This guideline will assist staff at Royal Women's Hospital (the Women's) in caring for pregnant women with drug and alcohol (D&A) issues. It provides a basic overview and should be used flexibly in accordance with the needs of individual women.
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This guideline is based on the National clinical guidelines for the management of drug use during pregnancy, birth and the early development years of the newborn. The quality of scientific evidence supporting guideline statements is indicated throughout using NHMRC levels of evidence.
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Definitions
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Alcohol or drug misuse: Maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances.2
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Dependence: characterised by a strong desire to take a drug. Indicators include: impaired control over drug use, a higher priority to drug use than other activities and obligations, increased tolerance, physical withdrawal symptoms, and repeated drug use to suppress withdrawal.1
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Neonatal abstinence syndrome (NAS) is a syndrome of drug withdrawal observed in babies of women physically dependent [in the 4-6 weeks prior to birth] on drugs (the national guidelines use the generic term drugs on p45 rather than anything more specific and maybe that is a good model to follow) manifested by non-specific symptoms and signs in the baby, including neurological excitability, gastrointestinal dysfunction, autonomic signs, poor feeding, sleep-wake abnormalities, vomiting, dehydration, poor weight gain, neuromuscular abnormalities and occasionally seizures [1].
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Pharmacotherapy: Substitution treatment using drugs. Pharmacotherapies for drug dependence include methadone or buprenorphine maintenance as a treatment for heroin dependence, and nicotine replacement therapy as a treatment for tobacco dependence.
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WADS D & A Assessment: Comprehensive assessment of drug use and psychosocial issues.
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Women's Alcohol and Drug Service (WADS): is a specialist statewide service at the Women's, for pregnant women with alcohol and drug issues. Access more information for health professionals about Women's Alcohol & Drug Service at the Women's.
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Women's Alcohol and Drug Service (WADS) screen: Initial phone call, between woman and duty worker, involving D&A screening and referral to most appropriate service.
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1. Principles of care:
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The following principles should underpin care of women with alcohol and drug issues (consensus, 1):
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- Engagement and continuity
- Referral for specialist treatment services
- Multidisciplinary teams
- Confidentiality
- Mental health care
- Communication
- Partner/family support and involvement
- Cultural care
- Child protection
- Harm minimization
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2. Access to care at the Royal Women's Hospital
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All pregnant women should be screened for alcohol and drug use (including tobacco), at the initial visit to help decide the appropriate model of pregnancy care (Consensus, 1).
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Criteria for Care with the Women's AD clinic
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A history of drug or alcohol use with:
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- No sign of substance dependence problems
- Stable on <80mg methadone or <6mg buprenorphine
- Attends community methadone prescriber regularly
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Criteria for care with Women's Alcohol and Drug Service (WADS)
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Willingness to attend WADS clinic with D & A counsellors, midwife and obstetrician
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- Willingness to work with all members of multidisciplinary team
- Complex substance use
- Complex psychosocial issues, for eg. Dual diagnosis, borderline personality disorder, psychiatric disability, intellectual disability, homelessness, child protection issues, recent or recurrent incarceration, challenging behaviour, issues around domestic violence.
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Consultation
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WADS accepts referrals for consultation and/or ongoing care, including shared care, for other Women's antenatal clients.
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Emergency contact & Secondary consultation
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24 hour emergency contact & secondary consultation from WADS clinicians is available to the Women's staff and external service providers. In hours, this is available through the duty system (ext 3631), or out of hours the WADS obstetrician on call via the Women's switchboard.
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Outreach services
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WADS clinicians will provide outreach services to a client's place of residence, agency or agreed venue in the following circumstances:
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- To provide support to clients withdrawing from drugs or alcohol in residential services.
- To provide ongoing pregnancy care for WADS clients.
- To support domiciliary visits if required.
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3. Antenatal care at Women's Alcohol and Drug Service (WADS)
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Criteria for care with Women's Alcohol and Drug Service (WADS)
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Willingness to attend WADS clinic with D & A counsellors, midwife and obstetrician.
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- Willingness to work with all members of multidisciplinary team
- Complex substance use
- Complex psychosocial issues, for eg. Dual diagnosis, borderline personality disorder, psychiatric disability, intellectual disability, homelessness, child protection issues, recent or recurrent incarceration, challenging behaviour, issues around domestic violence.
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3.1 Appointment schedule
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Scheduled appointments are provided with the multidisciplinary team every 2-3 weeks until 30 weeks pregnant, or as required, and then weekly until the birth. Visits are more frequent for these women due to the increased risks in pregnancy, including Intrauterine Growth Restriction (IUGR). Fetal growth should be monitored by measuring symphysis fundal height (consensus, 1), and ultrasonography at 32/40 gestation. At the Women's, CTG's are performed as required.
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3.2 WADS team
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The WADS multidisciplinary clinical team consists of obstetricians, midwives, counsellors, dietician, paediatrician, psychiatric registrar, housing support worker (from Home Ground) and pharmacist. WADS staff provide care coordination for WADS clients. Women should be offered information and services as for all pregnant women who attend the Women's, including childbirth education, lactation consultancy etc. Consider referral to bicultural worker or specific aboriginal health services if appropriate.
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3.3 Psychiatric referral
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The Psychiatry Registrar, under the supervision of a Consultant Psychiatrist, provides a Consultation and Liaison role to the Women's Alcohol and Drug Service. Consultations can be primary or secondary.
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Referral process
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Any member of the WADS team can make a direct referral to the Psychiatry Registrar. Once the client has had a psychiatric assessment, feedback will then be given to the team - usually in the forum of the weekly meeting. Following the initial assessment, there will then either be ongoing active involvement of the Psychiatry Registrar in the management of the client, or secondary consultation.
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Primary Consultations
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There is a range of reasons for considering referral to Psychiatry including:
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(i) concerns about a client's mental state (e.g severe depression, anxiety or eating disorders
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(ii) assessment of current risk to self (i.e. self-harm or suicidal ideation), or, depression &/or psychosis in the post-partum period, with potential risk to infant)
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(iii) pre-existing psychiatric illness &/or current treatment with psychotropic medication/s (e.g antidepressants, antipsychotics, mood stabilizers)
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(iv) clients with personality disorders who have challenging behaviours
Where clients have complex psychiatric issues as below, they should be referred to Psychiatry.
Clients with a past and / or current history of:
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- post-natal depression or puerperal psychosis
- psychotic, manic symptoms
- obsessive compulsive disorder
- bipolar affective disorder
- schizophrenia
- severe depression with suicide attempts
- where such clients have ceased their psychotropic medication/s just prior to or during pregnancy
- clients on doses of > 30mg diazepam equivalents
- clients attending psychiatric services
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If the client is already engaged with community psychiatric services, a referral should still be made to the Psychiatry Registrar for an assessment. This will enable continuity of care - especially around the time of delivery and during the early post-partum period - and help facilitate liaison with the client's community psychiatrist.
The Psychiatry Registrar can also assist in facilitating referrals to Mother Baby Units.
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Secondary Consultations
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These can be provided around such issues as:
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(i) unclear psychiatric issues
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(ii) liaison with community psychiatric services
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(iii) advice around managing more challenging clients
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Refer to the Women's procedure: Psychiatric Patients Attending Emergency (Intranet only - NB: under review).
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3.4 Communication
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Systematic communication strategies include:
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- Woman receives a copy of the care pathway, with contact details of her team.
- Documentation of care in hospital record by all disciplines, includes named WADS care provider
- Case conferences held for all clients, including non-attendees, following each clinic
- Detailed case notes in the WADS database
- Individual treatment plan (ITP) developed for each occasion of care
- Regular letter to methadone prescriber at 20, 28, 36 and 40 weeks (if not delivered)
- Compliance with the permit requirements for pharmacotherapy prescribing.
- As required, WADS provider attendance at the maternity communications meetings
- As required, WADS counsellors notify neonatal unit manager of potential 'at risk' families
- Documentation as required on the hospital record 'Alert' sheet and Confidential Client Summary,
- Documentation form 'Assessment for Infant Home Based Referral' completed at 36 weeks gestation in mother's hospital record and copy to SCN case manager
- Copy of Discharge Plan and Referral details in hospital record
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3.5 Childbirth education
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Childbirth education may be linked to general Women's classes or provided individually with a WADS midwife and should include (consensus, 1):
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- NAS (Neonatal abstinence syndrome)
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- Safe sleeping (Safe sleeping for your baby)
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- Oral health care (Dental health for people taking methadone)
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- Nutrition (Eating well and pregnancy)
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- Breastfeeding and drug use
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- Blood Borne Virus and breastfeeding and information on specific effects of drugs and alcohol (alcohol and other drugs, alcohol, amphetamines, cannabis, inhalants, opiates).
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See end of CPG for further information on drugs in pregnancy.
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The fact sheets are located on the Women's internet: Health Information (Pregnancy and Birth): Alcohol & Drugs during Pregnancy.
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3.6 Discharge planning
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Discharge planning should commence at the first antenatal visit, and include multi-agency collaboration (consensus, 1).
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3.7 Urine drug screen
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Urine should be screened for drug use if required. However, self disclosure of drug use may be reliable if there is a trusting therapeutic relationship (consensus, 1). At WADS urine testing is generally undertaken if required for child protection authorities, pre-requisite for admission to a parenting centre, or if there is suspected harmful drug use.
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3.8 Failure to attend appointments
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Clients who fail to attend should be actively followed-up by care provider at WADS.
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3.9 Dental care
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Pregnant women should be given priority access to dental care (consensus, 1). At WADS, women attend Dental Hospital Triage. The Women's has an arrangement with the dental hospital that women will have a consult within seven days.
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WADS Antenatal Care Pathway
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4. Antenatal Care at the Women's AD Clinic
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Criteria for Care with the Women's AD clinic
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A history of drug or alcohol use with:
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- No sign of substance dependence problems
- Stable on <80mg methadone or <6mg buprenorphine
- Attends community methadone prescriber regularly.
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4.1 Routine antenatal care, or as required, following screening and assessment for drug and alcohol use (Antenatal Care Schedule-Routine Low Risk).
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4.2 Continuity of Care should be maintained through team care program. The AD clinic team is multidisciplinary, including a social worker. Consider referral to:
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- External support agencies
- Dietetics
- Childbirth education
- Methadone prescriber
- Dental hospital
- Lactation consultant
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4.3 Medical support and consultations should be provided by WADS doctors
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4.4 Secondary consultation from WADS is available as required
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4.5 Investigations, screening and subsequent referrals as per WADS pathway (above).
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4.6 Follow-up clients who do not attend:
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First missed appointment:
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- Phone call and post out appointment.
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Second subsequent missed appointment:
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- If pharmacotherapy client, call prescriber to confirm still attending, and community chemist to check regular attendance for dosing. Consider faxing reminder letter for appointment.
- If not on pharmacotherapy, confirm contact details and inform AD clinic social worker. Discuss at weekly Clinical meeting.
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Third subsequent missed appointment:
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Secondary consultation with WADS.
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Fourth subsequent missed appointment:
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5. Labour and birth care
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5.1 Normal care in labour and birth as per the Women's CPG: Normal labour and birth - low risk.
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Specific labour considerations:
5.2 Women should be advised to attend early once they go into spontaneous labour (Consensus, 1). Early admission limits the woman's need to self-medicate at home during labour.
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5.3 All forms of pain relief should be offered in labour (Consensus, 1). Pethidine may be ineffective in women with opioid dependence, therefore regional anaesthesia may be more appropriate.
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5.4 Do not give ketamine to women using or suspected of using psychostimulants (Level IV evidence, 1)
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5.5 Do not give naloxone to babies of opioid dependant women (level IV evidence, 1). In the event of respiratory depression in an infant of an opioid dependent mother, normal resuscitation methods should be used (without naloxone), including thorough assessment and mechanical ventilation as required. (Consensus, 1)
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5.6 There is no indication for induction of labour if the baby is showing normal growth (consensus, 1), IOL is not indicated solely because a woman is on pharmacotherapy. Indicators for IOL may include IUGR, unstable drug use.
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5.7 Women should receive normal methadone dosing during labour, meeting jurisdictional requirements for prescribing and administering (consensus, 1). At the Women's this process includes:
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- inform dosing point that woman is an inpatient and will not be attending,
- confirm last dose,
- exclude recent opioid use,
- arrange for woman to have normal dose as an inpatient,
- observe for signs of withdrawal or overdose
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Note: Methadone does not replace the need for analgesia.
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5.8 Prevention of vertical transmission of Blood Borne Viruses:
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- HIV (Refer to the Women's CPG: HIV and Pregnancy).
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- Hep C: Caesarean section to prevent transmission is not justified (consensus, 1). Breastfeeding recommended, though not if nipples are cracked or bleeding (Level III, 1).
- Hep B: Caesarean section to prevent transmission is not justified (consensus, 1). Immunization and Immunoglobulin should be offered to babies of HBAg positive mothers at birth (consensus, 1).
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6. Postnatal care
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6.1 Standard postnatal care: Refer to the Women's CPG: Postnatal Care for low risk women and infants (Midwifery based care) (awaiting publication).
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6.2 Post natal analgesia (vaginal and C/S):
Paracetamol, tramadol hydrochloride and diclofenac are suitable analgesics. Avoid codeine. Consult with the pain team if additional medication is required.
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Management of baby at risk of NAS (click to link to NAS CPG)
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6.3 All babies of women dependent in the last six weeks of pregnancy on opioids, alcohol, amphetamines or sedatives are at risk of NAS and should be referred to a paediatrician after birth.
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6.4 Minimum seven days postnatal admission to allow assessment of NAS (consensus, 1). At the Women's, babies remain in the postnatal ward with mother, unless there are medical indications for admission to Special Care Nursery (SCN)
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6.5 Babies at risk of NAS should be monitored for NAS (Level III-2, 1). This should commence 2 hours after birth and continue every 4 hours. The modified Finnegan's neonatal abstinence severity score, for determining which infants have NAS should be used (Consensus, 1). Refer to NAS CPG for assessment and treatment of NAS (link).
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- If showing signs of withdrawal due to opioids, then morphine is the treatment of choice (level III-1, 1), starting when scores average 8 or more on 3 consecutive scores, or 12 or more on 2 consecutive scores (Level III-1, 1). At RWH, if babies show signs of significant withdrawal (i.e. >8), the paediatrician should be notified and the baby transferred to SCN if treatment with morphine is required.
- If reaching the treatment threshold and drugs used by mother are unknown, or are sedatives, such as benzodiazepines, or the infant was born to a mother intoxicated by alcohol, then phenobarbitone should be used as the initial treatment (consensus, 1). The baby should be transferred to SCN for treatment.
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6.6 Parents should be provided with education and encouragement to provide supportive care to infants at risk of NAS. This includes comforting, small frequent feeds, use of a pacifier, close skin contact, and supplementary feeds if required.
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6.7 Close monitoring of weight loss during the period of withdrawal is necessary because feeding disturbances are common. (Consensus, 1)
Babies are weighed daily.
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6.8 At the Women's, mothers and infants may be assessed as suitable for managing NAS at home. Assessment criteria are available from WADS or Women's Social Support Services, and is conducted at 36/40 and then repeated following commencement of treatment in SCN. Before an infant is discharged home on morphine or phenobarbitone, the treatment team must be satisfied of the safety of the home environment and of the parents' parenting abilities and ability to administer treatment (consensus, 1).
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6.9 Discharge planning should include referral to other community services, including early referral to Maternal Child Health, pharmacotherapy providers and General Practitioner.
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6.10 WADS clinicians should visit WADS clients daily in postnatal ward, to maintain continuity of care and care coordination (consensus, 1)
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6.11 Notification to child protection authorities should be made if there is considered to be a risk of harm or neglect to an infant (consensus, 1). In Victoria, notification may be made in the antenatal period (until March 2007 with mother's signed consent), or during the postnatal period. At the Women's, this is undertaken by WADS clinicians, or if patient of another antenatal clinic, Women's Social Support Services. Following notification, child protection authorities become the lead case manager for discharge planning and referrals.
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7. Specific drugs in pregnancy
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7.1 Methadone, Buprenorphine and Naltrexone
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Methadone maintenance treatment (MMT) is the treatment of choice for heroin dependant women.
MMT reduces the risk of Perinatal and infant mortality in heroin dependant women (Level III-2, 1) and provides an opportunity for the woman to reduce the risks associated with illicit drug use.
The methadone dose during pregnancy should be titrated to a level that not only blocks withdrawal symptoms, but also suppresses heroin use. During pregnancy, methadone dose increases may be required due to increased metabolism and increased blood volume. Dose should not be kept low in an attempt to reduce neonatal abstinence syndrome (Consensus, 1). There is no association with NAS in doses greater than 20 mg/day (Level III-3, 1).
Withdrawal from methadone is associated with a high risk of relapse to heroin use and should not be encouraged during pregnancy (level IV, 1).
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7.1.1 Methadone stabilization program
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If a woman is using or withdrawing from heroin or other opioid drugs, she should be offered the methadone maintenance program as an inpatient stabilization program brochure).
Following assessment of drug dependence, rapid induction onto methadone should be undertaken in consultation with WADS clinicians and under the management of the WADS obstetrician (link to methadone stabilization in pregnancy CPG-in development). Dosing needs to meet jurisdictional requirements, as outlined in the Methadone and buprenorphine dosing procedures
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7.1.2 Vomiting
Vomiting is a serious concern in pregnant women on methadone maintenance. Vomiting of a methadone dose may lead to withdrawal in both mother and fetus (consensus, 1).
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If methadone dose is vomited by a pregnant woman:
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- Within 10 minutes of vomiting - consider giving repeat dose
- Within 10-60 minutes of dosing - consider giving half a repeat dose
- More than 60 minutes after dosing - consider giving half a repeat dose if withdrawal occurs (assessed at 4-6 hours after vomiting, when effects of methadone should be at their peak) (consensus, 1).
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To prevent vomiting:
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- Women should be discouraged from ingesting methadone on an empty stomach.
- Women should be encouraged to sip their dose slowly.
- If consistently vomiting, consider splitting the dose or giving rectal prochlorperazine 30-60 minutes before the dosing.
- If vomiting constantly and not in relation to dose of methadone, she should be assessed and treated according to obstetric protocols for hyperemesis gravidarum
- (consensus, 1).
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7.1.3 Buprenorphine (Subutex)
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The safety of buprenorphine in pregnancy has not yet been demonstrated, therefore methadone is the preferred treatment. However, if women are already on buprenorphine, and wish to continue, or the woman refuses methadone, it may be used as a treatment (Consensus, 1). The woman must be able to provide informed consent.
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7.1.4 Combined buprenorphine-naloxone (Suboxone)
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Suboxone is not recommended in pregnancy (4). Women on Suboxone should be transferred to mono buprenorphine (Subutex)
Women on buprenorphine or Suboxone should be registered on the Victorian Buprenorphine in Pregnancy Register via our website.
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7.1.5 Naltrexone
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The safety of naltrexone in pregnancy has not been established, therefore Naltrexone should not be offered in pregnancy, except in the context of clinical trials. If a woman is already on Naltrexone, she should be advised the safety is not established, but if she wishes to continue on Naltrexone and can give informed consent, it is acceptable to continue (consensus, 1). Follow-up of babies exposed inutero is recommended.
WADS fact sheets for further information:
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7.2 Heroin
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A pregnant woman seeking withdrawal from heroin during pregnancy should be informed of the risks and benefits, including risks to the fetus (increased risk of infant mortality and lbw for gestational age) and high risk of relapse. MMT should be offered in the first instance (consensus, 1).
If the woman still refuses MMT, then the risks of withdrawal may be reduced under the following conditions (consensus, 1).
Attempt withdrawal:
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- in the second trimester only (weeks 14-32)
- with fetal monitoring
- using tapering doses of methadone
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WADS fact sheets for further information:
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Opioids: Heroin and other opiates
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7.3 Alcohol
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Alcohol is known to have teratogenic effects, though the level of drinking which causes significant fetal problems is not known (1). All women should be given information on risks associated with drinking and advised that no completely safe level of alcohol consumption has been determined for the fetus. (consensus, 1)
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Alcohol consumption is not recommended in pregnancy.
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Pregnant women identified as consuming risky levels of alcohol should have priority access to alcohol treatment services, including comprehensive assessment and detoxification. (consensus, 1)
WADS fact sheets for further information:
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7.4 Tobacco
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The harm caused by tobacco smoking during pregnancy is well established and includes an increased incidence of threatened and spontaneous miscarriage, premature birth, low birth weight for gestational age, Perinatal death, SIDS, and other longer term effects on the health of the child (1).
Information and services for smokers should be integrated into existing services.
All women should be screened for smoking, and smokers should be offered support for smoking cessation and relapse prevention early in pregnancy, and as a routine part of each antenatal, child health or clinic visit (Level 1 evidence, 1).
Discuss in a collaborative way how the woman feels about smoking, and the options and support for quitting. The "5 A's" brief intervention is described as a minimum approach to smoking cessation (Ask, Advise, Assess stage of change, Assist - information, motivational interviewing etc, Arrange follow-up)
Women on antipsychotic medications should quit in consultation with the prescribing psychiatrist, as dose adjustment may be necessary.
Women with a history of depression may experience an increase in symptoms after quitting, however, many do not.
There is currently a lack of evidence on the safety of NRT in pregnancy. But where a woman is otherwise unable to quit, it may be used (Consensus, 1,3). Where it is used, the clinician should consider monitoring drug levels, using low doses, and choosing an intermittent delivery system (Consensus, 1). At the Women's, intermittent delivery is administered as patches or gum.
WADS fact sheet for further information:
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7.5 Cannabis
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There is evidence that daily cannabis use increases the risk of anxiety and depression, and psychosis. (5) Cannabis use can adversely affect the quality of relationships, parenting, study and employment performance.
The health risks of cannabis in pregnancy are not clearly established beyond being similar to tobacco smoking. There is no current evidence indicating that cannabis is a teratagen.
There is low level evidence of mild withdrawal from sole cannabis use. Mothers should be advised that regular exposure to cannabis inutero may influence newborn infant behaviours in the first weeks of life (consensus, 1). Children born to cannabis dependent parents may have some developmental problems (Level III-2, 1).
Pregnant women who identify as regular cannabis users, should be offered a range of interventions to help them stop, including information, counselling and psychologically based treatment (Level II, 1).
WADS fact sheet for further information:
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7.6 Benzodiazepines
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The health risks of benzodiazepines in pregnancy are not clearly established. Regular use may be associated with NAS.
The recommended management of benzodiazepine-dependent pregnant woman is transfer to a long acting benzodiazepine and gradual dose reduction, with a view to being drug free at birth (Consensus, 1).
Babies of women dependent on benzodiazepines (sedatives) should be observed for NAS for one week in hospital, followed by weekly outpatient reviews. The Finnegan scale may be used to identify NAS. Supportive measures without drug treatment are the primary management of the baby (consensus, 1). If pharmacological management is required, the baby is transferred to SCN for treatment with phenobarbitone.
WADS fact sheet for further information:
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7.7 Stimulants (Amphetamines and Cocaine)
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The health risks of amphetamine use in pregnancy are not clearly established, though there may be a risk of NAS.
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Cocaine in pregnancy has been associated with an increased risk of intra-uterine growth restriction, placental abruption and premature rupture of membranes. Developmental problems have been observed in children exposed to cocaine in-utero (consensus, 1).
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Pregnant women using stimulants should be informed of risks to herself and her baby, and encouraged to reduce or cease stimulant use (consensus, 1).
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Babies of women with significant use of stimulants in the last 6 weeks of pregnancy should be:
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- referred to a paediatrician after birth
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- monitored for NAS in hospital for seven (7) days
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- reviewed weekly as an outpatient until 4 weeks of age
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Use of amphetamines is associated with mental illness in the user and mental health should be monitored (consensus, 1).
WADS fact sheet for further information:
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7.9 Inhalants and pregnancy
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Inhalant use is associated with long term CNS damage, low birth weight for gestational age, and increased risk of miscarriage, birth defects and SIDS. An abstinence syndrome has been observed in infants born to mothers known to be volatile substance users during pregnancy (Level IV evidence, 1).
WADS fact sheet for further information:
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8. Withdrawal
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Withdrawal support services are not offered at the Women's, as it is not a suitable environment. If pregnant women wish to undertake withdrawal they are referred to specialist withdrawal services such as DePaul or Moreland Hall. WADS clinicians will provide outreach consultation services to these centres. If withdrawal from drugs is to be attempted it should be discussed with the WADS obstetrician.
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9. References
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1. NSW Department of Health. 2006. National Clinical Guidelines for the management of drug use during pregnancy, birth and the early development years of the newborn. Report commissioned by the Ministerial Council on Drug Strategy under the Cost Shared Funding Model. www.health.nsw.gov.au/pubs/2006/ncg_druguse.html
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2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition. American Psychiatric Press Inc. Washington.
3. Fiore M, Bailey W, Cohen S, and Al E. 2000. Treating tobacco use and dependence. Clinical Practice Guideline. Rockville, MD, US Department of Health and Human Service. Public Health Service.
4. Lintzeris N, Clark N, Winstock A, Dunlop A, Muhleisen P, Gowing L, Ali R, Ritter A, Bell J, Quigley A, Mattick RP, Monheit B, White J. 2006. National Clinical Guidelines and Procedures for the Use of Buprenorphine in the Treatment of Opioid Dependence.
5. Patton, GC, Coffey, C, Carlin, JB, et al. Cannabis use and mental health in young people: cohort study. BMJ 2002; 325:1195.
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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