1 / 45

TREATMENT OF THE PREGNANT WOMAN MEANS THAT ONE IS CARING FOR TWO PATIENTS, NOT ONE

MATERNAL & NEONATAL WITHDRAWAL SYNDROME BY: Dr. F.Goudarzi Clinical Toxicologist SUMS. TREATMENT OF THE PREGNANT WOMAN MEANS THAT ONE IS CARING FOR TWO PATIENTS, NOT ONE

tiva
Download Presentation

TREATMENT OF THE PREGNANT WOMAN MEANS THAT ONE IS CARING FOR TWO PATIENTS, NOT ONE

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. MATERNAL & NEONATAL WITHDRAWAL SYNDROME BY:Dr. F.GoudarziClinical ToxicologistSUMS

  2. TREATMENT OF THE PREGNANT WOMAN MEANS THAT ONE IS CARING FOR TWO PATIENTS, NOT ONE * IT IS SUGGESTED THAT PHYSICIANS ADDRESS THE ISSUE OF ALCOHOL AND DRUG USE DURING PREGNANCY WITH ALL WOMEN OF CHILD BEARING AGE

  3. What is MNAS? • Presence of withdrawal behaviors in neonates exposed to dependency-producing substances in utero. • These behaviors include central nervous hypersensitivity, gastrointestinal dysfunction and vague autonomic symptoms. • 25-40 % of infants with known exposure are asymptomatic or display only mild symptoms

  4. Substances that can cause MNAS • Opiates- (55-94% of neonates exposed in utero will have withdrawal symptoms) • Alcohol • Tobacco • Benzodiazepines • Barbiturates • SSRIs (neonatal behavioral syndrome) • ?Amphetamines • ?Cocaine • ?Marijuana • TCA

  5. SEDATIVE/HYPNOTICS • BENZODIAZEPINE &PHENOBARBITAL WITHDRAWAL • NO DIFFERENCE BETWEEN PREGNANT AND NON-PREGNANT WOMAN, ALTHOUGH SEVERE WITHDRAWAL CAN PRODUCE STATUS EPILEPTICUS AND FETAL RESPIRATORY ARREST • CAN LAST 3 TO 5 WEEKS • VERY MUCH LIKE ACUTE ALCOHOL WITHDRAWAL • TIME COURSE AND SEVERITY DEPEND ON • DOSE OF DRUG • DURATION OF USE (DOES NOT WORSEN AFTER ONE YEAR OF USE) • DURATION OF DRUG ACTION

  6. FETAL EFFECTS FROM BARBITURATES • CLEFT PALATE • HYPOSPADIAS (PENILE ORIFICE IS TOO LOW) • MICROCEPHALY (SMALL HEAD SIZE) • SHORT NOSE

  7. FETAL EFFECTS FROM BENZODIAZEPINES • ????CLEFT LIP AND PALATE

  8. OPIOIDS

  9. OPIOIDS WITHDRAWAL IN THE MOTHER –EARLY & MIDDLE PHASE • RESTLESS SLEEP • DILATED PUPILS • ANOREXIA • GOOSEFLESH • IRRITABILITY • TREMOR

  10. OPIOIDS WITHDRAWAL IN THE MOTHER - LATE PHASE • INCREASE IN ALL PREVIOUS SIGNS AND SYMPTOMS • INCREASE IN HEART RATE • INCREASE IN BLOOD PRESSURE • NAUSEA AND VOMITING • DIARRHEA • ABDOMINAL CRAMPS • LABILE MOOD • DEPRESSION • MUSCLE SPASM • WEAKNESS • BONE PAIN

  11. OPIOIDS WITHDRAWAL • IT IS NOT RECOMMENDED TO TAPER PREGNANT WOMEN OFF OF METHADONE, BUT THE SAFEST TIME IS THE 2ND TRIMESTER (TIPS2) • BEFORE 14 WEEKS AND AFTER 32 WEEKS THERE IS AN INCREASED INCIDENCE OF SPONTANEOUS ABORTION AND PREMATURE LABOR

  12. OTHER WITHDRAWAL AGENTS • CLONIDINE • NO TERATOGENIC EFFECTS • LONG TERM USE NOT RECOMMENDED • BUPRENORPHINE • APPEARS SAFE WITH NO TERATOGENIC EFFECTS, BUT NOT APPROVED FOR USE YET ( JONES AND JOHNSON 2001) • NEVER USE NARCAN UNLESS AS A LAST RESORT • SPONTANEOUS ABORTION • PREMATURE LABOR • STILLBIRTH

  13. FETAL EFFECTS OF OPIOIDS • LOW BIRTH WEIGHT • FETAL DISTRESS • PREMATURITY • NEONATAL ABSTINENCE SYNDROME • STILLBIRTH • SUDDEN INFANT DEATH SYNDROME • MECONIUM ASPIRATION

  14. NEONATAL ABSTINENCE SYNDROME • 60-80% OF OPIOIDS EXPOSED INFANTS • 72 HOURS AFTER BIRTH • CNS EFFECTS • IRRITABILITY • HYPERTONIA (INCREASED MUSCLE TONE) • HYPERREFLEXIA • ABNORMAL SUCK • POOR FEEDING • SEIZURES ( 1 TO 3%) • GI EFFECTS • DIARRHEA • VOMITING

  15. METHADONE DOSING STRATEGIES IN THE PREGNANT WOMAN • INITIAL 10 TO 40 MG • EXTRA 5 TO 10 MG IN 3 TO 4 HOURS IF SIGNS AND SYMPTOMS OF WITHDRAWAL • REPEAT 5 TO 10 MG Q 3 TO 4 H PRN • STABILIZE AT THIS DOSE FOR SEVERAL DAYS • DECREASE BY 2 .5 MG Q 7 TO 10 DAYS AND MONITOR OB STATUS

  16. NEONATAL ABSTINENCE SYNDROME

  17. Diagnosis • Maternal history of drug use • Positive identification of substance in maternal or neonatal specimen • Scoring • Once diagnosed- consult social services

  18. TIME TO ONSET OF MATERNAL WITHDRAWAL SIGNS *MATERNAL WITHDRAWAL DEPENDS ON THE DRUG, FREQUENCY OF USE, AND DURATION OF USE. TIMES CAN VARY SIGNIFICANTLY.

  19. TIME TO ONSET OF NEONATAL WITHDRAWAL SIGNS USUALLY THE ONLY WITHDRAWAL SYNDROME THAT REQUIRES TREATMENT IS OPIOID WITHDRAWAL

  20. Onset of symptoms varies with the substance being used by the mother, the quantity, frequency and duration of intrauterine exposure, timing and amount of the last maternal use, as well as maternal and infant metabolism and excretion CNS Tremors, irritability, increased wakefulness, high-pitched crying, hypertonicity and hyperactive reflexes, seizures, yawning, sneezing and skin excoriation Gastrointestinal Poor feeding, uncoordinated and constant suck, vomiting or regurgitation, diarrhea, dehydration Autonomic Signs increased sweating. Nasal stuffiness. Rhinorrhea, mottling, temperature instability, fever, tearing Clinical Presentation

  21. W - wakefulness I - irritability T -tremors, twitching, tachypnea H - hyperventilation, hypertonia, hyperpyrexia, hyperaccusis, hiccups D - diarrhea, diaphoresis, R - rub marks A - alkalosis W - weight loss A - apnea L - lacrimation, S - seizures (myoclonic), sneezing, skin mottling

  22. Frequency of Clinical Signs • Disturbed sleep – 53% • Mottling 53% • Excess sucking 45% • Tremors 43% • Tachypnea – 43% • Hypertonia 41% • Fever 40% • Seizures 2-11% (often later)

  23. STIMULANTS

  24. STIMULANTS WITHDRAWAL IN THE MOTHER • DYSPHORIA • FATIGUE • UNPLEASANT DREAMS • INSOMNIA • HYPERSOMNIA (INCREASED SLEEP) • INCREASED APPETITE • PSYCHOMOTOR RETARDATION • AGITATION

  25. MATERNAL EFFECTS OF STIMULANT AND COCAINE • ABRUPTIO PLACENTAE • PREMATURE LABOR • SPONTANEOUS ABORTION • DECREASE DURATION OF DELIVERY • GREATER NUMBER OF OBSTETRICAL COMPLICATIONS

  26. NAS video clip

  27. ALCOHOL WITHDRAWAL

  28. MATERNAL WITHDRAWAL • THE RATE OF ALCOHOL METABOLISM MAY BE FASTER DURING PREGNANCY, SO BE AWARE THAT WITHDRAWAL CAN START SOONER THAN EXPECTED.

  29. MINOR WITHDRAWAL IN THE MOTHER TIME • 6 to 60 HOURS SYMPTOMS • TREMORS • INSOMNIA • NAUSEA • ANOREXIA • ANXIETY • WEAKNESS

  30. MINOR WITHDRAWAL IN THE MOTHER SIGNS • ACTION TREMOR • INATTENTION • EASY STARTLE • PLETHORA • CONJUNCTIVAL INJECTION • INCREASED REFLEXES

  31. EARLY WITHDRAWAL IN THE MOTHER TREATMENT • WATCH FOR DT’S • EVALUATE FOR OTHER ILLNESSES AND INJURIES • LIGHT SEDATION WITH BENZODIAZEPINES • THIAMINE • ELECTROLYTE BALANCE • PATIENTS MUST UNDERSTAND THAT THEY NEED FURTHER TREATMENT

  32. LATE WITHDRAWAL IN THE MOTHER DELIRIUM TREMENS • HIGH RISK FOR DT’S IF BLOOD ALCOHOL LEVEL GREATER THAN 300 mg% OR WITHDRAWAL SEIZURES • PROFOUND CONFUSION AND MISPERCEPTIONS • DISORIENTATION • HALLUCINATIONS • PARANOID DELUSIONS • MOTOR HYPERACTIVITY • TREMOR, RESTLESS, AGITATED, INCREASED REFLEXES • AUTONOMIC HYPERACTIVITY • INCREASED HEART RATE, PROFUSE SWEATING, DILATED PUPILS • MORTALITY OF THE MOTHER IS 10 to 15% IF UNTREATED, 1 to 2% IF TREATED

  33. FASD • BINGE DRINKING (5 OR MORE DRINKS ON ONE OCCASION) IS ESPECIALLY DETRIMENTAL TO THE FETUS • THERE IS NO PROVEN “SAFE” AMOUNT OF ALCOHOL TO USE DURING PREGNANCY • ALCOHOL HAS BEEN FOUND IN BREAST MILK

  34. NICOTINE AND TOBACCO

  35. NICOTINE AND TOBACCO • IF THE PREGNANT WOMAN CANNOT STOP SMOKING USING BEHAVIORAL INTERVENTIONS, THEN NICOTINE REPLACEMENT PRODUCTS CAN BE USED

  36. NICOTINE WITHDRAWAL SYMPTOMS IN THE MOTHER

  37. CANNABINOIDS

  38. CANNABINOIDS WITHDRAWAL IN THE MOTHER • 10 HOURS AFTER USE • TREMOR OF THE TONGUE AND EXTREMITIES • INSOMNIA • SWEATS • LATERAL GAZE NYSTAGMUS • EXAGGERATED DEEP TENDON REFLEXES

  39. MNASS • Used to initiate, adjust and wean pharmacologic treatment. • Scoring should begin within 4 hours after birth and continue every 4 hours until the onset of symptoms. At the onset of symptoms scoring should be done every 3 hours for 24 hours and then every 4 hours for the duration of treatment. • Observation should be made after feedings, newborns must be awake and calm to asses muscle tone, respirations and Moro reflex. Newborns should be observed for 20 to 30 minutes before scoring is determined.

  40. Supportive Swaddling ( decreases the added stimulation of startled movements) Reduction of environmental stimuli ( decreased light and noise) Frequent small feeding Frequent diaper change are necessary to reduce skin excoriation Monitor intake, output and weigh daily to assess hydration and caloric status related to vomiting, diarrhea and poor feeding status. Pharmacologic intervention is indicated for evidence of acute withdrawal such as seizures, poor feeding (excess weight loss), severe diarrhea, vomiting, dehydration, inability to sleep and fever not due to any infectious etiology 3 consecutive NAS scores of 8 or more or the average of 3 consecutive NAS scores is 8 or more. or 2 consecutive NAS scores of 12 or more or the average of 2 consecutive score is 12 or more. Pediatric consult is recommended when considering pharmacologic treatment. Cardio respiratory monitoring. Management

  41. Paregoric 0.2-0.5 ml/dose q 3-4 p.o. or 4-6 drops q 4-6h; may increase by 2 drops until clinical improvement Improves most of the withdrawal symptoms especially diarrhea, taper dose by 10-20% per day over 2-4 week after symptoms stable for 3-5 days. Neonatal Opium Dilution 0.4% solution (contains 0.4 mg morphine equivalent per ml)guidelines: 0.8 ml/kg/day for NAS 8-10 1.2 ml/kg/day for NAS 11-13 1.6 ml/kg/day for NAS 14-16 2.0 ml/kg/day for NAS >16 Doses given orally every 3-4 h with feeds ( not prn) Phenobarbital 15-20 mg/kg/day loading dose to achieve level of 20-40 mg/ml. Maintenance dose =2-8 mg/kg/day. Taper dose by 10-20% per day after symptoms stable for 3-5 days. Diazepam 0.3-0.5 mg/kg q 8 h; initial dose i.m then p.o Allows rapid suppression of symptoms, decreased suck, avoid in jaundice or premature infants. Pharmacologic Therapies in Neonatal Abstinence Syndrome

  42. Methadone 0.1-0.5 mg/kg/day divided q 4 to 12 h Increase by 0.05mg/kg/dose until symptoms are well controlled Taper dose by 10-20% per day over 1 mo Treatment usually longer (5 days-4 mo) Long half-life (26 h ) Chlorpromazine 0.5-0.7 mg/kg/dose loading then 2-2.8 mg/kg/day in divided doses q 6 h Decrease dose over 2-3 wk Clonidine 0.5-1 ug/kg single dose then 3-5 ug/kg/day divided dose q 4-6 h Increase by 0.5 ug/kg over 1-2 days until maintenance dose is achieved Pharmacologic Therapies in Neonatal Abstinence Syndrome

  43. Weaning Guidelines Once NAS are consistently 6-8, maintain the same therapeutic dose 48 hours before weaning. Wean by 10% of maximum dose every 1-2 days. If symptoms increase, return to effective dose. Therapeutic agents should be gradually decreased over a 2-6 week period. Neonatal opium solution should be weaned first, then Phenobarbital.

More Related