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How do we know the incidence of drug use during pregnancy?
- Self reporting – unreliable
- National survey of drug use and health
- Maternal lifestyle study
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What are the statistics related to drug use during pregnancy?
- 8% of population >12 are current drug users
- 75% of murders, assaults and child abuse are r/t drugs/alcohol
- 1/3 of the addicted population is women
- 15% of childbearing women are drug users
- 3-8% drug abuse during pregnancy
- 10-11% of all newborns are prenatally exposed to alcohol or drugs
- 75-90% of substance exposed infants are undetected and go home
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Why are the problems with drug use research?
- Methods for defining drug use are not clearly defined
- Multiple confounding variables make it difficulty to study cause and affect relationships of a single drug on child outcomes
- Multiple factors that can play a role in child growth and development (SES)
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How often is caffeine consumed during pregnancy
75% of pregnancies
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How does caffeine effect the neonate
- Increased respirations and heart rate
- Low birth weight
- Altered sleep pattern
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How does caffeine effect the fetus
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Does caffeine pass into breastmilk
A small amount crosses but the AAP considers it safe to breastfeed and consume caffeine
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What is the most often used drug in pregnancy
Cigarettes but it has declined over the last 2 decades, 10-20% of pregnant women smoke
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What is the mechanism of action of nicotine on the fetus
Exact mechanism is unknown but the nicotine and carbon monoxide play a role- they have a direct cytotoxic effect (cigarettes contain >2500 toxic chemicals)
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What perinatal complications are associated with cigarettes
- Spontaneous abortion and stillbirth
- 2x risk of placenta previa
- PROM
- IUGR
- CHD
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How does smoking affect the neonate
- Withdrawal like symptoms
- SIDS, otitis media
- ashthma
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How does quitting smoking affect the fetus/neonate?
Decreased stillbirth and decreased neonatal death
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Does nicotine cross into breastmilk
Yes
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How does smoking affect SIDS
- Smoking is independently associated with an increased risk
- There is a dose dependent relationship
- Smoking may cause altered lung function and altered CNS control pr arousal of respiration or both
- There is a loss of neonatal hypoxia tolerance after prenatal exposure – so infant stops breathing and doesn’t recognize the decreased oxygen levels since they were used to it in utero
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What is the most commonly abused drug during preganacy
Alcohol
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What is alcohol
- Analgesic that depresses the CNS, low doses act as a stimulant and relaxant causing sensations of euphoria
- Lipid and water soluble and easily passes through cell membrance
- Alcohol and its metabolite are toxic and fetus lacks the enzymes necessary to break the alcohol down
- The amniotic fluid becomes a reservoir for the alcohol and metabolites
- Major cause of MR today
- It is the only abusing drug that is well associated with teratogenic effects
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What birth defects are associated with alcohol
- Abnormal facial features
- Prenatal and postnatal growth deficiencies
- CNS problems
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What is fetal alcohol spectrum disorders (FASD)
- Umbrella term to describe a spectrum of effects resulting from maternal alcohol use during pregnancy
- It is not a medical dx
- What is the incidence of FAS
- .2-1.5/1000 births
- FASD may occur 3x more than FAS
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What are the contributing factors to FAS
- Poverty
- Advanced maternal age
- Nonwhite race
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How does alcohol cause birth defects
- Interrupts the normal accumulation and organization of protein
- Interferes with the primary function of the placenta to transport nutrients
- Has a direct effect on cell maturation, migration growth and division
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How much is too much alcohol
- The exact amount is unknown
- Number of binge drinking days has the strongest effect
- Effects are r/t the GA of exposure, amount ingested, frequency of exposure, peak blood concentrations, maternal alcohol metabolism and susceptibility of the infant
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What are the CNS effects of alcohol
- Microcephaly
- Dysgenesis corpus collosum (left brain –logic, right brain-impulse/feelings)
- Hypoplasia of basal ganglia – special memor, perception of time
- Hypoplasia of the cerebellum – coordination, movement, behavior, memory
- Prefrontal cortex – executive function
- Neurosensory hearing loss
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What are the facial characteristics of FAS
- Midface hypoplasia
- Broad,flat nasal bridge
- Poorly developed philtrum
- Thin upper lip
- Short palpable fissures
- Strabismus
- Ptosis and low set dysplastic ears
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What are the withdrawal symptoms of FAS
- Occurs shortly after birth with peak effects at 48 hours
- 72 hours period of hyperactivity, crying, tremors, irritability, seizures, poor sleep patterns, hyperphagia and diaphoresis followed by 48 hours phase of lethargy and return to baseline
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What are the long term effects of fetal alcohol
- Continued growth restriction
- Lower Bayley scores
- Learning difficulties, poor memory, poor language comprehension, and poor problem solving skills
- Inability to understand concepts such as time and money
- Poor coordination
- Poor socialization skills
- Lack of imagination or curiositybahavioral problems- hyperactive, social withdrawal, stubbornness, impulsiveness and anxity
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What is the average function a person with FAS
2nd or 3rd grade level
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What is the most common illegal drug used during pregnancy
THC
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What are congenital effects of infants with THC exposure
- Growth retardation
- Mild withdrawal syndrome
- No documented long term effects but may potentiate risk of prematurity, low birth weight and teratogenic effects of other drugs used during pregnancy
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What is cocaine
- Powerful addictive CNS stimulant
- Derived from the erythroxylon cocoa plant
- Chewed or made into tea for centuries
- Freud recommended it for alcohol and morphine addiction
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What is the 2nd most prevalent illegal drug used during pregnancy
Cocaine
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What is the MOA of cocaine
- Low molecular weight
- Water and lipid soluble
- Prevents reuptake of dopamine, norepi, and serotonin
- Results in intensified neurochemical responses
- Accumulation of neurotransmitters
- Causes the release of dopamine from the brain resulting in euphoria and cycle of sddiction
- Tryptophan uptake is inhibited so have more energy
- Blocks Na ion channels – anesthetic effect
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What is the duration of action of cocaine
- 5-10 minutes – smoking and injecting
- 15-20 – snorting
- ½ life is 16-90 minutes depending on dose and route
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What are the physical effects of cocaine
- Teratogenic effects are controversial
- Sypathomimetic effects on CNS
- Vasoconstriction decreased placental blood flow fetal hypoxia, IUGR
- Decreased vascular tone and perfusion increase chance of NEC, bowel perforation, HT, MI in newborn
- Maternal HT and fetal hypoxia increased risk of abrutipn
- GU anomalies (4x more)
- Midline defects (agenesis corpus colossum, ocular abnormalities)
- Vascular disruption (forearm defects, intestinal atresia)
- Tachycardia
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What are the withdrawal signs of cocaine exposure
- Wide range of neurobahvioral abnormalities most likely due to acute intoxication vs withdrawal
- Onset of signs occur in 0-3 days, peaks at 1-4 days
- Duration is unknown
- Signs include hypertonic, tremulous, irritable, abnormal crying, feeding and sleeping patterns
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What are the long-term effects of cocaine exposure?
- Increased r/o SIDS
- Most infants exhibit catch up growth by 12 months
- Studies agree that infants with small heads are at risk for intellectual and developmental problems
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What are amphetamines?
- CNS stimulant initially marketed for tx of obesity and narcolepsy but currently used for ADD
- Resemble effects of cocaine but duration is 2-12 hours
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What is the most common form of amphetamine abuse
Methamphetamine
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What are some properties of amphetamines
- Easily dissolves in water for injection (crystal)
- Readily goes from solid to gas (Ice)
- Cheap and easy to make
- Popular among teens and white women
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Why has methamphetamine use increased
Greater restrictions on cocaine importation
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What are the fetal effects of methamphetamine use
Poor growth, increased BP and stroke, birth defects (6x more): cleft lip and palate, CHD, kidney disease and gastroschesis
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What designer drug is related to methamphetamine
Escatsy and eve-there is just an alteration in the benzene ring
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What are withdrawal symptoms of methamphetamines
- Similar to methadone but less intense
- Onset is 48 to 72 hours
- ~10% will need medical intervention
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What are the long term affects of methamphetamine
- Intellectual capacity does not appear to be effected
- Hyperactive and aggressive
- Accelerated puberty in boys and delayed puberty in girls
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What is the opiate that is most abused during pregnancy
- Heroin
- They tend to inhale it
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What is Heroin
Synthetic opiate drug that is highly addictive, it is made from morphine, which is a naturally occurring substance extracted from the Asian opium poppy plant
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What characteristics do women who use heroin usually have
- Poor health, poor nutrition and multiple medical issues
- Less likely to seek PNC
- Higher rate of STDs, urinary and vaginal infections
- 5x higher rates of maternal hepatitis
- drug use is further complicated by HIV
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What are the fetal effects of heroin
- IUGR, small head circumference
- Increased Mec staining
- Low apgars
- Increased r/o syphilis and HIV
- Thrombocytosis
- 2-4x r/o SIDS
- NAS
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What is the long term outcomes of heroin children
- No major neuro deficits but “soft” signs are evident such as deviations in sensory, motor, and integrative functions that do not indicate localized brain injury
- Characteristics of ADD
- Aggressiveness and compulsiveness
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What is methadone
Synthetic narcotic used to treat opium addiction
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How does methadone treat opium addiction
Heroin releases an excess of dopamine and causes users to need an opiate to continuously occupy the opiod receptors-meth occupies this captor and is a stabilizing factor that permits addicts on methadone to change their behavior
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What are the benefits of methadone
- Doesn’t impair function
- No adverse effects on mental capability, intelligence or employability
- Not sedating or intoxicating
- Doesn’t interfere with ordinary activities such as driving a car
- Pts are able to feel and experience emotional reactions
- Prevents opiate withdrawal
- Better PNC and medical care
- Improved growth of the fetus
- Decreased prematurity, decreased perinatal infections
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What is the reason for better outcomes of the fetus with methadone
Stabilized uterine environment
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What is the recommended maternal dose of methadone
No dosing guidelines
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Can a mother on methadone breastfeed
- AAP states that it is compatible
- Some experts report that it is safe if the max dose is <120mg and no other medication
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What other drugs are associated with NAS
- Codeine, Talwin – less potent opiods
- Tranquilizers, sedatives, valium, serax – nonopiod CNS depressants
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How does drug screening work
- Testing is done based on maternal indicators and should be done on infants with unexplained symptoms
- Based on drug specific assays
- Drugs tested are determined by frequency of use, illegality and potential for harm
- Conducted as a two tiered procedure
- Testing is based on institutional policy
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Who determines appropriate drug level during drug testing?
National institute of drug abuse
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What is the concern with drug testing?
High cut off levels underestimate the true scope of drug abuse in pregnancy
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What is the goal of drug screening?
To know what the infant is withdrawing from
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What is the most common type of drug screening
Urine tox- it represents the ultrafiltration of plasma
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Why is the concentration of drugs higher in urine
The kidneys ability to concentrate substances
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What does a positive urine screen indicate
Recent drug use
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What is the urine clearance time of cocaine, heroin, methadone, alcohol, amphetamines and THC
- Cocaine 72-96 hours
- Heroin – 24-48 hours
- Methadone – up to 10 days
- Alcohol – 8-16 hrs
- Amphetamines – 48 hours
- THC – 5-20 days
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What is used as a secondary or confirmatory test for drugs
Meconium
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What does a positive meconium test indicate
Drug exposure as early as 20-24 weeks – drugs may be detected up to 3 days of age
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What are the cons with meconium testing
- Distribution of drugs is not uniform
- Results aren’t readily available
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Other than urine and Mec, what are other methods to test for drugs
Hair, nails, gastric aspirates
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A disorder presenting a clinical picture of CNS hyperirritability, GI dysfunction, respiratory distress and minor autonomic symptoms
NAS
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Who is at risk for NAS
Documented recent drug use, positive screens, unexplained CNS/GI symptoms, iatrogenic cause
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What percentage of drug infants require medication for NAS
50%
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What percentage of drug exposed infants demonstrate s/s of withdrawal
60-90%
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What determines the clinical presentation of withdrawal
- Drug
- Last dose
- Metabolism (maternal and infant)
- excretion
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When is the incidence low for withdrawal
If > 1 week since last exposure and delivery
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When does NAS usually occur
- Occurs in varying degrees
- Most opiates are short acting and symptoms exhibit in the 1st 24-72 hours
- Heroin exposed infants exhibit s/s earlier than meth infants
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How long do NAS symptoms last
- Acute s/s last for several weeks
- Subacute s/s ( irritability, hypertonia, sleep disturbances, hyperactivity, and feeding problems) persist for up to 6 months
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What are some CNS s/s of NAS
Irritability, altered sleep patterns, tremors, increased tone, myoclonic jerks, seizures (2-111%), increased moro
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What are respiratory s/s of NAS
Tacypnea, nasal stuffiness, sneezing, nasal flaring
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What are autonomic symptoms of NAS
Fever, sweating, mottling
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What are GI s/s of NAS
- Excessive uncoordinated sucking
- Poor feeding
- Emesis
- Loose/watery stools
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What is the purpose of evaluation tools for NAS
- To be objective but subjectivity is evident
- Used to guide management
- Important not to use the absolute score when evaluating pharmacological evaluation
- Should discuss the abnormal scores
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What is the most widely used too for scoring NAS
Finnegan tool-it is based on nursing observation
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What drugs don’t have a scoring tool
- Non-opiod drugs
- When would you notify a MD/NNP of NAS scores
- 8 or higher over 3 consecutive assessments or 12 or higher over 2 assessments – will evaluate for need of meds
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When would you stop scoring
3 days after d/c therapy if there is no increase in s/s or if score is <8 – if the s/s begin again then the scoring is started for at least another 4 days
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How do you score a preterm infant for NAS
- There is a lower risk of withdrawal possibly r/t immaturity of CNS or decreased exposure time
- Need to focus less on respiratory distress syndromes, tremulous movements and poor feeding and place more emphasis on irritability, diarrhea, sneezing and yawning
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What are the goals of medical management of NAS
- Maintain infant comfort
- Support the infants ability to sleep, feed and gain weight
- Standard medical practice incorporates both developmental and behavioral methods in conjuncture with pharmacologic agents to achieve above goals
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What are the nursing interventions for NAS
- Provide relief of nasal stuffiness
- Small frequent feedings
- Non-pharmacologic interventions
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What are the nonpharmacological interventions for NAS
- Swaddling.
Non-nutritive sucking.
Gentle rocking.
Reducing environmental stimuli at the patient's bedside.
Provide adequate pain management for painful procedures
- Assist infant with self-regulatory behaviors to decrease energy expenditure
- Provide good skin care
- Lactation consult
- Social work consult
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What should be considered before starting meds for NAS
- Rule out common neonatal metabolic imbalances that can mimic or potentiate withdrawal symptoms
- If pharmacologic intervention is initiated an assessment tool should be used to monitor the infant in an objective and consistent manner
- Tool is also used to monitor infants clinical response to pharmacotherapy
- Drug from same class as the drug causing withdrawal preferred
- Only drugs approved for the treatment of drug withdrawal are benzodiazepines for alcohol withdrawal and methadone for opioid withdrawal
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What does the AAP recommend for pharmacological treatment for NAS
AAP committee on Drugs (1998) recommends tincture of opium for opioid withdrawal and phenobarbital for sedative-hypnotic withdrawal
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What are the Legal Implications for NAS
- Currently only SC holds prenatal substance abuse as a criminal act of child abuse and neglect
- Minnesota, South Dakota and Wisconsin have laws that enforce admission to an inpatient treatment program
- 2004 Texas made it a felony to smoke marijuana while pregnant with a prison sentence of 2-20 yrs
- Other states have laws that address prenatal substance abuse
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What are the indications for narcan
- Not recommended during the initial steps of resuscitation
- Indications to give Narcan require both of the following according to NRP
- Continued resp depression after PPV has restored nml HR and color
- Hx of maternal narcotic administration within the last 4 hrs
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