anesthetic concerns for labor and delivery in the

Anesthetic Concerns for Labor and Delivery in the Substance Dependent Parturient

Manny Vallejo, MD, DMD SOAP Past President

Designated Institutional Official for GME

Assistant Dean and Professor of Medical Education, Anesthesiology, Obstetrics & Gynecology

West Virginia University

Financial Disclosures: BioQ and PACIRA

Objectives

1. Describe maternal and neonatal consequences of substance dependence in pregnancy

2. Describe the treatment modalities of methadone and buprenorphine for opioid maintenance in pregnancy

3. Describe analgesic requirements and treatment options in the substance dependent parturient for labor, vaginal, and cesarean delivery

Prescription Opioid Use

Fentanyl Overdose

• Explosion in fentanyl deaths and the persistence of widespread opioid addiction have swamped local and state resources

• Communities say their budgets are strained by additional needs =>

– increased police and medical care

– widespread naloxone distribution

– stronger foster care system that can handle the swelling number of neglected or orphaned children

Extent of Opioid Dependence (OD) in Pregnancy

• Statistics have shown that the abuse of opioids during pregnancy has risen significantly

• According to the 2010 National Survey on Drug Use and Health, an estimated 4.4% of pregnant women reported illicit drug use in the past 30 days

• The use of illicit opioids during pregnancy is associated with an risk of adverse outcomes

• Simultaneous in the rates of neonatal abstinence syndrome (NAS)

2010 National Survey on Drug Use and Health

Maternal and Neonatal Effects

• Approximately 30% of pregnancies complicated by OD end in preterm birth (<37 weeks) => 3 times the national average

• More likely to have low birth weight (<2500 grams), be admitted to the neonatal intensive care unit, and require prolonged treatment for neonatal abstinence syndrome (NAS)

• Average hospital costs for infants with NAS are $53,400 in comparison to $9,500 for all other hospital births (5.6 x)

Krans. Clin Obstet Gynecol. 2015 June; 58(2): 370–379


• From 2000 through 2009, incidence of maternal opioid use during pregnancy increased from 1.19 => 5.77 per 1,000 hospital live births per year (↑6x)

• Correspondingly, the rate of neonatal abstinence syndrome (NAS) or neonatal drug withdrawal after birth has also substantially from 1.20 => 3.39 per 1,000 hospital live births per year (↑3x)



• Pregnancy provides a unique opportunity to identify opioid dependence

• Health care providers can make a substantive impact in the lives of opioid dependent pregnant women and their children by treating and managing the problem effectively – Provide a medical home for patients during pregnancy

– Facilitate care coordination among providers

– Deliver comprehensive prenatal and postpartum care

– Provide and discuss postpartum contraception after delivery

• Goal => change opioid dependence to maintenance

• Work closely with specialists in the fields of – addiction medicine

– behavioral health

– social services

Medical Maternal Home

• Good rapport “trust” can be established between the care provider and the patient so that any fears that the patient has can be alleviated

• Treat and take care of multiple issues including:

– Polysubstance use

– Psychiatric disorders

– Stress factors

– Breastfeeding advice

– Contraception

Antepartum Care

• Facilitate conversion to opioid maintenance treatment

• Coordinate care among specialists in addiction medicine, behavioral health and social services

• Facilitate referrals to social services and case management to address long term needs after delivery

• Referral to a maternal-fetal medicine specialist is not necessary in the absence of any other medical indications, or need for intensive medical care

Social Stressors

• Support from social workers and social service organizations is critical due to:

• High risk for sexual violence, homelessness, prostitution and incarceration

• Many women do not have safe, drug-free living environments for themselves or their children

• Legal consequences

– loss of child custody, criminal proceedings, or incarceration

Psychiatric Disorders

• Screen for co-occurring mental disorders

• Benningfield et al. found 64.6% of OD pregnant women had symptoms related to co-occurring psychiatric disorder such as anxiety (40.0%), depression (32%), and suicidal thoughts (12.6%) with in the past 30 days

• Pharmacologic medications for psychiatric disorders should not be withheld because of pregnancy

• Selective serotonin reuptake inhibitors (SSRI's) can be safely used in pregnancy and are compatible with breastfeeding

• However, infants exposed to SSRI's in utero can exhibit an SSRI-induced withdrawal syndrome after birth that may mimic the signs and symptoms of NAS

Benningfield MM. Am J Addict. 2010; 19(5):416–421.

Heroin • Most rapidly acting of the opioids

• Highly addictive

• Can be injected, smoked, or inhaled

• Short half-life

• Opioid injection risks include: – cellulitis and abscess formation at the

injection site

– sepsis

– endocarditis

– osteomyelitis

– hepatitis B, hepatitis C, and human immunodeficiency virus (HIV) infection

Effects on Pregnancy and Pregnancy Outcome

• Association between 1st trimester use of codeine and congenital heart defects

• The small potential risk of birth defects associated with opioid-assisted therapy during pregnancy must be weighed against the clear risks associated with the ongoing use of illicit opioids by a pregnant woman

• During pregnancy, chronic untreated heroin use is associated with an risk of – fetal growth restriction

– abruptio placentae

– fetal death

– preterm labor

– intrauterine passage of meconium

Maternal and Neonatal Effects of Opioid Dependence

• > 35% of OD pregnant women screen + for additional drugs such as marijuana, cocaine and benzodiazepines on urine drug screens, and tobacco smoking rates range from 77-95%

• OD women are also more likely to use drugs with multiple partners and exchange sex for drugs

• Due to high rate of IVDA and sex-related risk patterns => 50-62% of OD women are Hepatitis C Virus (HCV) +, and 1-4% are HIV +

• => comprehensive drug screening


Substance Abuse Screening

• ACOG recommends all women should be screened for the use of drugs and/or alcohol during pregnancy

• Screening should consist of verbal or written questioning about past and current alcohol, tobacco, illegal drug use and the nonmedical use of prescription drugs

• Smoking cessation counseling has been significantly associated with both reduction and cessation of tobacco use during pregnancy

• Screening without consent, or based on clinician suspicion can adversely impact patient-provider trust, and discourage women from continuing to seek prenatal care and other beneficial health care services

ACOG Committee Opinion No. 524. 2012; 119(5):1070–1076.

Screening - 4P’s and CRAFFT

Screening and Counseling

• Screening for infectious diseases including

– HIV

– HCV

– Other sexually transmitted infections (i.e. gonorrhea, chlamydia) during the due to high rates of prostitution and exchange of sex for drugs

• Initial prenatal care visit, and repeated in the 3rd trimester

• HCV is especially prevalent due to high rates of IVDA => education and counseling regarding HCV risk factors and transmission should occur during prenatal care visits

Naloxone

• The use of an antagonist, such as naloxone, to diagnose opioid dependence in pregnant women is contraindicated because induced withdrawal may precipitate preterm labor or fetal distress

• Naloxone should be used only in the case of maternal overdose to save the woman’s life

Intrapartum Care and Management

• Abrupt discontinuation of opioids in an opioid-dependent pregnant woman can result in =>

– preterm labor

– fetal distress

– fetal demise

• Medically supervised tapered doses of opioids during pregnancy often result in relapse to former use

OD Maintenance Therapy

• Since the 1970s, maintenance therapy with methadone has been the standard treatment of heroin addiction during pregnancy

• The rationale for opioid-assisted therapy during pregnancy is to – prevent complications of illicit opioid use and narcotic

withdrawal

– encourage prenatal care and drug treatment

– reduce criminal activity

– avoid risks to the patient of associating with a drug culture

OD Maintenance Therapy

• OD is typically diagnosed after the patient manifests signs and symptoms of physical withdrawal (i.e. tachycardia, diarrhea, nausea and vomiting) after drug cessation, rapid dose reduction, or decreasing serum drug levels and/or administration of an opioid antagonist

• Methadone (a full mu opioid agonist) is the most common recommended medication for standard treatment for OD pregnant women

Buprenorphine

• In 2002, Food and Drug Administration approved buprenorphine (a partial mu opioid agonist) for the treatment of opioid addiction

• Multiple prospective randomized controlled trials have established its safety in pregnancy

• Buprenorphine is a partial opioid agonist and may have decreased ability to alleviate cravings and withdrawal for women with severe addiction

• Not effective for all patients

• Should not be administered to a patient taking methadone

ACOG Committee Opinion No. 524. 2012; 119(5):1070–1076. Krans. Clin Obstet Gynecol. 2015 June; 58(2): 370–379


• In general, patients undergoing opioid maintenance treatment will require higher doses of opioids to achieve analgesia

• Daily doses of methadone or buprenorphine should be maintained during labor to prevent withdrawal, and patients should be reassured of this plan in order to reduce anxiety

• Adequate pain relief can be achieved with short-acting opioids and anti-inflammatory medications => multimodal therapeutic approach

• NSAIDs, IV acetaminophen, Ketorolac are highly effective

• Maintenance dose for chronic pain

• Adjunctive Analgesics for acute pain

Postpartum Care and Management

• Most will require more analgesia in the immediate postpartum period due to inadequate pain tolerance related to chronic opioid use

• Oral and injectable nonsteroidal anti-inflammatory agents are often adequate after vaginal birth

• Additional doses of oral or intravenous short-acting opioids may be necessary for patients after CD in addition to their methadone or buprenorphine maintenance therapy

• Compared to matched controls, OD women had a 70% increase in opiate analgesic requirements following cesarean delivery for women on methadone maintenance therapy, and a 47% increase for women on buprenorphine maintenance therapy



• Epidural or spinal anesthesia offered when necessary for intrapartum pain management as opioid maintenance therapy does not provide adequate pain relief

• We give additional Subutex post C/S to treat acute pain

• Mixed agonist-antagonists (e.g. nalbuphine, butorphanol, pentazocine) should be avoided in all opioid dependent patients, and buprenorphine avoided in patients on methadone maintenance therapy as these agents may precipitate an acute withdrawal

• Pediatric care providers should be made aware and present at the delivery of all opioid-exposed infants


Intrathecal Durmorph®

• Preservative free morphine

• Onset of analgesia is 45-60 minutes and the duration analgesic effect 4-24 hours, typically at least 12 hours

• Rare to cause post-operative respiratory depression

– Increased minute ventilation in pregnancy (↑ 45%)

– Increased respiratory rate in pregnancy

– Increased tidal volume

Neonatal Abstinence Syndrome (NAS)

• An expected and treatable condition

• Pediatric staff should be notified of all narcotic-exposed infants

• Characterized by hyperactivity of the central and autonomic nervous systems

NAS cases per 1,000 hospital births.

Incidence of Neonatal Abstinence Syndrome — 28 States, 1999–2013. MMWR Morb Mortal Wkly Rep 2016;65:799–802.

Signs and Symptoms of NAS

• Excessive high-pitched cry

• Reduced quality and length of sleep

• Increased muscle tone

• Tremors accompanied by autonomic dysregulation (e.g. sweating, yawning, and increased respiration)

• Gastrointestinal manifestations (e.g. poor sucking reflexes, poor feeding, vomiting and diarrhea)

Neonatal Abstinence Syndrome (NAS)

• Infants require close observation for the development of NAS for 3 to 4 days for short acting opioids, and 5 to 7 days for long acting opioids

• Morphine terminal ½ life = 1.5-7 hours, Buprenorphine terminal ½ life = 24-60 hours

• Withdrawal is commonly determined by assessing infants every few hours with a tool such as the Finnegan scale

• Pharmacological intervention for withdrawal is required for 50-70% of infants, most commonly with morphine or methadone

• Treatment adequate if the infant has rhythmic feeding and sleep cycles, and optimal weight gain

• Once the infant is on a stable dose of the selected opioid medication, dose is slowly reduced over several days to weeks in a closely monitored medical withdrawal process

Finnegan LP. Addictive diseases. 1975; 2(1-2):141–158

Breastfeeding

• No need to pump and dump

• Infants fed breast milk are less likely to need pharmacologic treatment for NAS

• Require doses of morphine => shorter hospital stay

• Breastfeeding is not contraindicated for women with HCV and caution should only be exercised if a mother develops an open lesion on her nipples or breast

• Avoided however, in women who are actively using heroin and other illicit drugs as breastfeeding may cause tremors, restlessness, vomiting, respiratory suppression, lethargy and poor feeding in infants

Long Term Infant Outcome

• When matched for age, race, and socioeconomic status, studies have not found significant differences in cognitive development between children up to 5 years of age exposed to methadone in utero and control groups

Summary

• Early identification of opioid-dependent pregnant women improves maternal and infant outcomes

• Ensure appropriate pain management to prevent postpartum relapse and a risk of overdose, and to ensure adequate contraception to prevent unintended pregnancies

• Expect higher analgesic requirement during labor and delivery – Acute vs. Chronic baseline pain

– Supratentorial vs. Subtentorial pain (mental pain vs. noxious pain)

• Patient stabilization with opioid-assisted therapy is compatible with breastfeeding

References 1. Krans EE, Cochran G, Bogen DL. Caring for opioid dependent pregnant women: prenatal

and postpartum care considerations. Clin Obstet Gynecol. 2015 June; 58(2): 370–379

2. Patrick SW, Schumacher RE, Benneyworth BD, et al. Neonatal abstinence syndrome and associated health care expenditures: United States, 2000-2009. JAMA : the journal of the American Medical Association. 2012; 307(18):1934–1940.

3. Almario CV, Seligman NS, Dysart KC, et al. Risk factors for preterm birth among opiate-addicted gravid women in a methadone treatment program. American Journal of Obstetrics and Gynecology. 2009; 201(3):326.e321–326.e326.

4. Cleary BJ, Donnelly JM, Strawbridge JD, et al. Methadone and perinatal outcomes: a retrospective cohort study. American Journal of Obstetrics and Gynecology. 2011; 204(2):139.e131–139.e139.

5. Hulse GK, Milne E, English DR, et al. The relationship between maternal use of heroin and methadone and infant birth weight. Addiction. 1997; 92(11):1571–1579.

6. Keegan J, Parva M, Finnegan M, et al. Addiction in Pregnancy. Journal of Addictive Diseases. 2010; 29(2):175–191.

References 7. ACOG Committee Opinion No. 524. Opioid abuse, dependence, and addiction in

pregnancy. Obstetrics and gynecology. 2012; 119(5):1070–1076.

8. Benningfield MM, Arria AM, Kaltenbach K, et al. Co-occurring psychiatric symptoms are associated with increased psychological, social, and medical impairment in opioid dependent pregnant women. Am J Addict. 2010; 19(5):416–421.

9. Meyer M, Wagner K, Benvenuto A, et al. Intrapartum and postpartum analgesia for women maintained on methadone during pregnancy. Obstetrics and gynecology. 2007; 110(2 Pt 1):261– 266.

10. Meyer M, Paranya G, Keefer Norris A, et al. Intrapartum and postpartum analgesia for women maintained on buprenorphine during pregnancy. European journal of pain. 2010; 14(9):939–943.

11. Finnegan LP, Connaughton JF Jr. Kron RE, et al. Neonatal abstinence syndrome: assessment and management. Addictive diseases. 1975; 2(1-2):141–158.

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