Maternal & Newborn Effects of Prenatal Substance Abuse

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(

Maternal & Newborn Effects ofPrenatal Substance Abuse

Noori-Shadkam M)MD(

Objectives

Substance use and pregnancy Maternal & fetal effects during

pregnancy Withdrawal syndrome treatment

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

Drug Classes

Alcohol Opioids Stimulants Nicotine Marijuana

Opioids

Morphine heroin OxyContin methadone

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

Con…

•Anemia•Infections•Stillbirth

Opioids: Effects on fetus

Hyperactivity Hypoxia Meconium passage No known fetal

anomalies Utero demise

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

Neonatal withdrawal syn.

Follow-up reports

•Neurobehavioral deficits•Decrease visual & auditory orientation•Decrease motor maturity•More jerkiness•Tremulousness•Hypertonicity

Con…

•Irritability•Increase cry•Decrease PDI•Increase nystagmus;strabismus & otitis media

Stimulants

o Cocaineo Cracko Amphetamineo Methamphetamineo MDMA)Ecstasy(o Caffeine

Cocaine

Pharmacologic effects

Norepinephrine effect tachycardia arrhythmias hypertension vasoconstriction diaphoresis mild tremors

Pharmacologic effects

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

Effects on mother

•Spontaneous abortion•Abruptio placenta•PROM•STD

Effects on fetus & neonate

Fetal hypoxia Fetal hypertention Cocaine-Induced ischemia intestinal atresia infarction NEC

Con…

•G.U malformation•STD•Prematurity•IUGR•SIDS•Diminished alertness•Poorer state regulation

Con…

•Abnormal reflex;tone & motor maturity•Impaired autonomic control•Irritability•Poorer orientation•Decreased habituation

Amphetamine

Effects on mother

•Miscarriage•Placental hemorrhage

Effects on fetus

•Prematurity•IUGR•Congenital anomaly cardiovascular musculoskeletal

Complication•Cardiac arrhythmia•ARF•DIC•Rhabdomyolysis•Learning & memory damage

Con…

•Loss of sexual pleasure•Effect on cognitive;sleep;appetite•death

Nicotine

Cigarettes pipe

Nicotine release

•Acetylcholine•Norepinephrine•GABA•Glutamine•Dopamine

Nicotine

•Increase HR•Increase BP•Increase RR•Hyperglycemia•Decrease appetite

Nicotine:Withdrawal symptom

•Irritability•Headache•Nausea•Craving

Smoking: Effects on fetus

Prematurity IUGR SIDS Increased risk for oral

cleft

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

Marijuana & Hashish

Acute Effect

•Euphoria & Relaxation•Increase HR•Increase BP in a seated or supine•Decrease BP in a standing•Dizziness•Decrease salivation•Increase appetit

Con…

•Impaired coordination•Poor decision making•Delayed responding•Altered sense of time•Impaired concentration & learning

Effects on fetus & neonate

Brain abnormalities )in animal model(o LBW)?(o Meconium passage

treatment

Pregnancy

Neonate

Treatment in pregnancy Reduce disease & crime

Counseling Social service

Avoid withdrawal & craving

Maintenance vs.detoxification

Long-acting medication for control

o STD

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

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

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(

Buprenorphine and Pregnancy

Pregnancy Category C

Use Subutex instead of Suboxone to avoid naloxone

NAS less intense than with methadone

Studies ongoing, results encouraging

Treatment in neonate

The goal is an infant who

• No irritable• No vomitting• No diarrhea• Can feed well• Sleep between feeding

Symptomatic treatment

•Tight swaddling•Holding•Rocking•Placing in a slightly darkened quiet area •Hypercaloric formula•Never give naloxone

Medication

•Neonatal morphine solution)NMS(• Phenobarbital•NMS+Pb

NMS

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

Phenobarbital

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

NMS & pb

NMS 0.4ml/kg/day

Pb loading dose 10mg/kg then 5mg/kg/day