipe

29. Nicotine release Acetylcholine Norepinephrine GABA Glutamine Dopamine

30. Nicotine Increase HR Increase BP Increase RR Hyperglycemia Decrease appetite

31. Nicotine:Withdrawal symptom Irritability Headache Nausea Craving

32. Smoking: Effects on fetus • Prematurity • IUGR • SIDS • Increased risk for oral cleft

33. Neurobehavioral & Developmental Effects In Infancy Increase tremulousness Increase autonomic excitability Increase ADHD Decrease auditory habituation Decrease auditory responsiveness Decrease verbal comprehension Decrease verbal learning & memory

34. Marijuana & Hashish

35. Acute Effect Euphoria & Relaxation Increase HR Increase BP in a seated or supine Decrease BP in a standing Dizziness Decrease salivation Increase appetit

36. Con… Impaired coordination Poor decision making Delayed responding Altered sense of time Impaired concentration & learning

37. Effects on fetus & neonate • Brain abnormalities (in animal model) • LBW(?) • Meconium passage

38. treatment • Pregnancy • Neonate

39. Treatment in pregnancy • Reduce disease & crime Counseling Social service • Avoid withdrawal & craving Maintenance vs.detoxification Long-acting medication for control • STD

40. Methadone • Long-acting pure opioid agonist • Available for opioid addiction treatment • Requires daily clinic visits, but may get take-home dose privileges • Also used for pain like other Schedule II opioids

41. Methadone and Pregnancy • Standard of care for opioid-dependent pregnant women • Stabilization of mother and fetus • Medical and social • Higher dose in 3rd trimester • Improves growth of fetus & newborn • Decreases practice of high-risk behaviors

42. Buprenorphine • Long-acting opioid agonist-antagonist • Office-based opioid addiction treatment • Schedule III • Buy at local pharmacy (Subutex, Suboxone) • Very low risk of overdose • Combined with naloxone • Used for acute pain treatment (Buprenex)

43. Buprenorphine and Pregnancy • Pregnancy Category C • Use Subutex instead of Suboxone to avoid naloxone • NAS less intense than with methadone • Studies ongoing, results encouraging

44. Treatment in neonate

45. The goal is an infant who • No irritable • No vomitting • No diarrhea • Can feed well • Sleep between feeding

46. Symptomatic treatment Tight swaddling Holding Rocking Placing in a slightly darkened quiet area Hypercaloric formula Never give naloxone

47. Medication Neonatal morphine solution(NMS) Phenobarbital NMS+Pb

48. NMS score NMS 8-10 0.8ml/kg/day 11-13 1.2 14-16 1.6 17or >17 2

49. Phenobarbital Loading Maintenance 20mg/kg 5mg/kg/d 30 6.5 40 8

50. NMS & pb NMS 0.4ml/kg/day Pb loading dose 10mg/kg then 5mg/kg/day