Download Fetal Alcohol Syndrome

SUBSTANCE ABUSE &
NEWBORNS
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.
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 1530%.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
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.
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
Alcohol
 Associated with :
16
Teratogen
IUGR
Fetal alcohol spectrum disorder
Postnatal growth deficiency
Cranial dysmorphology
Mental retardation
Acute neonatal withdrawal20
Fetal Alcohol Syndrome
Fetal Alcohol Syndrome
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
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
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
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.
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
Tobacco
 No increased RATE of congenital
anomalies in smokers, but may
contribute to RISK of anomalies
associated with vascular disruption :
20
Cleft lip with/without cleft palate
Gastroschisis
Anal atresia
Digital anomalies
Tobacco
 Two to four fold increased risk of SIDS
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
20
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…
Tobacco
“Effects of cocaine use were
NO DIFFERENT
than those observed from cigarette
smoking”
on gestational age-adjusted BW, HC, and
length
16
Marijuana
 Mechanism unknown as to how it may
effect neonatal outcomes
16
 Proposed theory: reduced fetal
oxygenation causing diminished fetal
growth.
16
Marijuana
Inconclusive data on birth weight (BW)16 or
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.*
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.
 Opiates are not teratogens in humans
16
3
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
Opioids
 Proposed Mechanisms:
Anorexic effect on maternal nutrition16
Placental insufficiency11
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)
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
CLINICAL SIGNS associated
with Opiate Withdrawal in
Newborns
 Central Nervous System Dysfunction
 Autonomic Dysfunction
 Respiratory Dysfunction
 Gastrointestinal Dysfunction
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
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
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
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 mu 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 tx8
Likely due to long t1/2
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
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 Finland3 since 1996.14
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:
1
6
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
3
2
2,3,5,6,8,11
3,6
6
8
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.2
 Recommends buprenorphine monotherapy,
though admit it has great potential for abuse &
diversion.2
Oral slow release morphine
 Used in Austria since 1998 for
treatment of opioid dependence.
 One study showed better success over
methadone in helping pregnant women
abstain from illicit substances.
9
1
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
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 fetal death11
 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 drug11
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
Impact on Baby
 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 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…
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.
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….
Placenta
Breastfeeding in Opioid
Maintenance
 In brief, it’s OK to breastfeed on
Suboxone or methadone.
…so go ahead & encourage it!
 Contraindications:
illicit substance abuse
HIV
Breastfeeding in Opioid
Maintenance
 Buprenorphine:
 breastfeeding infant will receive only 1/5
to 1/10 of the total available
buprenorphine2,9.
 No evidence to support theory that
breastfeeding will help suppress NAS.2
 Likewise, NAS does not occur after
breastfeeding is discontinued.2
Postpartum Care in Opioid
Maintenance
 Continue maintenance opioid (or switch
to Suboxone if on Subutex).
 80% abstinence rate shown
postpartum at Mercy’s Recovery
Center in Westbrook, ME.
Opioid Maintenance
 Improved outcomes when therapy
includes :
3,11
 prenatal care
addiction treatment
other social services, including
individual/group/family therapy to address
the psychological and psychosocial factor
of substance abuse.
Future Research
National Institute on Drug Abuse16:
“little information is available as to whether
the detrimental effects seen in drugexposed offspring are the direct result of
perturbations in the development of
placenta & its functions
OR
caused by ‘host’ factors such as poor prenatal
care, stress, infection, and poor maternal
nutrition, which are common comorbid
factors in drug abusing women.”
Future research
 Chronic stress has consistently been
related to LBW and PTB
16
Hypothesis = neuroendocrine, immune,
and vascular roles that may influence
uteroplacental transfer & delivery.
 No studies of drug abuse in pregnancy
have controlled for chronic stress.
Future treatment
 Biggest influence of prenatal substance
abuse may in fact be the increased
postnatal risks rather than any direct
drug-effect:
16
Diminished bonding
Neglect
Foster care placement
Disruptions in home environment
Summary
 Prematurity and IUGR are associated with tobacco, alcohol,
opioids, cocaine, and maybe amphetamines.
 Teratogens: alcohol and barbiturates
 Adverse effects of prenatal drug exposure are usually selflimited and confined to infancy. Exceptions include:
 Alcohol  lifelong impairments
 Cigarettes  may have long term behavioral effects
 Psychosocial factors and concomitant maternal illnesses
may play an even larger role in long term development of
these infants.
Summary
 Thus, when caring for a drug-addicted
pregnant woman, understanding the
complex roles that illicit drugs, inner
stressors, and her surrounding external
environment will not only help us better
provide interventions to improve pregnancy
outcomes, but also to give both her and her
child a stepping stone toward a healthier
lifestyle in the future.
REFERENCES
Albersheim, S. (1991). Newborn Patients of Mothers with Substance AbuseProviding proper
health care for mothers and their babies. Can Fam Physician.(37):1739–1746.
Bertrand J, Floyd LL, Weber MK. Guidelines for identifying and referring persons with fetal
alcohol syndrome. MMWR Recomm Rep. 2005 Oct 28;54(RR-11):1-14.
Gorski, Terence T. (2001). Cocaine use during pregnancy. Gorski-Cenaps Web Publications.
Retrieved on November 10, 2009.
http://www.tgorski.com/Prevention/cocaine_use_during_pregnancy.htm
Nazario, Brunilda MD. Smoking During Pregnancy, Retrieved November 10, 2009.
http://www.nlm.nih.gov/medlineplus/ency/article/000911.htm
Perinatal Substance Abuse. UCSF Children’s Hospital:
http://www.ucsfchildrenshospital.org/pdf/manuals/59_SubAbuse.pdf
Stoll BJ. Metabolic disturbances. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds.
Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap
106.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Minozzi S, Amato L, Vecchi S, Davoli M. Maintenance agonist treatments for opiate dependent pregnant
women (Review). The Cochrane Library, Issue 2, 2008: 1-20.
Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the
Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS publication no.
(SMA) 07-3939. Rockville, MD: Substance Abuse and Mental Health Services Administration. 2007:6771.
Kahila H, Saisto T, Kivitie-Kallio S, et. al. A prospective study on buprenorphine use during pregnancy:
effects on maternal and neonatal outcome. Acta Obstetricia et Gynecologica. 2007; 86: 185-190.
Alford D, Compton P, Samet J. Acute pain management for patients receiving maintenance methadone
or buprenorphine therapy. Annals of Internal Medicine. 2006; 144:127-135.
Jones HE, Johnson RE, Jasinski DR, Milio L. Randomized controlled study transitioning opioiddependent pregnant women from short-acting morphine to buprenorphine or methadone. Drug and
Alcohol Dependence. 2005; 78: 33-38.
Kakko J, Heilig M, Sarman I. Buprenorphine and methadone treatment of opiate dependence during
pregnancy: Comparison of fetal growth and neonatal outcomes in two consecutive case series. Drug
and Alcohol Dependence. 2008; 96: 69-78.
Jones HE, Suess P, Jasinski DR, Johnson, RE. Transferring methadone-stabilized pregnant patients to
buprenorphine using an immediate-release morphine transition: An open-label exploratory study. The
American Journal on Addictions. 2006; 15: 61-70.
Binder T, Vavřinková B. Prospective randomised comparative study of the effect of buprenorphine,
methadone and heroin on the course of pregnancy, birthweight of newborns, early postpartum
adaptation and course of the neonatal abstinence syndrome in women followed up in the outpatient
department. Neuroendocrinology Letters. 2008; 29: 80-86.
Schindler SD, Eder H, Ortner R, et al. Neonatal outcome following buprenorphine maintenance during
conception and throughout pregnancy. Addiction. 2003; 98: 103-110.
Personal communication. Gary Kaufman, MD, Director of Maternal Fetal Medicine at DartmouthHitchcock/Nashua and Director of its methadone program for pregnant patients.
References
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid
Treatment Programs. Treatment Improvement Protocol (TIP) Series 43. DHHS publication no. (SMA)
06-4214. Rockville, MD: Substance Abuse and Mental Health Services Administration. 2006: 211-224.
Personal communication. Mark Publicker, MD, Mercy Hospital Recovery Center, Westbrook, Maine.
Colombini N, Elias R, et al. Hospital morphine preparation for abstinence syndrome in newborns
exposed to buprenorphine or methadone. Pharmacy World & Science. 2008; 30: 227-234.
Kaymba-Kay’s S, Laclyde JP. Buprenorphine withdrawal syndrome in newborns: a report of 13 cases.
Addiction. 2003; 98:1599-1604.
Ebner N, Rohrmeister K, et al. Management of neonatal abstinence syndrome in neonates born to
opioid maintained women. Drug and Alcohol Dependence. 2007; 87: 131-138.
Schempf, AH. Illicit drug use and neonatal outcomes: A critical review. Obstetrical and Gynecological
Survey. 2007; 67:749-757.
DHHS State of Maine. Substance abuse trends in Maine: July through December 2006. CESN Report.
August 2007: 1-26.
Chiriboga CA. Fetal alcohol and drug effects. Neurologist. 2003 Nov; 9(6):267-79.
Bauer CR, et al.The Maternal Lifestyle Study: drug exposure during pregnancy and short term maternal
outcomes. American Journal of Obstetrics and Gynecology. 2002 Mar; 186(3):487-95.
Sielski, LA. Infants of mothers with substance abuse. UpToDate.com. 2008.