1. Perinatal Substance Abuse Denice Gardner, MSN, NNP-BC

2. Discuss Perinatal Substance Abuse and its affect on the newborn Objectives

3.  Pictures used in this presentation were obtained from the Mosby’s Nursing Consult web site

4.  Tobacco/Nicotine  Alcohol  Stimulants  Narcotics & Opioids  Sedatives/Hypnotics  Antidepressants Categories of Drugs

5.  Spontaneous abortion  Placenta previa  Placental abruption  Preterm labor  Premature rupture of membranes  C-Section delivery  Precipitous delivery  Hypertension Effects of Drugs on Pregnancy

6.  Tobacco is a CNS stimulant  Active components of cigarette smoke  Nicotine  Tar  Carbon monoxide  Cyanide  Plus, thousands of other compounds Tobacco & Nicotine

7.  Nicotine-water & fat soluble; cross the placenta  Carbon Monoxide- combines with hemoglobin & impairs oxygenation for mother & fetus; causes placental vasoconstriction & vasospasm  Dose/Response relationship- the higher the number of cigarettes smoked – the greater the effect on the fetus Tobacco & Nicotine

8.  Fetal/ Newborn Effects  Intrauterine growth restriction  Slight increase in risk for congenital malformations  Neurobehavioral effects  Sudden Infant Death Syndrome  Increased cost of hospitalization & medical care  Increased perinatal mortality Tobacco & Nicotine

9.  Nursing Considerations  EDUCATION  Follow infant’s growth  Provide information regarding smoking cessation programs & encourage participation Tobacco & Nicotine

10.  CNS depressant  Absorbed rapidly through the stomach & intestines; metabolized by the liver; excreted through the kidneys & lungs  Fetal alcohol is eliminated only after being broken down in the maternal liver  Diffuses across the placenta & impairs flow of nutrients to the fetus Alcohol

11.  Broken down into acetaldehyde & acetate. (Acetaldehyde is MORE toxic than alcohol).  Is a known teratogen  Fetal effects are directly related to dose, chronicity of use, gestational age, & duration of exposure Alcohol

12.  Fetal Alcohol Spectrum Disorder (FASD)  Fetal Alcohol Syndrome (FAS)  Partial Fetal Alcohol Syndrome  Alcohol-Related Birth Defects (ARBD)  Alcohol-Related Neurodevelopmental Disorder (ARND) Alcohol

13.  Most severe form of FASD  Most common identifiable cause of mental retardation (also is a preventable cause)  Abnormalities in 3 domains  Poor growth  CNS abnormalities (developmental delays, impaired brain growth, abnormal structure, etc.)  Dysmorphic facial features (thin, upper lip; smooth philtrum; short palpebral fissures, etc.)  Alcohol exposure may or may not be confirmed Fetal Alcohol Syndrome

15.  Typical dysmorphic facial features  Abnormality in one of the domains  CNS abnormality  Growth  Behavioral or cognitive ability  Confirmed prenatal alcohol exposure Partial Fetal Alcohol Syndrome

16.  Typical dysmorphic facial features  Normal growth and brain function/structure  Congenital anomalies in other organs (cardiac, skeletal, renal, eyes, ears)  Confirmed prenatal alcohol exposure Alcohol-Related Birth Defects (ARBD)

17.  Absence of typical dysmorphic facial features  Normal Growth  CNS abnormalities:  Decreased cranial size at birth  Structural brain abnormalities  Impairment of neurologic status in relation to age  Behavioral or cognitive abnormalities inconsistent with age/developmental level  Confirmed prenatal alcohol exposure Alcohol-Related Neurodevelopmental Disorder (ARND)

18. Fetal Alcohol Syndrome

19.  Begins anytime between birth & 12 hours after birth  Symptoms  Tremors  Hypertonia  Opisthotonos  Weak suck & poor feeding  Sleeplessness  Excessive crying  Excessive mouthing behavior Withdrawal from Alcohol

20.  Cocaine  Amphetamines  Cannabinoids Stimulants

21.  One of most powerful addictive substances  Is fat-soluble with low molecular weight so readily crosses blood-brain barrier & placenta  Rarely used alone  Long half-life (can be present in infant’s urine for up to 7 days of age) Cocaine

22.  Fetal/Newborn Effects  No increase in congenital malformations  Multi-organ dysfunction  CNS: abnormal sleep pattern, EEG, & cry; seizures/tremors; cerebral infarctions  Sensory organs: increased auditory startle response; abnormal ABR  Cardiac: arrhythmias; hypertension; decreased cardiac output Cocaine

23.  Fetal/Newborn Effects  Multi-organ dysfunction (cont.)  Respiratory: apnea; periodic breathing  Renal: ectopia  GI: intestinal perforation; early-onset NEC  Eye: vascular, disruptive lesions; retinal hemorrhage Cocaine

24.  Felt to be due to CNS irritability from effects of cocaine rather than from withdrawal  Initial period of hyperirritability followed by drowsiness &/or lethargy  Changes in behavioral state  Difficulty responding to human voice/face, comforting, &/or environmental stimuli  Difficulty maintaining alert states or rapid change is states  Hyperactive startle Withdrawal from Cocaine

25.  Used medically for treatment of narcolepsy, depression, weight loss, hyperactivity  Neurotoxic  Fetal/Newborn effects:  IUGR Amphetamines

26. Withdrawal from Amphetamines  Abnormal sleep patterns  Diaphoresis  Vomiting after birth  Agitation alternating with lethargy  Constriction of pupils  High-pitched cry  Loose stools  Yawning  Fever  Hyperreflexia

27.  CNS- both depressant & mild hallucinogenic effects  High affinity for lipids & accumulates in fatty tissue of body  Placental transfer is greatest during first trimester of pregnancy  Results in increased carbon monoxide levels in blood causing hypoxia Cannabinoids

28.  Natural Opioids  Morphine & Opium  Semi-synthetic Opioids  Heroin & methadone  Synthetic Opioids  Oxycodone, hydromorphone, oxycodone, Fentanyl, etc. Narcotics & Opioids

29.  Fetal/Newborn Effects  Readily crosses placenta  Lower Apgar Scores  Do NOT use naloxone for with known/suspected narcotic & opioid dependence due to creation of rapid withdrawal & seizures  Meconium aspiration  IUGR  Lower incidence of RDS Narcotics & Opioids

30.  Congenital infections  Increased incidence of SIDS  Low birth weight  Microcephaly  Increased chromosomal abnormalities in heroine-exposed infants Narcotics & Opioids

31.  Barbiturates  Benzodiazepines Sedatives/Hypnotics

32.  Readily crosses placenta  Fetal blood levels are similar to maternal blood levels  Accumulate in adipose tissue  High concentration also present in brain, lungs, & heart  Fetuses exposed to long-term benzodiazepines may have hypotonia, feeding difficulty, & withdrawal symptoms Sedative/Hypnotics

33.  Selective Serotonin Reuptake Inhibitors (SSRIs)  Sertaline (Zoloft), Fluoxetine (Prozac), Escitalopram (Lexapro), Paroxetine (Paxil), etc.  Tricyclic Antidepressants (TCAs)  Amitriptyline (Elavil), Nortriptyline, etc.  Monoamine Oxidase Inhibitors (MAOIs)  Phenelzine (Nardil), Isocarboxazid (Marplan), etc. Antidepressants

34.  Onset may vary from shortly after birth to 2 weeks  Duration may range from 8 to 16 weeks  Severity of presentation varies  Infants of chronic drug abusers usually have more severe withdrawal  The closer to delivery the drug is taken, the later the signs of withdrawal appear & the more severe the symptoms will be Neonatal Abstinence Syndrome

35.  Multiorgan/System Disorder  Most common symptoms  Neurologic  Increased tone  Tremors  Exaggerated reflexes  Irritability/restlessness  High-pitched cry  Difficulty sleeping  Seizures Neonatal Abstinence Syndrome

36.  Most common Symptoms  Autonomic  Yawning  Nasal stuffiness  Sweating  Sneezing  Low-grade fever  Mottling Neonatal Abstinence Syndrome

37.  Most Common Symptoms  GI  Loose stools  Vomiting/regurgitation  Poor feeding  Difficulty swallowing  Excessive sucking Neonatal Abstinence Syndrome

38.  Most Common Symptoms  Respiratory  Tachypnea  Others  Skin excoriation Neonatal Abstinence Syndrome

39.  Onset of withdrawal symptoms  Alcohol- usually 3-12 hours after delivery  Narcotics- usually 48-72 hours after delivery, but may be as long as 4 weeks  Barbiturates- usually 4-7 days after delivery but can occur 1-14 days after delivery  Cocaine- usually 48-72 hours after delivery Neonatal Abstinence Syndrome

40.  Severity of NAS depends on  The type of drug used  Half-life of the drug  Time of last exposure before delivery  Dose taken  Quality of labor Neonatal Abstinence Syndrome

41.  Severity of NAS depends on  Type of analgesia/anesthesia used during labor  Maturity & status of infant  Gestational age  Nutritional status of mother Neonatal Abstinence Syndrome

42.  Scoring Systems  Modified Finnegan Scoring Tool  Gold Standard***  Neonatal Drug Withdrawal Scoring System  Neonatal Withdrawal Inventory Neonatal Abstinence Syndrome

43.  Screening Tools  Maternal  Thorough history & assessment  Drug testing (urine is most commonly used)  Infant  Thorough assessment  Urine Drug screen  Meconium Drug Screen  Newer testing: hair and umbilical cord testing Neonatal Abstinence Syndrome

44.  Nursing Management  Accurate assessment, evaluation, & use if institution’s screening tool  Comfort measures (swaddling, holding, cuddling, response to stress cues, etc.)  Assessment & encouragement of mother/infant interaction  Maternal/family support Neonatal Abstinence Syndrome

45.  Pharmacologic management  Tincture of opium  Camphorated Tincture of Opium (Paregoric)  Morphine (most common)  Methadone  Clonidine  Chlorpromazine (Thorazine)  Phenobarbital  Diazepam Neonatal Abstinence Syndrome

46.  Breastfeeding  Cigarettes:  not contraindicated  encourage decreasing numbers of cigarettes smoked & smoking cessation  Smoke after breast feeding  Alcohol: use should be discouraged Neonatal Abstinence Syndrome

47.  Breastfeeding  Cocaine: contraindicated during active use  Marijuana: contraindicated  Heroin: contraindicated  Methadone: not contraindicated; should not be stopped abruptly  Sedatives/Hypnotics: dose-dependent; discontinue with signs of lethargy &/or weight loss Neonatal Abstinence Syndrome

48. Chang, G., Lockwood, C.J., & Barss. (2012). Substance Use In Pregnancy. Retrieved from www.uptodate.com on 8/17/2012.www.uptodate.com Sielski, L.A., Garcia-Prats, J.A., & Kim, M.S. (2012). Infants of Mothers with Substance Abuse. Retrieved from www.uptodate.com on 8/17/2012. www.uptodate.com References

49. Sielski, L.A., Garcia-Prats, J.A., & Kim, M.S. (2012). Neonatal Opioid Withdrawal (Neonatal Abstinence Syndrome). ` Retrieved from www.uptodate.com on 8/17/2012. Verklan, M.T. & Walden, M. (2009). Core Curriculum for Neonatal Intensive Care Nursing (4 rd Edition). Elseiver Saunders: St. Louis. Retrieved from Mosby’s Nursing Consult web site on 6/16/2012. References