Prenatal Exposure to Drugs Flashcards
Addiction Definition
a primary chronic disease of brain reward, motivation, memory, & related circuitry
Components of Addiction
Inability to abstain, impaired behavioral control, craving, diminished recognition of problems resulting from it, Dysfunctional Emotional Response
Family & Addiction
History in grandparents & other family
Lack of access to resources & support
Low SES
Domestic violence
Abusive behavior (physical, emotional, sexual)
Mental health issues in mother and other family members
Extensiveness of Problem
3 million 12 year olds and up used illicit drugs for the first time in 2010
8100 people a day used illicit drugs for the first time in 2010
Average age of initiation was 19.1 years
Whatever age they start using is their mental age until they get clean
Pregnancy & Illicit Drug Use
6% of pregnant women ages 15-44 reported non-medical use of prescription type psychotherapeutic drugs in the past year
4.5% of pregnant women used illicit drugs the month before delivery
Types of drugs: 4.4% pain relievers, 2% tranquilizers, 1.3% stimulants, .8% methamphetamines, .3% sedatives
Crack/cocaine most common followed by meth then marijuana
Most common age is 15-17 yo, least common is 26-44 yo
NAS
Generalized disorder characterized by central nervous system hyper-irritability, gastro-intestinal dysfunction, respiratory distress and vague autonomic symptoms
Occurs due to exposure in-utero to licit or illicit drugs of abuse or from postnatal iatrogenic effects
Opioids (ex. Methadone, codeine, oxycodone, heroin) most common drugs from which infants withdraw
Exposure to opiates can lead to it in 60-90% of infants (up to 60% require pharmacologic tx)
Opioid withdrawal is 1 of few disorders that can be treated
Actual disorder in which they are addicted
Can be prenatally exposed w/o having it
Neonatal withdrawal usually occurs 48-72 hours after birth, sometimes it’s after 2 to 4 wks (& then it’s too late to test mom)
Sx’s most severe may last up to 6-12 months (sweating, tremors, etc.)
General Risks Associated with Prenatal Exposure to Drugs
SIDS, IUGR (intrauterine growth retardation), pre-term labor & delivery, learning disabilities
Infant Red-Flags of When to Screen for NAS
Prematurity, unexplained IUGR, neurobehavioral abnormalities, atypical CVAs, myocardial infarctions, NEC (necrotizing entercolitis-part of bowel dies)
Mother Red-Flags of When to Screen for NAS
Lack of prenatal care, unexplained fetal demise, placental abruption, severe mood swings, CVAs, myocardial infarctions, repeated spontaneous abortions
Preterm infants less than 30 wks. gestation have a _____ risk of drug withdrawal than infants born later
Lower: less exposure & because CNS is under-developed
How do we test Prenatal Drug Exposure?
Urine drug screening (only recent exposure: high false negative), meconium drug testing (4-5 months; more accurate), Umbilical cord toxicology screening (not as accurate as meconium but still used), hair testing (for several months)
Presentation of NAS differs based on 3 primary factors:
Type (not amount) of drug abused
Time between last use by mother & delivery
Maternal / infant metabolism & excretion
Other factors may impact how infant presents
Signs & Sx’s of NAS
Neurological excitability
Gastrointestinal dysfunction
Autonomic signs
Neurological excitability
tremor, high-pitched crying, exaggerated reflexes, sneezing, yawning, difficulty getting to sleep
2-11% with opioid withdrawal also have seizures
Gastrointestinal dysfunction
poor feeding, vomit & diarrhea, uncoordinated suck, dehydration
Autonomic Signs
(sweating, etc.), nasal stuffiness, temp instability, fever, modeling
Feeding the Infant with NAS
Poor feeding, uncoordinated suck, vomiting, diarrhea, dehydration, poor weight gain
Managing poor feeding in infant with NAS
Low lactose, soy, or elemental formula (helps with feeding intolerance & cramping)
Mylicon (avoid use of sucrose)
Managing environment: decrease extraneous noise, consistency, dim lighting
Managing GERD in infants with NAS
Elevating head of bed
Thickening feedings (though research doesn’t support use of thickened liquid as reliable for managing reflux; no longer indicated in literature, but can work for some)
Increase frequency/reduce volume of feeding
Managing Poor Sucking in Infants with NAS
Uncoordinated sucking prevents infant from efficient intake
Frustration increases due to inability to take in liquid efficiently
Hyperactive gag: may be exacerbated due to incoordination
Swaddling may support organization; external pacing may be required; temp control may influence organization
Vomiting & Diarrhea in Infants with NAS
Lead to dehydration/poor weight gain
Increased caloric expenditure secondary to increased activity/agitation (even keeping body temp up burns calories)
Increasing caloric density may promote weight gain (24-27 cal/oz)
May use Immodium if diarrhea causes too much weight loss
Clonidine
Breast Feeding the Infant with NAS
Only minimal amts of methadone cross into breast milk so advantages outweigh issues
MBM is more easily tolerated
Indirectly decreases sx’s of NAS: decreases GI irritation scores; improved GI tolerance results in better growth; lowered NAS scores result in less dosage of meds needed to tx infant for withdrawal
When not to breast feed
If mother is taking: amphetamines (more irritable & sleep probs), marijuana (fat soluble), cocaine (irritability, vomiting, diarrhea, tremors, seizures), heroin (?)
Pharmacologic Tx of NAS
Primary: morphine & methadone
Secondary: clonidine, phenobarbital
Fetal & Neonatal Effects of Marijuana
THC easily crosses the placenta & is present in amniotic fluid
High lipid solubility, slow elimination, prolonged fetal exposure
Cannabinoid receptors present in early gestation, modifies neurotransmitters (serotonin, dopamine, GABA), altered neuronal growth, maturation & differentiation, & structural or functional abnormalities
Impact generally subtle, outcomes usually associated with heavy or frequent use
Intrapartum Complications of Fetal Exposure to Marijuana
Dysfunctional labor
Meconium stained AF (not itself a big deal; usually indicative of distress)
Neonatal Complications of Fetal Exposure to Marijuana
Prematurity
Long Term Complications of Fetal Exposure to Marijuana
Fine tremors, poor sleep, visual reasoning poor (reading affected down the road), poor memory & verbal skills, abnormal attention, slightly increased risk for SIDS
Neurotransmitters Affected by Cocaine
Norepinephrine, serotonin, dopamine
Inhibits reuptake of NE and D, accumulates at synapse, resulting in prolonged stimulation of receptors
Low molecular weight, high lipid solubility, crosses placenta by simple diffusion
Cocaine & metabolites slow to be eliminated which increases toxicity to fetus
Placental perfusion decreases (blood flow from mom to fetus decreases)
Congenital malformation not increased
NE Stimulation
Tachycardia, HTN, diaphoresis, tremors
Dopamine Stimulation
Increased alertness, euphoria, enhanced feeling of well-being, heightened energy
Antenatal Complications of Exposure to Cocaine
Stillbirth, abortion, infection/STD, placental infarcts, IUGR, abnormal fetal breathing
Intrapartum Complications of Exposure to Cocaine
Premature labor, PROM (premature rupture of membranes), shortened labor, meconium stained AF
Neonatal Complications of Exposure to Cocaine
PT, LBW, SGA; postnatal growth restriction; cerebral infarction, seizures, cortical atrophy, IVH, abnormal EEG & BAER; NEC; intestinal perforation
Long-term Complications of Exposure to Cocaine
Expressive/receptive language delay/d/o
Poor recognition/memory/info processing
Decreased visual attention
Behavioral issues (ADHD)
Methyphenyethlamine
stimulant of norepinephrine, dopamine, & serotonin release
Metamphetamine (meth, speed, ice, crystal)
Higher CNS stimulation; less PNS & cardiovascular stimulation
Effects of Amphetamines
Euphoria, aggressive behavior, arrhythmias, anxiety, seizures, shock, stroke, abdominal cramps, insomnia, death
Antenatal Complications of Amphetamines
Fetal death, retroplacental hemmorhage
Neonatal Complications of Amphetamines
Premature, neonatal death, drug intoxication, tremors, abnormal sleep cycles, poor feeding, hypertonia, sneezing, high-pitched cry, loose stools, fever, yawning, hyperreflexia
Long-term Complications of Amphetamines/Methamphetamines
Decreased IQ, aggressive behavior, peer-related problems, poor academic performance
Tobacco Use during Pregnancy
Approximately 20% of women smoke during pregnancy
Nicotine is a primary psychoactive chemical
Fetal Complications of Exposure to Tobacco
SAB, stillbirth, placental decidual necrosis
Intrapartum Fetal Complications of Exposure to Tobacco
Abruption, premature labor
Neonatal Fetal Complications of Exposure to Tobacco
IUGR (small), CHD (congenital heart disease), deformities of extremities, polycystic kidneys, gastroschisis (intestine outside body), skull deformities, PPHN (persistent pulmonary HTN)
Long-term Fetal Complications of Exposure to Tobacco
Low test scores (cognitive, language, general academic achievement), behavior disorder, adolescent onset of drug dependence, SIDS
Teratogenic Effects of Alcohol
Direct toxic effect on cells
Hypoxia (secondary to impaired placental/fetal blood flow)
Cell migration in brain affected
Apoptosis is affected
Characteristics of FAS
Sx’s range from mild to severe, abnormal facial features, smooth philtrum, small head size, shorter than avg height, low body weight, poor coordination, hyperactive behavior, problems with heart, kidney, bones; difficulty paying attention; poor memory; difficulty in school (esp. math); LD’s; S-L delays; ID or low IQ; poor reasoning/judgment; sleep probs as baby; sucking probs as baby; vision & hearing issues
