Module - 4 Substance exposure in pregnancy

Substance Exposure During Pregnancy - Cocaine & Methamphetamine

*Cocaine*- Can cause gestational *hypertension*, *abruptio placentae*, *CNS effects* and *IUGR* - *Crack* is the freebase form of *cocaine* *Methamphetamine*- (speed, meth, or chalk) The effects of maternal use during pregnancy are not well , known, seen low birth weight, *smaller head circumference NAS*, preterm births, anomalies, *cleft lip palate*, and *lip*, and *cardiac defects* *Cocaine* produces vasoconstriction and hypertension in both mother and fetus. *Uteroplacental insufficiency* results from reduced blood flow and placental perfusion. Cocaine use may increase the risk of *uterine rupture* and *abruption*. These infants to not develop NAS but they can be *irritable* and *hard to soothe*. Studies have shown the use of methamphetamines have increased significantly in the past 10 years in certain regions of the US. Use of meth in pregnancy is now higher than cocaine and cocaine use is second only to marijuana. High risk for preterm birth, placenta abruption is associated with methamphetamines.. The effects of methamphetamine maternal and fetal are not well known, and many times poly drug use is seen in these moms, making it difficult to study. Low birth weight in methamphetimes, preterm, anomalies, cleft palate and cardiac defects have been reported. ., similar to cocaine may affect areas in brain responsible for higher level functioning.

Substance Exposure During Pregnancy - Nicotine

*Nicotine*- Proven link between maternal smoking and reduced birth weights, increased rates of miscarriages, and *increased premature rupture of membranes*, and *fetal demise*. Contributes to *low fetal iron stores*. Second hand smoke in the home is a risk factor for SIDS Smoking during pregnancy has been consistent with low birth weight babies, mothers need to be educated on the possibility of miscarriage!!!!! and the that *quitting before 16 weeks decreases adverse effects*.

Substance Exposure During Pregnancy - Opiates

*Opiates & Narcotics* - Opium, morphine, heroin, codeine, hydromorphone, oxycodone, methadone. - CNS depressants - Highly addictive to mother & newborn - May lead to *Neonatal Abstinence Syndrome*

Screening Tools *RAFT*

*R- Relax* : Do you drink or take drugs to Relax, improve your self image, or to fit in? *A-Alone* : Do you drink or take drugs while alone? *F-Friends* : Do you have any close friends who drink or take drugs? *F-Family* : Does a close family member have a problem with alcohol or drugs? *T-Trouble* : Have you ever gotten in trouble from drinking or taking drugs? For this tool you would assess for substance abuse by asking a series of questions about the use of substance abuse then use this tool for additional information... *which is a sensitive screening tool*. The questions are seen in the box Have you ever used recreational drugs, have you ever taken a preserciption drug for anything other than as intended What are your feelings about drug use during pregnancy, how often drink alcohol, have you ever felt guilty about drinking or drug use?

Substance Exposure During Pregnancy

Alcohol-The exact effects of alcohol in pregnancy have not been quantified and its mode of action is largely unexplained. It may cause *fetal alcohol syndrome* which leads to *learning disabilities* and *hyperactivity*. It is the leading cause of *intellectual disability*. It can cause *SAB*, *inadequate weight gain*, and *IUGR*. *Smoking* during pregnancy has been consistent with *low birth weight babies*, mothers need to be educated on the possibility of *miscarriage!!!!!* and the that *quitting before 16 weeks decreases adverse effects*. *Alcohol* can cause the newborn to have distinct features including *microcephaly* , *small philtrum*, and *small eye opening*, and *palpebral fissures* *Alcohol - no safe amount!!!! Avoid during pregnancy*

Impact of Substance Abuse on Pregnancy

Avoidance of obtaining care. Substance abuse/use increase risk of medical complication in both mother & poor birth outcomes in the newborn. *Remember, the placenta is not a filter.* What are the laws in various states regarding substance use? A woman who is pregnant and has a substance abuse problem is a woman who has a substance abuse problem who just happens to be pregnant. *Addiction does not end when a woman becomes pregnant.*

Substance Exposure During Pregnancy- Caffeine

Caffeine- If pregnant do *not* consume *more than 300mg of coffee per day*. The effect of caffeine during pregnancy on fetal growth and development is still unclear Caffeine has no research documenting teratogenic effects. *Energy drinks*

Caring for the Newborn with NAS

Care is individualized with developmental considerations to facilitate self-consoling and self-regulating behaviors. *rap infant snugly, rock, & hold to limit their ability to self stimulate*. An inside look......... Drug-Dependent Infants Detox in Tennessee NICU(internet)

Care of the Substance Abuse Mother

Drug testing during pregnancy Screening for substance abuse Initial care *Methadone maintenance program* Follow-up care Initial Care: Intervention should begin with education about the specific effects on pregnancy, the fetus and the newborn for each drug used., and of course we want *ABSTINENCE!!* *Abstinence should be recommended as the safest course of action, unless the woman is abusing opioids.* *Women are more open to making lifestyle changes than any other time in their life*, and more like likely to stop smoking during pregnancy than any other time in their life. *Periodic screening during pregnancy may help with abstinence*. Keep in mind urine drug screens will show drugs days to weeks after ingestion by the mother, depending on how it metabolizes, BUT a *meconium drug screen is most accurate in what was used in pregnancy!!!!* Follow up care is important, social worker is involved when the newborn is born, we want to make sure the living conditions are safe. Home care nurse is often sent out to make visits.

Fetal Alcohol Spectrum Disorder - Common Problems

Inability to foresee consequence Inability to learn from previous experience Lack of organization Intellectual disability or low IQ Difficulty in school, especially with math Learning difficulties Poor abstract thinking poor reasoning and judgment skills Poor memory Poor impulse control Speech and Language delays Poor judgment This is a list of common problems associated with children who have FASD. *The goal is abstinence from alcohol during pregnancy*. It is not known exactly how much alcohol is safe during pregnancy or if there is a minimal amount that is safe. So complete avoidance is what is recommended.

Caring for the Newborn with NAS , cont.

Infants are difficult to comfort and cry for long periods of time. It is important to establish rapport and contact with the families for follow up. Withdrawal symptoms can develop after the infant gets home. Methadone treatment will not prevent symptoms but therapy can be modified. Best not to stop opioids suddenly. Treatment in the methadone clinic is to be supportive and goal is to prevent perinatal loss. *Can not stop suddenly. Stopping suddenly may lead to SAB(Spontaneous Abortion), premature labor and delivery!* Mothers lack confidence, and poor self image, interpersonal relationships and may desire an infant to meet a psychological need. The drug exposed infants are demanding on the caregivers! Careful evaluation is considered with discharge planning for the child, and whether the child should be placed outside of the home.

Fetal Alcohol Spectrum Disorder

Low nasal bridge Short palpebral fissures Short nose Flat midface Epicanthal folds Minor ear abnormalities Thin upper lip Receding jaw

Substance Exposure During Pregnancy - Cannabis

Marijuana- Crosses the placenta, however specific effects on the fetus have been difficult to determine d/t common polysubstance abuse. Low birth weight, fetal growth restriction with chronic use combined with cigarette smoking is common. *The use of marijuana is has replaced cocaine as the most common illicit drug used women 18-44, non pregnant and pregnant.* When looking at the effects of marijuana they are other variables that are compounding such multidrug use, tobacco, alcohol...

NAS, cont.

Most infants will not demonstrate immediate untoward effects and appear normal at birth. *Infants exposed to heroin* may begin to exhibit signs and symptoms of drug *withdrawal within 12-24 hours*. If the mother is on *methadone* the infant may exhibit signs and symptoms of *withdrawal 24 hours to 48 hours* or could be up to *2-3 weeks after birth*. Careful monitoring of this infants are important. IF we send the newborn home to early then they may begin to withdrawal at home, have a negative effect, on perhaps... CNS... leading to *seizures*.. IF used heroin typically newborn could withdrawal in 12 to 24 hours. If mothers on methadone signs may appear later... 1-2 days and sometimes 2 weeks to 3 weeks If infant is sent home without proper monitoring they could end up going through withdrawal at home, and then have to be readmitted to the hospital...

Neonatal Abstinence Syndrome Signs of Withdrawal in the neonate

Neurological - *Irritability, seizures, hyperactivity, high-pitched cry, tremors, exaggerated Moro reflex, hypertonicity of muscles* Gastrointestinal - *Poor feeding, diarrhea, dehydration, vomiting, frantic uncoordinated suck, gastric residuals* Autonomic (metabolic , vasomotor, respiratory disturbances) - *Diaphoresis, fever, mottled skin, nasal stuffiness* Miscellaneous - *Disrupted sleep pattern, diaphoresis, excoriations on knees and face, temperature instability*

Screening Tools Screening with the *4 P's Plus*

Parents : Did either of your parents have a problem with alcohol? Partner : Does your partner have a problem with alcohol or drugs? Past : Have you ever had any beer or wine or liquor? Pregnancy : In the month before you were pregnant, how many cigarettes did you smoke? In the month before you knew you were pregnant, how much beer, wine or liquor did you drink? *Screening should be done in the first prenatal visit*, for all alcohol and drug abuse, in *ALL women*. The tool is good to use and takes little time. The tool helps identify pregnant women who need more in depth assessment. Encourage truth-telling After we have identified a risk factor we need to follow - up with the proper paths for the women to take... Women greater chance more likely to under report or deny during pregnancy.. Assessing use before is effective tool. *Screening first* should be done with asking the mother about her *over the counter medications*. Next ask her about the use of *caffiene, nicotine, and alcohol...legal* Then should ask her about the use of *licit drugs, cocaine, heroin, and marijuana*. What is important to ask when assessing the use of these ? ......*the amount and frequency*

Perinatal Substance Abuse

The use of alcohol and other drugs by pregnant women - Includes prescription and nonprescription substances - *More than 20%* of women used *alcohol during pregnancy* - *More than 19% smoke* cigarettes during pregnancy. Substance abuse or use is not limited to a certain social class; it crosses social and class lines. Pertains to multiple substances - not just a few. Examples include alcohol, methamphetamine, crack, cocaine, and some people would include tobacco and caffeine. There is conclusive evidence that supports cigarette smoking is harmful in pregnancy. There is no conclusive evidence that caffeine is harmful. The legality of tobacco negates the harmfulness of it and so it can be difficult to combat.

Types of Drug Testing

Urine toxicology Meconium testing Cord toxicology

Neonatal Abstinence Syndrome

What is NAS?? - It is a group of similar behavioral and physiological signs and symptoms in the neonate caused by withdrawal from various pharmacological agents!

Neonatal Abstinence Syndrome (NAS)

What is it ? NAS- Is the term used to describe the set of behaviors exhibited by infants exposed to narcotics in utero. 55% to 94% of infants born narcotic addicted mothers show signs of withdrawal What is NAS?? It is a group of similar behavioral and physiological signs and symptoms in the neonate caused by withdrawal from various pharmacological agents exposed to in utero! NAS- Is the term used to describe the set of behaviors exhibited by infants exposed to narcotics in utero. Drugs such as opiates,espicaelly *OxyContin, heroin* and *methadone* the unborn child may also become chemically dependent or passively addicted, and this places them *at risk for withdrawal* The adverse effects of exposure of a fetus to drugs are varied. They include transient changes such as alterations in breathing, movements and irreversible effects such as fetal death., IUGR, structural malformations, behavior problems or cognitive impairment. Narcotics have a low molecular weight and cross the placental membrane and enter the fetal system. *Illicit substances* may also be transmitted to the newborn through the *breastmilk*

Caring for the Newborn with NAS

When NAS has been identified in the infant nursing care is directed toward treating the presenting signs, decreasing stimuli that may precipitate hyperactivity and irritability. *Dim lights, decrease noise level, provide cluster care*. Provide adequate *hydration and nutrition*, and *promote mother-infant or parent- infant bonding*. *It is important to first identify the substance early that the pregnant woman is abusing*. Why is this important? *So the mother can receive proper care during the pregnancy, and side effects are minimized*. Often times the mother is afraid to admit she has a problem for fear of social and legal repercussions... what would be examples of these? Loose the baby, what others will think of them, lableling, stigma Breastfeeding: - *Breastfeeding is a way to promote mother infant bonding, and can initatied if the mother is not HIV positive, and using illicit drugs, if they are enrolled in the methadone clinic treatment program and compliant they can still breastfeed, the small amounts have not been proved to harmful...and can reduce some of the withdrawals effects!!!!*