Management of Opioid Dependence in Pregnancy and of Neonatal Abstinence Syndrome (NAS)
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Context
Preconception to postpartum
In situations where a woman is pregnant and taking opioids, opioids cross the placenta. Therefore, withdrawal has the same physical effects on the fetus as it does on the woman.
During pregnancy, withdrawal is also associated with placental abruption and could be life-threatening for the woman.
When an infant is born to a mother who is dependent on opioids there is a recognizable withdrawal syndrome called Neonatal Abstinence Syndrome (NAS). If untreated, NAS can be fatal.
Management/Treatment
For the detection and management of Neonatal Abstinence Syndrome (NAS), refer to the Recommendations from the Provincial Council for Maternal and Child Health.
Scale: Modified Finnegan Scoring System.
During pregnancy:
- The goal is to minimize withdrawal and prevent relapses. Refer to the NAS Maternal Guidelines: Preconception, Prenatal, Intrapartum, Postpartum, Discharge Planning.
- Maintenance medications are the mainstay of treatment. Offer the patient methadone or buprenorphine (or morphine when methadone or buprenorphine are not available).
- Based on recent evidence, there is minimal risk associated with tapering opioids during pregnancy. However, there is significant risk of relapse due to instability. Monitor closely for withdrawal, signs of obstetrical complications (uterine cramping, vaginal bleeding) and relapse to opioid use.
- Tapering in pregnancy should be attempted by no more than 10% of the dose per week. Be prepared to stop the taper if any adverse events are reported.
- WARNING: DO NOT START SUBOXONE IN PREGNANCY BECAUSE IT CONTAINS NALOXONE – SAFETY HAS NOT BEEN ESTABLISHED.
Buprenorphine alone may also precipitate withdrawal in opioid users who are not in withdrawal. - DO NOT STOP SUBOXONE SUDDENLY IF WOMEN BECOMES PREGNANT WHILE ON THE MEDICATION.
Birth in specialized centres: level II nursery where appropriate.
Please refer to the 2011 Summary of Recommendations from the Provincial Council for Maternal and Child Health.
Key safety issues for consideration
- Psychosocial interventions and treatment as well as prenatal care are necessary.
- Poly-drug use and tobacco use are associated with high risk for SIDS
- Monitor for partner's use of drugs and violence in the relationship
- Consider reporting to child protection agencies if you think the child is at risk under the Child and Family Services Act
- No indication to report unborn child (i.e., fetus).
- Encourage self-report once patient has reached clinical and social stability.
- Report sooner if woman has other children in her care.
- Discharge neonate home if minimal withdrawal based on NAS or once weaning from morphine is complete.
In select cases, providers may consider discharging infant home to continue weaning from morphine, if specific community supports are available.
Further reading:
- Provincial Council for Maternal and Child Health (PCMCH) at www.pcmch.on.ca
- Long-Acting Morphine Protocol for Pregnant Women
The Opioid Advice series was produced in collaboration with the Ministry of Health and Long-Term Care.
Related links