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    The opioid crisis: Prenatal and postnatal care

    Recent data support treating opioid use in pregnant patients with MAT

     

    Medication-assisted withdrawal (MAW)

    This approach involves stabilizing a patient with OUD with opioids (often methadone or buprenorphine) and subsequent slow, tapered withdrawal of that medication. Historically, MAW was discouraged in pregnancy due to concerns about fetal stress.20 However, recent data indicate that slow, controlled MAW is unlikely to be associated with poor obstetric outcomes. Regardless, the concern for maternal relapse rates remains high and long-term maternal complication and relapse rates have not been evaluated.21 For that reason, for pregnant women with OUD, MAT remains the recommended therapy of choice.5    

    Delivery and postpartum care

    Women on MAT should have their medication doses continued through their labor and postpartum courses. Epidural and spinal anesthesia are appropriate unless contraindicated. Patients maintained on methadone for MAT should NOT receive partial opioid agonist-antagonists such as butorphanol, nalbuphine, or pentazocine because that may precipitate withdrawal. Postoperative pain can be successfully treated with acetaminophen, nonsteroidal anti-inflammatory drugs and full agonist opioids such as oxycodone) as needed. Many patients with a history of OUD experience hypersensitivity to pain and poor pain tolerance although that most often occurs in the first 24 hours post-cesarean—when it can be expected that patients may require extra pain medication (up to 50% more). There is no evidence to support increased incidence of relapse in patients on MAT who receive properly prescribed opioid medications for pain control.22  

    As long as no contraindications exist, breastfeeding should be encouraged. The benefits to both mother and infant are numerous, including improvement in NAS. 

    Upon discharge and in follow-up, careful communication with the prescribing provider and psychosocial support services are essential. 

    Infant Care

    Neonatal abstinence syndrome (NAS) is the postnatal withdrawal syndrome experienced by infants who are exposed to opioids, either illicit or prescribed. While NAS is generally considered to be less severe in infants exposed to prescribed MAT, published rates vary (30%–80%). Symptoms usually evolve over 12 to 72 hours (up to 120 hours).23

    Development and severity of NAS likely depends on the interaction of several factors including substance exposure/timing, gestational age, genetic/epigenetic factors, smoking, polysubstance use and/or other medications.24 Development of NAS does not appear to be related to the dose of MAT that patients are prescribed.25

    Many hospitals have protocols for observation and treatment of NAS. While usually treated pharmacologically, NAS is also treated with adjunctive, non-pharmacologic methods such as massage.23 Rooming-in has been shown to both decrease NAS rates and improve maternal-neonatal bonding.24 Breastfeeding is associated with improved bonding, decreased rates of NAS, less need for medication and shorter hospital stays.23

     

    NEXT: Conclusion and references

    Agatha S. Critchfield, MD
    Dr. Critchfield is Assistant Professor of Obstetrics and Gynecology, University of Kentucky College of Medicine, Lexington.
    Wendy F. Hansen, MD
    Dr. Hansen is Professor and John W. Greene, Jr., MD Chair, Department of Obstetrics and Gynecology, University of Kentucky College of ...

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