Perinatal Substance Abuse Denice Gardner, MSN, NNP-BC.

Perinatal Substance Abuse

Denice Gardner, MSN, NNP-BC

• Discuss Perinatal Substance Abuse and its affect on the newborn

Objectives

Pictures used in this presentation were obtained from the Mosby’s Nursing Consult web site

Tobacco/Nicotine Alcohol Stimulants Narcotics & Opioids Sedatives/Hypnotics Antidepressants

Categories of Drugs

Spontaneous abortion Placenta previa Placental abruption Preterm labor Premature rupture of membranes C-Section delivery Precipitous delivery Hypertension

Effects of Drugs on Pregnancy

Tobacco is a CNS stimulant Active components of cigarette smoke

Nicotine Tar Carbon monoxide Cyanide Plus, thousands of other compounds

Tobacco & Nicotine

Nicotine-water & fat soluble; cross the placenta

Carbon Monoxide- combines with hemoglobin & impairs oxygenation for mother & fetus; causes placental vasoconstriction & vasospasm

Dose/Response relationship- the higher the number of cigarettes smoked – the greater the effect on the fetus

Tobacco & Nicotine

Fetal/ Newborn Effects Intrauterine growth restriction Slight increase in risk for congenital

malformations Neurobehavioral effects Sudden Infant Death Syndrome Increased cost of hospitalization &

medical care Increased perinatal mortality

Tobacco & Nicotine

Nursing Considerations EDUCATION Follow infant’s growth Provide information regarding

smoking cessation programs & encourage participation

Tobacco & Nicotine

CNS depressant Absorbed rapidly through the stomach

& intestines; metabolized by the liver; excreted through the kidneys & lungs

Fetal alcohol is eliminated only after being broken down in the maternal liver

Diffuses across the placenta & impairs flow of nutrients to the fetus

Alcohol

Broken down into acetaldehyde & acetate. (Acetaldehyde is MORE toxic than alcohol).

Is a known teratogen Fetal effects are directly related to

dose, chronicity of use, gestational age, & duration of exposure

Alcohol

Fetal Alcohol Spectrum Disorder (FASD) Fetal Alcohol Syndrome (FAS) Partial Fetal Alcohol Syndrome Alcohol-Related Birth Defects (ARBD) Alcohol-Related Neurodevelopmental

Disorder (ARND)

Alcohol

Most severe form of FASD Most common identifiable cause of

mental retardation (also is a preventable cause)

Abnormalities in 3 domains Poor growth CNS abnormalities (developmental

delays, impaired brain growth, abnormal structure, etc.)

Dysmorphic facial features (thin, upper lip; smooth philtrum; short palpebral fissures, etc.)

Alcohol exposure may or may not be confirmed

Fetal Alcohol Syndrome

Typical dysmorphic facial features Abnormality in one of the domains

CNS abnormality Growth Behavioral or cognitive ability

Confirmed prenatal alcohol exposure

Partial Fetal Alcohol Syndrome

Typical dysmorphic facial features Normal growth and brain

function/structure Congenital anomalies in other organs

(cardiac, skeletal, renal, eyes, ears) Confirmed prenatal alcohol exposure

Alcohol-Related Birth Defects (ARBD)

Absence of typical dysmorphic facial features

Normal Growth CNS abnormalities:

Decreased cranial size at birth Structural brain abnormalities Impairment of neurologic status in

relation to age Behavioral or cognitive abnormalities

inconsistent with age/developmental level

Confirmed prenatal alcohol exposure

Alcohol-Related Neurodevelopmental Disorder

(ARND)

Begins anytime between birth & 12 hours after birth

Symptoms Tremors Hypertonia Opisthotonos Weak suck & poor feeding Sleeplessness Excessive crying Excessive mouthing behavior

Withdrawal from Alcohol

CocaineAmphetaminesCannabinoids

Stimulants

One of most powerful addictive substances

Is fat-soluble with low molecular weight so readily crosses blood-brain barrier & placenta

Rarely used alone Long half-life (can be present in

infant’s urine for up to 7 days of age)

Cocaine

Fetal/Newborn Effects No increase in congenital malformations Multi-organ dysfunction

CNS: abnormal sleep pattern, EEG, & cry; seizures/tremors; cerebral infarctions

Sensory organs: increased auditory startle response; abnormal ABR

Cardiac: arrhythmias; hypertension; decreased cardiac output

Cocaine

Fetal/Newborn Effects Multi-organ dysfunction (cont.)

Respiratory: apnea; periodic breathing

Renal: ectopiaGI: intestinal perforation; early-onset

NECEye: vascular, disruptive lesions;

retinal hemorrhage

Cocaine

Felt to be due to CNS irritability from effects of cocaine rather than from withdrawal

Initial period of hyperirritability followed by drowsiness &/or lethargy

Changes in behavioral state Difficulty responding to human

voice/face, comforting, &/or environmental stimuli

Difficulty maintaining alert states or rapid change is states

Hyperactive startle

Withdrawal from Cocaine

Used medically for treatment of narcolepsy, depression, weight loss, hyperactivity

Neurotoxic Fetal/Newborn effects:

IUGR

Amphetamines

Withdrawal from Amphetamines

Abnormal sleep patterns

Diaphoresis Vomiting after birth Agitation alternating

with lethargy Constriction of pupils High-pitched cry

Loose stools Yawning Fever Hyperreflexia

CNS- both depressant & mild hallucinogenic effects

High affinity for lipids & accumulates in fatty tissue of body

Placental transfer is greatest during first trimester of pregnancy

Results in increased carbon monoxide levels in blood causing hypoxia

Cannabinoids

Natural Opioids Morphine & Opium

Semi-synthetic Opioids Heroin & methadone

Synthetic Opioids Oxycodone, hydromorphone,

oxycodone, Fentanyl, etc.

Narcotics & Opioids

Fetal/Newborn Effects Readily crosses placenta Lower Apgar Scores Do NOT use naloxone for with

known/suspected narcotic & opioid dependence due to creation of rapid withdrawal & seizures

Meconium aspiration IUGR Lower incidence of RDS

Narcotics & Opioids

Congenital infections Increased incidence of SIDS Low birth weight Microcephaly Increased chromosomal

abnormalities in heroine-exposed infants

Narcotics & Opioids

Barbiturates Benzodiazepines

Sedatives/Hypnotics

Readily crosses placenta Fetal blood levels are similar to

maternal blood levels Accumulate in adipose tissue High concentration also present in

brain, lungs, & heart Fetuses exposed to long-term

benzodiazepines may have hypotonia, feeding difficulty, & withdrawal symptoms

Sedative/Hypnotics

Selective Serotonin Reuptake Inhibitors (SSRIs)

Sertaline (Zoloft), Fluoxetine (Prozac), Escitalopram (Lexapro), Paroxetine (Paxil), etc.

Tricyclic Antidepressants (TCAs) Amitriptyline (Elavil), Nortriptyline, etc.

Monoamine Oxidase Inhibitors (MAOIs)

Phenelzine (Nardil), Isocarboxazid (Marplan), etc.

Antidepressants

Onset may vary from shortly after birth to 2 weeks

Duration may range from 8 to 16 weeks Severity of presentation varies Infants of chronic drug abusers usually

have more severe withdrawal The closer to delivery the drug is taken,

the later the signs of withdrawal appear & the more severe the symptoms will be

Neonatal Abstinence Syndrome

Multiorgan/System Disorder Most common symptoms

Neurologic Increased toneTremorsExaggerated reflexes Irritability/restlessnessHigh-pitched cryDifficulty sleepingSeizures


Most common Symptoms Autonomic

YawningNasal stuffinessSweatingSneezingLow-grade feverMottling


Most Common Symptoms GI

Loose stoolsVomiting/regurgitationPoor feedingDifficulty swallowingExcessive sucking


Most Common Symptoms Respiratory

Tachypnea Others

Skin excoriation


Onset of withdrawal symptoms Alcohol- usually 3-12 hours after delivery Narcotics- usually 48-72 hours after

delivery, but may be as long as 4 weeks Barbiturates- usually 4-7 days after

delivery but can occur 1-14 days after delivery

Cocaine- usually 48-72 hours after delivery


Severity of NAS depends on The type of drug used Half-life of the drug Time of last exposure before

delivery Dose taken Quality of labor


Severity of NAS depends on Type of analgesia/anesthesia used

during labor Maturity & status of infant Gestational age Nutritional status of mother


Scoring Systems Modified Finnegan Scoring Tool

Gold Standard*** Neonatal Drug Withdrawal Scoring

System Neonatal Withdrawal Inventory


Screening Tools Maternal

Thorough history & assessmentDrug testing (urine is most

commonly used) Infant

Thorough assessmentUrine Drug screenMeconium Drug ScreenNewer testing: hair and umbilical

cord testing


Nursing Management Accurate assessment, evaluation, &

use if institution’s screening tool Comfort measures (swaddling, holding,

cuddling, response to stress cues, etc.) Assessment & encouragement of

mother/infant interaction Maternal/family support


Pharmacologic management Tincture of opium Camphorated Tincture of Opium

(Paregoric) Morphine (most common) Methadone Clonidine Chlorpromazine (Thorazine) Phenobarbital Diazepam


Breastfeeding Cigarettes:

not contraindicated encourage decreasing numbers of cigarettes smoked & smoking cessation

Smoke after breast feeding Alcohol: use should be discouraged


Breastfeeding Cocaine: contraindicated during

active use Marijuana: contraindicated Heroin: contraindicated Methadone: not contraindicated;

should not be stopped abruptly Sedatives/Hypnotics: dose-

dependent; discontinue with signs of lethargy &/or weight loss


Chang, G., Lockwood, C.J., & Barss. (2012). Substance Use In Pregnancy. Retrieved from www.uptodate.com on 8/17/2012.Sielski, L.A., Garcia-Prats, J.A., & Kim, M.S. (2012). Infants of Mothers with Substance Abuse. Retrieved from

www.uptodate.com on 8/17/2012.

References

Sielski, L.A., Garcia-Prats, J.A., & Kim, M.S. (2012). Neonatal Opioid Withdrawal

(Neonatal Abstinence Syndrome). `Retrieved from www.uptodate.com on 8/17/2012.

Verklan, M.T. & Walden, M. (2009). Core Curriculum for Neonatal Intensive Care Nursing (4rd Edition). Elseiver Saunders: St. Louis. Retrieved from Mosby’s Nursing

Consult web site on 6/16/2012.

References

Perinatal Substance Abuse Denice Gardner, MSN, NNP-BC.

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