Neonatal outcome following maternal opiate use in late pregnancy

Opioid Detoxification During Pregnancy: A Systematic Review

OBJECTIVE

To systematically review maternal and neonatal outcomes associated with opioid detoxification during pregnancy.

DATA SOURCES

PubMed, PsycINFO, EMBASE, Cochrane, and ClinicalTrials.gov databases were searched from January 1, 1966, to September 1, 2016.

METHODS OF STUDY SELECTION

English-language studies that reported outcomes associated with opioid detoxification among pregnant women with opioid use disorder were included. Nonoriginal research articles (case reports, editorials, reviews) and studies that failed to report outcomes for detoxification participants were excluded. Bias was assessed using the Cochrane Collaboration's tool for assessing risk of bias and quality was assessed using the U.S. Preventive Service Task Force Quality of Evidence scale.

TABULATION, INTEGRATION, AND RESULTS

Of 1,315 unique abstracts identified, 15 met criteria for inclusion and included 1,997 participants, of whom 1,126 underwent detoxification. Study quality ranged from fair to poor as a result of the lack of a randomized control or comparison arm and high risk of bias across all studies. Only nine studies had a comparison arm. Detoxification completion (9-100%) and illicit drug relapse (0-100%) rates varied widely across studies depending on whether data from participants who did not complete detoxification or who were lost to follow-up were included in analyses. The reported rate of fetal loss was similar among women who did (14 [1.2%]) and did not undergo detoxification (17 [2.0%]).

CONCLUSIONS

Evidence does not support detoxification as a recommended treatment intervention as a result of low detoxification completion rates, high rates of relapse, and limited data regarding the effect of detoxification on maternal and neonatal outcomes beyond delivery.

Impact of timing of methadone initiation on perinatal outcomes following delivery among pregnant women on methadone maintenance therapy in Ontario

BACKGROUND AND AIMS

Methadone maintenance therapy (MMT) is associated with improved outcomes for children exposed to maternal opioid dependence in utero. We examined Ontario's population of pregnant women on MMT and determined the impact of timing of MMT initiation on perinatal outcomes.

DESIGN

Cohort study.

SETTING

Ontario, Canada.

PARTICIPANTS

Women eligible for public drug benefits and on MMT during pregnancy between 2005 and 2015.

MEASUREMENTS

We stratified women based on their timing of MMT initiation: (1) stabilized prior to conception, (2) newly initiated prior to conception, (3) initiation in trimester 1, (4) initiation in trimester 2 or (5) initiation in trimester 3. The primary outcomes in the multivariable logistic regression analysis were key perinatal health indicators: small for gestational age, preterm birth, congenital anomalies, severe maternal morbidity, caesarean section and induced labor. Secondary outcomes were specific to maternal opioid dependence: neonatal abstinence syndrome (NAS), admission to a neonatal intensive care unit (NICU), NAS treatment, removal from mother's custody at hospital discharge and neonatal death.

FINDINGS

Among 1842 women on MMT during pregnancy, 87.6% (n = 1614) initiated MMT before conception. Almost a quarter of their infants (22.2%; n = 408) were born small for gestational age, 17.5% (n = 323) were preterm and 5.9% (n = 109) were born with a congenital anomaly. The odds of primary outcomes occurring did not differ based on timing of methadone initiation; however, infants of mothers who initiated methadone during pregnancy had up to a fourfold increase in the odds of social services removal at the hospital [adjusted odds ratio (aOR) range = 3.70-4.19] compared with those whose mothers were stabilized on MMT prior to conception.

CONCLUSIONS

Later initiation of methadone maintenance therapy among pregnant women in Ontario, Canada has not been found to be clearly related to most key perinatal adverse health outcomes.

Safe management of chronic pain in pregnancy in an era of opioid misuse and abuse

Safe and effective management of chronic pain in pregnancy is challenging. Use of over-the-counter analgesics, opioids, opioid substitution therapies, complementary and alternative therapies, antidepressants, and anxiolytics each have benefits and risks for the mother and neonate that must be considered. Because of their potency, opioids are often used despite associated risks for adverse effects, abuse, diversion, and addiction. Development of a pain management protocol for the counsel and care of pregnant women with pain is necessary.

Methadone use in pregnancy: evidence of progression in the severity of addiction

The number of opiate users is well documented; however, the severity of opiate use has received little attention. This retrospective study in a North of England hospital updates the progression in the severity of addiction in pregnancy. Patients treated were reviewed and the doses of prescribed methadone documented. Historical data were also used for comparison. The severity in addiction in pregnancy was assessed by the woman's drug usage expressed as the daily dose of prescribed methadone at the end of pregnancy. From 2001 to 2008 there was an increase in the mean dose of methadone prescribed at delivery from 28.2 ml/day in 2001 to 57.9 ml/day in 2008. Historically, the use was 27.3 ml/day in 1992-1996 and 32.4 ml/day in 1997-2003. No trend was noted in the number of pregnant users. In conclusion, we observed no recent increase in the number of methadone users presenting, but the severity of drug usage in pregnancy has increased.

Prenatal exposure to methadone and buprenorphine: a review of the potential effects on cognitive development

The amount of opioid users receiving opioid maintenance therapy has increased significantly over the last few years. As a result, an increasing number of children are prenatally exposed to long-lasting opioids such as methadone and buprenorphine. This article reviews the literature on the cognitive development of children born to mothers in opioid maintenance therapy. Topics discussed are the effects of prenatal exposure on prematurity, somatic growth, brain volume, myelination, and the endocrine and neurotransmitter system. Social-environmental factors, including parental functioning, as well as genetic factors are also described. Areas requiring further research are identified.

Methadone dose and neonatal abstinence syndrome-systematic review and meta-analysis

AIM

To determine if there is a relationship between maternal methadone dose in pregnancy and the diagnosis or medical treatment of neonatal abstinence syndrome (NAS).

METHODS

PubMed, EMBASE, the Cochrane Library and PsychINFO were searched for studies reporting on methadone use in pregnancy and NAS (1966-2009). The relative risk (RR) of NAS was compared for methadone doses above versus below a range of cut-off points. Summary RRs and 95% confidence intervals (CI) were estimated using random effects meta-analysis. Sensitivity analyses explored the impact of limiting meta-analyses to prospective studies or studies using an objective scoring system to diagnose NAS.

RESULTS

A total of 67 studies met inclusion criteria for the systematic review; 29 were included in the meta-analysis. Any differences in the incidence of NAS in infants of women on higher compared with lower doses were statistically non-significant in analyses restricted to prospective studies or to those using an objective scoring system to diagnose NAS.

CONCLUSIONS

Severity of the neonatal abstinence syndrome does not appear to differ according to whether mothers are on high- or low-dose methadone maintenance therapy.

The influence of maternal opiate use in pregnancy on second trimester biochemical markers for Down syndrome

OBJECTIVE

The object of this study is to examine the influence of maternal opiate use on the levels of second trimester biochemical markers for Down syndrome. Maternal opiate use is known to be associated with problems of placental origin and it is possible that the secretion of alpha-feto protein (AFP), free-beta human chorionic gonadotrophin (HCG) and unconjugated oestriol (UE) differs from that of a normal population.

METHOD

Seventy nine women who used opiates in pregnancy were compared to a control group of seventy nine women who did not use opiates and their adjusted marker levels analysed.

RESULTS

The adjusted median MoM in the opiate and control groups respectively were: AFP (1.00 vs 0.94), HCG (0.95 vs 1.04) and UE (0.96 vs 1.02), with no significant difference between these groups.

CONCLUSION

This study suggests that the current practice of calculating the risk of Down syndrome from second trimester biochemistry in women using opiate can be performed using data derived from a normal population.

Using population data to examine the prevalence and correlates of neonatal abstinence syndrome

The objective of this study was to determine the population prevalence and correlates of neonatal abstinence syndrome among neonates born to women on methadone, using a cross-sectional analysis of linked population health data. A total of 2941 live births to women actively on methadone at delivery were analysed over an 11-year period (1992 - 2002). Of these births, 796 neonates (27%) were diagnosed with an International Classification of Diseases - 9CM (ICD-9CM) or International Classification of Diseases ICD - 10AM (ICD-10AM) diagnosis related to neonatal withdrawal from exposure to opiates in utero (NAS). There were significant differences found between mothers whose neonates did and did not receive an International Classification of Diseases NAS-related diagnosis. Mothers of neonates with a NAS-related diagnosis had a higher number of previous pregnancies, were more likely to be indigenous, to smoke more heavily and were more likely to present for delivery unbooked. Neonates diagnosed with NAS were admitted to Special Care Nursery more often. NAS is diagnosed less frequently using International Classification of Diseases (ICD) codes than when using clinical scales measuring opiate-related neonatal withdrawal. This suggests that NAS may be under-represented in hospital morbidity databases that use ICD codes to quantify patient throughput and in some circumstances this may result from under-detection of the condition. Future research should therefore seek to determine the validity of NAS recording in hospital morbidity databases reliant on the use ICD codes.

A survey of postnatal contraception in opiate-using women

OBJECTIVE

To document the contraceptive choices and continuation rates for different contraceptives in a group of pregnant women who use opiates.

METHODS

A prospective study set in a large city in the north of England that looked at 40 pregnant women who used opiates in the index pregnancy. The study involved reviewing the records from the patients' general practitioners with information on the continuation rates of the chosen method of contraception and any related problems.

RESULTS

The women given Depo-Provera (n = 14) did not continue the method after the first injection. Those given implants (n = 20) had a 95% continuation rate at a mean follow-up of over 11 months.

CONCLUSIONS

Implants had a good continuation rate when used for postnatal contraception in women who used opiates in pregnancy. Depo-Provera may not be a suitable choice since all the women who chose this contraceptive method failed to continue with it.

Pregnancy outcome in women who use opiates

BACKGROUND

Opiate use in pregnancy is on the increase. There are a number of complications associated with this problem but current data from UK centres are sparse.

DESIGN

A retrospective study.

SETTING

A North of England Hospital.

METHODS

Maternal and neonatal case records were studied and a standard data set completed.

MAIN OUTCOME MEASURES

Maternal and neonatal outcomes were classified by the woman's drug usage at the end of pregnancy.

RESULTS

One hundred and ten babies born to 108 women were studied and 41% had evidence of previous exposure to the hepatitis C virus. Women who took heroin in later pregnancy were significantly more likely than women who were stabilised on methadone to have a baby who needed morphine (40% versus 19%), had higher mean maximum neonatal abstinence scores (NAS) (5.8 versus 4.7) and stayed in the neonatal unit significantly longer (mean 17.2 days versus 11.8 days). There were two neonatal deaths and the overall rate of prematurity was 29%.

CONCLUSIONS

The outcome for pregnancy in women who use opiates is complicated by high rates of prematurity and neonatal death. Women who used heroin in later pregnancy had babies who developed more severe NAS and needed a longer hospital stay than women who used only methadone.

Migraine during pregnancy: options for therapy

Migraine is common during pregnancy, but fortunately this combination of conditions obviously exists for only a finite period. The greatest frequency of migraine attacks occurs during the first trimester. Accurate diagnosis is a sine qua non in this setting as in any headache patient. It is in the first trimester that the fetus is at greatest risk from abortifacient and teratogenic drugs, and when very early pregnancy may be undiagnosed. Ergot alkaloids (including methysergide) should be avoided during pregnancy because of their teratogenicity, and most other drug classes should be used only when unavoidable. The use of prophylactic agents during pregnancy should be the exception, not the rule, and preferably only during the second and third trimesters; propranolol is probably safest in this situation. De novo headache during pregnancy usually requires expert review of the patient. Treatment tactics for uncomplicated migraine in pregnancy depend on the concurrent clinical situation. Paracetamol (acetaminophen) is the mainstay for the patient whose typical attacks continue into the first trimester. If paracetamol is insufficient, then partial agonist opioids may be used if typical migraine attacks persist in the second and third trimesters (which is uncommon). 'Chronic migraine' in pregnancy, i.e. >or=15 headache days per month, is rare, and is the greatest therapeutic challenge. Co-morbidities such as depression or epilepsy require specialised approaches. The complexities associated with these tactics are discussed in this article, and it is emphasised that none has the specific approval of regulatory authorities. Heightened pharmacovigilance will better inform the future pregnant migraineur. However, this type of information is less likely to be available for novel classes of neuropharmacological agents than for existing ones.

Epidemiology of substance use disorders in women

Significant gender differences exist in the prevalence of substance use disorders in the United States. There is a trend among boys and girls aged 12 to 17 years toward comparable rates of use and initiation for alcohol, cocaine, heroin, and tobacco. If this trend continues, over time there may be a narrowing of the male-to-female prevalence ratios of substance abuse in the older age groups. This possibility is particularly disturbing because women have a heightened vulnerability to medical, physical, mental, and social consequences of substance use. Women also carry additional unique risks during pregnancy because of the effect on neonates. In addition, they have certain gender-specific cancer risks. Given this and the declining age of initiation of substance use in women, prevention and treatment efforts especially geared toward women (eg, education of all medical and paramedical staff, screening in primary care clinics, detection of drug use early in pregnancy or before conception, brief interventions and treatment programs that integrate women's needs) are exceedingly important to stop and ultimately reverse this growing trend.

Endogenous opiates and behavior: 2001

This paper is the twenty-fourth installment of the annual review of research concerning the opiate system. It summarizes papers published during 2001 that studied the behavioral effects of the opiate peptides and antagonists. The particular topics covered this year include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (Section 2), and the roles of these opioid peptides and receptors in pain and analgesia (Section 3); stress and social status (Section 4); tolerance and dependence (Section 5); learning and memory (Section 6); eating and drinking (Section 7); alcohol and drugs of abuse (Section 8); sexual activity and hormones, pregnancy, development and endocrinology(Section 9); mental illness and mood (Section 10); seizures and neurologic disorders (Section 11); electrical-related activity and neurophysiology (Section 12); general activity and locomotion (Section 13); gastrointestinal, renal and hepatic functions (Section 14); cardiovascular responses (Section 15); respiration and thermoregulation (Section 16); and immunological responses (Section 17).