NAS.txt

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tracey
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11899
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NAS.txt
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2010-03-25 22:36:57
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Lecture # 1 Management Final Perinatal Substance
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Perinatal substance abuse
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  1. How do we know the incidence of drug use during pregnancy?
    • Self reporting – unreliable
    • National survey of drug use and health
    • Maternal lifestyle study
  2. What are the statistics related to drug use during pregnancy?
    • 8% of population >12 are current drug users
    • 75% of murders, assaults and child abuse are r/t drugs/alcohol
    • 1/3 of the addicted population is women
    • 15% of childbearing women are drug users
    • 3-8% drug abuse during pregnancy
    • 10-11% of all newborns are prenatally exposed to alcohol or drugs
    • 75-90% of substance exposed infants are undetected and go home
  3. Why are the problems with drug use research?
    • Methods for defining drug use are not clearly defined
    • Multiple confounding variables make it difficulty to study cause and affect relationships of a single drug on child outcomes
    • Multiple factors that can play a role in child growth and development (SES)
  4. How often is caffeine consumed during pregnancy
    75% of pregnancies
  5. How does caffeine effect the neonate
    • Increased respirations and heart rate
    • Low birth weight
    • Altered sleep pattern
  6. How does caffeine effect the fetus
    • Increased HR
    • Still birth
  7. Does caffeine pass into breastmilk
    A small amount crosses but the AAP considers it safe to breastfeed and consume caffeine
  8. What is the most often used drug in pregnancy
    Cigarettes but it has declined over the last 2 decades, 10-20% of pregnant women smoke
  9. What is the mechanism of action of nicotine on the fetus
    Exact mechanism is unknown but the nicotine and carbon monoxide play a role- they have a direct cytotoxic effect (cigarettes contain >2500 toxic chemicals)
  10. What perinatal complications are associated with cigarettes
    • Spontaneous abortion and stillbirth
    • 2x risk of placenta previa
    • PROM
    • IUGR
    • CHD
  11. How does smoking affect the neonate
    • Withdrawal like symptoms
    • SIDS, otitis media
    • ashthma
  12. How does quitting smoking affect the fetus/neonate?
    Decreased stillbirth and decreased neonatal death
  13. Does nicotine cross into breastmilk
    Yes
  14. How does smoking affect SIDS
    • Smoking is independently associated with an increased risk
    • There is a dose dependent relationship
    • Smoking may cause altered lung function and altered CNS control pr arousal of respiration or both
    • There is a loss of neonatal hypoxia tolerance after prenatal exposure – so infant stops breathing and doesn’t recognize the decreased oxygen levels since they were used to it in utero
  15. What is the most commonly abused drug during preganacy
    Alcohol
  16. What is alcohol
    • Analgesic that depresses the CNS, low doses act as a stimulant and relaxant causing sensations of euphoria
    • Lipid and water soluble and easily passes through cell membrance
    • Alcohol and its metabolite are toxic and fetus lacks the enzymes necessary to break the alcohol down
    • The amniotic fluid becomes a reservoir for the alcohol and metabolites
    • Major cause of MR today
    • It is the only abusing drug that is well associated with teratogenic effects
  17. What birth defects are associated with alcohol
    • Abnormal facial features
    • Prenatal and postnatal growth deficiencies
    • CNS problems
  18. What is fetal alcohol spectrum disorders (FASD)
    • Umbrella term to describe a spectrum of effects resulting from maternal alcohol use during pregnancy
    • It is not a medical dx
    • What is the incidence of FAS
    • .2-1.5/1000 births
    • FASD may occur 3x more than FAS
  19. What are the contributing factors to FAS
    • Poverty
    • Advanced maternal age
    • Nonwhite race
  20. How does alcohol cause birth defects
    • Interrupts the normal accumulation and organization of protein
    • Interferes with the primary function of the placenta to transport nutrients
    • Has a direct effect on cell maturation, migration growth and division
  21. How much is too much alcohol
    • The exact amount is unknown
    • Number of binge drinking days has the strongest effect
    • Effects are r/t the GA of exposure, amount ingested, frequency of exposure, peak blood concentrations, maternal alcohol metabolism and susceptibility of the infant
  22. What are the CNS effects of alcohol
    • Microcephaly
    • Dysgenesis corpus collosum (left brain –logic, right brain-impulse/feelings)
    • Hypoplasia of basal ganglia – special memor, perception of time
    • Hypoplasia of the cerebellum – coordination, movement, behavior, memory
    • Prefrontal cortex – executive function
    • Neurosensory hearing loss
  23. What are the facial characteristics of FAS
    • Midface hypoplasia
    • Broad,flat nasal bridge
    • Poorly developed philtrum
    • Thin upper lip
    • Short palpable fissures
    • Strabismus
    • Ptosis and low set dysplastic ears
  24. What are the withdrawal symptoms of FAS
    • Occurs shortly after birth with peak effects at 48 hours
    • 72 hours period of hyperactivity, crying, tremors, irritability, seizures, poor sleep patterns, hyperphagia and diaphoresis followed by 48 hours phase of lethargy and return to baseline
  25. What are the long term effects of fetal alcohol
    • Continued growth restriction
    • Lower Bayley scores
    • Learning difficulties, poor memory, poor language comprehension, and poor problem solving skills
    • Inability to understand concepts such as time and money
    • Poor coordination
    • Poor socialization skills
    • Lack of imagination or curiositybahavioral problems- hyperactive, social withdrawal, stubbornness, impulsiveness and anxity
  26. What is the average function a person with FAS
    2nd or 3rd grade level
  27. What is the most common illegal drug used during pregnancy
    THC
  28. What are congenital effects of infants with THC exposure
    • Growth retardation
    • Mild withdrawal syndrome
    • No documented long term effects but may potentiate risk of prematurity, low birth weight and teratogenic effects of other drugs used during pregnancy
  29. What is cocaine
    • Powerful addictive CNS stimulant
    • Derived from the erythroxylon cocoa plant
    • Chewed or made into tea for centuries
    • Freud recommended it for alcohol and morphine addiction
  30. What is the 2nd most prevalent illegal drug used during pregnancy
    Cocaine
  31. What is the MOA of cocaine
    • Low molecular weight
    • Water and lipid soluble
    • Prevents reuptake of dopamine, norepi, and serotonin
    • Results in intensified neurochemical responses
    • Accumulation of neurotransmitters
    • Causes the release of dopamine from the brain resulting in euphoria and cycle of sddiction
    • Tryptophan uptake is inhibited so have more energy
    • Blocks Na ion channels – anesthetic effect
  32. What is the duration of action of cocaine
    • 5-10 minutes – smoking and injecting
    • 15-20 – snorting
    • ½ life is 16-90 minutes depending on dose and route
  33. What are the physical effects of cocaine
    • Teratogenic effects are controversial
    • Sypathomimetic effects on CNS
    • Vasoconstriction decreased placental blood flow fetal hypoxia, IUGR
    • Decreased vascular tone and perfusion increase chance of NEC, bowel perforation, HT, MI in newborn
    • Maternal HT and fetal hypoxia increased risk of abrutipn
    • GU anomalies (4x more)
    • Midline defects (agenesis corpus colossum, ocular abnormalities)
    • Vascular disruption (forearm defects, intestinal atresia)
    • Tachycardia
  34. What are the withdrawal signs of cocaine exposure
    • Wide range of neurobahvioral abnormalities most likely due to acute intoxication vs withdrawal
    • Onset of signs occur in 0-3 days, peaks at 1-4 days
    • Duration is unknown
    • Signs include hypertonic, tremulous, irritable, abnormal crying, feeding and sleeping patterns
  35. What are the long-term effects of cocaine exposure?
    • Increased r/o SIDS
    • Most infants exhibit catch up growth by 12 months
    • Studies agree that infants with small heads are at risk for intellectual and developmental problems
  36. What are amphetamines?
    • CNS stimulant initially marketed for tx of obesity and narcolepsy but currently used for ADD
    • Resemble effects of cocaine but duration is 2-12 hours
  37. What is the most common form of amphetamine abuse
    Methamphetamine
  38. What are some properties of amphetamines
    • Easily dissolves in water for injection (crystal)
    • Readily goes from solid to gas (Ice)
    • Cheap and easy to make
    • Popular among teens and white women
  39. Why has methamphetamine use increased
    Greater restrictions on cocaine importation
  40. What are the fetal effects of methamphetamine use
    Poor growth, increased BP and stroke, birth defects (6x more): cleft lip and palate, CHD, kidney disease and gastroschesis
  41. What designer drug is related to methamphetamine
    Escatsy and eve-there is just an alteration in the benzene ring
  42. What are withdrawal symptoms of methamphetamines
    • Similar to methadone but less intense
    • Onset is 48 to 72 hours
    • ~10% will need medical intervention
  43. What are the long term affects of methamphetamine
    • Intellectual capacity does not appear to be effected
    • Hyperactive and aggressive
    • Accelerated puberty in boys and delayed puberty in girls
  44. What is the opiate that is most abused during pregnancy
    • Heroin
    • They tend to inhale it
  45. What is Heroin
    Synthetic opiate drug that is highly addictive, it is made from morphine, which is a naturally occurring substance extracted from the Asian opium poppy plant
  46. What characteristics do women who use heroin usually have
    • Poor health, poor nutrition and multiple medical issues
    • Less likely to seek PNC
    • Higher rate of STDs, urinary and vaginal infections
    • 5x higher rates of maternal hepatitis
    • drug use is further complicated by HIV
  47. What are the fetal effects of heroin
    • IUGR, small head circumference
    • Increased Mec staining
    • Low apgars
    • Increased r/o syphilis and HIV
    • Thrombocytosis
    • 2-4x r/o SIDS
    • NAS
  48. What is the long term outcomes of heroin children
    • No major neuro deficits but “soft” signs are evident such as deviations in sensory, motor, and integrative functions that do not indicate localized brain injury
    • Characteristics of ADD
    • Aggressiveness and compulsiveness
  49. What is methadone
    Synthetic narcotic used to treat opium addiction
  50. How does methadone treat opium addiction
    Heroin releases an excess of dopamine and causes users to need an opiate to continuously occupy the opiod receptors-meth occupies this captor and is a stabilizing factor that permits addicts on methadone to change their behavior
  51. What are the benefits of methadone
    • Doesn’t impair function
    • No adverse effects on mental capability, intelligence or employability
    • Not sedating or intoxicating
    • Doesn’t interfere with ordinary activities such as driving a car
    • Pts are able to feel and experience emotional reactions
    • Prevents opiate withdrawal
    • Better PNC and medical care
    • Improved growth of the fetus
    • Decreased prematurity, decreased perinatal infections
  52. What is the reason for better outcomes of the fetus with methadone
    Stabilized uterine environment
  53. What is the recommended maternal dose of methadone
    No dosing guidelines
  54. Can a mother on methadone breastfeed
    • AAP states that it is compatible
    • Some experts report that it is safe if the max dose is <120mg and no other medication
  55. What other drugs are associated with NAS
    • Codeine, Talwin – less potent opiods
    • Tranquilizers, sedatives, valium, serax – nonopiod CNS depressants
  56. How does drug screening work
    • Testing is done based on maternal indicators and should be done on infants with unexplained symptoms
    • Based on drug specific assays
    • Drugs tested are determined by frequency of use, illegality and potential for harm
    • Conducted as a two tiered procedure
    • Testing is based on institutional policy
  57. Who determines appropriate drug level during drug testing?
    National institute of drug abuse
  58. What is the concern with drug testing?
    High cut off levels underestimate the true scope of drug abuse in pregnancy
  59. What is the goal of drug screening?
    To know what the infant is withdrawing from
  60. What is the most common type of drug screening
    Urine tox- it represents the ultrafiltration of plasma
  61. Why is the concentration of drugs higher in urine
    The kidneys ability to concentrate substances
  62. What does a positive urine screen indicate
    Recent drug use
  63. What is the urine clearance time of cocaine, heroin, methadone, alcohol, amphetamines and THC
    • Cocaine 72-96 hours
    • Heroin – 24-48 hours
    • Methadone – up to 10 days
    • Alcohol – 8-16 hrs
    • Amphetamines – 48 hours
    • THC – 5-20 days
  64. What is used as a secondary or confirmatory test for drugs
    Meconium
  65. What does a positive meconium test indicate
    Drug exposure as early as 20-24 weeks – drugs may be detected up to 3 days of age
  66. What are the cons with meconium testing
    • Distribution of drugs is not uniform
    • Results aren’t readily available
  67. Other than urine and Mec, what are other methods to test for drugs
    Hair, nails, gastric aspirates
  68. A disorder presenting a clinical picture of CNS hyperirritability, GI dysfunction, respiratory distress and minor autonomic symptoms
    NAS
  69. Who is at risk for NAS
    Documented recent drug use, positive screens, unexplained CNS/GI symptoms, iatrogenic cause
  70. What percentage of drug infants require medication for NAS
    50%
  71. What percentage of drug exposed infants demonstrate s/s of withdrawal
    60-90%
  72. What determines the clinical presentation of withdrawal
    • Drug
    • Last dose
    • Metabolism (maternal and infant)
    • excretion
  73. When is the incidence low for withdrawal
    If > 1 week since last exposure and delivery
  74. When does NAS usually occur
    • Occurs in varying degrees
    • Most opiates are short acting and symptoms exhibit in the 1st 24-72 hours
    • Heroin exposed infants exhibit s/s earlier than meth infants
  75. How long do NAS symptoms last
    • Acute s/s last for several weeks
    • Subacute s/s ( irritability, hypertonia, sleep disturbances, hyperactivity, and feeding problems) persist for up to 6 months
  76. What are some CNS s/s of NAS
    Irritability, altered sleep patterns, tremors, increased tone, myoclonic jerks, seizures (2-111%), increased moro
  77. What are respiratory s/s of NAS
    Tacypnea, nasal stuffiness, sneezing, nasal flaring
  78. What are autonomic symptoms of NAS
    Fever, sweating, mottling
  79. What are GI s/s of NAS
    • Excessive uncoordinated sucking
    • Poor feeding
    • Emesis
    • Loose/watery stools
  80. What is the purpose of evaluation tools for NAS
    • To be objective but subjectivity is evident
    • Used to guide management
    • Important not to use the absolute score when evaluating pharmacological evaluation
    • Should discuss the abnormal scores
  81. What is the most widely used too for scoring NAS
    Finnegan tool-it is based on nursing observation
  82. What drugs don’t have a scoring tool
    • Non-opiod drugs
    • When would you notify a MD/NNP of NAS scores
    • 8 or higher over 3 consecutive assessments or 12 or higher over 2 assessments – will evaluate for need of meds
  83. When would you stop scoring
    3 days after d/c therapy if there is no increase in s/s or if score is <8 – if the s/s begin again then the scoring is started for at least another 4 days
  84. How do you score a preterm infant for NAS
    • There is a lower risk of withdrawal possibly r/t immaturity of CNS or decreased exposure time
    • Need to focus less on respiratory distress syndromes, tremulous movements and poor feeding and place more emphasis on irritability, diarrhea, sneezing and yawning
  85. What are the goals of medical management of NAS
    • Maintain infant comfort
    • Support the infants ability to sleep, feed and gain weight
    • Standard medical practice incorporates both developmental and behavioral methods in conjuncture with pharmacologic agents to achieve above goals
  86. What are the nursing interventions for NAS
    • Provide relief of nasal stuffiness
    • Small frequent feedings
    • Non-pharmacologic interventions
  87. What are the nonpharmacological interventions for NAS
    • Swaddling.
Non-nutritive sucking.
Gentle rocking.
Reducing environmental stimuli at the patient's bedside.
Provide adequate pain management for painful procedures
    • Assist infant with self-regulatory behaviors to decrease energy expenditure
    • Provide good skin care
    • Lactation consult
    • Social work consult
  88. What should be considered before starting meds for NAS
    • Rule out common neonatal metabolic imbalances that can mimic or potentiate withdrawal symptoms
    • If pharmacologic intervention is initiated an assessment tool should be used to monitor the infant in an objective and consistent manner
    • Tool is also used to monitor infants clinical response to pharmacotherapy
    • Drug from same class as the drug causing withdrawal preferred
    • Only drugs approved for the treatment of drug withdrawal are benzodiazepines for alcohol withdrawal and methadone for opioid withdrawal
  89. What does the AAP recommend for pharmacological treatment for NAS
    AAP committee on Drugs (1998) recommends tincture of opium for opioid withdrawal and phenobarbital for sedative-hypnotic withdrawal
  90. What are the Legal Implications for NAS
    • Currently only SC holds prenatal substance abuse as a criminal act of child abuse and neglect
    • Minnesota, South Dakota and Wisconsin have laws that enforce admission to an inpatient treatment program
    • 2004 Texas made it a felony to smoke marijuana while pregnant with a prison sentence of 2-20 yrs
    • Other states have laws that address prenatal substance abuse
  91. What are the indications for narcan
    • Not recommended during the initial steps of resuscitation
    • Indications to give Narcan require both of the following according to NRP
    • Continued resp depression after PPV has restored nml HR and color
    • Hx of maternal narcotic administration within the last 4 hrs

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