Exam 4 - Neonatal Abstinence Syndrome Flashcards
What substance is the most dangerous to consume during pregnancy?
Alcohol - can lead to serious, permanent impairment
What effects does tobacco use during pregnancy have on the newborn?
- Low birth weight
- Behavior problems
True/false: research suggests that most of the illicit drugs used by mothers during pregnancy are more dangerous than they were previously thought to be
False - they are less dangerous
True/false: children of mothers who use drugs during pregnancy are at higher risk for physical, sexual, and emotional abuse
True - more common among mothers in lower SES, but abuse occurs across all socioeconomic classes
When should the provider consider drug abuse during pregnancy?
- Physical evidence found on exam
- Track marks
- Nasal hyperemia
- Septal defects
When should the provider consider drug abuse during pregnancy?
- High risk historical or social factors
- No prenatal care
- Denial of pregnancy
- Family history
- Previous child abuse or neglect
- Lack of support system
- Psychiatric problems
- History of legal problems
What obsteric complications could occur with drug use during pregnancy?
- Abruption
- Unexplained preterm labor
- Uterine trauma/abuse
- IUGR
- Previous poor birth outcome
Neurologic maternal complications from substance abuse
- Cocaine, amphetamines and LSD, heroin
Cocaine: seizures, postpartum intracerebral hemorrhage
Amphetamines and LSD: psychosis
Heroin: abstinence syndrome, menoneuritis, polyneuritis, transverse myelitis
Cardiovascular maternal complications from substance abuse
- Cocaine and amphetamines, IV drug use
Cocaine, amphetamines: HTN, infarction, cardiomyopathy, arrhythmias, sudden death
IV drug use: bacterial endocarditis
Infectious maternal complications from substance abuse
- IV drugs, and all drugs
IV drugs: hep B and C, HIV, cellulitis
All drugs: PNA, UTI, STIs
GI maternal complications from substance abuse
- Cocaine, IV drug use
Cocaine: intestinal infarction
IV drug use: acute and chronic hepatitis
Nutrition maternal complications from substance abuse
Poor nutrition
What things should the provider do while collecting the patients substance abuse history?
- Obtain verbally, no questionnaires
- Private setting
- Nonjudgemental
- Be direct
- Ask about drug abuse among household members
- If admission of drug abuse, ask about dose, routes, duration of use
Can hospitals obtain drug screenings from pregnant women without their consent?
No - cannot test women for illegal drug use without conset and cannot report positive test results to law enforcement
Can hospitals obtain a drug test if a neonate presents with unexplained neurological symptoms?
Yes - drug test on the infant may be included without parental consent
Under what conditions can the provider contact child protective services?
If there are prior reports and to request a home evaluation
Urine toxicology time periods for positive test after last use
- Alcohol, amphetamines and cocaine, opiates, LSD, marijuana
- Alcohol: hours
- Amphetamines and cocaine: 1-3 days
- Opiates: 2-4 days
- LSD: 2-3 days
- Marijuana: 7-30 days
If the provider wants to identify whether an infant has been exposed to illegal substances, who should they collect a urine sample from?
Either maternal or neonatal urine sample
- Urine tests for narcotics are negative at the time the neonate develops symptoms of withdrawal
Always review medical records for ___ ordered during labor to avoid false accusations
Narcotics or sedatives
___ and ___ screenings can be used to detect drug abuse during the ___ half of pregnancy
Meconium and hair screening can be used to detect drug abuse during the second half of pregnancy
- Collect meconium sample from first 48 hours of life
What is cocaine?
Local anesthetic and CNS stimulant
Can cocaine cross the placenta? Does it have associated withdrawal symptoms?
Believed to be a teratogen and crosses the placenta
There is NO clinically documented neonatal withdrawal syndrome
Signs and symptoms of cocaine abuse
- Premature labor
- Placental abruption
- Fetal asphyxia
Many infants show no s/s of affects of cocaine
When do neurobehavorial findings present in infants exposed to cocaine in utero?
Tend to present on days 2-3
Newborn findings that might indicate cocaine abuse during pregnancy
- Low birth weight
- IUGR
- Prematurity
- Fetal distress
- Meconium staining
- Microcephaly
- Anomalies of urinary or GI tracts
- Feeding difficulties
- Irritability
- Abnormal sleep patterns
- Hypertonia
Can cocaine be found in breastmilk?
Yes - detectable in breastmilk so mothers who have used cocaine recently should not breastfeed
Management of cocaine-exposed neonates
- Offer quiet environment
- Involve child/family services
- Higher rates of STIs in women who use cocaine - consider testing
What are the long term effects of perinatal cocaine exposure?
- Changes in IQ or behavior
- Neurobehavorial dysfunction
- Hyperactivity
- Aggression
- Short term attention span problems
What is the definition of narcotic dependence?
Simultaneous tolerance to narcotics of any type, with symptoms of withdrawal upon discontinuation
Examples of naturally occuring narcotics
- Codeine
- Morphine
- Opium
Examples of synthetic and semisynthetic narcotics
- Fentanyl
- Heroin
- Hydromorphone (dilaudid)
- Methadone
- Meperidine (demerol)
- Oxycodone (percodan and percocet)
- Propoxyphene (darvon)
True/false: withdrawal syndrome is less severe and less prolonged with methadone than with heroin
False - withdrawal syndrome is more severe and more prolonged with methadone than with heroin
What medication can be given as an alternative to decrease the severity of withdrawal symptoms and reduce dependence?
Suboxone
Are spontaneous abortions and stillbirths associated with narcotic use during pregnancy?
Yes - increased rates of spontaneous abortion and stillbirths, sometimes as a result of withdrawal syndrome
What is thought to be the cause of IUGR in neonates to mothers who used narcotics during pregnancy?
May be due to direct effect on growth, poor nutrition, stressed lifestyle
Sign and symptoms of neonatal abstinence syndrome (NAS)
- High pitched cry
- Tremulousness
- Sleeplessness
- Difficulty feeding
- Sweating
- Nasal stuffiness
- Sneezing
- Vomiting
- Cramping
- Diarrhea
- Seizures
- EEG abnormalities
How do s/s of NAS differ in premature infants?
Symptoms tend to be less common in premature infants likely due to immature neurological system
When is the usual onset of NAS?
Usually develops within 48 hours of life - 96% by 4 days
- Symptoms usually present within 48-72 hours but can be delayed up until 4 weeks
- Depends on half-life of drug of abuse and mothers last dose
- If mothers last dose was >1 week prior to delivery, very low likelihood of withdrawal symptoms
Does methadone withdrawal begin later or earlier than heroin withdrawal?
Methadone withdrawal begins later than heroin withdrawal but both typically begain before 48 hours of life
When can neonates with NAS be discharged in relation to short acting and long acting opiates?
Babies asymptomatic at 72 hours (short acting opiate) or 5-7 days (long acting opiate) of life are usually discharged with plan for close follow up
How long can symptoms of NAS persist after birth?
Symptoms can persist for 4-6 months after birth
Maternal screening for comorbidities such as ___ need to be performed in association with NAS
HIV, hep B or C, and polydrug abuse
What have many OB/GYN providers done to methadone dosages to reduce the severity of neonatal withdrawal?
Many obstetricians reduce the mother’s daily methadone dosage to <20 mg/kg because several studies have demonstrated a lower incidence and decreased severity of neonatal withdrawal with lower dosages
Why have some obstetricins been reluctant to wean maternal methadone in late pregnancy?
Out of concern that the mother may turn to other illicit drugs
- Some suggest increasing maternal methadone late in pregnancy based on lower maternal methadone plasma levels for the same dose
What is the finnegan score used for?
Assesses neonatal drug withdrawal syndrome
How should the provider utilize the finnegan score? How is it performed?
Assess the infant initially 2 hours after birth and then q4h –> total points for s/s seen during that interval
- If score is >8, change to q2h and continue until 24 hours after the last total score of >8, then resume q4h
- Use a new sheet for each day
- Include mother in assessment of symptoms
How is the lipsitz tool different from the finnegan score when assessing for neonatal drug withdrawal syndrome?
Lipsitz tool offers the advantages of a relatively simple numeric system and a reported 77% sensitivity using a value >4 as an indication of significant withdrawal signs
How is the ostrea system different from the lipsitz tool and finnegan score?
The six criteria in the ostrea system are feasible, but the method is limited by the use of simple ranking rather than a numeric scale precluding summing the severity scores of multiple signs of withdrawal
How would the provider treat NAS?
- Frequent small feddings of hypercaloric formula (24 cal/oz)
- 150 to 250 cal/kg/day needed for proper growth in neonates suffering withdrawal
- Suck, swaddle, “sush”, swing
- IV fluids/electrolyte replacement
Do infants with confirmed drug exposure who do not have signs of withdrawal require therapy?
Infants who do not have signs of withdrawal do not require therapy
What is the only defined benefit of using pharmacological intervention in NAS?
Short term amelioration of clinical signs
What are the risks associated with pharmacological therapy to treat NAS?
- Prolongs drug exposure and hospitalization time –> serves as detriment to maternal/infant bonding
- Some believe pharmacological therapy of infant may reinforce maternal idea that discomfort or annoying behavior should be treated with drugs
- Unknown risks (unproven)
- Neonatal drug withdrawal decreased by pharmacological management of symptomatic infants
- Risk of compounding intrauterine induced deficits with neonatal exposure to other drugs
If pharmacologic management is chosen, what important detail regarding the type of medication should be considered?
Choose a drug from the same class as that causing withdrawal
When do hospitals normally begin pharmacological therapy based on screening tools?
Most facilities begin treatment when three consecutive finnegan scores are >8 or when the sum of three consecutive finnegan scores is >24
What are the only FDA approved drugs for the treatment of drug withdrawal?
- Benzodiazepines for alcohol withdrawal
- Methadone for opioid withdrawal
What other agents that are not FDA approved has been shown to be favorable in the management of drug withdrawal?
- Tincture of opium
- Morphine
- Clonidine
- Phenobarbital
- Diazepam
What are the usual morphine doses to treat drug withdrawal?
0.24 to 1.3 mg/kg/day
What other interventions would help improve the efficacy of pharmacological therapy in treating drug withdrawal?
- Normal temperature curve
- Ability of the infant to sleep between feeding and medications
- Decrease in activity and crying
- Decrease in motor instability
- Weight gain
What commonly medication category has been linked to neonatal withdrawal symptoms?
SSRIs (e.g. prozac, celexa, lexapro, zoloft, luvox)
Research has linked third trimester use of SSRIs to neonatal signs of withdrawal. What are these symptoms?
- Excessive crying
- Irritability
- Jitteriness
- Shivering
- Restlessness
- Feeding difficulties
- Sleep disturbance
- Tremors
- Hypertonia or rigidity
- Tachypnea
- Respiratory distress
- Hypoglycemia
- Seizures
Onset and duration of SSRI withdrawal symptoms in neonates
Onset: several hours to several days
Duration: 1-2 weeks
Are there associated neurodevelopmental outcomes in babies born to women on SSRIs?
No adverse neurodevelopmental outcomes
Can SSRIs be continued during pregnancy?
SSRIs should be continued during pregnancy at the lowest possible dose
- Withdrawal of medication could have harmful effects on the mother-baby dyad
True/false: developmental scores on the mental index on the Bayley Scales of Infant Development are affected by severity of withdrawal or the treatment chosen
Developmental scores on the mental index on the Bayley Scales of Infant Development are NOT affected by severity of withdrawal or the treatment chosen
What are the characteristics of withdrawal associated seizures in the neonate?
- Primarily myoclonic
- Respond to opiates
- Carry no increased risk of poor outcome
