Prenatal Opioid Exposure and Immune-Related Conditions in Children

Importance

Prenatal opioid exposure (POE) may alter with fetal development of the immune system, which may influence long-term health and susceptibility to immune-related conditions.

Objective

To compare the risk of hospitalization and emergency department presentation for immune-related conditions in children with and without POE.

Design, Setting, and Participants

This retrospective, population-based cohort study used linked administrative health records of all children born in Western Australia between January 1, 2003, and December 31, 2018 (N = 401 462).

Exposure

Prenatal exposure to prescription opioids (overall and by trimester), neonatal abstinence syndrome diagnosis, and opioid indication (pain or opioid use disorder [OUD]).

Main Outcomes and Measures

The main outcome was hospital admissions and emergency department presentations during which a child was diagnosed with an immune-related condition, including infections, conditions associated with an overactive immune system (eg, asthma, eczema, and allergy and anaphylaxis), and autoimmune diseases diagnosed before age 5 years or June 30, 2020. Data were analyzed between August 30, 2022, and February 27, 2023.

Results

Neonates with POE (1656 [0.4%]; mean [SD] gestational age, 37.7 [2.1] weeks; 836 females [50.5%]; 820 males [49.5%]) were more likely to be born preterm, have low birth weight for gestational age, and be coexposed to cigarette smoke compared with nonexposed neonates. Perinatal opioid exposure was associated with an increased risk of perinatal infection (adjusted odds ratio [AOR], 1.62; 95% CI, 1.38-1.90) and eczema and dermatitis (AOR, 11.91; 95% CI, 9.84-14.41) compared with nonexposure. Neonatal abstinence syndrome was also associated with both conditions (AOR, 2.91 [95% CI, 2.36-3.57] and 31.11 [95% CI, 24.64-39.28], respectively). Prenatal opioid exposure was also associated with an increased risk of childhood asthma (adjusted hazard ratio [AHR], 1.44; 95% CI, 1.16-1.79), but not allergies and anaphylaxis. It was also associated with an increased risk of childhood eczema and dermatitis, but only in children with POE from opioids used to treat OUD (AHR, 1.47; 95% CI, 1.08-1.99) rather than pain. In contrast, POE from opioids used for pain was associated with an increased risk of infection (AHR, 1.44; 95% CI, 1.32-1.58), but POE to opioids used to treat OUD was not. Autoimmune conditions were rare and were not observed to be associated with POE.

Conclusions and Relevance

In this cohort study, POE was associated with an increased risk of infection, eczema and dermatitis, and asthma, but not allergies and anaphylaxis or autoimmune conditions. These findings highlight the importance of further study of opioid-induced immune changes during pregnancy, the potential impact on long-term health in exposed children, and the mechanisms of opioid-induced immune dysregulation.

Advances in the Care of Infants With Prenatal Opioid Exposure and Neonatal Opioid Withdrawal Syndrome

A significant number of advances have been made in the last 5 years with respect to the identification, diagnosis, assessment, and management of infants with prenatal opioid exposure and neonatal opioid withdrawal syndrome (NOWS) from birth to early childhood. The primary objective of this review is to summarize major advances that will inform the clinical management of opioid-exposed newborns and provide an overview of NOWS care to promote the implementation of best practices. First, advances with respect to standardizing the clinical diagnosis of NOWS will be reviewed. Second, the most commonly used assessment strategies are discussed, with a focus on presenting new quality improvement and clinical trial data surrounding the use of the new function-based assessment Eat, Sleep, and Console approach. Third, both nonpharmacologic and pharmacologic treatment modalities are reviewed, highlighting clinical trials that have compared the use of higher calorie and low lactose formula, vibrating crib mattresses, morphine compared with methadone, buprenorphine compared with morphine or methadone, the use of ondansetron as a medication to prevent the need for NOWS opioid pharmacologic treatment, and the introduction of symptom-triggered dosing compared with scheduled dosing. Fourth, maternal, infant, environmental, and genetic factors that have been found to be associated with NOWS severity are highlighted. Finally, emerging recommendations on postdelivery hospitalization follow-up and developmental surveillance are presented, along with highlighting ongoing and needed areas of research to promote infant and family well-being for families impacted by opioid use.

Neonatal Opioid Withdrawal Syndrome Following Prenatal Use of Supplements Containing Tianeptine

Tianeptine is an opioid receptor agonist that is prescribed as an antidepressant in many countries. In the United States, tianeptine is not approved for medical use because of its potential for abuse and addiction. Nonetheless, products containing tianeptine are easily obtainable and are marketed as dietary supplements. There are increasing reports of adverse effects and fatal toxicities resulting from tianeptine use among adolescents and adults. This emerging public health threat could escalate the opioid epidemic and drive increased newborn perinatal exposure. The impact of in utero exposure to tianeptine has not been studied, and to our knowledge, the authors of only 1 report have documented possible neonatal effects. Here, we describe a case of chronic prenatal exposure to tianeptine in the setting of maternal dependence on dietary supplements. This infant developed signs of severe withdrawal shortly after birth that were refractory to treatment with oral phenobarbital but responded to subsequent oral morphine therapy. On further questioning, the mother revealed the use of a tianeptine-containing dietary supplement. We did not perform confirmatory toxicology testing because tianeptine is not assayed by usual urine drug screening tests. For infants with clinical signs of opioid withdrawal without known etiology, we suggest that the maternal interview should inquire about the use of neurotropic over-the-counter drugs.

Prenatal Substance Exposure and Neonatal Abstinence Syndrome: State Estimates from the 2016-2020 Transformed Medicaid Statistical Information System

INTRODUCTION

Estimating Neonatal Abstinence Syndrome (NAS) and prenatal substance exposure rates in Medicaid can help target program efforts to improve access to services.

METHODS

The data for this study was extracted from the 2016-2020 Transformed Medicaid Statistical Information System (T-MSIS) Analytic Files (TAF) Research Identifiable Files (RIF) and included infants born between January 1, 2016 and December 31, 2020 with a either a NAS diagnosis or prenatal substance exposure.

RESULTS

Between 2016 and 2020, the estimated national rate of NAS experienced a 18% decline, while the estimated national rate of prenatal substance exposure experienced a 3.6% increase. At the state level in 2020, the NAS rate ranged from 3.2 per 1000 births (Hawaii) to 68.0 per 1000 births (West Virginia). Between 2016 and 2020, 28 states experienced a decline in NAS births and 20 states had an increase in NAS rates. In 2020, the lowest prenatal substance exposure rate was observed in New Jersey (9.9 per 1000 births) and the highest in West Virginia (88.1 per 1000 births). Between 2016 and 2020, 38 states experienced an increase in the rate of prenatal substance exposure and 10 states experienced a decline.

DISCUSSION

Estimated rate of NAS has declined nationally, but rate of prenatal substance exposure has increased, with considerable state-level variation. The reported increase in prenatal substance exposure in the majority of US states (38) suggest that substances other than opioids are influencing this trend. Medicaid-led initiatives can be used to identify women with substance use and connect them to services.

Decreased myelin-related gene expression in the nucleus accumbens during spontaneous neonatal opioid withdrawal in the absence of long-term behavioral effects in adult outbred CFW mice

Prenatal opioid exposure is a major health concern in the United States, with the incidence of neonatal opioid withdrawal syndrome (NOWS) escalating in recent years. NOWS occurs upon cessation of in utero opioid exposure and is characterized by increased irritability, disrupted sleep patterns, high-pitched crying, and dysregulated feeding. The main pharmacological strategy for alleviating symptoms is treatment with replacement opioids. The neural mechanisms mediating NOWS and the long-term neurobehavioral effects are poorly understood. We used a third trimester-approximate model in which neonatal outbred pups (Carworth Farms White; CFW) were administered once-daily morphine (15 mg/kg, s.c.) from postnatal day (P) day 1 through P14 and were then assessed for behavioral and transcriptomic adaptations within the nucleus accumbens (NAc) on P15. We also investigated the long-term effects of perinatal morphine exposure on adult learning and reward sensitivity. We observed significant weight deficits, spontaneous thermal hyperalgesia, and altered ultrasonic vocalization (USV) profiles following repeated morphine and during spontaneous withdrawal. Transcriptome analysis of NAc from opioid-withdrawn P15 neonates via bulk mRNA sequencing identified an enrichment profile consistent with downregulation of myelin-associated transcripts. Despite the neonatal behavioral and molecular effects, there were no significant long-term effects of perinatal morphine exposure on adult spatial memory function in the Barnes Maze, emotional learning in fear conditioning, or in baseline or methamphetamine-potentiated reward sensitivity as measured via intracranial self-stimulation. Thus, the once daily third trimester-approximate exposure regimen, while inducing NOWS model traits and significant transcriptomic effects in neonates, had no significant long-term effects on adult behaviors.

[Neonatal abstinence syndrome due to kratom]

BACKGROUND

Kratom (Mitragyna speciosa) is a herbal product obtained from the tropical tree family 'Rubiaceae'. Kratom is available without prescription in several formulations. The active component mitragynine acts in high dose as a mu-opioid agonist. It is misconceived to be a safe alternative to conventional opioid drugs for the treatment of chronic pain. Therefore, maternal use of Kratom is not without risks as opioid use during pregnancy is associated with Neonatal Abstinence Syndrome (NAS).

CASE DESCRIPTION

In this case report we describe a term neonate with severe NAS as a result of daily Kratom ingestion by the mother during pregnancy. Presence of mitragynine was confirmed in serum of the neonate. NAS was successfully treated with oral phenobarbital.

CONCLUSION

Maternal Kratom use during pregnancy can cause severe NAS via in utero exposure. Physicians should be aware of the possible maternal use of Kratom in the case of a neonate with NAS. NAS as a result of maternal Kratom use can be effectively treated with oral phenobarbital.

Neonatal withdrawal syndrome following in utero exposure to antidepressants: a disproportionality analysis of VigiBase, the WHO spontaneous reporting database

BACKGROUND

Evidence on neonatal withdrawal syndrome following antidepressant intrauterine exposure is limited, particularly for antidepressants other than selective serotonin reuptake inhibitor (SSRIs).

METHODS

In our case/non-case pharmacovigilance study, based on VigiBase®, the WHO database of suspected adverse drug reactions, we estimated reporting odds ratio (ROR) and the Bayesian information component (IC) with 95% confidence/credibility intervals (CI) as measures of disproportionate reporting of antidepressant-related neonatal withdrawal syndrome. Antidepressants were first compared to all other medications, then to methadone, and finally within each class of antidepressants: SSRIs, tricyclics (TCA) and other antidepressants. Antidepressants were ranked in terms of clinical priority, based on semiquantitative score ratings. Serious v. non-serious reports were compared.

RESULTS

A total of 406 reports of neonatal withdrawal syndrome in 379 neonates related to 15 antidepressants were included. Disproportionate reporting was detected for antidepressants as a group as compared to all other drugs (ROR: 6.18, 95% CI 5.45-7.01, IC: 2.07, 95% CI 1.92-2.21). Signals were found for TCAs (10.55, 95% CI 8.02-13.88), followed by other antidepressants (ROR: 5.90, 95% CI 4.74-7.36) and SSRIs (ROR: 4.68, 95% CI 4.04-5.42). Significant disproportionality emerged for all individual antidepressants except for bupropion, whereas no disproportionality for any antidepressant was detected v. methadone. Eleven antidepressants had a moderate clinical priority score and four had a weak one. Most frequent symptoms included respiratory symptoms (n = 106), irritability/agitation (n = 75), tremor (n = 52) and feeding problems (n = 40).

CONCLUSIONS

Most antidepressants are associated with moderate signals of disproportionate reporting for neonatal withdrawal syndrome, which should be considered when prescribing an antidepressant during pregnancy, irrespective of class.

Duration and Timing of In Utero Opioid Exposure and Incidence of Neonatal Withdrawal Syndrome

OBJECTIVE

To evaluate the association between prenatal prescription opioid analgesic exposure (duration, timing) and neonatal opioid withdrawal syndrome (NOWS).

METHODS

We conducted a retrospective cohort study of Wisconsin Medicaid-covered singleton live births from 2011 to 2019. The primary outcome was a NOWS diagnosis in the first 30 days of life. Opioid exposure was identified with any claim for prescription opioid analgesic fills during pregnancy. We measured exposure duration cumulatively in days (1-6, 7-29, 30-89, and 90 or more) and identified timing as early (first two trimesters only) or late (third trimester, regardless of earlier pregnancy use). We used logistic regression modeling to assess NOWS incidence by exposure duration and timing, with and without propensity score matching.

RESULTS

Overall, 31,456 (14.3%) of 220,570 neonates were exposed to prescription opioid analgesics prenatally. Among exposed neonates, 19,880 (63.2%) had 1-6 days of exposure, 7,694 (24.5%) had 7-29 days, 2,188 (7.0%) had 30-89 days, and 1,694 (5.4%) had 90 or more days of exposure; 15,032 (47.8%) had late exposure. Absolute NOWS incidence among neonates with 1-6 days of exposure was 7.29 per 1,000 neonates (95% CI 6.11-8.48), and incidence increased with longer exposure: 7-29 days (19.63, 95% CI 16.53-22.73); 30-89 days (58.96, 95% CI 49.08-68.84); and 90 or more days (177.10, 95% CI 158.90-195.29). Absolute NOWS incidence for early and late exposures were 11.26 per 1,000 neonates (95% CI 9.65-12.88) and 35.92 per 1,000 neonates (95% CI 32.95-38.90), respectively. When adjusting for confounders including timing of exposure, neonates exposed for 1-6 days had no increased odds of NOWS compared with unexposed neonates, whereas those exposed for 30 or more days had increased odds of NOWS (30-89 days: adjusted odds ratio [aOR] 2.15, 95% CI 1.22-3.79; 90 or more days: 2.80, 95% CI 1.36-5.76). Late exposure was associated with elevated odds of NOWS (aOR 1.57, 95% CI 1.25-1.96) when compared with unexposed after adjustment for exposure duration.

CONCLUSION

More than 30 days of prenatal prescription opioid exposure was associated with NOWS regardless of exposure timing. Third-trimester opioid exposure, irrespective of exposure duration, was associated with NOWS.

Comparative Safety Analysis of Opioid Agonist Treatment in Pregnant Women with Opioid Use Disorder: A Population-Based Study

INTRODUCTION AND OBJECTIVE

Receipt of opioid agonist treatment during early and late pregnancy for opioid use disorder may relate to varying perinatal risks. We aimed to assess the effect of time-varying prenatal exposure to opioid agonist treatment using buprenorphine or methadone on adverse neonatal and pregnancy outcomes.

METHODS

We conducted a retrospective cohort study of pregnant women with opioid use disorder using Rhode Island Medicaid claims data and vital statistics during 2008-16. Time-varying exposure was evaluated in early (0-20 weeks) and late (≥ 21 weeks) pregnancy. Marginal structural models with inverse probability of treatment weighting were applied.

RESULTS

Of 400 eligible pregnancies, 85 and 137 individuals received buprenorphine and methadone, respectively, during early pregnancy. Compared with 152 untreated pregnancies with opioid use disorders, methadone exposure in both periods was associated with an increased risk of preterm birth (adjusted odds ratio [aOR]: 2.52; 95% confidence interval [CI] 1.07-5.95), low birth weight (aOR: 2.99; 95% CI 1.34-6.66), neonatal intensive care unit admission (aOR, 5.04; 95% CI 2.49-10.21), neonatal abstinence syndrome (aOR: 11.36; 95% CI 5.65-22.82), respiratory symptoms (aOR, 2.71; 95% CI 1.17-6.24), and maternal hospital stay > 7 days (aOR, 14.51; 95% CI 7.23-29.12). Similar patterns emerged for buprenorphine regarding neonatal abstinence syndrome (aOR: 10.27; 95% CI 4.91-21.47) and extended maternal hospital stay (aOR: 3.84; 95% CI 1.83-8.07). However, differences were found favoring the use of buprenorphine for preterm birth versus untreated pregnancies (aOR: 0.17; 95% CI 0.04-0.77), and for several outcomes versus methadone.

CONCLUSIONS

Methadone and buprenorphine prescribed for the treatment of opioid use disorder during pregnancy are associated with varying perinatal risks. However, buprenorphine may be preferred in the setting of pregnancy opioid agonist treatment. Further research is necessary to confirm our findings and minimize residual confounding.

Characteristics of Prescription Opioid Analgesics in Pregnancy and Risk of Neonatal Opioid Withdrawal Syndrome in Newborns

IMPORTANCE

Prescription opioids are often used during pregnancy even though they are associated with neonatal opioid withdrawal syndrome (NOWS). Most studies of adverse outcomes of opioid use for pain have assessed only the class-wide outcome despite the pharmacodynamic and pharmacokinetic heterogeneity across opioid medications.

OBJECTIVE

To compare the risk of NOWS across common types of opioids when prescribed as monotherapy during the last 3 months of pregnancy.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed administrative claims data of Medicaid-insured mothers and newborns in 46 states and Washington DC from January 1, 2000, through December 31, 2014. Participants were mothers with 2 or more dispensed opioid prescriptions within 90 days before delivery and their eligible live-born neonates. Data were analyzed from February 2020 to March 2021.

EXPOSURE

Different types of opioid medications were compared by agonist strength (strong vs weak) and half-life (medium vs short and long vs short) of the opioid active ingredient.

MAIN OUTCOMES AND MEASURES

The primary outcome was NOWS, which was identified using an International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic code in the 30 days after delivery. Relative risks (RRs) were adjusted for an exposure propensity score, including demographic characteristics, comorbidities, other medication use, and opioid treatment characteristics (including morphine milligram equivalents), using fine stratification.

RESULTS

The cohort comprised 48 202 opioid-exposed pregnancies with live newborns. A total of 1069 neonates (2.2%) had NOWS and 559 (1.2%) had severe NOWS. Opioid exposure during pregnancy included 16 202 pregnancies exposed to codeine, 4540 to oxycodone, 1244 to tramadol, 260 to methadone (dispensed for pain), 90 to hydromorphone, and 63 to morphine compared with 25 710 exposed to hydrocodone. Demographic characteristics varied across opioids, with tramadol, oxycodone, methadone, hydromorphone, and morphine being more commonly dispensed at older maternal age (≥35 years). Compared with hydrocodone, codeine had a lower adjusted RR of NOWS (0.57; 95% CI, 0.46-0.70), with a similar adjusted RR for tramadol (RR, 1.06; 95% CI, 0.73-1.56), and 2- to 3-fold higher adjusted RRs for oxycodone (1.87; 95% CI, 1.66-2.11), morphine (2.84; 95% CI, 1.30-6.22), methadone (3.02; 95% CI, 2.45-3.73), and hydromorphone (2.03; 95% CI, 1.09-3.78). Strong agonists were associated with a higher risk of NOWS than weak agonists (RR, 1.97; 95% CI, 1.78-2.17), and long half-life opioids were associated with an increased risk compared with short half-life products (RR, 1.33; 95% CI, 1.12-1.56). Findings were consistent across sensitivity and subgroup analyses.

CONCLUSIONS AND RELEVANCE

Results of this study show higher risk of NOWS and severe NOWS among neonates with in utero exposure to strong agonists and long half-life prescription opioids. Information on the opioid-specific risk of NOWS may help prescribers select opioids for pain management in late stages of pregnancy.

Maternal continuous oral oxycodone self-administration alters pup affective/social communication but not spatial learning or sensory-motor function

BACKGROUND

The broad use/misuse of prescription opioids during pregnancy has resulted in a surge of infants with Neonatal Opioid Withdrawal Syndrome (NOWS). Short-term irritability and neurological complications are its hallmarks, but the long-term consequences are unknown.

METHODS

A newly-developed preclinical model of oxycodone self-administration enables adult female rats to drink oxycodone (∼10/mg/kg/day) before and during pregnancy, and after delivery, and to maintain normal liquid intake, titrate dosing, and avoid withdrawal.

RESULTS

Oxycodone was detected in the serum of mothers and pups. Growth parameters in dams and pups and litter mass and size were similar to controls. There were no differences in paw retraction latency to a thermal stimulus between Oxycodone and Control pups at postnatal (PN) 2 or PN14. Oxycodone and Control pups had similar motor coordination, cliff avoidance, righting time, pivoting, and olfactory spatial learning from PN3 through PN13. Separation-induced ultrasonic vocalizations at PN8 revealed higher call frequency in Oxycodone pups relative to Control pups (p<0.031; Cohen's d=1.026). Finally, Oxycodone pups displayed withdrawal behaviors (p's<0.029; Cohen's d's>0.806), and Oxycodone males only vocalized more than Control pups in the first minute of testing (p's<0.050; Cohen's d's>.866). Significant effects were corroborated by estimation plots.

CONCLUSIONS

Our rat model of oral oxycodone self-administration in pregnancy shows exacerbated affect/social communication in pups in a sex-dependent manner but spared cognition and sensory-motor behaviors. This preclinical model reproduces selective aspects of human opioid use during pregnancy, enabling longitudinal analysis of how maternal oxycodone changes emotional behavior in the offspring.

Assessing the relationship between neonatal abstinence syndrome and birth defects in Delaware

BACKGROUND

Neonatal abstinence syndrome (NAS) is a withdrawal syndrome in newborns and is frequently caused by maternal opioid use during pregnancy. Our study examines whether NAS is associated with birth defects in Delaware.

METHODS

We conducted a retrospective analysis of linked Delaware birth certificate data (BCD), hospital discharge data (HDD), and birth defects registry (BDR) data to examine the association between NAS and birth defects for all hospital births to Delaware residents from 2010 to 2017. Birth defects data were abstracted from medical records from Delaware's BDR. We used International Classification of Diseases Ninth and Tenth Revision Clinical Modification (ICD-9-CM/ICD-10-CM) 779.5 and P96.1 codes to determine NAS using HDD and excluded iatrogenic cases of NAS. We estimated crude and adjusted odds ratio with 95% confidence intervals (CIs).

RESULTS

During 2010-2017, there were 2,784 cases of birth defects and 1,651 cases of NAS in Delaware. Among infants with a diagnosis of NAS, 56 also had a birth defect (3.4%), similar to 2,728 birth defects among 79,636 infants without a diagnosis of NAS (3.4%). We found no statistically significant association between an NAS diagnosis and birth defects (adjusted odds ratios = 1.0; 95% CI: 0.8-1.3).

CONCLUSIONS

Our multiyear state-wide study using linked BCD, HDD, and BDR data for Delaware did not show a statistically significant association between infants diagnosed with NAS and birth defects, overall.

Prevalence and Geographic Distribution of Obstetrician-Gynecologists Who Treat Medicaid Enrollees and Are Trained to Prescribe Buprenorphine

IMPORTANCE

The incidence of opioid use during pregnancy is increasing, and drug overdoses are a leading cause of postpartum mortality. Most women who are pregnant do not receive medications for treatment of opioid use disorder, despite the mortality benefit that these agents confer. Furthermore, buprenorphine is associated with milder symptoms of neonatal abstinence syndrome (NAS) compared with methadone.

OBJECTIVE

To describe the prevalence and geographic distribution across the US of obstetrician-gynecologists who can prescribe buprenorphine (henceforth described as X-waivered) in 2019.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional, nationwide study linking physician-specific data to county- and state-level data was conducted from September 1, 2019, to March 31, 2020. Data were obtained on 31 211 obstetrician-gynecologists who accept Medicaid insurance through the Centers for Medicare & Medicaid Services Physician Compare data set and linked to the Drug Addiction Treatment Act buprenorphine-waived clinician list.

EXPOSURES

State-level NAS incidence and county-level uninsured rates and rurality.

MAIN OUTCOMES AND MEASURES

Prevalence and geographic distribution of obstetrician-gynecologists who are trained to prescribe buprenorphine.

RESULTS

Among the 31 211 identified obstetrician-gynecologists, 18 710 (59.9%) were women. Most had hospital privileges (23 236 [74.4%]) and worked in metropolitan counties (28 613 [91.7%]). Only 560 of the identified obstetrician-gynecologists (1.8%) were X-waivered. Obstetrician-gynecologists in counties with fewer than 5% uninsured residents had nearly twice the odds of being X-waivered (adjusted odds ratio [aOR], 1.59; 95% CI, 1.04-2.44; P = .04) compared with those in counties with greater than 15% uninsured residents. Compared with those located in metropolitan counties, obstetrician-gynecologists in suburban counties (eg, urban population of ≥20 000 and adjacent to a metropolitan area) were more likely to be X-waivered (aOR, 1.85; 95% CI, 1.26-2.71; P = .002). Compared with states with an NAS rate of 5 per 1000 births or less, obstetrician-gynecologists in states with an NAS rate of 15 per 1000 births or greater had nearly 5 times the odds of being X-waivered (aOR, 4.94; 95% CI, 3.60-6.77; P < .001). Obstetrician-gynecologists without hospital privileges were more likely to be X-waivered (aOR, 1.32; 95% CI, 1.08-1.61; P = .007).

CONCLUSIONS AND RELEVANCE

Fewer than 2% of obstetrician-gynecologists who accept Medicaid are able to prescribe buprenorphine, and their geographic distribution appears to be skewed in favor of suburban counties. This finding suggests that there is an opportunity for health systems and professional societies to incentivize X-waiver trainings among obstetrician-gynecologists to increase patients' access to buprenorphine, especially during pregnancy.

Innovative approaches to reduce unintended pregnancy and improve access to contraception among women who use opioids

Dramatic increases in the rate of opioid use disorder (OUD) during pregnancy have been paralleled by substantial increases in the number of neonates diagnosed with neonatal abstinence syndrome (NAS). Women with OUD have reliably reported high rates of unintended pregnancy and a number of studies also indicate they desire easier access to contraception. Recent statements from the Centers for Disease Control and Prevention and the American Academy of Pediatrics/American College of Obstetricians and Gynecologists have drawn increased attention to efforts to prevent unintended pregnancy and improve access to contraception among women with OUD. We briefly review a number of innovative clinical approaches in these areas, including efforts to integrate family planning services into substance use disorder (SUD) treatment and other settings that serve people with OUD and interventions that aim to make family planning a higher priority among women with OUD. Results suggest many of these approaches have led to increases in contraceptive use and may aid in efforts to reduce unintended pregnancy and improve access to contraception among women with OUD now and in the future.

Methadone dosing strategies in preterm neonates can be simplified

AIMS

A dramatic increase in newborn infants with neonatal abstinence syndrome has been observed and these neonates are frequently treated with complex methadone dosing schemes to control their withdrawal symptoms. Despite its abundant use, hardly any data on the pharmacokinetics (PK) of methadone is available in preterm neonates. Therefore we investigated developmental PK of methadone and evaluated current dosing strategies and possible simplification in this vulnerable population.

METHODS

A single-centre open-label prospective study was performed to collect PK data after a single oral dose of methadone in preterm neonates. A population PK model was built to characterize developmental PK of (R)- and (S)-methadone. Model-based simulations were performed to identify a simplified dosing strategy to reach and maintain target methadone exposure.

RESULTS

A total of 121 methadone concentrations were collected from 31 preterm neonates. A one-compartment model with first order absorption and elimination kinetics best described PK data for (R)- and (S)-methadone. Clearance increases with advancing gestational age and differs between R- and S-enantiomer, being slightly higher for the former (0.244 vs 0.167 L/h). Preterm neonates reached target exposure after 48 hours with currently used dosing schedules. Output from simulations revealed that target exposures can be achieved with a simplified dosing strategy during the first 4 days of treatment.

CONCLUSION

Methadone clearance in preterm neonates increases with advancing gestational age and its disposition is influenced by its chirality. Simulations that account for developmental PK changes indicate a shorter methadone dosing strategy can maintain target exposure to control withdrawal symptoms.

Diverse changes in myelin protein expression in rat brain after perinatal methadone exposure

The national incidence of neonatal abstinence syndrome has dramatically increased over the last decade due to an increase in antenatal opioid exposure. Recent human and animal studies suggest that antenatal opioid exposure impacts the developing brain. The purpose of this study is to evaluate the effects of perinatal methadone exposure on myelination in multiple regions in the developing rat brain. Pregnant Sprague-Dawley rats were randomly assigned into three experimental groups and subsequently exposed to drinking water alone or drinking water containing methadone from 7 days post coitum through day 7 or through day 19 after delivery. Two male neonatal rats were randomly selected from each litter and terminated at day 19. The cerebral cortex, hippocampus, cerebellum, and brainstem were dissected and analyzed for three myelin specific proteins - CNP, PLP, and MBP - by Western blot analysis. All pups with exposure to methadone demonstrated decreased expression of CNP, PLP, and MBP in the cerebral cortex and hippocampus. In the cerebellum, PLP expression was down‑regulated without apparent alteration of CNP and MBP expression. PLP and MBP expression, but not CNP expression, were significantly inhibited in the brainstem. Compared to the pups with postnatal methadone exposure via maternal milk through day 7, partial recovery of CNP and PLP expression only occurred in the cerebral cortices of the pups exposed through day 19. The findings show that antenatal opioid exposure in rat pups is associated with regionally‑specific alterations in brain myelination that diversely affects myelin proteins.

Relationship Between Methadone, Selective Serotonin Reuptake Inhibitors, and Neonatal Abstinence Syndrome

OBJECTIVE

To compare incidence and severity of neo- natal abstinence syndrome (NAS) in neonates exposed to methadone and selective serotonin reuptake inhibitors (SSRIs) with neonates ex- posed to methadone alone.

STUDY DESIGN

Retro- spective cohort study of women on methadone main- tenance with live births be- tween January 1, 2003, and December 31, 2009, at a tertiary care hospital. Data were abstracted from electronic medical records, exclud- ing cases of multiple gestations and lack of neonatal abstinence score documentation. Data analysis included Mann-Whitney U, Fisher's exact test, a receiver operat- ing characteristic curve, and a scatter diagram.

RESULTS

A total of 91 cases comprised our study population, with 85 (93.4%) assigned to the methadone- only group and 6 (6.6%) assigned to the methadone and SSRIs group. NAS incidence was not significantly different between the methadone/SSRI group and the methadone group (5/6 [83.3%] vs. 43/85 [50.6%], p=0.21). However, severity of NAS (median 14.0 vs. 10.0, p=0.04) and neonatal intensive care unit stay were significantly higher and longer in the methadone/ SSRI group.

CONCLUSION

While currently neonates exposed to SSRIs are not screened for NAS, health care providers may need to pay closer attention to the effects of SSRIs on neonates.

Drug Screening in Neonates

Gestational substance exposure continues to be a significant problem. Neonates may be exposed to various substances including illicit drugs, prescription drugs, and other legal substances that are best not used during pregnancy because of their potential deleterious effects as possible teratogens or their potential to create dependence and thus withdrawal in the neonate. Screening the newborn for gestational substance exposure is important for both acute care and early intervention to promote the best possible long-term outcomes. This column provides insight into what is known about the extent of substance use by pregnant women, an overview of neonatal biologic matrices for drug testing, and a discussion of the legal implications of neonatal substance screening.

Long-Term Outcomes of Infants with Neonatal Abstinence Syndrome

Parents of infants with neonatal abstinence syndrome (NAS) in the NICU may have questions about the long-term consequences of prenatal exposure to methadone, both asked and unasked. Although the signs of withdrawal will abate relatively quickly, parents should be aware of potential vision, motor, and behavioral/cognitive problems, as well as sleeping disturbances and ear infections so their infants can be followed closely and monitored by their pediatrician with appropriate referrals made. Furthermore, this knowledge may inspire parents to enroll their infants in an early intervention program to help optimize their outcomes. There are still many unanswered questions about epigenetic consequences, risk for child abuse/neglect, and risk of future substance abuse in this population.

Baclofen and pregnancy: birth defects and withdrawal symptoms

A comparison of 134 pregnant women who had taken baclofen in early pregnancy and 400 pregnant controls showed an increased risk of major malformations. Several infants exposed to baclofen until birth exhibited withdrawal symptoms.

Caring for Opioid-dependent Pregnant Women: Prenatal and Postpartum Care Considerations

Pregnancy is an opportune time to identify opioid dependence, facilitate conversion to opioid maintenance treatment, and coordinate care with specialists in addiction medicine, behavioral health, and social services. Comprehensive prenatal care for opioid-dependent women involves the evaluation and the management of co-occurring psychiatric disorders, polysubstance use, infectious diseases, social stressors, and counseling regarding the importance of breastfeeding, contraception, and neonatal abstinence syndrome. Although the complex psychiatric, social, and environmental factors faced by this population pose significant challenges to obstetric care providers, the development of strong patient-provider relationships can facilitate the ability to deliver efficient and effective health care during pregnancy.

Exposure to prescription opioid analgesics in utero and risk of neonatal abstinence syndrome: population based cohort study

OBJECTIVE

To provide absolute and relative risk estimates of neonatal abstinence syndrome (NAS) based on duration and timing of prescription opioid use during pregnancy in the presence or absence of additional NAS risk factors of history of opioid misuse or dependence, misuse of other substances, non-opioid psychotropic drug use, and smoking.

DESIGN

Observational cohort study.

SETTING

Medicaid data from 46 US states.

PARTICIPANTS

Pregnant women filling at least one prescription for an opioid analgesic at any time during pregnancy for whom opioid exposure characteristics including duration of therapy: short term (<30 days) or long term (≥ 30 days); timing of use: early use (only in the first two trimesters) or late use (extending into the third trimester); and cumulative dose (in morphine equivalent milligrams) were assessed.

MAIN OUTCOME MEASURE

Diagnosis of NAS in liveborn infants.

RESULTS

1705 cases of NAS were identified among 290,605 pregnant women filling opioid prescriptions, corresponding to an absolute risk of 5.9 per 1000 deliveries (95% confidence interval 5.6 to 6.2). Long term opioid use during pregnancy resulted in higher absolute risk of NAS per 1000 deliveries in the presence of additional risk factors of known opioid misuse (220.2 (200.8 to 241.0)), alcohol or other drug misuse (30.8 (26.1 to 36.0)), exposure to other psychotropic medications (13.1 (10.6 to 16.1)), and smoking (6.6 (4.3 to 9.6)) than in the absence of any of these risk factors (4.2 (3.3 to 5.4)). The corresponding risk estimates for short term use were 192.0 (175.8 to 209.3), 7.0 (6.0 to 8.2), 2.0 (1.5 to 2.6), 1.5 (1.0 to 2.0), and 0.7 (0.6 to 0.8) per 1000 deliveries, respectively. In propensity score matched analyses, long term prescription opioid use compared with short term use and late use compared with early use in pregnancy demonstrated greater risk of NAS (risk ratios 2.05 (95% confidence interval 1.81 to 2.33) and 1.24 (1.12 to 1.38), respectively).

CONCLUSIONS

Use of prescription opioids during pregnancy is associated with a low absolute risk of NAS in the absence of additional risk factors. Long term use compared with short term use and late use compared with early use of prescription opioids are associated with increased NAS risk independent of additional risk factors.

Delivery and management of a preterm infant in the burn unit: a multidisciplinary approach

Burns during pregnancy can have profound effects on both the mother and her fetus. While the mother can suffer cardiovascular collapse, infection, hemorrhage and inhalation injury with respiratory failure, the fetus is affected through the placenta by all of these changes as well as by the transfer of drugs administered to the mother. We report a case of severely burned female patient at 29 weeks gestation, who, due to deteriorating maternal condition, was delivered and managed at 32 weeks gestation by a multidisciplinary team. To the best of our knowledge this is the first reported case of a preterm infant delivered in a burn unit.

Narcotic tapering in pregnancy using long-acting morphine: an 18-month prospective cohort study in northwestern Ontario

OBJECTIVE

To document the management of and outcomes for patients receiving narcotic replacement and tapering with long-acting morphine preparations during pregnancy.

DESIGN

A prospective cohort study over 18 months.

SETTING

Northwestern Ontario.

PARTICIPANTS

All 600 births at Meno Ya Win Health Centre in Sioux Lookout, Ont, from January 1, 2012, to June 30, 2013, including 166 narcotic-exposed pregnancies.

INTERVENTION

Narcotic replacement and tapering of narcotic use with long-acting morphine preparations.

MAIN OUTCOME MEASURES

Prenatal management of maternal narcotic use, incidence of neonatal abstinence syndrome, and other neonatal outcomes.

RESULTS

The incidence of neonatal abstinence syndrome fell significantly to 18.1% of pregnancies exposed to narcotics (from 29.5% in a previous 2010 study, P = .003) among patients using narcotic replacement and tapering with long-acting morphine preparations. Neonatal outcomes were otherwise equivalent to those of the nonexposed pregnancies.

CONCLUSION

In many patients, long-acting morphine preparations can be safely used and tapered in pregnancy, with a subsequent decrease in observed neonatal withdrawal symptoms.

Buprenorphine: a new player in neonatal withdrawal syndrome

OBJECTIVE

To study the incidence and patient characteristics of Neonatal Abstinence Syndrome (NAS) in infants who were born to opioid addicted mothers and required NICU admission over the three year period.

STUDY DESIGN

From 2009 to 2011, data of infants admitted in WVUH NICU with history of maternal drug exposure were extracted and reviewed. Infants born to mothers treated with buprenorphine (BPN) and those with methadone (MTD) were compared.

RESULTS

Incidence of drug exposure infants significantly increased in 2011. BPN exposure infants increased substantially while the number of MTD exposure infants did not significantly change. Eighty-one percent of those MTD exposure infants required drug treatment for NAS compared to 26% of BPN exposure infants.

CONCLUSION

Significant increase in opioid exposure infants with NAS was observed in our unit in 2011. Although, the incidence of BPN exposure with NAS increased significantly, only 25% of them required drug treatment.

Neonatal withdrawal syndrome and perinatal asphyxia. How to manage the patient? Case Report

The aim of this work is to present the pitfalls of management of newborns with neonatal withdrawal syndrome (NWS) of different forms, which were complicated with the presence of severe perinatal asphyxia. The authors present some case reports of asphyxiated newborns of different gestational age with different forms of NWS. Prenatal and perinatal asphyxia determines the prognosis of future development of newborn. The combination of the asphyxia and NWS is stressful not only for the patient, but also for the physician. The most important step in management of this group of patients is to know the detailed mother's and patient's history and to perform detailed physical investigation. The optimal prenatal, perinatal and postnatal management with good cooperation between gynecologist and neonatologist can improve the quality of newborn's life. Care of newborn requires all the time teamwork.

Prenatal buprenorphine versus methadone exposure and neonatal outcomes: systematic review and meta-analysis

Increasing rates of maternal opioid use during pregnancy and neonatal withdrawal, termed neonatal abstinence syndrome (NAS), are public health concerns. Prenatal buprenorphine maintenance treatment (BMT) versus methadone maintenance treatment (MMT) may improve neonatal outcomes, but associations vary. To summarize evidence, we used a random-effects meta-analysis model and estimated summary measures of BMT versus MMT on several outcomes. Sensitivity analyses evaluated confounding, publication bias, and heterogeneity. Subjects were 515 neonates whose mothers received BMT and 855 neonates whose mothers received MMT and who were born from 1996 to 2012 and who were included in 12 studies. The unadjusted NAS treatment risk was lower (risk ratio=0.90, 95% confidence interval (CI): 0.81, 0.98) and mean length of hospital stay shorter (-7.23 days, 95% CI: -10.64, -3.83) in BMT-exposed versus MMT-exposed neonates. In treated neonates, NAS treatment duration was shorter (-8.46 days, 95% CI: -14.48, -2.44) and morphine dose lower (-3.60 mg, 95% CI: -7.26, 0.07) in those exposed to BMT. BMT-exposed neonates had higher mean gestational age and greater weight, length, and head circumference at birth. Fewer women treated with BMT used illicit opioids near delivery (risk ratio=0.44, 95% CI: 0.28, 0.70). Simulations suggested that confounding by indication could account for some of the observed differences. Prenatal BMT versus MMT may improve neonatal outcomes, but bias may contribute to this protective association. Further evidence is needed to guide treatment choices.

How long should infants at risk of drug withdrawal be monitored after birth?

AIM

Neonatal abstinence syndrome (NAS) is an increasingly common disorder diagnosed in infants exposed to various drugs, causing immense financial and social burden. Recommendations from various bodies are for babies to be monitored for 4 to 7 days following birth so that prompt treatment can commence should symptoms develop. We aimed to determine the best post-natal observation period in babies at risk of NAS.

METHODS

A retrospective review was undertaken of infants ≥35 weeks' gestation who received treatment for NAS in the period 2001-2010. During this time, the standard post-natal observation period was a minimum of 7 days. Data including drug exposure, day of admission and day of treatment were collected.

RESULTS

Two hundred and ten babies were included. Drug exposure was predominantly to opiates (99%); however, most infants (58%) were exposed to additional substances (benzodiazepines, cannabis or amphetamines). Ninety-five per cent of infants were admitted by day 5 of life. Of the babies treated by day 7, 98.5% had been admitted to the nursery by day 5. Infants with polydrug exposure were admitted significantly earlier; however, time to treatment was not significantly different to those exposed to opiate replacement therapy alone.

CONCLUSIONS

In our hospital, babies treated for NAS often required admission before day 5. This has implications for hospital resource allocation, suggesting that routine post-natal observation for NAS could be shortened to 5 days. Further research is needed to help identify neonates who require more careful post-natal observation.

Emergence of opiate-induced neonatal abstinence syndrome

Neonatal abstinence syndrome (NAS) is the clinical picture of infants withdrawing from in-utero substance exposure. The incidence of NAS rose in Dublin maternity hospitals in the 1970's and '80's in parallel with increasing in opiate abuse in that city. The purpose of this study was to determine if a similar pattern was emerging in Cork University Maternity Hospital. Data from the Erinville Hospital (2000-2007) and CUMH (2008-2011) were compared. Sixteen cases of NAS were identified, two at Erinville Hospital (22,987 deliveries; incidence = 0.09/1000 deliveries) and 14 at CUMH (37,414 deliveries; incidence = 0.38/1000 deliveries; p < 0.01). Five of the 16 mothers were using heroin, while ten were on methadone maintenance. All were multi-drug abusers. Newborns requiring pharmacotherapy for NAS (5/16) had prolonged hospitalisations compared to those requiring supportive care. NAS in Cork is increasing. Primary, secondary and tertiary preventative measures are warranted to prevent further escalation.

[Pregnancy and parenthood in the context of addiction]

Addictive behaviour in the perinatal period gives rise to significant health risks for the infant and the mother. When the experience of new parenthood coincides with the problem of addiction the parents' psychological problems can be intensified. These specific issues, sometimes difficult for the teams to have to deal with, require the creation of a complex and coordinated care programme.

[The treatment of drug-addicted parents and their children]

The specificities of the parent-child relationship in cases of addiction, as well as the role of opiate substitution treatments in the support of parenthood, can be analysed by studying the place of drugs within the psychological processes. The objective is to enable drug-addicted parents to situate themselves in transfer and affiliation approaches.

Managing opioid dependence in pregnancy -- a general practice perspective

BACKGROUND

Managing opioid dependence in pregnant women is a complex and potentially challenging task. Drug-dependent women may be difficult to engage in antenatal care and opioid substitution requires careful dose titration. Pregnancy, however, can be an opportune time to effect behaviour change, and supporting an opioid-dependent woman through pregnancy can be a rewarding clinical experience.

OBJECTIVE

This article provides an overview of treatment principles for managing opioid dependence in pregnancy, and reviews current treatment guidelines for use of opioid-substitution therapy in pregnant women.

DISCUSSION

The management of opioid dependence during pregnancy requires holistic and comprehensive assessment and referral to specialist services is often appropriate. Specific issues that may need to be addressed include decision-making regarding the choice of opioid-substitution therapy and the potential for neonatal abstinence syndrome in the newborn. General practitioners are often well placed to support and coordinate care of their opioid-dependent pregnant patients.

Neonatal abstinence syndrome: treatment and pediatric outcomes

Recent rise in rates of opiate replacement therapy among pregnant women have resulted in increasing number of infants requiring treatment for neonatal abstinence syndrome (NAS). Short-term and long-term developmental outcomes associated with prenatal opiate exposure are discussed, including symptoms and severity of NAS, and early cognitive and motor delays. Maternal and infant risk factors are discussed, and include patterns of maternal substance use during pregnancy, genetic risk, polysubstance exposure pharmacological treatment for NAS and breastfeeding. The importance of characterizing corollary environmental risk factors is also considered.

[Neonatal abstinence syndrome after maternal use of tramadol]

BACKGROUND

Tramadol is an opioid with lipophilic characteristics that freely crosses the placenta. Due to the placental transfer, there is a risk of neonatal withdrawal symptoms. Therefore, chronic use during pregnancy is not advised.

CASE DESCRIPTION

A 25-year-old pregnant woman, gravida 3, para 1, used tramadol 100 mg 3 times a day for chronic headache and migraine during this pregnancy. Because of the risk for neonatal abstinence syndrome, delivery took place in the hospital and the neonate had to stay at least 3 days for observation. The newborn developed neonatal withdrawal symptoms 36 hours after delivery. Treatment with phenobarbital was effective; 9 days after delivery the newborn was discharged without further treatment.

CONCLUSION

When tramadol is used during pregnancy, there is a serious risk for neonatal abstinence syndrome. Phenobarbital proved to be effective for the treatment of neonatal tramadol withdrawal.

Methadone and perinatal outcomes: a prospective cohort study

AIMS

  Methadone use in pregnancy has been associated with adverse perinatal outcomes and neonatal abstinence syndrome (NAS). This study aimed to examine perinatal outcomes and NAS in relation to (i) concomitant drug use and (ii) methadone dose.

DESIGN

  Prospective cohort study.

SETTING

  Two tertiary care maternity hospitals.

PARTICIPANTS

  A total of 117 pregnant women on methadone maintenance treatment recruited between July 2009 and July 2010.

MEASUREMENTS

  Information on concomitant drug use was recorded with the Addiction Severity Index. Perinatal outcomes included pre-term birth (<37 weeks' gestation), small-for-gestational-age (<10th centile) and neonatal unit admission. NAS outcomes included: incidence of medically treated NAS, peak Finnegan score, cumulative dose of NAS treatment and duration of hospitalization.

FINDINGS

  Of the 114 liveborn infants 11 (9.6%) were born pre-term, 49 (42.9%) were small-for-gestational-age, 56 (49.1%) had a neonatal unit admission and 29 (25.4%) were treated medically for NAS. Neonates exposed to methadone-only had a shorter hospitalization than those exposed to methadone and concomitant drugs (median 5.0 days versus 6.0 days, P = 0.03). Neonates exposed to methadone doses ≥80 mg required higher cumulative doses of morphine treatment for NAS (median 13.2 mg versus 19.3 mg, P = 0.03). The incidence and duration of NAS did not differ between the two dosage groups.

CONCLUSIONS

  The incidence and duration of the neonatal abstinence syndrome is not associated with maternal methadone dose, but maternal opiate, benzodiazepine or cocaine use is associated with longer neonatal hospitalization.

[Withdrawal in newborns after exposure to psychotropic medications during pregnancy]

The use of psychotropic medications during pregnancy causes withdrawal symptoms in 20-30% of the newborns. The literature on withdrawal symptoms is not unanimous concerning their recognition and treatment. A search of PubMed and Embase revealed 198 articles in which potential withdrawal symptoms in newborns were described following exposure to psychotropic medications during pregnancy. Commonly occurring withdrawal symptoms are mostly mild, including restlessness and sleeping and feeding difficulties. Severe symptoms such as convulsions are rare. It can sometimes be difficult to differentiate between symptoms of intoxication and symptoms of withdrawal. The Finnegan scale is widely used to recognise withdrawal from psychotropic medication. An observation period of at least 48 h post-partum is advised. Recognition of withdrawal is important to prevent needless additional tests. In withdrawal symptoms supportive measures such as feeding on demand and swaddling are usually sufficient. If withdrawal symptoms are severe, phenobarbital is a therapeutic option.

Current trends in narcotic use in pregnancy and neonatal outcomes

OBJECTIVE

The purpose of this study was to evaluate trends and prevalence of chronic prescription narcotic use during pregnancy and the subsequent neonatal outcomes.

STUDY DESIGN

We conducted a retrospective cohort study of all deliveries at Mayo Clinic from 1998 through 2009; the data was obtained from prospectively maintained obstetrics and neonatal databases.

RESULTS

Over the study time period, there were 26,314 deliveries; 167 women used prescription narcotics chronically during pregnancy. The prevalence of women who used chronic narcotics during their pregnancy increased over the time period from 1998-2009 (P < .0001). Neonatal withdrawal syndrome occurred in 10 of neonates (5.6%), and all but 1 of these neonates required pharmacologic treatment for the disease.

CONCLUSION

Chronic narcotic use during pregnancy is increasing in prevalence. Neonatal withdrawal syndrome occurred in 5.6% of the exposed neonates. Although neonatal withdrawal syndrome is uncommon, it is clinically significant. Physicians need to consider the risks and benefits carefully when prescribing narcotic pain medications during pregnancy.

Drug addiction during pregnancy: correlations between the placental health and the newborn's outcome - elaboration of a predictive score

During pregnancy, drug addiction represents one of the most dangerous situations. Each drug can badly affect the fetal development and, when the pregnancy is over, the negative influence continues in the newborn which is exposed to many risks, in particular the withdrawal syndrome. Since it is difficult to predict the newborn's outcome only on the basis of the kind of drug assumed by the mother during pregnancy, we propose the idea of a score based on the placenta's state of health. The aim of the study is to correlate the placental score to the withdrawal symptoms graveness. Our retrospective study includes 35 newborns exposed in uterus to illegal and legal drugs. We used the Finnegan's scoring system to quantify withdrawal symptoms and the placental score, based on the anatomopathological analysis, to assess the placenta's health. The newborns included in our study have been divided into two groups depending on the result of the placental score (< or =2 or > or =3). We found a significant statistical difference between the newborns whose placental score was low (< or =2) and those whose score was high (> or =3): the second group showed severe withdrawal symptoms for a longer time during the hospital stay (p = 0.014).

Depression and pregnancy

Women of childbearing age with depression present with a unique set of risks. This article will discuss the following topics: these specific risks, current literature on treating depression in the peripartum, and roles of physician and patient in peripartum treatment.