PBLD8: Maternal Substance Abuse during Pregnancy Tweet to @SOAPhq Case Description A 26-year-old gravida 5 para 4 at 34-weeks gestation presents to OB Triage via EMS with altered mental status. She is combative and strapped to the gurney with restraints. Her boyfriend called EMS when she began to “shake” and has been unable to give any history other than the patient has had no prenatal care during this pregnancy but all her other children were “natural.” As the intern begins the history, the patient vomits and becomes nearly unresponsive. The OB intern calls for a rapid response evaluation for this patient. Question 1: Opioid-dependent or opioid abusing parturients have a higher incidence of in-hospital mortality than non-opioid users. True False Not only do drug-users/abusers have higher odds of in-hospital mortality, but also an extended length of delivery hospitalization (>7 days), transfusion, and oligohydramnios. In addition, well-established studies reveal a higher risk for cesarean delivery, preterm birth, and intrauterine growth restriction. Question 2: Compared to the general population, opioid abusers have an increased incidence of postpartum pain. True False Opioid tolerance and hyperalgesia develop in women who are dependent on or abuse opioids, and they often experience more postpartum pain than the general obstetric population. Question 3: Which of the following risk factors further increase the risk of morbidity and mortality in parturients with a substance abuse history? A. Lack of prenatal care B. Cigarette smoking C. Preterm labor D. Human immunodeficiency virus (HIV) + status E. All of the above Each of these factors confers increased risk for substance use/abuse. Question 4: Signs and symptoms of cocaine use include which of the following: A. Hypertension and tachycardia B. Hyperreflexia C. Seizure D. Fever E. All of the above While each of these signs and symptoms is seen in patients with acute cocaine toxicity, a differential diagnosis of preeclampsia/eclampsia should also be explored. Urine drug toxicology should elucidate a clearer picture. Question 5: The above patient needs an urgent cesarean delivery due to a fetal category 2 tracing. Which type of anesthetic would you choose? A. General anesthesia with rapid sequence induction B. Spinal anesthesia C. Epidural anesthesia D. Combined spinal-epidural anesthesia E. It depends… Choice of anesthetic technique depends on maternal and fetal indications for cesarean delivery as well as other mitigating factors. Timing and emergent nature of surgery secondary to fetal tracing usually determine whether general anesthesia versus neuraxial anesthesia is utilized. Maternal cocaine use can result in thrombocytopenia and/or placental abruption, both of which would contraindicate the use of a neuraxial technique. Anticipation of difficult airway, non-NPO status, lab values and other maternal factors may weigh the decision in favor of neuraxial if/when the fetal tracing has periods of recovery. Importantly, a combative, and acutely intoxicated patient may make neuraxial placement difficult. Phenylephrine has become the drug of choice to treat spinal mediated hypotension in cesarean delivery. If general anesthesia is selected, the hemodynamic response to laryngoscopy should be attenuated prior to/and during intubation with fast-acting antihypertensive medications. Question 6: True or False: Smoking during pregnancy increases the risk of developing preeclampsia. True False Tobacco abuse in pregnancy has been associated with spontaneous abortion, ectopic pregnancy, IUGR, increased incidence of preterm premature rupture of membranes (PPROM), preterm labor, placenta previa, placental abruption, and sudden infant death syndrome (SIDS). Functional physiologic alterations, such as vascular constriction, decreased uteroplacental perfusion, and impaired oxygen exchange, may occur and adversely affect pregnancy outcomes. Interestingly, the risk of preeclampsia may be decreased in women who smoke during pregnancy. Smoking should not,however, be encouraged as a way to reduce preeclampsia risk. Question 7: True or False: For parturients who smoke, neuraxial analgesia/anesthesia is contraindicated. True False Neuraxial anesthesia is preferred in tobacco users/abusers as the respiratory complications associated with general anesthesia in smokers, including bronchospasm and post-operative pulmonary complications, are avoided. Question 8: On post-operative day 2, the anesthesia provider is called to manage poor pain control for this patient. What is the best method for preventing and managing post cesarean delivery pain? A. Intravenous morphine PCA B. Post-operative transversus abdominis plane (TAP) block C. PRN NSAID utilization D. Multimodal pain regimen that includes TAP block+ scheduled NSAIDs Many institutions are utilizing multimodal pain management regimens that include ERAS protocols for cesarean delivery. These protocols utilize such medications as acetaminophen, NSAIDs, gabapentin, and TAP blocks in a scheduled rather than PRN manner. Patients on medications such as Suboxone and Subutex should continue these medications throughout the hospital course. Pain-management specialists can be consulted for assistance in managing these medications. Question 9: True or False: To manage breakthrough pain in opioid users, benzodiazepines and sedative drugs should be utilized. True False Benzodiazepines and other sedatives, which are often used in opioid-dependent or opioid-abusing parturients to manage insomnia and anxiety, are synergistic in their respiratory depressant effects. Physician error in conversion of opioid equivalents and an association between sleep apnea and chronic opioid use may also contribute to poor outcomes. Consultation with pain-management anesthesia specialists is recommended along with maximizing multimodal perioperative pain management. More intensive intrapartum respiratory monitoring in these patients may help to prevent these complications. Question 10: Which medication is the best choice for managing opioid users/abusers during pregnancy? A. Methadone B. Buprenorphine C. Buprenorphine + Naloxone D. It depends … When selecting amongst methadone, buprenorphine, and buprenorphine + naloxone, the decision to select a drug is based on several factors. If a single agent can be used and neonatal exposure to naloxone can be avoided, either methadone or buprenorphine should be selected. Both methadone and buprenorphine are widely used to treat opioid use disorder; however, compared with methadone, buprenorphine is associated with shorter treatment duration, less medication needed to treat neonatal abstinence syndrome (NAS) symptoms, and shorter hospitalizations for neonates. Local and state rules and regulations may impact whether a mother is placed on methadone or Subutex and familiarity with these rules can be helpful. Question 11: True or False: Men are more likely to be opioid users/abusers. True False Women are more likely than men to be prescribed opioids, receive higher doses, and take opioids for longer durations. Emergency department visits for opioid misuse and abuse are more likely in women of childbearing age than in any other age group. References: Birnbach DJ, Stein DJ, Thomas K, et al. Cocaine abuse in the parturient: What are the anesthetic implications? Anesthesiology 1993; 79:A988 (abstr). Castles A, Adams EK, Melvin CL, et al. 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