MMT for clients who are pregnant​

Cycles of opioid intoxication and withdrawal are harmful to the pregnant woman, but they are especially harmful to the fetus. Pregnant women who misuse opioids may be receiving inadequate nutrition, rest and obstetrical care. Withdrawal may trigger uterine cramping, which may cause spontaneous abortion or premature labour (Finnegan, 1991). Also, there is a risk of harm to the fetus from exposure to infections and contaminants related to injection drug use. These factors place pregnant clients at a high risk for obstetrical problems (Jones et al., 1999). In addition, medical problems such as urinary tract infection, septicemia and bacterial endocarditis are prevalent among these clients.

Methadone maintenance treatment (MMT) is a valuable first step to reduce risk for the client and her fetus. MMT provides opportunities for more regular medical care, including obstetrical care, primary care and mental health care. It also allows the client to access psychosocial counselling to help her make the lifestyle changes required for treatment success and to help her prepare for the birth and parenting of her child. MMT clients who are pregnant may benefit from:

• safer, medically supervised administration of methadone
• better fetal growth and the likelihood of carrying the pregnancy to term
• fewer complications, including reduced risk of pre-eclampsia and neonatal abstinence syndrome (withdrawal symptoms experienced by newborns whose mothers are dependent on substances)
• less risk for HIV and other blood-borne diseases (the child may benefit from this as well)
• greater likelihood of maintaining custody of the child, once the client can demonstrate clinical stability.

The College of Physicians and Surgeons of Ontario (CPSO) advises physicians to seek guidance from a colleague who is experienced in managing MMT care during pregnancy. Ideally, a pregnant client should be admitted to hospital as she begins MMT to monitor for withdrawal and fetal distress until the methadone dose is stabilized. However, clients can be stabilized on an outpatient basis with careful monitoring of the dose. All pregnant clients should have access to after-hours emergency care for help with any withdrawal symptoms that may trigger opioid use. Risk of overdose must always be carefully considered.

During the third trimester, some pregnant clients may need dose increases due to increases in metabolism and volume of distribution. Alternatively, daily doses could be split and taken morning and evening.

Physicians should encourage pregnant clients to continue with their MMT. If a client insists on tapering, the safest time to begin is between the 14th and 32nd weeks of gestation.

Many clients fear losing custody of their child to child protection agencies, which may be a barrier to their entering treatment. MMT providers should acknowledge and address this fear in a compassionate, non-judgmental way and explain to clients that child protection agencies will not necessarily become involved. With hard work, clients may make progress and stabilize their lives before the child is born. Being stable can have a major impact on a client's ability to parent.