Transcript Antenatal Case Study

Antenatal Case Study
Serah Mungai & Hywel Mackey
Learning Outcomes
1. Overview of normal antenatal care
2. The initiation and monitoring of methadone in pregnancy
3. The effects of methadone throughout pregnancy
4. Neonatal sequelae after methadone therapy
Antenatal Care
Detect any complications that may affect the outcome of pregnancy
Plan the mode of delivery with the parents
Provide education to the parents
First Booking Visit should be before 10 weeks:
Full history and examination
Assessment of pregnancy risk
Scans
11-14 weeks (dating scan)
Crown-Rump Length (CRL)
Multiple pregnancies
Nuchal translucency measurement
20 weeks (biparietal diameter)
Fetal abnormalities (e.g. neural tube defects)
Investigations
Full Blood Count
Check for anaemia
Serum antibodies
Check anti-D status
Rubella immunity
HIV blood test
Glucose tolerance testing (GTT)
Health Promotion
Folic acid (400mcg/day)
5mg for high risk mothers
Antipsychotics; antiepileptics; DM; previous history of NT defects
Balanced diet with 2,500 calories
Avoid alcohol completely
Smoking cessation advice
Exercise is recommended
Case Presentation
Miss W
30 year old lady
Primigravida
39 + 0 gestation
Well lady
Under consultant led care
History
Normal fetal movements
No contractions
No bleeding
O/E:
Well nourished
Blood pressure 123/68 mmHg
Urine dip negative
All scans have been normal
Social History
Smokes 5/day, has cut down from 30/day since becoming pregnant
Has a stable partner, who is father of the baby
Polysubstance abuse:
Snowballing
Heroin
Crack cocaine
Valium
Stopped using at 35 weeks gestation
Methadone in Pregnancy
Detox is not advised in pregnancy
Increased risk of relapse postnatally
Usual regimen is BD/split dosing
Most effective with least side effects
Initiated at 20-30mg as an in-patient
Increased incrementally by 5-10 mg
Weekly urine drug screen performed
Effects on Mother and Baby
Cigarette smoking:
Delays onset neonatal abstinence syndrome
Increases severity of neonatal withdrawal
Cessation is advised
Polysubstance abuse:
Methadone + Benzodiazepines = excessive sedation
Methadone + Alcohol = ↓[Methadone]
Perinatal and Postnatal Considerations
Analgesia/ Anesthesia
Substance abusing mothers may require higher doses
Labour and delivery
Sclerosed veins, cellulitis
Breast feeding
Low rates in high-risk mothers
Transferred into milk at small concentrations
Methadone Fetal and Neonatal Issues
Preterm birth <32 weeks gestation
Small for gestational age
↑SCBU admissions
Effects on developing visual system:
↓acuity, nystagmus, strabismus, refractive errors
Neonatal Abstinence Syndrome (NAS):
Well recognised symptoms: feeding difficulties, GI disturbance, sleep
Questions?
References
UpToDate:
Methadone Maintenance Therapy during Pregnancy
Neonatal Abstinence Syndrome
Obstetrics & Gynaecology, Impey