Drug Abuse in Pregnancy
Content
Substance
Abuse in
Pregnancy
Title
Substance Abuse During Pregnancy
(SAMHSA, 2005)
• Pregnant women are less likely to use
substances than their peers.
• The exception is pregnant women aged
15 to 17; this substance use rate is 26
percent for pregnant women, compared
with 19.6 percent for non-pregnant
women.
• Women more prone to substance
abuse:
– Earn below poverty level
– Were exposed to violence as a child
– Have a history of domestic abuse
– Have less than a high school education
– Are unmarried
– Are unemployed
– Are involved with the criminal justice system
– Suffer depression or other mental health
problems
Most Commonly Abused Substances
During Pregnancy
•
•
•
•
•
•
•
•
•
•
•
Alcohol
Tobacco
Caffeine – incidence unknown, purportedly very high
Benzodiazepines
Opiates
Cocaine
Ecstasy
Hallucinogens
Methamphetamine
Solvents
Other
Impact of Substance Abuse
Alcohol
Miscarriage
Tobacco
Cannabis
Amphetamine
Cocaine
Opioids
+
+
+
+
+
+
+
+
Fetal Morbidity
+
Perinatal Mortality
+
+
IUGR
+
+
PROM
+
+
Preterm Delivery
+
+
LBW
+
+
+
+
+
+
+
+
Neonatal Resp.
+
Neonatal
Withdrawal
+
Developmental
+
+
+
+
+
Alcohol use in Pregnancy
• There is no safe amount of alcohol
consumption during pregnancy
(Jones & Chambers, 1999).
Alcohol Use in Pregnancy:
Maternal Effects
•
•
•
•
•
Cardiovascular and liver disease
Breast and gynecological cancer
Osteoporosis
Menstrual symptoms
Neurological and mental health
problems
• Compromised ability to conceive
• Spontaneous abortion
Alcohol Use in Pregnancy:
Fetal Effects
• Abnormalities in brain and neuron
development
• Growth deficiency
• Structural changes
• Prematurity
• LBW
• Decreased length and head circumference
Alcohol Use in Pregnancy:
Neonatal Effects
• Fetal alcohol syndrome (FAS)
• Mental retardation
• Developmental, learning and
behavior problems
Fetal Alcohol Syndrome
• Leading preventable
cause of mental
retardation
Symptoms of a baby with FAS
• 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
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
Alcohol Use Assessment
• Women are quite reliable in reporting
alcohol use in pregnancy (Jacobson et al.,
2002).
• The TWEAK is used to screen pregnant
women for alcohol misuse.
TWEAK Alcohol Dependence
Screening Tool
T Tolerance
How many drinks does it take to make you feel high?
W Worry
Have close friends or relatives worried or complained
about
your drinking in the past year?
E EyeOpener
Do you sometimes have a drink in the morning when
you first
get up?
A Amnesia
(blackouts
)
Has a friend or family member ever told you about things
you
said or did while you were drinking that you could not
remember?
K Cutting
down
Do you sometimes feel the need to cut down on your
drinking?
Smoking while Pregnant
• Cigarettes, cigars, pipes, “snuff,” “chew”
• Stimulant & relaxes
• Acute effects
– Vasoconstriction
secretions
• 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
• Chronic effects
– Lung disease, heart disease
– Cancer
• Very short-acting, so high-frequency use
– Very reinforcing
Maternal Effects:
• Cigarette smoking is the most common form of
substance abuse in pregnancy. It is linked to:
• Decreased fertility
• Spontaneous abortion
• Placenta previa
• Placental abruption
• Ectopic pregnancy
• Preterm premature rupture of membranes
(PPROM)
• Preeclampsia
Fetal Effects
• Impaired transfer of oxygen and nutrition
• Long-term cognitive function and
increased risk of brain damage
• Chronic low-level hypoxia
• Intrauterine growth restriction (IUGR)
• Preterm delivery
• Low birthweight (LBW) in term infants
Neonatal Effects
• Impaired respiratory function in premature
infants
• Low neurobehavior scores and higher
withdrawal-symptom scores
• Asthma, respiratory illness and pneumonia
• Infections of the middle ear
• Increased risk of cancer and SIDS
Nicotine Withdrawal in mother
• craving for tobacco
• irritability, frustration,
anger
• anxiety
• difficulty concentrating
• restlessness
• decreased heart rate
• increased appetite or
weight gain
• depression
• disrupted sleep
• sedation
Smoking Treatment:
• Self-Determination Model
• The nurse uses motivational interviewing
or autonomy-promoting counseling to elicit
the woman’s personal values and goals.
• The nurse and woman explore the aspects
of unhealthy behavior, focusing on the
discrepancy between the desired goals
and the behavior.
Smoking Treatment:
The Five A’s (Fiore et al., 2000)
1.
2.
3.
4.
5.
Ask about tobacco use.
Advise to quit.
Assess willingness to quit.
Assist in attempting to quit.
Arrange follow-up.
The Five A’s are recommended for patients who
are willing to quit.
Smoking Treatment:
The Five R’s (Fiore et al., 2000)
1.
2.
3.
4.
5.
Relevance of quitting
Risks of continued smoking
Rewards of quitting
Roadblocks to quitting
Repetition
The Five R’s are recommended for patients who
are unwilling to quit.
Smoking Treatment:
Follow-up During Pregnancy
• Follow-up should focus on how the
effort is going; support and
reinforcement for even small
successes; suggestions to overcome
obstacles; and health progress
reports.
Smoking Treatment: Bupropion (Zyban)
• Used as an antidepressant and as a
smoking cessation aid
• Shows no harmful effects on pregnant
women treated for depression (Kuller et al., 1996)
Opioids
• Morphine, heroin,
OxyContin, methadone
• Analgesics: disconnect
from pain
• Euphoria, disconnection,
sedation
• Nausea, constipation,
itching
• Oversedation, respiratory
depression
• 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
Effects on Fetus
• No known fetal anomalies
• Intrauterine growth
retardation
• Neonatal abstinence
syndrome
– Continuous exposure
– Use up to delivery
• Neonatal complications :
3,1
– 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)
• 60-90% of opiate
exposed infants develop
neonatal abstinence
syndrome (NAS).
• Symptoms will
• manifest within
• 48 to 72 hours
after birth
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
Signs of Neonate Withdrawal
•
•
•
•
•
•
•
•
•
•
•
•
Irritability
Tachypena
Tremors
Shrill Cry
Mottling
Hypertonicity of muscles
Frantic Sucking of hands
Temperature instability
Loose diarrheal stools
Seizures
Nasal stuffiness
Sleep Disturbances
CLINICAL SIGNS associated with Opiate Withdrawal in
Newborns
• Central Nervous System Dysfunction
• Autonomic Dysfunction
• Respiratory Dysfunction
• Gastrointestinal Dysfunction
• Heroin
– 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.
• Preferred over illicit substance abuse:
– less drug-seeking and criminal behavior,
fewer relapses, decreased STDs,
improved prenatal care and compliance,
improved nutrition3
– Consistent maintenance opioid
treatment prevents repeated fetal
withdrawals.
Heroin
Maternal Effects
•Heroin can cause severe
physiological withdrawal
symptoms, including fatal seizures
when withheld for 12 to 48 hours.
Heroin: Fetal Effects
• Opiates, such as heroin, methadone and
buprenorphine, have not been linked to
fetal anomalies.
• Fetal withdrawal responses include
arrhythmias, seizure activity and fetal
demise.
Heroin: Neonatal Effects
•
•
•
•
•
•
•
•
•
Drug withdrawal
Suck-swallow difficulties
Central nervous system (CNS) irritability
Gastrointestinal upset
Yawning
Sneezing
Frantic sucking with uncoordinated feeding
High-pitched cry
Increased or decreased muscle tone
Heroin: Treatment
• Methadone
– The most common treatment for heroin
abuse in pregnant women
– During pregnancy, brings addicted women
into agencies that promote prenatal care
• Buprenorphine
– Linked to better treatment adherence with
fewer side effects and overdoses than
methadone
Opioid Maintenance
•
•
•
•
Methadone
Subutex (Buprenorphine)
Suboxone (Buprenorphine/Naloxone)
Oral slow release morphine
1 g heroin ~ 8 mg buprenorphine ~ 80 mg methadone
Methadone
• Pregnancy Category C
• Full opioid agonist
• First-line treatment of opioid addiction in
pregnancy in the US , UK, and Australia .
• Requires daily visits to methadone clinic.*
2,5,6
1
Methadone
• Higher infant BW and less IUGR than
seen in heroin-addicted moms.
• NAS in 60-100% of neonates
• Longer duration of NAS treatment vs.
buprenorphine & heroin
1,8
– 30 days vs. 11-12 days tx
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.
– 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.
• Standard of care for opioiddependent pregnant women
• Stabilization of mother and
fetus
– Medical and social
– Higher dose in 3rd trimester
• Improves growth of fetus &
newborn
• Decreases practice of highrisk behaviors
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.*
• However, is considered safe in pregnancy.
• First choice for opioid maintenance programs &
in pregnant women in Finland since 1996.
3
Subutex
• May have less placenta exposure than
methadone
• Partial agonist profile may lower liability for
NAS
• Cochrane Review favored buprenorphine
over methadone in regards to:
6
– Higher infant BW*
– Shorter hospital stay
Subutex
• Low rates of prematurity (ave 39.2 wks)
• NAS occurs in 62%, but only half
require treatment
• Less severe NAS than methadone
(though no RCTs yet*) with ↓ incidence
and ↓ need for pharmacologic treatment
vs. methadone.
• Shorter duration of NAS treatment vs.
methadone
2
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
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.
– Recommends buprenorphine monotherapy, though
admit it has great potential for abuse & diversion.
Opioid Maintenance –
Monitoring in pregnancy
• UDS, UDS, UDS
• At increased risk for: anemia, malnutrition, HTN,
hyperglycemia, STDs, TB, hepatitis, and
preeclampsia.
– Regular Prenatal panel
– LFTs, Renal function, PPD, glucose intolerance, antiHCV antibody
– Consider repeat CBC, serology at 24-28 wks.
Opioid Maintenance dosing in
pregnancy
• Varied opinion on monitored detoxification &
abstinence during pregnancy.
• If attempt to wean, suggested in 1 st vs. 2nd
Trimester
– 1st – theoretical risk of miscarriage
– 3rd – risk of premature labor or fetal death
11
11
• 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
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 drug
11
Pain Management during Labor
& Delivery
o 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
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
Cocaine
• Not teratogenic
• Neonatal complications
– LBW
– ↓ HC and birth length
– IUGR
– Increased incidence of infant infection with
hepatitis & HIV
Cocaine
• 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
• Early studies cited severe and irreversible
consequences of prenatal cocaine
exposure due to disruption of CNS of
developing brain.
• However, more recent studies show little or
no long term developmental effects of
prenatal cocaine exposure.
• Lack of data on older children precludes
any absolute statements that cocaine
exposure in utero has no long term effects.
Cocaine
• Local anesthetic – blocks sodium channels
• Blocks reuptake of dopamine,
norepinephrine and serotonin in CNS.
• Euphoria, hypertension, tachycardia,
vasconstriction, coronary vasospasm,
thrombosis.
Cocaine
• Increases vascular cell adhesion
molecules (promoting white cell infiltration
into tissues)
• Promotes thrombosis
• Cocaine is like obesity and hyperglycemia
in this respect!
Cocaine:
Maternal Effects
•
•
•
•
•
•
Hypertension
Tachycardia
Cardiac events and maternal death
Spontaneous abortion
Placental abruption
Premature rupture of membranes (PROM)
Cocaine:
Fetal Effects
•Fetal effects of cocaine are caused by the
drug’s direct effects (vasoconstriction and
neuroexcitation) and by lifestyle issues that
maternal drug use brings, including poor
nutrition and avoidance of prenatal care.
Cocaine:
Neonatal Effects
•
•
•
•
•
Jitteriness
Hyperactivity
Inconsolability
Poor feeding and state regulation
No physiological withdrawal: Neonates are
not dependent on cocaine and do not
need medication to lessen withdrawal.
Amphetamines
Maternal Effects
•
•
•
•
•
•
Stroke
Cardiac problems
Psychiatric emergencies
Growth restriction
Placental abruption
Preterm delivery
Amphetamines:
Fetal and Neonatal Effects
• Similar effects to cocaine, with
decreased fetal growth
• Some researchers expect that, like with
cocaine (Wouldes et al., 2004), effects can
be seen early in life but are quickly
overpowered by environmental factors.
•
•
•
•
MDMA (Ecstasy): Maternal
Effects
Anxiety
Twitching
Depression
Impaired cognitive processing and
memory performance
MDMA: Fetal and Neonatal
Effects
• Animal studies do not show an increase
in harmful fetal effects.
• A small, uncontrolled, retrospective
study suggests a possible increase in
ventricular septal defects (Bateman et al.,
2004).
• Nurses should treat infants and families
based on demonstrated health needs.
Introducing Social Issues
•The nurse should begin to explore the
woman’s home situation, including:
– Stress related to work, finances,
family and pregnancy
– Satisfaction with the amount and
kind of support in her social network
– Feelings about self-esteem and
ability to cope with stressors
• Benzodiazepines,
barbiturates, other
sleeping pills
(Ambien, Lunesta)
• Sedation, anxiolytic
• Respiratory
depression in
overdose
• Withdrawal similar to
alcohol DT’s
• Common to both: • Seen in
withdrawal, but
– Restlessness
not pregnancy:
– Insomnia
– Nausea/vomiting
– High blood
pressure
– Rapid heart rate
– Rapid breathing
– Seizures
– Distractibility
– Impaired memory
– Agitation
– Tremor
– Fever
– Sweating
– Hallucinations
• Withdrawal symptoms may be lifethreatening to mother and fetus
• Acute withdrawal treatment should be
accomplished in an inpatient setting
• Risk to mother/fetus of untreated
withdrawal is greater than risk from
exposure to medications in a controlled
setting
Marijuana
• Marijuana, hashish,
hash oil
• active ingredient: THC
• relaxation,
hallucination
• panic attacks
• short-term memory
impairment, amnesia
Maternal Effects
• Is the illicit drug most commonly used
during pregnancy, although only 3.6
percent of pregnant women report using it
(SAMSHA, 2005)
• Does not cause a defined physical
withdrawal syndrome
• Heavy use linked to lung problems
Effects on Fetus
• Intrauterine growth
retardation
• Abnormal startle
reflexes in
newborns
• Reduced memory
& verbal skills at
age 4 years
Screening
• All pregnant women should
be screened for drug and
alcohol use
– T-ACE: emphasizes tolerance
over guilt
• A positive screen indicates
the need for further
evaluation
Types of Treatment
•
•
•
•
•
•
•
Detoxification
12-Step groups
Outpatient counseling
Intensive outpatient
Inpatient
Residential
Opioid Maintenance
– Methadone
– Buprenorphine
Addiction Counseling
• Network therapy
• Family therapy
• Supportive
psychotherapy
• Contingency
management
• Building Social
networks
• Twelve-Step
facilitation
• Perceptual Adjustment
therapy
• Rational Recovery
• Medication
management
• Brief intervention
Maintenance Pharmacotheraphy
• Long-acting medication in controlled
setting
– Counseling
– Social services
• Avoid withdrawal & craving
• Reduce disease & crime
• Maintenance vs. detoxification
• Pregnancy Category C
• Use Subutex instead of
Suboxone to avoid
naloxone
• NAS less intense than
with methadone
• Studies ongoing, results
encouraging
• Characterized by
– Hyperactivity, irritable
– Hypertonia
– Difficulty/excessive sucking
– High-pitched cries
• Begins 3h to 12d after
delivery, depending on
drugs used by mother
• Initial treatment is supportive
–Swaddling, frequent feeding, IV fluids
• Assess regularly for symptoms and failure
to thrive
• Pharmacotherapy
–Usually opioids, occasionally sedative-hypnotic
–Tincture of opium, paregoric, methadone,
phenobarbital
–Encourage involvement of significant other
–Lack of support can lead to relapse
• Social services may need to be notified of
unsafe living conditions
• Addicted pregnant woman often product of
poor parenting
• Support network for new mother
–Family, 12-Step group, health care workers
• Most common obstetrical effect of illicit
drugs is low birthweight
• Methadone maintenance is treatment of
choice for opioid-addicted pregnant
women
• Breastfeeding is encouraged (as long as
not actively using illicit drugs or alcohol)
• Support for mother is essential
• Anticipate and educate to prevent relapse
Abuse in
Pregnancy
Title
Substance Abuse During Pregnancy
(SAMHSA, 2005)
• Pregnant women are less likely to use
substances than their peers.
• The exception is pregnant women aged
15 to 17; this substance use rate is 26
percent for pregnant women, compared
with 19.6 percent for non-pregnant
women.
• Women more prone to substance
abuse:
– Earn below poverty level
– Were exposed to violence as a child
– Have a history of domestic abuse
– Have less than a high school education
– Are unmarried
– Are unemployed
– Are involved with the criminal justice system
– Suffer depression or other mental health
problems
Most Commonly Abused Substances
During Pregnancy
•
•
•
•
•
•
•
•
•
•
•
Alcohol
Tobacco
Caffeine – incidence unknown, purportedly very high
Benzodiazepines
Opiates
Cocaine
Ecstasy
Hallucinogens
Methamphetamine
Solvents
Other
Impact of Substance Abuse
Alcohol
Miscarriage
Tobacco
Cannabis
Amphetamine
Cocaine
Opioids
+
+
+
+
+
+
+
+
Fetal Morbidity
+
Perinatal Mortality
+
+
IUGR
+
+
PROM
+
+
Preterm Delivery
+
+
LBW
+
+
+
+
+
+
+
+
Neonatal Resp.
+
Neonatal
Withdrawal
+
Developmental
+
+
+
+
+
Alcohol use in Pregnancy
• There is no safe amount of alcohol
consumption during pregnancy
(Jones & Chambers, 1999).
Alcohol Use in Pregnancy:
Maternal Effects
•
•
•
•
•
Cardiovascular and liver disease
Breast and gynecological cancer
Osteoporosis
Menstrual symptoms
Neurological and mental health
problems
• Compromised ability to conceive
• Spontaneous abortion
Alcohol Use in Pregnancy:
Fetal Effects
• Abnormalities in brain and neuron
development
• Growth deficiency
• Structural changes
• Prematurity
• LBW
• Decreased length and head circumference
Alcohol Use in Pregnancy:
Neonatal Effects
• Fetal alcohol syndrome (FAS)
• Mental retardation
• Developmental, learning and
behavior problems
Fetal Alcohol Syndrome
• Leading preventable
cause of mental
retardation
Symptoms of a baby with FAS
• 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
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
Alcohol Use Assessment
• Women are quite reliable in reporting
alcohol use in pregnancy (Jacobson et al.,
2002).
• The TWEAK is used to screen pregnant
women for alcohol misuse.
TWEAK Alcohol Dependence
Screening Tool
T Tolerance
How many drinks does it take to make you feel high?
W Worry
Have close friends or relatives worried or complained
about
your drinking in the past year?
E EyeOpener
Do you sometimes have a drink in the morning when
you first
get up?
A Amnesia
(blackouts
)
Has a friend or family member ever told you about things
you
said or did while you were drinking that you could not
remember?
K Cutting
down
Do you sometimes feel the need to cut down on your
drinking?
Smoking while Pregnant
• Cigarettes, cigars, pipes, “snuff,” “chew”
• Stimulant & relaxes
• Acute effects
– Vasoconstriction
secretions
• 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
• Chronic effects
– Lung disease, heart disease
– Cancer
• Very short-acting, so high-frequency use
– Very reinforcing
Maternal Effects:
• Cigarette smoking is the most common form of
substance abuse in pregnancy. It is linked to:
• Decreased fertility
• Spontaneous abortion
• Placenta previa
• Placental abruption
• Ectopic pregnancy
• Preterm premature rupture of membranes
(PPROM)
• Preeclampsia
Fetal Effects
• Impaired transfer of oxygen and nutrition
• Long-term cognitive function and
increased risk of brain damage
• Chronic low-level hypoxia
• Intrauterine growth restriction (IUGR)
• Preterm delivery
• Low birthweight (LBW) in term infants
Neonatal Effects
• Impaired respiratory function in premature
infants
• Low neurobehavior scores and higher
withdrawal-symptom scores
• Asthma, respiratory illness and pneumonia
• Infections of the middle ear
• Increased risk of cancer and SIDS
Nicotine Withdrawal in mother
• craving for tobacco
• irritability, frustration,
anger
• anxiety
• difficulty concentrating
• restlessness
• decreased heart rate
• increased appetite or
weight gain
• depression
• disrupted sleep
• sedation
Smoking Treatment:
• Self-Determination Model
• The nurse uses motivational interviewing
or autonomy-promoting counseling to elicit
the woman’s personal values and goals.
• The nurse and woman explore the aspects
of unhealthy behavior, focusing on the
discrepancy between the desired goals
and the behavior.
Smoking Treatment:
The Five A’s (Fiore et al., 2000)
1.
2.
3.
4.
5.
Ask about tobacco use.
Advise to quit.
Assess willingness to quit.
Assist in attempting to quit.
Arrange follow-up.
The Five A’s are recommended for patients who
are willing to quit.
Smoking Treatment:
The Five R’s (Fiore et al., 2000)
1.
2.
3.
4.
5.
Relevance of quitting
Risks of continued smoking
Rewards of quitting
Roadblocks to quitting
Repetition
The Five R’s are recommended for patients who
are unwilling to quit.
Smoking Treatment:
Follow-up During Pregnancy
• Follow-up should focus on how the
effort is going; support and
reinforcement for even small
successes; suggestions to overcome
obstacles; and health progress
reports.
Smoking Treatment: Bupropion (Zyban)
• Used as an antidepressant and as a
smoking cessation aid
• Shows no harmful effects on pregnant
women treated for depression (Kuller et al., 1996)
Opioids
• Morphine, heroin,
OxyContin, methadone
• Analgesics: disconnect
from pain
• Euphoria, disconnection,
sedation
• Nausea, constipation,
itching
• Oversedation, respiratory
depression
• 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
Effects on Fetus
• No known fetal anomalies
• Intrauterine growth
retardation
• Neonatal abstinence
syndrome
– Continuous exposure
– Use up to delivery
• Neonatal complications :
3,1
– 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)
• 60-90% of opiate
exposed infants develop
neonatal abstinence
syndrome (NAS).
• Symptoms will
• manifest within
• 48 to 72 hours
after birth
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
Signs of Neonate Withdrawal
•
•
•
•
•
•
•
•
•
•
•
•
Irritability
Tachypena
Tremors
Shrill Cry
Mottling
Hypertonicity of muscles
Frantic Sucking of hands
Temperature instability
Loose diarrheal stools
Seizures
Nasal stuffiness
Sleep Disturbances
CLINICAL SIGNS associated with Opiate Withdrawal in
Newborns
• Central Nervous System Dysfunction
• Autonomic Dysfunction
• Respiratory Dysfunction
• Gastrointestinal Dysfunction
• Heroin
– 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.
• Preferred over illicit substance abuse:
– less drug-seeking and criminal behavior,
fewer relapses, decreased STDs,
improved prenatal care and compliance,
improved nutrition3
– Consistent maintenance opioid
treatment prevents repeated fetal
withdrawals.
Heroin
Maternal Effects
•Heroin can cause severe
physiological withdrawal
symptoms, including fatal seizures
when withheld for 12 to 48 hours.
Heroin: Fetal Effects
• Opiates, such as heroin, methadone and
buprenorphine, have not been linked to
fetal anomalies.
• Fetal withdrawal responses include
arrhythmias, seizure activity and fetal
demise.
Heroin: Neonatal Effects
•
•
•
•
•
•
•
•
•
Drug withdrawal
Suck-swallow difficulties
Central nervous system (CNS) irritability
Gastrointestinal upset
Yawning
Sneezing
Frantic sucking with uncoordinated feeding
High-pitched cry
Increased or decreased muscle tone
Heroin: Treatment
• Methadone
– The most common treatment for heroin
abuse in pregnant women
– During pregnancy, brings addicted women
into agencies that promote prenatal care
• Buprenorphine
– Linked to better treatment adherence with
fewer side effects and overdoses than
methadone
Opioid Maintenance
•
•
•
•
Methadone
Subutex (Buprenorphine)
Suboxone (Buprenorphine/Naloxone)
Oral slow release morphine
1 g heroin ~ 8 mg buprenorphine ~ 80 mg methadone
Methadone
• Pregnancy Category C
• Full opioid agonist
• First-line treatment of opioid addiction in
pregnancy in the US , UK, and Australia .
• Requires daily visits to methadone clinic.*
2,5,6
1
Methadone
• Higher infant BW and less IUGR than
seen in heroin-addicted moms.
• NAS in 60-100% of neonates
• Longer duration of NAS treatment vs.
buprenorphine & heroin
1,8
– 30 days vs. 11-12 days tx
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.
– 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.
• Standard of care for opioiddependent pregnant women
• Stabilization of mother and
fetus
– Medical and social
– Higher dose in 3rd trimester
• Improves growth of fetus &
newborn
• Decreases practice of highrisk behaviors
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.*
• However, is considered safe in pregnancy.
• First choice for opioid maintenance programs &
in pregnant women in Finland since 1996.
3
Subutex
• May have less placenta exposure than
methadone
• Partial agonist profile may lower liability for
NAS
• Cochrane Review favored buprenorphine
over methadone in regards to:
6
– Higher infant BW*
– Shorter hospital stay
Subutex
• Low rates of prematurity (ave 39.2 wks)
• NAS occurs in 62%, but only half
require treatment
• Less severe NAS than methadone
(though no RCTs yet*) with ↓ incidence
and ↓ need for pharmacologic treatment
vs. methadone.
• Shorter duration of NAS treatment vs.
methadone
2
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
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.
– Recommends buprenorphine monotherapy, though
admit it has great potential for abuse & diversion.
Opioid Maintenance –
Monitoring in pregnancy
• UDS, UDS, UDS
• At increased risk for: anemia, malnutrition, HTN,
hyperglycemia, STDs, TB, hepatitis, and
preeclampsia.
– Regular Prenatal panel
– LFTs, Renal function, PPD, glucose intolerance, antiHCV antibody
– Consider repeat CBC, serology at 24-28 wks.
Opioid Maintenance dosing in
pregnancy
• Varied opinion on monitored detoxification &
abstinence during pregnancy.
• If attempt to wean, suggested in 1 st vs. 2nd
Trimester
– 1st – theoretical risk of miscarriage
– 3rd – risk of premature labor or fetal death
11
11
• 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
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 drug
11
Pain Management during Labor
& Delivery
o 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
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
Cocaine
• Not teratogenic
• Neonatal complications
– LBW
– ↓ HC and birth length
– IUGR
– Increased incidence of infant infection with
hepatitis & HIV
Cocaine
• 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
• Early studies cited severe and irreversible
consequences of prenatal cocaine
exposure due to disruption of CNS of
developing brain.
• However, more recent studies show little or
no long term developmental effects of
prenatal cocaine exposure.
• Lack of data on older children precludes
any absolute statements that cocaine
exposure in utero has no long term effects.
Cocaine
• Local anesthetic – blocks sodium channels
• Blocks reuptake of dopamine,
norepinephrine and serotonin in CNS.
• Euphoria, hypertension, tachycardia,
vasconstriction, coronary vasospasm,
thrombosis.
Cocaine
• Increases vascular cell adhesion
molecules (promoting white cell infiltration
into tissues)
• Promotes thrombosis
• Cocaine is like obesity and hyperglycemia
in this respect!
Cocaine:
Maternal Effects
•
•
•
•
•
•
Hypertension
Tachycardia
Cardiac events and maternal death
Spontaneous abortion
Placental abruption
Premature rupture of membranes (PROM)
Cocaine:
Fetal Effects
•Fetal effects of cocaine are caused by the
drug’s direct effects (vasoconstriction and
neuroexcitation) and by lifestyle issues that
maternal drug use brings, including poor
nutrition and avoidance of prenatal care.
Cocaine:
Neonatal Effects
•
•
•
•
•
Jitteriness
Hyperactivity
Inconsolability
Poor feeding and state regulation
No physiological withdrawal: Neonates are
not dependent on cocaine and do not
need medication to lessen withdrawal.
Amphetamines
Maternal Effects
•
•
•
•
•
•
Stroke
Cardiac problems
Psychiatric emergencies
Growth restriction
Placental abruption
Preterm delivery
Amphetamines:
Fetal and Neonatal Effects
• Similar effects to cocaine, with
decreased fetal growth
• Some researchers expect that, like with
cocaine (Wouldes et al., 2004), effects can
be seen early in life but are quickly
overpowered by environmental factors.
•
•
•
•
MDMA (Ecstasy): Maternal
Effects
Anxiety
Twitching
Depression
Impaired cognitive processing and
memory performance
MDMA: Fetal and Neonatal
Effects
• Animal studies do not show an increase
in harmful fetal effects.
• A small, uncontrolled, retrospective
study suggests a possible increase in
ventricular septal defects (Bateman et al.,
2004).
• Nurses should treat infants and families
based on demonstrated health needs.
Introducing Social Issues
•The nurse should begin to explore the
woman’s home situation, including:
– Stress related to work, finances,
family and pregnancy
– Satisfaction with the amount and
kind of support in her social network
– Feelings about self-esteem and
ability to cope with stressors
• Benzodiazepines,
barbiturates, other
sleeping pills
(Ambien, Lunesta)
• Sedation, anxiolytic
• Respiratory
depression in
overdose
• Withdrawal similar to
alcohol DT’s
• Common to both: • Seen in
withdrawal, but
– Restlessness
not pregnancy:
– Insomnia
– Nausea/vomiting
– High blood
pressure
– Rapid heart rate
– Rapid breathing
– Seizures
– Distractibility
– Impaired memory
– Agitation
– Tremor
– Fever
– Sweating
– Hallucinations
• Withdrawal symptoms may be lifethreatening to mother and fetus
• Acute withdrawal treatment should be
accomplished in an inpatient setting
• Risk to mother/fetus of untreated
withdrawal is greater than risk from
exposure to medications in a controlled
setting
Marijuana
• Marijuana, hashish,
hash oil
• active ingredient: THC
• relaxation,
hallucination
• panic attacks
• short-term memory
impairment, amnesia
Maternal Effects
• Is the illicit drug most commonly used
during pregnancy, although only 3.6
percent of pregnant women report using it
(SAMSHA, 2005)
• Does not cause a defined physical
withdrawal syndrome
• Heavy use linked to lung problems
Effects on Fetus
• Intrauterine growth
retardation
• Abnormal startle
reflexes in
newborns
• Reduced memory
& verbal skills at
age 4 years
Screening
• All pregnant women should
be screened for drug and
alcohol use
– T-ACE: emphasizes tolerance
over guilt
• A positive screen indicates
the need for further
evaluation
Types of Treatment
•
•
•
•
•
•
•
Detoxification
12-Step groups
Outpatient counseling
Intensive outpatient
Inpatient
Residential
Opioid Maintenance
– Methadone
– Buprenorphine
Addiction Counseling
• Network therapy
• Family therapy
• Supportive
psychotherapy
• Contingency
management
• Building Social
networks
• Twelve-Step
facilitation
• Perceptual Adjustment
therapy
• Rational Recovery
• Medication
management
• Brief intervention
Maintenance Pharmacotheraphy
• Long-acting medication in controlled
setting
– Counseling
– Social services
• Avoid withdrawal & craving
• Reduce disease & crime
• Maintenance vs. detoxification
• Pregnancy Category C
• Use Subutex instead of
Suboxone to avoid
naloxone
• NAS less intense than
with methadone
• Studies ongoing, results
encouraging
• Characterized by
– Hyperactivity, irritable
– Hypertonia
– Difficulty/excessive sucking
– High-pitched cries
• Begins 3h to 12d after
delivery, depending on
drugs used by mother
• Initial treatment is supportive
–Swaddling, frequent feeding, IV fluids
• Assess regularly for symptoms and failure
to thrive
• Pharmacotherapy
–Usually opioids, occasionally sedative-hypnotic
–Tincture of opium, paregoric, methadone,
phenobarbital
–Encourage involvement of significant other
–Lack of support can lead to relapse
• Social services may need to be notified of
unsafe living conditions
• Addicted pregnant woman often product of
poor parenting
• Support network for new mother
–Family, 12-Step group, health care workers
• Most common obstetrical effect of illicit
drugs is low birthweight
• Methadone maintenance is treatment of
choice for opioid-addicted pregnant
women
• Breastfeeding is encouraged (as long as
not actively using illicit drugs or alcohol)
• Support for mother is essential
• Anticipate and educate to prevent relapse
