Opioid misuse in pregnancy 2021 TOG

Question 1

Opioids are responsible for what proportion of drugs fatal overdoses?

Answer 1

85%

Question 2

What can be give as opioid substitution

Answer 2

Methadone (opioid agonist)

Buprenorphine (partial opioid agonist/antagonist)

Question 3

Pros and cons of Methadone/Buprenorphine

Answer 3

Buprenorphine: Low risk fatal overdose in 1st few weeks, withdrawal Sx less severe

Methadone: Effective at retaining patients - more suitable if IV use, severe opioid dependance. Risk of death highest in 1st few weeks of methadone Tx, needs to be closely monitored

Question 4

Maternal and fetal complications with opioid use in pregnancy

Answer 4

Question 5

What are the features of neonatal abstinence syndrome (NAS)? What proportion of babies suffer NAS? When does it present?

Answer 5

55-95% babies
Present 24-72 hours

Question 6

Management strategies in pregnancy

Answer 6

Question 7

AN care

Answer 7

o Urgently refer Drug services, if not known
o Cons les clinc with drugs/alcohol serive.
o Explain importance of sharing information, provide best care and support them & unborn child
o Involve woman +/- partner in decision making
o IV/sex workers – test Hep, consider sexual health screening
o Urine toxicology @ booking and during preg – verbal consent
o Opioids eliminated from urine 48-72hrs. Cannabis – 30 days
o No differences in preg outcomes – methadone/buprenorphine – methadone 1st line as more robest. Substitue prescribing does not eliminate risk of NAS, NAS less severe with buprenorphine
o Not advised to stop substitution in pregnancy – risk of fetal loss with withdrawal. Gradual detoxification during 2nd trimester (2-3mg methadone every 3-5 days). Metabolism of methadone increases in 3rd trimester – may need to increase dose or split dose
o If also taking SSRI – can exacerbate severity of NAS, SSRI should not be withheld if deemed inappropriate. Fetal Cardiac scan should be performed if SSRI, small increased risk congential malformation.
o Review 32 weeks to review safegaruding social/anaesthetics to review pain mgmt. in labour

Question 8

Intrapartum care

Answer 8

o MW delivery but hospital with neonatal support
o IV access can be difficult
o Cont methadone/buprenorphine throughout labour
o Likely will need higher doses opiates – pethidine likely ineffective
o If Opioid analgesic given, wait 2-8hrs before buprenorphine, if taken too soon – acute withdrawal
o Encourage epidural
o CONG CTG – increased risk hypoxia, compromise and meconium, compare CTG to AN CTG to assess if changes on CTG acute or related to opioid use
o Naloxone can be given to neonata if resp depression

Question 9

Postnatal care

Answer 9

o Often need more analgesia – NSAIDs for VD, short course PO or IV opioids for CS, with methadone/buprenorphine. Avoid Oxycodone.
o Infants exposed to opioids should remain in hospital for 72H, monitored using validated tool assessing withdrawal, 2h after birth then 4 hourly
o Mild-moderate NAS – supportive measurs. Cont NAS scoring for 1 week after delivery.
o Severe NAD – admission SCBU + medications e.g. oral morphine
o Encoruage BF – reduces severity of SCBU. Heroin users – unsafe to BF, acoid codeine and oxycodone. Cross into breast milk, baby risk resp depression. Replacement ok to BF.
o Discuss contraception – LARC
o Discharging meeting, continue support in community and supply of replacemtn. Community MW, healthworker.
o Higher risk SIDS, higher risk PND