Printer Friendly

Heroin detoxification during pregnancy: A systematic review and retrospective study of the management of heroin addiction in pregnancy.

Diacetylmorphine was first synthesised by C R Alder Wright in 1874 as a highly potent, acetylated form of morphine. By 1898, Bayer pharmaceutical company marketed this drug under the trademark name of heroin. It was initially sold as a non-addictive morphine substitute and cough suppressant. However, heroin was soon found to be twice as powerful as morphine because it is highly fat soluble and rapidly crosses the blood-brain barrier. Despite subsequent strict controls imposed on the use of heroin, it remains the most widely used opiate. [1]

In 2009, there were an estimated 12-14 million heroin users worldwide. [1] Europe and Asia remain the key opiate consumption markets, but reports indicate that opiate use in Africa is increasing. [1] The 2010 South African Community Epidemiology Network on Drug Use (SACENDU) statistics reveal that 5-20% of patients in specialist treatment centres in South Africa (SA) use heroin as their primary illicit drug of choice. In SA, heroin is primarily used by individuals aged 22-30 years, [2] and 20-40% of those treated for heroin abuse are female, which is a higher percentage than for most other illicit substances.

Opiate use is associated with menstrual irregularities, which combined with the often erratic lifestyles of drug-abusing women leads to a high rate of unplanned pregnancies. Heroin-dependent pregnant women represent an extremely vulnerable group of patients, who present with various medical, obstetric and psychiatric problems. There has been considerable debate about how best to manage these patients, as the needs of both fetus and mother require careful attention.

The ideal goal during pregnancy is for the mother to abstain from any drug use. When faced with a pregnant patient who is actively abusing heroin, one needs to offer treatment that will best minimise any further fetal and maternal harm. Given the highly addictive nature of opiates, it is difficult for many of these individuals to remain drug free, and some form of maintenance treatment is therefore usually offered.

An alternative to maintenance treatment is opioid withdrawal using methadone. Methadone detoxification involves using tapering doses of methadone to create a smooth transition from heroin use to a drug-free state. Withdrawal from methadone during pregnancy is not generally recommended in the literature, [3-5] except in specific situations such as when a motivated patient expresses a wish to withdraw from all opiates, or when methadone maintenance is unavailable - a state of affairs that is prevalent across all SA public treatment facilities.

Because pregnant women are rarely included in psychotropic clinical trials, relatively little information is available about the use of medication during pregnancy. The evidence-based management of pregnant patients who are dependent on opioids is therefore particularly challenging. While guidance is scarce, the prevailing opinion is that methadone maintenance is the gold standard of treatment in pregnancy. [3-5] This option is not available in SA state facilities, where only methadone withdrawal is offered. It is therefore useful to review the data in the literature on the efficacy of methadone withdrawal in pregnancy.

Objectives

To conduct a systematic review of the literature on heroin detoxification in pregnancy, and to report on pregnancy outcomes of heroin users who were detoxified with methadone at Groote Schuur Hospital (GSH), a teaching hospital in Cape Town, SA, during the 5-year period 2006-2010. No cases were noted in the records between 2006 and 2007.

Methods

Systematic review

The electronic databases PubMed, PsychINFO and the Cochrane Library were searched using a combination of the following search terms: pregnancy, heroin, opiate, methadone, buprenorphine, and treatment. Using the above terms, 14 English articles were located. Of these articles, 5 were relevant to the study. However, by using the article references, a total of 18 relevant articles were found and reviewed.

All relevant articles in English, reporting original data related to the treatment of heroin addiction in pregnancy, were included.

Using the above terms, 12 English articles were located on a PubMed search. Of these articles, 3 were relevant to the study. However, by using the article references, a total of 18 relevant articles were found and reviewed.

Clinical study

Location

GSH is a tertiary state hospital in Cape Town. The patients were managed in the labour ward or in C23, the emergency psychiatric ward.

Subjects

The study population included all pregnant heroin-addicted patients who underwent methadone detoxification at GSH between 2006 and 2010, although the first recorded case was in 2008. The labour ward and C23 keep a register of all patients who have received methadone.

Methadone detoxification at GSH

A history of substance use is obtained from all patients admitted to maternity, bearing in mind that signs of heroin withdrawal appear within 8 hours after last dose and peak at 36-72 hours. GSH stocks equity methadone, which contains two milligrams of methadone per millilitre.

Following a positive history for heroin use, symptoms of heroin withdrawal are assessed. These symptoms are assessed using the Objective Opiate Withdrawal Scale (OOWS). This is a 13-item interview and observation tool that assesses for signs of heroin withdrawal.

In pregnant women, 5 mg/2.5 mL of oral methadone is administered if the OOWS score is 3-4. In women with an OOWS score of >4, 10 mg/5 mL methadone is given. The OOWS is repeated 2 hours later and further methadone administered as per the above scores. A maximum of 30 mg is administered; however, a doctor may give permission to give top-up doses in severe cases. Once the baseline dose has been established, a total dose of methadone can be given 12-hourly. This is withdrawn slowly.

Further care depends on patient motivation and financial support. Patients who are not motivated to stop using heroin continue methadone during their hospital stay and are referred to a rehabilitation centre to continue motivational interviewing and psychosocial support. Patients who are motivated to stop using heroin can continue detoxification with support and follow-up. For patients who are financially able and willing, maintenance methadone is continued for the duration of the pregnancy.

Data collection

Pregnant patients treated during the study period were identified by means of information obtained from the methadone register. Both methadone registers were scrutinised carefully to ensure that all pregnant patients treated at GSH were identified. The outcomes of these pregnancies were then determined by looking at specific maternal and fetal parameters as listed in the 'Prospective case series', 'Literature reviews' and 'Case studies' sections of Table 1.

Ethical considerations

The study was approved by the University of Cape Town Human Research Ethics Committee (ref. no. 072/2010), and permission was granted to access information from the clinical files. Only information relevant to the study was extracted from the patient files, and all the identifying data were kept confidential.

Results

Systematic review

A total of 20 relevant articles were found, which were reported in 15 publications. The majority were prospective case series, but others included retrospective case series, case reports, literature reviews and descriptive studies (Table 1).

Heroin is not considered to be grossly teratogenic, but it is highly lipophilic and readily crosses the placenta. Untreated heroin use is associated with intrauterine growth restriction, premature delivery, increased neonatal mortality and neonatal abstinence syndrome (NAS), which is characterised by a variety of signs and symptoms in the neonate that indicate dysfunction of the autonomic nervous system, gastrointestinal tract and respiratory system. There is therefore a need for any kind of intervention that will reduce or eliminate maternal heroin use in order to improve pregnancy outcomes.

Maas et al. [8] published an intervention study in 1990 that compared the pregnancy outcomes of mothers joining a methadone detoxification programme with those of mothers who continued uncontrolled street-drug use. They found that 17 out of 58 women successfully completed heroin detoxification during the antenatal period. The incidence of neonatal abstinence syndrome was reduced after maternal participation in the detoxification programme--55% v. 88%. Newborns of mothers who had successfully detoxified experienced fewer withdrawal symptoms, and no adverse obstetric complications were reported in this group.

According to most widely accepted recommendations, withdrawal of methadone is not advised before 14 weeks' gestation because of the potential risk of inducing abortion, and should not be performed after the 32nd week of pregnancy because of possible withdrawal-induced stress. [4,5] This view is largely the result of two influential case reports published in the 1970s. Rementeria and Nunag [5] described a stillbirth at term following acute methadone withdrawal, and Zuspan et al. [18] described a case of increased amniotic fluid epinephrine levels during methadone withdrawal, which resolved once the methadone dose was increased.

These initial concerns have since been challenged. In a retrospective study in 2003, Luty et al. [20] reviewed 101 case reports of methadone withdrawal conducted at various stages of pregnancy. They concluded that detoxification treatment was not associated with any risk of miscarriage in the second trimester or with premature delivery in the third trimester. Similarly, Dashe et al. [9] conducted a prospective study in which 35 opioid-addicted pregnant patients were offered inpatient opiate detoxification with methadone; 59% of them successfully completed heroin detoxification, did not relapse, and had no adverse pregnancy outcomes.

Apart from the risk of fetal harm during methadone detoxification, the major concern with not providing long-term methadone treatment is an increased risk of relapse to illicit drug use. There is a perception that mothers engaged in maintenance programmes are less likely than those who are not to use illicit drugs, or to engage in other drug-seeking behaviours such as prostitution.

Wong et al. [3] conducted a literature review of substance abuse in pregnancy in order to provide recommendations on management. They concluded that methadone maintenance treatment is associated with longer adherence to treatment and a decreased risk of relapse to opioid use, and therefore proposed that the preferred standard of care for pregnant opioid-dependent women is substitution therapy.

However, some studies have shown that methadone maintenance treatment does not guarantee abstinence. Kashiwagi et al. [10] explored pregnancy outcomes among women in a major Swiss methadone maintenance programme, and 64% of the women were found to be co-users of cocaine and/or heroin.

Apart from not always curtailing illicit drug use, management with methadone poses its own risks. Fetal methadone dependence has been associated with fetal death, growth restriction, preterm birth, meconium aspiration and NAS. [7] It has been estimated that 60-87% of neonates born to methadone-maintained mothers require treatment for NAS. Neonates suffering from NAS grow poorly in the neonatal period, and have reduced height compared with controls at 3 years of age. [12]

The longer-term implications of methadone maintenance treatment are also not clear. Hunt et al. [6] conducted a study on infants who had developed NAS, and found that they had evidence of both cognitive and psychomotor deficit on psychometric testing compared with non-opiate-exposed controls. Recent literature has also reported an increased incidence of ocular abnormalities in infants of methadone-maintained mothers. The possibility of long-term visual and cortical defects is alarming, and requires further research.

Methadone withdrawal is the standard management of pregnant heroin addicts in state hospitals in SA. This is largely due to financial constraints, as methadone maintenance management is more costly than withdrawal. This concept has, however, been challenged by Daley et al., [12] who suggest that the healthcare costs should not be viewed in isolation. They argue that maintenance treatment reduces maternal criminal behaviour by reducing illicit drug use, which has secondary cost implications for society. The authors conducted a study in Massachusetts, USA, which indicated that the cost of crime far outweighed that of substance abuse treatment.

It seems that medical professionals need to shift the focus of attention from the medical management of cravings and fluctuating maternal opiate levels to providing a more comprehensive care package. Studies conducted by Chang et al. [13] and Finnegan [14] found that methadone maintenance, in addition to intensive antenatal care, is compatible with an uneventful pregnancy and birth of a healthy infant.

The GSH study

Because methadone is a highly addictive schedule 6 drug, its administration is recorded in a methadone register. This register shows that only six pregnant heroin-addicted patients received methadone detoxification at GSH between 2006 and 2010, although the first case recorded was in 2008. The clinical details of these patients are shown in Tables 2-4.

A total of six pregnant patients received methadone withdrawal at GSH between 2008 and 2010. Their ages ranged from 17 to 37 years. Four of the six patients were single and one was divorced, and half of them were of high parity. Apart from patient D, all the patients booked late (defined as booking after 20 weeks' gestation). All the patients were HIV-negative, and none had current syphilis infection.

Surprisingly, none of the patients abused alcohol, and patients B and F were the only two patients who used other substances benzodiazepines and methamphetamine, respectively. All six patients underwent detoxification at some point during their pregnancies, with patients A and B requiring detoxification prior to delivery. There was no record of any psychiatric follow-up for any of the patients after detoxification, apart from patient D, who could afford a private rehabilitation facility.

Four of the patients delivered at term, patient B delivered at 33 weeks' gestation following heroin detoxification with methadone, and patient F delivered spontaneously 1 week short of term. Half of the patients required caesarean section. Patient A required an emergency caesarean section for fetal distress due to placental abruption; however, it was not clear from the records if this was due to her ongoing heroin use or another obstetric cause. Interestingly, all the neonates had Apgar scores ranging from 7 to 10, and none of them required resuscitation. None of the neonates showed signs of NAS. All the patients were discharged from the maternity ward within 3 days after delivery.

Discussion

After review of the various studies found in the literature, it is apparent that data on the safety and efficacy of methadone detoxification are limited. There are, however, good data on the need to develop comprehensive treatment programmes that go beyond the dispensing of methadone and/or other medication. Pregnancy is often described as a useful period for encouraging behavioural changes. However, methadone alone, whether given as detoxification or maintenance, does not correct underlying psychosocial problems or address behaviour changes. The best outcomes are most likely to be reached by using an integrated care plan incorporating pharmacological, psychotherapeutic and social interventions. The most striking feature of our case series is the relatively low number of patients who received methadone detoxification, despite the rising rates of heroin use and the burden of disease encountered in Cape Town.

Given that the 2010 SACENDU statistics reveal that heroin is the primary substance of abuse among 13% of substance abusers in the Western Cape Province, [2] it may be speculated that heroin-addicted pregnant patients are inadequately screened for, or are offered detoxification with only benzodiazepines and analgesics. There are two possible explanations for this. Firstly, these patients may face tremendous stigma, not only from their families and society but also from healthcare providers, and they may therefore be treated with little sympathy, being perceived as attempting to manipulate the system by requesting methadone treatment. Secondly, healthcare workers may be concerned about the risk of exposing the fetus to another potentially harmful substance.

Five of the six patients had received methadone detoxification prior to delivery, while patient B went into labour during her withdrawal. Of the five patients who completed their detoxification, three resumed using heroin prior to their delivery, with patient A requiring a second detoxification at the time of delivery. In this small sample, the relapse rate is low given the fact that only one patient received continued psychosocial support after discharge. This low rate of relapse indicates that methadone detoxification may be a successful way of managing these patients. One of the main criticisms of withdrawal treatment is the high rate of relapse to heroin use, which was shown not to be the case in this small population. This having been said, a relapse rate of 60% is not negligible, and ideally, further psychosocial measures should be implemented to assist in maintaining abstinence.

A major concern with methadone maintenance treatment is the high risk of NAS. This syndrome is characterised by central nervous system excitability in newborn infants, and in many cases requires pharmacological withdrawal treatment. All the infants of the six patients described were born without showing any sign of opioid withdrawal, had good Apgar scores and required no resuscitation. As mentioned earlier, the literature suggests that NAS requiring treatment occurs in at least two-thirds of infants born to mothers on methadone maintenance. The positive neonatal outcome in this group is therefore significant, as it highlights a major advantage of methadone detoxification over maintenance.

Rementeria and Nunag [5] cautioned against detoxification after 32 weeks' gestation owing to concerns about precipitating early delivery. Four of the six patients (A, B, E and F) were detoxified after 32 weeks, with patient A requiring a second detoxification at term, and two of the four (A and B) went into labour during the detoxification process, patient B having premature delivery at 33 weeks. These findings support the view that detoxification is safest during the second trimester.

An interesting finding in these six patients was the low rate of comorbid substance abuse, and the fact that none of them were infected with HIV or with syphilis. This group of patients is usually at high risk for polysubstance abuse and sexually transmitted infections. The absence of these common additional problems may also partly explain the relatively good neonatal outcomes in the group.

The apparent discrepancy in the resources available to heroin-addicted pregnant women in developed countries compared with SA is disheartening. The focus of most research has shifted from determining the merits of maintenance v. withdrawal to determining which medication is superior in maintenance management. SA state facilities continue to offer only methadone as substitution medication, and only for a limited period while undergoing withdrawal. This management of heroin withdrawal by detoxification and lack of opiate substitution treatment in government facilities in SA highlights the need for a greater focus on pharmacological harm reduction strategies in low- and middle-income countries.

Study limitations

The limitations of the current data set include the small sample size, the retrospective ratings, and the lack of any follow-up information. Despite this, however, these data suggest that favourable outcomes of pregnancies managed with methadone withdrawal are possible. Additional research is nevertheless required to confirm these preliminary findings.

Conclusions

There is limited evidence on the management of heroin addiction during pregnancy, and the only two guidelines identified suggest that methadone maintenance is preferable to methadone withdrawal. The favourable pregnancy outcomes in this small sample of patients managed with methadone withdrawal suggest that it may be safe and deserves further study.

Acknowledgements. DJS is supported by the South African Medical Research Council.

Author contributions. KVG: first author; LD: second author; DJS: second supervisor; BV: primary supervisor. Funding. None. Conflicts of interest. None.

[1.] United Nations Office on Drugs and Crime. World Drug Report 2011, pp. 45-55. https://www.unodc.org/ unodc/en/data-and-analysis/WDR-2011.html (accessed 13 December 2017).

[2.] Pluddemann A, Dada S, Parry C, et al. Monitoring alcohol & drug abuse trends in South Africa (July 1996-December 2009): Phase 27. SACENDU Research Brief 2010; 13(1):1-11. http://hdl.handle. net/20.500.11910/3905 (accessed 5 January 2018).

[3.] Wong S, Ordean A, Kahan M, et al. Substance use in pregnancy. J Obstet Gynaecol Can 2011; 33(4):367-384. https://doi.org/10.1016%2Fs1701-2163%2816%2934855-1

[4.] Fischer G, Bitschau M, Peternell A, et al. Pregnancy and substance abuse. Arch Womens Ment Health 1999; 2(2):57-65. https://doi.org/10.1007%2Fs007370050037

[5.] Rementeria JL, Nunag NN. Narcotic withdrawal in pregnancy: Stillbirth incidence with a case report. Am J Obstet Gynecol 1973; 116(8):1152-1156. https://doi.org/10.1016%2F0002-9378%2873%2990953-8

[6.] Hunt RW, Tzioumi D, Collins E, Jeffery HE. Adverse neurodevelopmental outcome of infants exposed to opiate in-utero. Early Hum Dev 2008; 84(1):29-35. https://doi.org/10.1016%2Fj.earlhumdev.2007.01.013

[7.] Alroomi LG, Davidson J, Evans TJ, Galea P, Howat R. Maternal narcotic abuse and the newborn. Arch Dis Child 1988; 63(1):81-83. https://doi.org/10.1136/adc.63.L81

[8.] Maas U, Kattner E, Weingart-Jesse B, et al Infrequent neonatal opiate withdrawal following maternal methadone detoxification during pregnancy. J Perinat Med 1990; 18(2):111-118. https://doi.org/10.151 5%2Fjpme.1990.18.2.111

[9.] Dashe JS, Jackson GL, Olscher DA, et al Opioid detoxification in pregnancy. Obstet Gynaecol 1998; 92(5):854-858. https://doi.org/10.1097%2F00006250-199811000-00022

[10.] Kashiwagi M, Arlettaz R, Lauper U, et al. Methadone maintenance program in a Swiss perinatal centre (I): Management and outcome of 89 pregnancies. Acta Obstet Gynecol Scand 2005; 84(2):140-144. https:// doi.org/10.1080%2Fj.0001-6349.2005.00497.x

[11.] Jones HE, O Grady KE, Malfi D, Tuten M. Methadone maintenance vs methadone taper during pregnancy: Maternal and neonatal outcomes. Am J Addict 2008; 17(5):372-386. https://doi. org/10.1080/10550490802266276

[12.] Daley M, Argerio M, McCarty D, et al The cost of crime and the benefits of substance treatment for pregnant women. J Subst Abuse Treat 2000; 19(4):445-458. https://doi.org/10.1016/s0740-5472(00)00138-0

[13.] Chang G, Carroll KM, Behr HM, Kosten TR. Improving treatment outcome in pregnant opiate-dependent women. J Subst Abuse Treat 1992; 9(4):327-330. https://doi.org/10.1016/0740-5472(92)90026-k

[14.] Finnegan LP. Management ofpregnant drug-dependent women. Ann N Y Acad Sci 1978; 311(1):135-146. https://doi.org/10.1111%2Fj.1749-6632.1978.tb16770.x

[15.] Lejeune C, Simmat-Durand L, Gourarier L, Aubisson S. Prospective multicenter observational study of 260 infants born to 259 opiate-dependent mothers on methadone or high-dose buprenophine substitution. Drug Alcohol Depend 2006; 82(3):250-252. https://doi.org/10.1016/j.drugalcdep.2005.10.001

[16.] Wang EC. Methadone treatment during pregnancy. J Obstet Gynecol Neonatal Nurs 1999; 28(6):615-622. https://doi.org/10.1111/j.1552-6909.1999.tb02170.x

[17.] Winklbaur B, Kopf N, Ebner N, Jung E, Thau K, Fischer G. Treating pregnant women dependent on opioids is not the same as treating pregnancy and opioid dependence: A knowledge synthesis for better treatment for women and neonates. Addiction 2008; 103(9):1429-1440. https://doi.org/10.1111/j.13600443.2008.02283.x

[18.] Zuspan FP, Gumpel JA, Mejia-Zelaya A, et al. Fetal stress from methadone withdrawal. Am J Obstet Gynecol 1975; 122(1):43-46. https://doi.org/10.1016%2F0002-9378%2875%2990613-4

[19.] Annitto WJ. Detoxification with buprenorphine of a pregnant heroin addict. Am J Addict 2000; 9(1):92-97. https://doi.org/10.1080/10550490050172272

[20.] Lutty J, Nikolaou V, Bearn J. Is opiate detoxification unsafe in pregnancy? J Subst Abuse Treat 2003; 24(4):363-367. https://doi.org/10.1016/S0740-5472(03)00035-7

[21.] Edelin KC, Gurganious L, Golar K, Oellerich D, Kyei-Aboagye K, Hamid MA. Methadone maintenance in pregnancy: Consequences to care and outcome. Int J Gynecol Obstet 1989; 28(3):311-312. https://doi. org/10.1016/0020-7292(89)90748-0

[22.] Allen MH. Detoxification considerations in the medical management of substance abuse in pregnancy. Bull N Y Acad Med 1991; 67(3):270-276.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1807924/?page=1 (accessed 15 January 2018).

[23.] Mactier H. The management of heroin misuse in pregnancy: Time for a rethink? Arch Dis Child Fetal Neonatal Ed 2011; 96(6):F457-F460. https://doi.org/10.1136/adc.2009.181057

Accepted 31 August 2017.

K V Gilfillan, (1) FCPsych, MMed (Psych); L Dannatt, (2) FCPsych, MMed (Psych); D J Stein, (2,3) FRCPC, PhD; B Vythilingum, (1,2) FCPsych, MMed (Psych)

(1) Kenilworth Clinic, Cape Town, South Africa

(2) Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, South Africa

(3) Medical Research Council Unit on Risk and Resilience in Mental Disorders, Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, South Africa

Corresponding author: L Dannatt (lisa.dannatt@uct.ac.za)
Table 1. Summary of systematic review

Title                    Authors               Journal and year

Literature review and prospective case series

  Adverse                Hunt et al. [6]       Early Human
  neurodevelopmental                           Development, 2008
  outcome of infants
  exposed to opiate in
  utero

Prospective case series

  Maternal narcotic      Alroomi et al. [7]    Archives of Disease in
  abuse and the                                Childhood, 1988
  newborn

  Infrequent neonatal    Maas et al. [8]       Journal of Perinatal
  opiate withdrawal                            Medicine, 1990
  following maternal
  methadone
  detoxification
  during pregnancy

  Opioid                 Dashe et al. [9]      Obstetrics and
  detoxification in                            Gynaecology, 1998
  pregnancy

  Methadone              Kashiwagi et          Acta Obstetricia
  maintenance            al. [10]              et Gynecologica
  programme in a Swiss                         Scandinavica, 2005
  perinatal centre:
  Management and
  outcome of 89
  pregnancies

  Methadone              Jones et al. [11]     American Journal on
  maintenance v.                               Addictions, 2008
  methadone taper
  during pregnancy:
  Maternal and
  neonatal outcomes

  The cost of crime      Daley et al. [12]     Journal of Substance
  and the benefits of                          Abuse Treatment,
  substance abuse                              2000
  treatment for
  pregnant women

  Improving treatment    Chang et al. [13]     Journal of Substance
  outcome in pregnant                          Abuse Treatment,
  opiate-dependent                             1992
  women.

  Management of          Finnegan [14]         Annals of the New
  pregnant drug-                               York Academy of
  dependent women                              Sciences, 1978

  Prospective            Lejeune et al. [15]   Drug and Alcohol
  multicentre                                  Dependence, 2006
  observational study
  of 260 infants born
  to 259 opiate-
  dependent mothers on
  methadone or high-
  dose buprenophine
  substitution

Literature reviews

  Methadone treatment    Wang [16]             Journal of Obstetric,
  during pregnancy                             Gynecologic, and
                                               Neonatal Nursing,
                                               1999

  Treating pregnant      Winklbaur             Addiction, 2008
  women dependent on     et al. [17]
  opioids is not the
  same as treating
  pregnancy and opioid
  dependence

Case studies

  Narcotic withdrawal    Rementeria and      American Journal
  in pregnancy:          Nunag [5]           of Obstetrics and
  Stillbirth incidence                       Gynecology, 1973
  with a case report

  Fetal stress from      Zuspan et al. [18]  American Journal
  methadone withdrawal                       of Obstetrics and
                                             Gynecology, 1975

  Detoxification with    Annitto [19]        American Journal on
  buprenorphine of a                         Addictions, 2000
  pregnant heroin
  addict

Retrospective case series

  Is opiate              Luty et al. [20]    Journal of Substance
  detoxification                             Abuse Treatment,
  unsafe in pregnancy?                       2003

  Methadone              Edelin et al. [21]  Obstetrics and
  maintenance in                             Gynaecology, 1989
  pregnancy:
  Consequences to care
  and outcomes

Descriptive studies

  Detoxification         Allen [22]          Bulletin of the New
  considerations in                          York Academy of
  the medical                                Medicine, 1991
  management of
  substance abuse in
  pregnancy

  The management of      Mactier [23]        Archives of Disease in
  heroin misuse in                           Childhood, Fetal and
  pregnancy: Time for                        Neonatal Edition,
  a rethink?                                 2011

Systematic review

  Substance use in       Wong et al. [3]     Journal of Obstetrics
  pregnancy                                  and Gynaecology
                                             Canada, 2011

Title                    Summary

Literature review and prospective case series

  Adverse                Review of the literature examining
  neurodevelopmental     neurodevelopmental outcome in
  outcome of infants     infants with NAS. 33 opiate-
  exposed to opiate in   exposed infants who were identified
  utero                  after development of NAS compared
                         with controls. Opiate-exposed
                         infants showed neurodevelopmental
                         impairment and reduced growth.

Prospective case series

  Maternal narcotic      Opiate-exposed infants have higher
  abuse and the          rates of NAS, preterm delivery,
  newborn                IUGR and neonatal mortality.

  Infrequent neonatal    Influence of maternal participation
  opiate withdrawal      in a methadone detox programme was
  following maternal     compared with street drug use on
  methadone              neonatal morbidity in 75 neonates.
  detoxification         NAS occurred in 63% of neonates,
  during pregnancy       and was less frequent after
                         methadone detox.

  Opioid                 34 pregnant opiate-dependent women
  detoxification in      offered methadone detoxification.
  pregnancy              59% were successfully detoxified
                         with no adverse pregnancy outcomes,
                         or relapse to illicit substances.

  Methadone              84 pregnant opiate-dependent women
  maintenance            offered methadone maintenance. 11
  programme in a Swiss   attempted detoxification, but ~50%
  perinatal centre:      returned to maintenance therapy.
  Management and         64% continued to use illicit
  outcome of 89          substances while in programme.
  pregnancies

  Methadone              175 opioid-dependent pregnant women
  maintenance v.         given methadone maintenance,
  methadone taper        methadone withdrawal alone, or
  during pregnancy:      withdrawal followed by maintenance.
  Maternal and           Given the poor maternal outcomes
  neonatal outcomes      with withdrawal alone, maintenance
                         should be considered as the primary
                         treatment approach.

  The cost of crime      Differences in criminal activity
  and the benefits of    were measured in 439 pregnant women
  substance abuse        entering five different treatment
  treatment for          programmes. The reduction in
  pregnant women         crime-related costs was greatest in
                         residential substance abuse
                         facilities. The cost of the
                         treatment facility was more than
                         covered by the cost-saving in crime
                         reduction.

  Improving treatment    Outcomes of 6 pregnant
  outcome in pregnant    methadone-maintained opiate-
  opiate-dependent       dependent women in an enhanced
  women.                 programme were compared with those
                         of 6 women receiving conventional
                         methadone maintenance. The
                         enhanced-programme participants had
                         better pregnancy outcomes than the
                         controls.

  Management of          The pregnancy outcomes of 367
  pregnant drug-         opiate-dependent women were
  dependent women        compared with 215
                         non-drug-dependent women. The
                         groups were further divided into
                         those receiving an enhanced
                         prenatal programme v. standard
                         care. Infant mortality was reduced
                         in the opiate- dependent group in
                         the enhanced programme.

  Prospective            Substitution with methadone or
  multicentre            buprenorphine improves pregnancy
  observational study    outcomes.
  of 260 infants born
  to 259 opiate-
  dependent mothers on
  methadone or high-
  dose buprenophine
  substitution

Literature reviews

  Methadone treatment    Methadone treatment is only
  during pregnancy       beneficial if administered as part
                         of a comprehensive care package.

  Treating pregnant      Use of opioid medication for detox
  women dependent on     or maintenance should follow
  opioids is not the     established national guidelines,
  same as treating       but should be done in a
  pregnancy and opioid   co-ordinated and supportive
  dependence             environment.

Case studies

  Narcotic withdrawal    Description of one patient who had
  in pregnancy:          a stillbirth following
  Stillbirth incidence   third-trimester methadone
  with a case report     withdrawal. The authors therefore
                         caution against methadone
                         withdrawal in the third trimester.

  Fetal stress from      Description of one patient who
  methadone withdrawal   developed increased amniotic fluid
                         epinephrine levels while undergoing
                         methadone withdrawal. The authors
                         recommend avoiding detoxification.

  Detoxification with    Description of a patient withdrawn
  buprenorphine of a     successfully using buprenorphine.
  pregnant heroin        The author cautions that more
  addict                 information is needed regarding
                         buprenorphine withdrawal.

Retrospective case series

  Is opiate              101 pregnant opiate-dependent women
  detoxification         underwent detoxification at various
  unsafe in pregnancy?   pregnancy stages. Methadone detox
                         was not associated with adverse
                         effects in the second or third
                         trimester.

  Methadone              Pregnancy outcomes of 26
  maintenance in         narcotic-addicted women enrolled in
  pregnancy:             a methadone maintenance programme
  Consequences to care   compared with 37 polydrug users not
  and outcomes           in the programme.

                         No major difference in outcomes
                         found between the two groups.

Descriptive studies

  Detoxification         Methadone maintenance has become
  considerations in      the mode of therapy for most
  the medical            patients based on early case
  management of          reports.
  substance abuse in
  pregnancy

  The management of      There is increasing evidence of
  heroin misuse in       adverse effects upon developing
  pregnancy: Time for    cortical and visual function in
  a rethink?             children of treated heroin-addicted
                         mothers. Studies are needed that
                         take into account longer-term
                         outcomes for the child.

Systematic review

  Substance use in       Review of the literature of
  pregnancy              substance abuse in pregnancy.
                         Methadone maintenance recommended
                         owing to reduced relapse to illicit
                         substances.

NAS = neonatal abstinence syndrome; IUGR = intrauterine
growth retardation.

Table 2. Maternal demographic data

                       Patient

                       A           B                 C

Age, years             24          37                21
Marital status         Divorced    Single            Single
Gestation, weeks       37+         33                42+
Obstetric history      G5P2M1SB1   G1P0              G1P0
Blood results          Rh+ HIV-    Rh+ HIV-          Rh+ HIV-
                       VDRL-       VDRL-             VDRL-
Booking, weeks         29          32                31
Antenatal
  Visits, n            8           2                 4
  Complications        No          Admitted          No
Nicotine use           Yes         Yes               No
Alcohol use            No          No                No
Other substance use    Heroin      Heroin            Heroin
                                   Benzodiazepines

                       Patient

                       D          E          F

Age, years             34         17         28
Marital status         Single     Single     Married
Gestation, weeks       39         38+        36
Obstetric history      G5P1M2T1   G1P0       G4P3
Blood results          Rh+ HIV-   Rh+ HIV-   Rh+ HIV-
                       VDRL-      VDRL-      VDRL-
Booking, weeks         11         24         33
Antenatal
  Visits, n            5          4          1
  Complications        No         No         No
Nicotine use           No         Yes        Yes
Alcohol use            No         No         No
Other substance use    Heroin     Heroin     Heroin
                                             Meth

G = gravida; P = para; M = miscarriage; SB = stillbirth; T =
termination; Meth = methamphetamine.

Table 3. Heroin use and methadone withdrawal

                              Patient

                              A
Antenatal management of
heroin use
  Admission (for detox)       Yes
  Place                       STH
  Duration                    30 Jun-7 Sep 2009

  After detox                 No known follow-up

  Ongoing use of heroin       Yes
  post detox
Admission date to maternity   27 Oct for detox
wards and reason

Date of last heroin use       F
Methadone use during          28-30 Oct: 10 mL/20 mg
admission to maternity        31 Oct-1 Nov: 8 mL/16 mg
                              2-3 Nov: 6 mL/12 mg

                              Patient

                              B                 C
Antenatal management of
heroin use
  Admission (for detox)       Yes               Yes
  Place                       GSH               GSH
  Duration                    5 Jun 2008        9-11 Mar 2010

  After detox                 Labour and        CTDC referral
                              delivery
  Ongoing use of heroin       No                Yes
  post detox
Admission date to maternity   5 Jun for detox   24 May in
wards and reason                                labour

Date of last heroin use       4 Jun             22 May
Methadone use during          9-11 Jun:         None
admission to maternity        8 mL/16 mg

                              Patient

                              D               E
Antenatal management of
heroin use
  Admission (for detox)       Yes             Yes
  Place                       GSH             GSH
  Duration                    21-23 Apr       15-21 Jul 2010
                              2010
  After detox                 Private rehab   STH detox
                                              ward
  Ongoing use of heroin       No              Yes
  post detox
Admission date to maternity   16 Jun for      11 Aug with
wards and reason              elective        pre-labour
                              caesarean       ROM
                              section
Date of last heroin use       21 Apr          28 Jul
Methadone use during          None            None
admission to maternity

                              Patient

                              F
Antenatal management of
heroin use
  Admission (for detox)       Yes
  Place                       GSH
  Duration                    9-11 Mar

                              2010
  After detox                 STH detox
                              ward
  Ongoing use of heroin       No
  post detox
Admission date to maternity   23 Mar in
wards and reason              labour

Date of last heroin use       9 Mar
Methadone use during          None
admission to maternity

Table 4. Neonatal data

                        Patient

                        A                  B             C

Delivery
  Mode                  CS                 Vacuum        CS
  Indication            AP, FDS            Spontaneous   FDS
                                           abour
  Date                  4 Nov 2009         10 Jun 2008   25 May 2010
Apgar score

  1 min                 8/10               7/10          9/10
  5 min                 10/10              9/10          10/10
Sex of neonate          F                  M             M
Measurements
  Birth weight, g       2 200              2 110         3 960
  Head circumference,   33                 34            36
  cm
Resuscitation           No                 No            No
NAS                     No                 No            No
Discharge
  Date                  7 Nov              13 Jun        28 May
  Treatment             Referred to C23,   Diazepam      No meds
                        self-discharge
                        against advice

                        Patient

                        D             E                 F

Delivery
  Mode                  CS            NVD               NVD
  Indication            Previous CS   Pre-labour ROM    Spontaneous
                                                        labour
  Date                  16 Jun 2010   Pre-labour ROM    23 Mar 2010
Apgar score                           on 11 Aug 2010,
                                      given oxytocin
                                      NVD 13 Aug 2010
  1 min                 9/10          8/10              9/10
  5 min                 10/10         10/10             9/10
Sex of neonate          F             M                 F
Measurements
  Birth weight, g       2 600         3 540             3 240
  Head circumference,   31            33                34
  cm
Resuscitation           No            No                No
NAS                     No            No                No
Discharge
  Date                  19 Jun        14 Aug            24 Mar
  Treatment             No meds       No meds           No meds

CS = caesarean section; NVD = normal vertex delivery; AP = abruptio
placentae; FDS = fetal distress syndrome; ROM = rupture of membranes;
F = female; M = male; NAS = neonatal abstinence syndrome; C23 =
emergency psychiatric ward.
COPYRIGHT 2018 Health & Medical Publishing Group
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2018 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Title Annotation:RESEARCH
Author:Gilfillan, K.V.; Dannatt, L.; Stein, D.J.; Vythilingum, B.
Publication:SAMJ South African Medical Journal
Article Type:Report
Geographic Code:6SOUT
Date:Feb 1, 2018
Words:5795
Previous Article:Characteristics and early outcomes of children and adolescents treated with darunavir/ritonavir-, raltegravir- or etravirine-containing...
Next Article:Colorectal cancer in South Africa: An assessment of disease presentation, treatment pathways and 5-year survival.
Topics:

Terms of use | Privacy policy | Copyright © 2020 Farlex, Inc. | Feedback | For webmasters