Perinatal Substance
Abuse
Denice Gardner, MSN, NNP-BC
Objectives
• Discuss Perinatal Substance Abuse and
its affect on the newborn
 Pictures used in this presentation were
obtained from the Mosby’s Nursing
Consult web site
Categories of Drugs
 Tobacco/Nicotine
 Alcohol
 Stimulants
 Narcotics & Opioids
 Sedatives/Hypnotics
 Antidepressants
Effects of Drugs on Pregnancy
 Spontaneous abortion
 Placenta previa
 Placental abruption
 Preterm labor
 Premature rupture of membranes
 C-Section delivery
 Precipitous delivery
 Hypertension
Tobacco & Nicotine
 Tobacco is a CNS stimulant
 Active components of cigarette smoke
 Nicotine
 Tar
 Carbon monoxide
 Cyanide
 Plus, thousands of other compounds
Tobacco & Nicotine
 Nicotine-water & fat soluble; cross the
placenta
 Carbon Monoxide- combines with
hemoglobin & impairs oxygenation for
mother & fetus; causes placental
vasoconstriction & vasospasm
 Dose/Response relationship- the higher
the number of cigarettes smoked – the
greater the effect on the fetus
Tobacco & Nicotine
 Fetal/ Newborn Effects
 Intrauterine growth restriction
 Slight increase in risk for congenital
malformations
 Neurobehavioral effects
 Sudden Infant Death Syndrome
 Increased cost of hospitalization & medical
care
 Increased perinatal mortality
Tobacco & Nicotine
 Nursing Considerations
 EDUCATION
 Follow infant’s growth
 Provide information regarding smoking
cessation programs & encourage
participation
Alcohol
 CNS depressant
 Absorbed rapidly through the stomach &
intestines; metabolized by the liver;
excreted through the kidneys & lungs
 Fetal alcohol is eliminated only after being
broken down in the maternal liver
 Diffuses across the placenta & impairs flow
of nutrients to the fetus
Alcohol
 Broken down into acetaldehyde & acetate.
(Acetaldehyde is MORE toxic than alcohol).
 Is a known teratogen
 Fetal effects are directly related to dose,
chronicity of use, gestational age, &
duration of exposure
Alcohol
 Fetal Alcohol Spectrum Disorder (FASD)
 Fetal Alcohol Syndrome (FAS)
 Partial Fetal Alcohol Syndrome
 Alcohol-Related Birth Defects (ARBD)
 Alcohol-Related Neurodevelopmental
Disorder (ARND)
Fetal Alcohol Syndrome
 Most severe form of FASD
 Most common identifiable cause of mental
retardation (also is a preventable cause)
 Abnormalities in 3 domains
 Poor growth
 CNS abnormalities (developmental delays,
impaired brain growth, abnormal structure,
etc.)
 Dysmorphic facial features (thin, upper lip;
smooth philtrum; short palpebral fissures,
etc.)
 Alcohol exposure may or may not be
confirmed
Fetal Alcohol Syndrome
Partial Fetal Alcohol Syndrome
 Typical dysmorphic facial features
 Abnormality in one of the domains
 CNS abnormality
 Growth
 Behavioral or cognitive ability
 Confirmed prenatal alcohol exposure
Alcohol-Related Birth Defects (ARBD)
 Typical dysmorphic facial features
 Normal growth and brain
function/structure
 Congenital anomalies in other organs
(cardiac, skeletal, renal, eyes, ears)
 Confirmed prenatal alcohol exposure
Alcohol-Related Neurodevelopmental
Disorder (ARND)
 Absence of typical dysmorphic facial features
 Normal Growth
 CNS abnormalities:
 Decreased cranial size at birth
 Structural brain abnormalities
 Impairment of neurologic status in relation
to age
 Behavioral or cognitive abnormalities
inconsistent with age/developmental level
 Confirmed prenatal alcohol exposure
Fetal Alcohol Syndrome
Withdrawal from Alcohol
 Begins anytime between birth & 12 hours after
birth
 Symptoms
 Tremors
 Hypertonia
 Opisthotonos
 Weak suck & poor feeding
 Sleeplessness
 Excessive crying
 Excessive mouthing behavior
Stimulants
 Cocaine
 Amphetamines
 Cannabinoids
Cocaine
 One of most powerful addictive
substances
 Is fat-soluble with low molecular weight so
readily crosses blood-brain barrier &
placenta
 Rarely used alone
 Long half-life (can be present in infant’s
urine for up to 7 days of age)
Cocaine
 Fetal/Newborn Effects
 No increase in congenital malformations
 Multi-organ dysfunction
 CNS: abnormal sleep pattern, EEG, & cry;
seizures/tremors; cerebral infarctions
 Sensory organs: increased auditory startle
response; abnormal ABR
 Cardiac: arrhythmias; hypertension;
decreased cardiac output
Cocaine
 Fetal/Newborn Effects
 Multi-organ dysfunction (cont.)
 Respiratory: apnea; periodic breathing
 Renal: ectopia
 GI: intestinal perforation; early-onset NEC
 Eye: vascular, disruptive lesions; retinal
hemorrhage
Withdrawal from Cocaine
 Felt to be due to CNS irritability from effects
of cocaine rather than from withdrawal
 Initial period of hyperirritability followed by
drowsiness &/or lethargy
 Changes in behavioral state
 Difficulty responding to human voice/face,
comforting, &/or environmental stimuli
 Difficulty maintaining alert states or rapid
change is states
 Hyperactive startle
Amphetamines
 Used medically for treatment of
narcolepsy, depression, weight loss,
hyperactivity
 Neurotoxic
 Fetal/Newborn effects:
 IUGR
Withdrawal from Amphetamines
 Abnormal sleep
patterns
 Diaphoresis
 Vomiting after birth
 Agitation alternating
with lethargy
 Constriction of pupils
 High-pitched cry
 Loose stools
 Yawning
 Fever
 Hyperreflexia
Cannabinoids
 CNS- both depressant & mild hallucinogenic
effects
 High affinity for lipids & accumulates in fatty
tissue of body
 Placental transfer is greatest during first
trimester of pregnancy
 Results in increased carbon monoxide levels in
blood causing hypoxia
Narcotics & Opioids
 Natural Opioids
 Morphine & Opium
 Semi-synthetic Opioids
 Heroin & methadone
 Synthetic Opioids
 Oxycodone, hydromorphone, oxycodone,
Fentanyl, etc.
Narcotics & Opioids
 Fetal/Newborn Effects
 Readily crosses placenta
 Lower Apgar Scores
 Do NOT use naloxone for with
known/suspected narcotic & opioid
dependence due to creation of rapid
withdrawal & seizures
 Meconium aspiration
 IUGR
 Lower incidence of RDS
Narcotics & Opioids
 Congenital infections
 Increased incidence of SIDS
 Low birth weight
 Microcephaly
 Increased chromosomal abnormalities in
heroine-exposed infants
Sedatives/Hypnotics
 Barbiturates
 Benzodiazepines
Sedative/Hypnotics
 Readily crosses placenta
 Fetal blood levels are similar to maternal
blood levels
 Accumulate in adipose tissue
 High concentration also present in brain,
lungs, & heart
 Fetuses exposed to long-term
benzodiazepines may have hypotonia, feeding
difficulty, & withdrawal symptoms
Antidepressants
 Selective Serotonin Reuptake Inhibitors
(SSRIs)
 Sertaline (Zoloft), Fluoxetine (Prozac),
Escitalopram (Lexapro), Paroxetine (Paxil),
etc.
 Tricyclic Antidepressants (TCAs)
 Amitriptyline (Elavil), Nortriptyline, etc.
 Monoamine Oxidase Inhibitors (MAOIs)
 Phenelzine (Nardil), Isocarboxazid (Marplan),
etc.
Neonatal Abstinence Syndrome
 Onset may vary from shortly after birth to 2
weeks
 Duration may range from 8 to 16 weeks
 Severity of presentation varies
 Infants of chronic drug abusers usually have
more severe withdrawal
 The closer to delivery the drug is taken, the
later the signs of withdrawal appear & the
more severe the symptoms will be
Neonatal Abstinence Syndrome
 Multiorgan/System Disorder
 Most common symptoms
 Neurologic
 Increased tone
 Tremors
 Exaggerated reflexes
 Irritability/restlessness
 High-pitched cry
 Difficulty sleeping
 Seizures
Neonatal Abstinence Syndrome
 Most common Symptoms
 Autonomic
Yawning
Nasal stuffiness
Sweating
Sneezing
Low-grade fever
Mottling
Neonatal Abstinence Syndrome
 Most Common Symptoms
 GI
Loose stools
Vomiting/regurgitation
Poor feeding
Difficulty swallowing
Excessive sucking
Neonatal Abstinence Syndrome
 Most Common Symptoms
 Respiratory
Tachypnea
 Others
Skin excoriation
Neonatal Abstinence Syndrome
 Onset of withdrawal symptoms
 Alcohol- usually 3-12 hours after delivery
 Narcotics- usually 48-72 hours after
delivery, but may be as long as 4 weeks
 Barbiturates- usually 4-7 days after
delivery but can occur 1-14 days after
delivery
 Cocaine- usually 48-72 hours after
delivery
Neonatal Abstinence Syndrome
 Severity of NAS depends on
 The type of drug used
 Half-life of the drug
 Time of last exposure before delivery
 Dose taken
 Quality of labor
Neonatal Abstinence Syndrome
 Severity of NAS depends on
 Type of analgesia/anesthesia used during
labor
 Maturity & status of infant
 Gestational age
 Nutritional status of mother
Neonatal Abstinence Syndrome
 Scoring Systems
 Modified Finnegan Scoring Tool
Gold Standard***
 Neonatal Drug Withdrawal Scoring
System
 Neonatal Withdrawal Inventory
Neonatal Abstinence Syndrome
 Screening Tools
 Maternal
 Thorough history & assessment
 Drug testing (urine is most commonly
used)
 Infant
 Thorough assessment
 Urine Drug screen
 Meconium Drug Screen
 Newer testing: hair and umbilical cord
testing
Neonatal Abstinence Syndrome
 Nursing Management
 Accurate assessment, evaluation, & use if
institution’s screening tool
 Comfort measures (swaddling, holding,
cuddling, response to stress cues, etc.)
 Assessment & encouragement of
mother/infant interaction
 Maternal/family support
Neonatal Abstinence Syndrome
 Pharmacologic management
 Tincture of opium
 Camphorated Tincture of Opium (Paregoric)
 Morphine (most common)
 Methadone
 Clonidine
 Chlorpromazine (Thorazine)
 Phenobarbital
 Diazepam
Neonatal Abstinence Syndrome
 Breastfeeding
 Cigarettes:
not contraindicated
 encourage decreasing numbers of
cigarettes smoked & smoking cessation
Smoke after breast feeding
 Alcohol: use should be discouraged
Neonatal Abstinence Syndrome
 Breastfeeding
 Cocaine: contraindicated during active use
 Marijuana: contraindicated
 Heroin: contraindicated
 Methadone: not contraindicated; should not
be stopped abruptly
 Sedatives/Hypnotics: dose-dependent;
discontinue with signs of lethargy &/or
weight loss
References
Chang, G., Lockwood, C.J., & Barss. (2012).
Substance Use In Pregnancy. Retrieved
from www.uptodate.com on 8/17/2012.
Sielski, L.A., Garcia-Prats, J.A., & Kim, M.S.
(2012). Infants of Mothers with Substance
Abuse. Retrieved from
www.uptodate.com on 8/17/2012.
References
Sielski, L.A., Garcia-Prats, J.A., & Kim, M.S.
(2012). Neonatal Opioid Withdrawal
(Neonatal Abstinence Syndrome). `
Retrieved from www.uptodate.com on
8/17/2012.
Verklan, M.T. & Walden, M. (2009). Core
Curriculum for Neonatal Intensive Care
Nursing (4rd Edition). Elseiver Saunders:
St. Louis. Retrieved from Mosby’s Nursing
Consult web site on 6/16/2012.