Prolactin response to breast stimulation in lactating women is not mediated by endogenous opioids

Implementation of a Prenatal Naloxone Distribution Program to Decrease Maternal Mortality from Opioid Overdose

INTRODUCTION

Maternal mortality rates have been increasing in the United States for decades. For several years, opioid overdoses have been a leading cause of maternal mortality in several states. New Hampshire (NH) is a particularly severe case, with 50% of all maternal deaths being caused by drug-related overdoses from 2016 to 2017. We report on the implementation of a point-of-care naloxone distribution program for an Ob/Gyn clinic in NH.

METHODS

Naloxone distribution was tracked to measure program implementation. Proportion of patients screened for naloxone need was calculated monthly. Proportion of patients with which discussions about naloxone took place was calculated quarterly. Patient and provider perspectives on the program were captured periodically. Statistical process control charts monitored change over time and evaluated for special-cause variation.

RESULTS

The clinic has distributed 12 doses of naloxone since program implementation in April 2020. Despite the challenges posed by the COVID-19 pandemic, screening for naloxone need has remained at pre-pandemic rates (moving average: 73%), except for a decrease in April-May 2020. Patient-provider discussions about naloxone have also remained at pre-pandemic rates (moving average: 51%). Qualitative feedback from patients and providers has indicated that the program has been well-received by both groups.

DISCUSSION

The purpose of this description is to provide a framework for other Ob/Gyn clinics to use in implementing similar naloxone distribution programs. Although too early to determine whether this intervention will result in a significant decrease in maternal mortality due to opioid overdose in our patients, this measure will continue to be tracked annually. Implementation of a naloxone program in the obstetrical context provides an important way to improve outcomes for a vulnerable perinatal population.

Pregnancy, breast-feeding and drugs used in dentistry

BACKGROUND AND OVERVIEW

Despite advances in the study of birth defects related to drug exposures during pregnancy, medication use during pregnancy still causes anxiety and misunderstanding among both members of the public and health care professionals. This may result in a woman's unknowingly taking a medication that may harm the fetus or cause a birth defect or discontinuing medications necessary for treating chronic conditions. Using medications while breast-feeding also represents a challenge for patients and prescribers. Many mothers are told they must stop breast-feeding or "pump and discard" their breast milk if they are taking certain medications; however, in many cases, this advice-based on what may be limited education on the part of the health care provider about breast-feeding and medication use-may be incorrect. The authors review the current evidence regarding drugs that may be safe for pregnant or breast-feeding patients and medications that such patients should avoid.

CONCLUSIONS

When considering prescribing in pregnancy, the dentist must weigh the risk to the fetus versus the benefit to the mother, and the appropriate conclusion should reflect current evidence. In some cases medication dosing should be avoided or altered; however, there are times when it is unnecessary to stop the use of medications. Breast-feeding also represents a clinical challenge, the risks and benefits of which need to be understood by both the patient and practitioner before any medication is administered.

PRACTICE IMPLICATIONS

Dentists should be familiar with the risks and benefits for pregnant or breast-feeding patients posed by five types of medications: analgesics and anti-inflammatories, antibiotics, local anesthetics, sedatives and emergency medications.

Physiological mechanisms underlying lactational amenorrhea

Breastfeeding delays the resumption of normal ovarian cycles by disrupting the pattern of pulsatile release of GnRH from the hypothalamus and hence LH from the pituitary. The plasma concentrations of FSH during lactation are sufficient to induce follicle growth, but the inadequate pulsatile LH signal results in a reduced estradiol production by these follicles. When follicle growth and estradiol secretion does increase to normal, the suckling stimulus prevents the generation of a normal preovulatory LH surge and follicles either fail to rupture, or become atretic or cystic. Only when the suckling stimulus declines sufficiently to allow generation of a normal preovulatory LH surge to occur will ovulation take place with the formation of a corpus luteum of variable normality. Thus suckling delays the resumption of normal ovarian cyclicity by disrupting but not totally inhibiting, the normal pattern of release of GnRH by the hypothalamus. The mechanism of suckling-induced disruption of GnRH release remains unknown. It does not appear to involve prolactin, dopamine or opiates although a combination of these factors might be involved. Prolactin is the major hormone responsible for milk production and is present in sufficient quantities in almost all women to allow the establishment of normal lactation. Oxytocin is essential for milk let down and is susceptible to inhibition of release by stress. The successful initiation of lactation which would lead to the potential of utilizing breastfeeding as contraceptive may require more attention to be paid to the establishment of non-stress release of oxytocin.

Corticotropin-releasing hormone and opioid peptides in reproduction and stress

Increased knowledge on the mechanisms whereby corticotropin releasing hormone (CRH) and opioid peptides mediate the effects of stress has helped us to understand the relationship between stress and disturbed reproductive function. Increases of CRH and beta-endorphin in the hypothalamus in stressful situations inhibits the secretion of gonadotropins, oxytocin and vasopressin. This may lead to amenorrhea, which often is a consequence of intensive training or psychological stress, or it may disrupt parturition and lactation. There is a relationship between ovarian function and opioid peptides in the hypothalamus. Opioid peptides increase during puberty and fall at the menopause. Oestradiol and progesterone increase beta-endorphin concentrations in the luteal phase of the menstrual cycle, and this is followed by a rapid fall at menstruation. These changes may mediate symptoms typical of the premenstrual syndrome. Rather intensive exercise is required to increase plasma concentrations of beta-endorphin and corticotropin. During labour the amounts of beta-endorphin and corticotropin reach the values found in athletes during maximal exercise. The placenta produces increasing amounts of CRH towards the end of pregnancy which may help the mother and fetus to withstand the increased demands of labour. The placenta may thus be involved in the adaptation of the stress mechanism during pregnancy. CRH has also a paracrine function in different biological processes of the placenta and fetal membranes. It is possible to counteract the deleterious effects of stress on reproductive function by the administration of opiate antagonists. Induction of ovulation with naltrexone has been shown in patients with hypothalamic amenorrhea but the effect on fertility is not known.

The effect of ergometrine on breast feeding

A randomised, controlled trial of 1429 women was carried out to compare 'active' management of the third stage of labour, using i.v. Ergometrine 0.5 mgs, with a method of 'physiological' management, in women at 'low risk' to haemorrhage. A separate sub-study, with 168 women in each of the two groups, examined the possible effects of Ergometrine on serum prolactin levels and the duration of breast feeding. No difference was found in peak (post-suckling) serum prolactin levels taken from 126 women between 48 and 72 hours postnatal. Further studies with larger sample sizes would give a more dependable result. Women who did not receive the drug Ergometrine were more likely to continue breast feeding for longer than four weeks than those who did (p less than 0.05). It is recommended that this drug should not be given routinely to women intending to breast feed.