The Opioid-Exposed Woman

Transcription

1 The Opioid-Exposed Woman Management Considerations for Labor and Delivery Jane Sublette, MS, RN, CNM, WHNP-BC Fairview Ridges Hospital Objectives Describe opioid-associated risks to the mother and fetus with labor management implications. Explain rationale for opioid-assisted therapy for pregnant women who are challenged with opioid addiction. Discuss pain management strategies for mothers who may be dependent on opioids. 1

2 Risks to Woman Third trimester bleeding Poor antenatal nutrition Concurrent abuse of other substances IV use related complications: cellulitis, endocarditis, chorioamnionitis, bloodborne disease (HIV) Concurrent sexually transmitted infection Hepatitis C Social: prostitution, violence, incarceration, loss of custody Risks to Fetus/Newborn Intrauterine growth restriction Preterm birth Transmission of maternal infection Malpresentation Meconium Decreased APGAR Acute opioid withdrawal: HTN, tachycardia, preterm birth, abruption, meconium aspiration, abnormal FHR patterns Neonatal abstinence syndrome Additional Barriers to Pregnancy Health Lack prenatal care or late presentation shame fear of stigmatization fear of pressure to enroll in a treatment program Limited social support: many come from multigenerational drug abusing families Lack of positive parenting role models Psychiatric illness 56-73% Past trauma/sexual abuse 39% History of participation in sex trafficking 32% (Source: McKeever, et al. 2014) 2

3 Comprehensive Care Opioid-assisted therapy (generally preferable to withdrawal) Social Housing Employment Parenting more likely to lack role model or social support in family Intimate partner violence Legal needs Chemical dependency counseling Family therapy Nutritional education/monitor weight Behavioral health Home visits/community health nurse Why Treat With Opioids? Withdrawal risk to fetus: Preterm labor Fetal distress/fetal demise Prevent complications associated with illicit use Increased consistency of prenatal care Opportunity to encourage treatment Reduce criminal activity Less risk to patient from association with drug culture Reduced risk of obstetric complications Methadone Standard treatment for heroin addiction and recently for other opioids Requires daily dispensing from a federally authorized treatment program Blocks euphoria from other opioids Dosage adjusted to avoid withdrawal symptoms metabolism may change with pregnancy Inadequate dose harmful to fetus and increases potential for illicit use 3

4 Buprenorphine Can be prescribed in office setting by specifically credentialed physicians Lack of evidence from long term neurodevelopmental studies Available as single agent (Subutex-advised for pregnancy) or in combination with naloxone (Suboxone) Minimizes withdrawal symptoms and blocks effects of illicit opioids Self-administered Risk of diversion with single agent Lower risk of overdose Fewer drug interactions Less severe neonatal abstinence Labor Care Potential increased anxiety and more pain especially if sexual trauma history No difference in intrapartum pain perception noted by Meyer and colleagues (2007) No reason to suspect drug-seeking in stable mom Should not be denied adequate pain management maintenance opioids not adequate Non-pharmacologic measures should be included Nitrous? Notify pediatric provider Medical Pain Management in Labor Avoid narcotic agonist-antagonist drugs due to risk of acute withdrawal (butorphanol, nalbuphine, pentazocine) Early labor/prodrome Morphine Fentanyl micrograms every mins Maintain daily maintenance of methadone or buprenorphine Reassure patient of plan Dividing dose to 3-4 doses every 6-8 hours may help (but additional analgesia required. If patient on methadone, do not administer buprenorphine Epidural with local anesthetic (bupivicaine) 4

5 Postpartum care Time of greatest risk for relapse Heightened pain sensitivity Meyer and colleagues noted increased pain postpartum and increased post-cesarean opioid requirement for methadone patients (2007) Pain often undertreated Monitor for postpartum depression Comprehensive care transition: Nurse home visits Addiction specialist (avoid interruption in medication) Postpartum Pain Medication Management Will require higher doses of opioids to achieve analgesia Continue methadone or buprenorphine (dividing dose may help) Multimodal pain management Non-steroidal antiinflamatory(ketorolac) Morphine PCA may help after C-birth Long acting regional morphine with NSAIDs Epidural may help with significant pelvic floor trauma Monitor for over-sedation 14 Breastfeeding Encourage breastfeeding if no HIV Avoid breastfeeding if illicit substance or heroin Minimal levels methadone buprenorphine in breastmilk Challenges due to neonatal abstinence: poor latch, newborn irritability, poor suck coordination Challenges caring for newborn at home: impatience, frustration, poor bonding, depression 5

6 Conclusion 6