Contributed by Cresta Wedel Jones, MD
The standard of care for maternal opioid use disorders is medication-assisted therapy (MAT) with methadone or buprenorphine. An accepted sequelae of treatment is neonatal abstinence syndrome (NAS), which is experienced by 30% to 70% of these neonates; however, risk of NAS cannot be predicted by the maternal medication dose.1,2 In this case, a woman given MAT throughout her pregnancy delivered a baby with no evidence of NAS, but did require significant multispecialty collaboration for optimal pain control after delivery.
A 30-year-old pregnant woman at 13-weeks gestation presented to a University of Minnesota Health maternal-fetal medicine clinic. Her medical history was significant for a diagnosis of pulmonary arterial hypertension (PAH) with right heart dysfunction, which had improved without any specific therapy. A pulmonary biopsy taken at the time of diagnosis demonstrated perivascular granulomas with foreign material. Extensive evaluation could not identify an etiology for the PAH. It was eventually determined that the findings were consistent with long-term injection and inhalation of prescription opioid pills. She was ultimately diagnosed with opioid use disorder and given MAT (buprenorphine 24 mg daily). The patient had a history significant for ADHD, which was successfully treated with amphetamine and dextroamphetamine salts (Adderall).
The patient continued on buprenorphine therapy during her pregnancy to reduce the risk of relapse to illicit opioid use. Additional care was coordinated with University of Minnesota specialists in addiction medicine, pulmonology, and cardiology.
At 14-weeks gestation the patient developed progressive hypertension and shortness of breath on exertion despite a normal echocardiogram. This was initially felt to be associated with the high dose Adderall therapy, which was discontinued. Her blood pressure improved initially, but then rose and was associated with intermittent tachycardia. At 28 weeks, she was hospitalized for worsening shortness of breath and hypertension. CT imaging did not identify any lung pathology. EKG and serum evaluation did not suggest myocardial infarction. The patient underwent a right heart catheterization with no evidence of PAH, and no explanation for the symptoms. Her hypertension and shortness of breath spontaneously improved, and she was discharged home. However, at 32-weeks gestation, she developed more severe hypertension and at 36 weeks, she was delivered by cesarean section. Hypertension was treated with oral nifedipine.
Throughout the pregnancy, she was continued on buprenorphine without evidence of withdrawal or relapse. Delivery anesthesia included combined spinal/epidural regional anesthesia. Postpartum pain treatment included epidural anesthesia, patient-controlled analgesia (PCA) using IV hydromorphine, and ketorolac. Bilateral transversus abdominus plane blocks were added on postoperative day 1. On day 2, the hydropmorphone PCA was discontinued. The patient was then placed on oral oxycodone 20-30 mg every 3 hours, as well as scheduled ibuprofen and acetaminophen (Tylenol). Hydromorphone 1-2 mg IV was ordered for severe breakthrough pain. Nonpharmacologicagents (e.g., massage) were also offered. The patient also continued buprenorphine without complications. On day 3, she was able to decrease her oxycodone dosing, while continuing the acetaminophen and ketorolac. A lidocaine patch was added.
On day 4, the patient was discharged on oral nifedipine for hypertension, an oxycodone 1-week taper, acetaminophen, ibuprofen, a lidocaine patch, and buprenorphine.
Upon delivery, the 2.46 kg female infant cried spontaneously and underwent the usual warming, drying, and stimulation. At 4 minutes of life, the infant became limp with poor respiratory effort and required nasal CPAP and supplemental oxygen. She had persistent retractions, with APGAR scores of 8, 3, and 9 at 1, 5, and 10 minutes, respectively. The infant was taken to the neonatal intensive care unit for evaluation, monitoring, and treatment of respiratory distress syndrome and possible sepsis. Throughout 7 days of hospitalization, the infant demonstrated no signs or symptoms of NAS and needed no pharmacologic or nonpharmacologic treatment for opioid withdrawal. The infant was successfully breastfeeding at discharge.
With the rise in opioid abuse, an increasing number of infants are born with neonatal abstinence syndrome. M Health specialists provide insight into the latest care approaches for these patients and their mothers.Continue reading