Flashcards in Week 13 Deck (43):
Screening for alcohol and drug use/abuse in pregnant women
Screen all pregnant women for substance abuse and all women should be routinely asked about their use of alcohol and drugs including prescription opioids. Assure your patients that you ask everyone these questions and remind them the information is confidential. Be caring and nonjudgmental. Use a validated screening tool/questionnaire. We use the 4 P's (Parents, Partners (have any problems with drugs) and Past and Present (use of drugs)
Drug screening and the law
Drug screening laws vary state to state, but many hospitals are prohibited from testing women for illegal drug use without consent. So, obtain consent. If neonate presents with unexplained neurological symptoms a drug test on the infant can be done without parental consent. Appropriate to contact state child protective services when drug abuse concerns and to request a home visit.
Cocaine vs heroin and methadone and infants
Infants frequently don’t have a clinically documented withdrawal with cocaine. It crosses the placenta, but they don’t usually have withdrawal symptoms. Have neurobehavior and IQ changes through continued exposure to cocaine. Hx of placenta abruptio can be indicative of cocaine use.
S/S of cocaine use in the infant/child
Irritable, high-pitched cry, trouble sleeping, more aggressive, hyperactive. Severe problems such as seizures and cerebral hemorrhage. Long-term exposure leads to IQ changes.
5 S’s to soothe a baby
Suck, swaddle, shush, swing, side/stomach position
Key factors that indicate drug abuse
Missed/absent prenatal visits, denial of pregnancy, personal or family hx of alcohol/drug abuse, previous child abuse or neglect, hx of domestic violence, psych problems, hx of preterm babies, hx of legal problems or DUIs.
Physical evidence of drug use/abuse in mother
Intoxication, track marks, skin pocking, abscess from shooting up drugs, nasal hyperemia or septal defects from snorting, Hep C positive.
Neonatal Abstinence syndrome
Onset from 48 hours to 4 weeks. Most have onset within 4 days. Symptoms: High-pitched cry, tremulousness, sleeplessness, difficulty feeding, sweating, nasal stuffiness, sneezing, vomiting, cramping, diarrhea, seizures, and EEG abnormalities.
To test baby for drug exposure
Collect meconium sample or neonatal urine sample (hair samples if baby has any hair). Meconium can detect back as early as second half of pregnancy. Meconium can see further back how long baby has been exposed vs urine. Consider how long past time the last drug use was. With urine, it might not be positive if use was outside of timeframe. So, meconium is better. Supportive care: Frequent small feedings of hypercaloric (24cal/oz) formula, suck/swaddle/shush, swing; IV fluids/lyte replacement, 150-250 cal/kg/day. Usually don’t need pharmacological except with: Seizures, poor feeding, diarrhea, and vomiting resulting in excessive wt loss and dehydration, inability to sleep, and fever unrelated to infx. Use same class as drug causing withdrawal; usually give when 3 consecutive Finnegan scores >8 or total >24 • FDA only approves methadone for opioid withdrawal, and benzos for etoh withdrawal; but tincture of opium, morphine, clonidine, phenobarbital, and diazepam have favorable experience – AAP recommends using morphine with phenobarbital as 2nd drug if needed. **Majority of time, no pharmacologic treatment is used.**
Neonatal abstinence syndrome is more common with ________ and________ but not _______
heroin and methadone, not cocaine. But with cocaine can have long-term issues (IQ, behavior). With NAS, usually babies recover and don’t have lifelong issues unlike with alcohol or cocaine.
Medicated Assisted Treatment of Opioid Use Disorder. Use Suboxone (buprenorphine + naloxone) or Subutex to withdraw from drugs. Don’t abruptly withdraw during pregnancy, as can cause worse neonatal outcomes. ACOG does not recommend abrupt withdrawal. Use only Subutex (buprenorphine) in pregnancy.
Suspect drug abuse
Legal problems, past hx of maternal problems (abruptio placenta), poor backgrounds, no or missing prenatal care, physical exam indications, Hep C positive.
Drug testing tips for newborn
If you use neonatal urine sample, it can sometimes be negative even though they have signs of withdrawal. False negative. So, meconium tox or hair sample more accurate.
No withdrawal symptoms usually. Effects are from continued drug effect on infant.
Withdrawal in 48 hours to 4 days usually. Can take up to 4 weeks.
__________ to fetus to abruptly withdraw moms from drugs when pregnant.
Fetal Alcohol Syndrome
Alcohol is the most dangerous of the common substances abused by pregnant women, as it has the most permanent damage. Screen before they are pregnant if possible. Goal is to not drink at all during pregnancy.
Alcohol use during pregnancy
**Binge drinking is more harmful than 1 drink/day. There is NO safe amount of alcohol b/c they do not know the relationship between amount of alcohol consumed and degree or presence of FAS.**
Maternal risk factors to develop FAS
Advanced maternal age, increased parity, poor maternal nutritional status, mothers of AA or Native American descent
Diagnosing newborn with FAS
May be difficult to diagnose during neonatal period. Clarify alcohol use. May be crossover of facial characteristics with Down syndrome (epicanthal fold, lip changes, nose changes).
Face changes in FAS
Thin upper lip, low flat nasal bridge, ptosis, short upturned nose, ear abnormalities (railroad track ears), smooth philtrum, epicanthal folds, small palpebral fissures.
FAS differs from Down syndrome
Brushfield spots, protruding tongue, higher nasal bridge found in Down syndrome.
Long-term effects of FAS
Developmental delays, brain misfunction, mental retardation
More important notes about FAS
• Involves comprehensive care: Referral to specialty. Support for families.
• Key is to abstain from alcohol. Do not binge drink. AMA higher risk (this is the biggest maternal risk factor). No older pregnant women binge drinking!
STD screening and pregnancy
Screen all women for chlamydia, gonorrhea, and trich at initial prenatal and then again at 28 weeks if high risk. Again, if high risk at 36 weeks with GBS screen. Screen, screen, screen. 50% of infants born vaginally to infected mothers will acquire chlamydia.
Prenatal care and screening aggressively during pregnancy is important.
Newborn and Chlamydia
Inoculates in eyes or respiratory tract (conjunctivitis or pneumonia). Onset is variable: Several days to 3-4 weeks. **Treatment: Eye drops alone are not enough. Must be treated internally. Use erythromycin for 10-14 days. Chlamydia is not prophylactically treated in positive mothers b/c risk of hypertrophic pyloric stenosis from erythromycin.**
Newborn and Gonorrhea
Exudate of eye or mucus membranes. If born with mother of active gonorrhea, **given single shot of ceftriaxone (Rocephin) of 25-50 mg/kg (MAX 125 mg)**. All infants are routinely given prophylaxis: silver nitrate, tetracycline, or erythromycin. **Complications: blindness, neonatal sepsis, arthritis, meningitis.**
________ is given prophylactic treatment for + mothers, but__________ is not.
Can be normal flora in mothers. 50% mortality rate. Leading cause of sepsis in infants. Screen all moms at 36 weeks. Infant risk factors: **Premature, SGA infants, VLBW, infants born to mothers with prolonged ROM.**
Leading cause of mortality in infants. Infant risk factors: Premature, SGA infants, VLBW, infants born to mothers with prolonged ROM. Best prevention is screen all pregnant women at 35-37 weeks with rectal/vaginal culture. Treat GBS+ moms with IV penicillin or ampicillin at onset of labor and q4 hours until delivery.
GBS S/S include
Poor feeding, temp instability, cyanosis, apnea, tachypnea, grunting, flaring, retractions; seizures, lethargy, bulging fontanelle; rapid onset and deterioration. Can come on quickly and deteriorate fast.
Usually diagnosed by CSF (lumbar puncture) and blood cx.
Treatment: Ampicillin + Gentamycin IV. **If woman is GBS+, given IV PCN or ampicillin at onset of labor and repeated Q4 hours until delivery. If planned C-section with intact membranes, no need for IV prophylaxis.**
If conjunctivitis and pneumonia symptoms, there is a high suspicion of
chlamydia. Must be treated orally.
Prophylaxis is erythromycin eye ointment. If for sure exposed, IM ceftriaxone (25-50 mg/kg not more than 125 mg).
Can be moderate to severe. Just skin to dissemination in organs. Treat 14 days for skin, eye, mouth. 21 days for signs of dissemination or CNS S/S. Most women are often unaware they have it and the primary outbreak has a higher risk of transmission.
HSV Symptoms in newborns
Microcephaly, SGA, skin/eye lesions, cataracts, scarring on skin, infx more disseminated (all organs). Can be as soon as 1st 2 weeks of life. Culture lesions if present (most common). Spinal fluid testing. Serous drainage. Must treat aggressively.
HSV: Must they have C-section?
Only if active herpetic lesions at delivery time.
Risk of acquiring is lower if C-section is performed before ROM in active lesions.
No active lesions, no need for C-section.
HSV, Pregnancy and infant
Prevention is goal. Screen for risk factors. Protect from HSV during pregnancy, b/c most harm is if primary outbreak during pregnancy. 20-30% of women of childbearing age have serologic infection with no hx of outbreak. Many born to mothers who are unaware of infection (no S/S of outbreak). 50% of all infants with untreated HSV will die.
Are women routinely put on acyclovir (or other antiviral) if hx of HSV?
Not recommended universally, but can be used during last half of pregnancy. It may decrease risk of C-section. Safe to take during pregnancy and breastfeeding.
HSV and breastfeeding
Don’t breastfeed if herpetic lesions on breast.
SIDS risk factors
Males (3:2), prone and side sleeping, maternal smoking during pregnancy, 2nd hand smoke, overheating, soft bedding, young maternal age, inadequate prenatal care, prematurity/low birth wt, AA or American Indian/Alaskan native heritage. **Room sharing is ok but not bed sharing.**
Cause of SIDS
Unknown cause for SIDS. Sudden unexplained death before 1 year of age. They think it might be multifactorial. 3 possible pathological causes: decreased arousal, asphyxia/rebreathing, thermal stress.