The following approaches are used to manage the pregnant, opioid-addicted woman. The first approach is methadone maintenance combined with psychosocial counselling. This is a well-documented approach to improve outcomes for both the woman and her fetus.
The second approach is slow medical withdrawal with methadone.
Opioid Withdrawal Signs and Symptoms
Mild withdrawal signs and symptoms include:
- Generalized anxiety
- Opioid craving
- Restlessness
- Slight aching of muscles, joints, and bones
- Lower back pain
Mild to moderate withdrawal signs and symptoms include:
- Tension
- Yen sleep (mild insomnia)
- Mydriasis (pupils dilated)
- Lethargy
- Diaphoresis (increased perspiration)
Moderate withdrawal signs and symptoms include:
- Chills alternating with flushing and diaphoresis (sweating)
- Nausea and/or stomach cramps
- Rhinorrhea (runny nose)
- Moderate aching of muscles, joints, and bones
- Lower back pain
- Anorexia
- Nausea and/or stomach cramps
- Yawning
- Lacrimation (tearing)
- Goose flesh (earlier if client is in a cold, drafty room)
- Elevated pulse and blood pressure
Moderate to severe withdrawal signs and symptoms include:
- Diarrhea
- Vomiting
- Tremors
- Tachycardia (pulse over 100 BPM)
- Increased respiratory rate and depth
Severe withdrawal signs and symptoms include:
- Doubling over with stomach cramps
- Kicking movements
- Elevated temperature (usually low grade, less than 100° F)
Note: Withdrawal signs and symptoms differ in their order of appearance from one individual to another. Some individuals may not exhibit certain withdrawal signs and symptoms. Signs may also include uterine irritability, increased fetal activity, or rarely, hypotension.
Symptoms of Opioid Withdrawal Syndrome
Despite its dramatic appearance, the opioid withdrawal syndrome is rarely life-threatening or permanently disabling to an adult. However, there is good evidence that the fetus may be more susceptible to withdrawal symptoms than the mother. In the mother, the initial signs of opioid withdrawal progress to increasingly painful physical symptoms. In addition to these signs, patients show compelling psychological cravings for drugs, as well as drug-seeking behavior.
Methadone substitution is the standard treatment for heroin addiction. Methadone treatment alternatives consist of (1) high-dose blockage; (2) low-dose maintenance; and (3) medical withdrawal.
Methadone maintenance is the treatment of choice. In addition to methadone maintenance, a comprehensive multidisciplinary approach is needed that will provide the patient with counselling and other services.
The administration of methadone, combined with any opioid agonist/antagonist such as pentazocine (Talwin), will precipitate withdrawal. Any pregnant woman receiving methadone should be advised against taking opioid agonist/antagonists under all circumstances.
Neonatal abstinence syndrome (NAS) may or may not be related to maternal dose of methadone; NAS may also be related to fetal gestational age and infant weight. However, studies in both pregnant women and other adults have shown that larger doses of methadone result in a decreased use of other drugs.
Maternal and Fetal Effects of Opioids
These effects may be the result of concomitant maternal lifestyle factors rather than the direct result of drug use.
1. Possible effects on the pregnancy:
- Toxemia
- Intrauterine growth retardation
- Miscarriage
- Premature rupture of membranes
- Infections
- Breech presentation (abnormal presentation due to premature delivery)
- Preterm labor
- No effect
2. Possible effects on the mother:
- Poor nourishment, with vitamin deficiencies, iron deficiency anemia, and folic acid deficiency anemia
- Medical complications from frequent use of dirty needles (abscesses, ulcers, thrombophlebitis, bacterial endocarditis, hepatitis, and urinary tract infection)
- Sexually transmitted diseases (gonorrhea, chlamydia, syphilis, herpes, and HIV infection)
- Hypertensive disorder
- No effect
3. Possible effects on the fetus and newborn infant:
- Low birth weight
- Prematurity
- Neonatal abstinence syndrome
- Stillbirth
- Sudden infant death syndrome
- No effect
Opioid Conversion and Methadone Stabilization
The goal of the methadone strategy is to stabilize the patient without producing any indication of opioid abstinence syndrome.
Procedures at the Time of Admission
1. Obtain a detailed health history, including alcohol and other drug use and arrangements for prenatal care.
2. Conduct a comprehensive physical examination, including weight, vital signs, and an obstetrical evaluation.
3. Obtain laboratory tests, including:
a) Initial blood workup that includes, but is not limited to
- Blood group, Rh factor determination, and antibody screen
- Serological test for syphilis
- Hepatitis B and C screens
- HIV Screening
- Complete blood count with indices
b) Other initial laboratory tests that include, but are not limited to:
- Cervical cytology smear (Pap smear), unless the provider has results of a test performed within the past 3 months
- Cervical culture for gonorrhea
- Urine screen for urinary tract infection, kidney disease, protein, and glucose
- Chlamydia screen
4. Obtain purified protein derivative of tuberculin (PPD) test with antigen panel.
5. Obtain urine and/or blood toxicologies
6. Provide for HIV antibody counselling and testing.
7. Obtain baseline sonogram if appropriate.
Guidelines for Methadone Maintenance
Methadone maintenance is strongly encouraged for all pregnant, opioid-dependent women. It provides the following advantages:
- Reduces illegal opioid use as well as use of other drugs
- Helps to remove the opioid-dependent woman from the drug-seeking environment and eliminates the necessary illegal behavior
- Prevents fluctuations of the maternal drug level that may occur throughout the day
- Improves maternal nutrition, increasing the weight of the newborn
- Improves the woman's ability to participate in prenatal care and other rehabilitation efforts
- Enhances the woman's ability to prepare for the birth of the infant and begin homemaking
- Reduces obstetrical complications.
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