Physical examination

In addition to screening, a pregnant patient may present with certain signs and symptoms that warrant further assessment.3 She will often seek prenatal care late in the pregnancy, have a high noncompliance rate with appointments and have difficulty following medical recommendations, may experience poor weight gain, or exhibit signs of eccentric behavior, intoxication, or sedation. On physical examination, track marks from IV drug use may be evident, as well as lesions from injections, resulting in abscesses or cellulitis.3

Laboratory testing

All pregnant patients should have a prenatal panel that includes a complete blood count, screening for human immunodeficiency virus and hepatitis B, a rapid plasma reagin test for syphilis, rubella, and gonorrhea, and a chlamydial culture and urine culture, as this is the recommended screening for all women in the United States. For patients who are suspected of drug abuse, screening for hepatitis C and a urine drug screen should be performed as well. A urine drug screen can only be performed with a patient’s consent and in compliance with state laws.3

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Treatment and management

Comprehensive treatment of the patient includes psychosocial intervention, detoxification, or methadone maintenance therapy (Figure 1). The earlier a psychosocial intervention can occur in the pregnancy, the greater chance the woman has of establishing a safe and healthy living environment, as well as taking care of judicial and financial issues.6 Although not always ideal, detoxification may be available to those patients who are highly motivated to remain drug free. In these limited circumstances, women should be referred to a specialized opioid detoxification center or treated while under direct supervision of an experienced perinatal addiction physician. When indicated, the American Society of Addiction Medicine recommends detoxification during the second trimester to avoid risk of miscarriage, and after 32 weeks to limit the risk of preterm labor.4 Detoxification is not without risks, and a high proportion of women (as much as 50%) will return to illicit opioid use.7

Methadone maintenance therapy

The recognized treatment since the 1960s for heroin and opiate addiction has been methadone maintenance therapy, although it is currently not approved by the FDA for this purpose. Ultimately, the goal is to prevent complications of use and withdrawal, encourage prenatal care and abuse recovery, and reduce activity and avoidance of illegal or criminal behavior that may be associated with drug culture.3 Maintenance methadone therapy is prescribed and dispensed by a registered substance abuse treatment specialist who works within registered programs. These programs can be accessed at the Substance Abuse and Mental Health Services Administration’s website. They are part of a comprehensive package that includes prenatal care, family counseling, chemical dependency rehabilitation, nutritional education, and psychosocial treatment services.3

Initially, 10 to 30 mg of methadone should be taken daily. Within 4 to 5 days, a steady maintenance dose should be achieved. For women who are vulnerable to short-acting oral opioids such as oxycodone, codeine, and hydrocodone, the lower dose is usually appropriate. Additional doses of 5 to 10 mg every 4 to 6 hours may be administered for breakthrough withdrawal while the patient is awake. 8 Although the optimal dose for methadone maintenance in pregnancy is controversial, the average dose is approximately 120 mg.7 Once maintenance dosing as been achieved, it is essential for all members of the health care team to understand the pharmacokinetic changes that occur during pregnancy. Methadone plasma levels progressively decrease and clearance increases with advancing gestational age. The half-life significantly decreases from 22 to 24 hours in nonpregnant patients to approximately 8 hours in pregnant women. Due to these effects, increased doses or even split doses are needed to maintain therapeutic effects.7 However, overall daily doses should not be increased more frequently than every 3 to 5 days to prevent overdose.8