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 ﻣﺮﺩﻡ ﺩﻭ ﺩﺳﺘﻪ ﺍﻧﺪ: ﺩﺳﺘﻪ ﺍﻱ ﺑﺮﺍﺩﺭ ﺩﻳﻨﻲ ﺗﻮ ﻭ ﺩﺳﺘﻪ ﺩﻳگﺮ ﻫﻤﺎﻧﻨﺪ ﻣﺮﺩﻡ ﺩﻭ ﺩﺳﺘﻪ ﺍﻧﺪ: ﺩﺳﺘﻪ ﺍﻱ ﺑﺮﺍﺩﺭ ﺩﻳﻨﻲ ﺗﻮ ﻭ ﺩﺳﺘﻪ ﺩﻳگﺮ ﻫﻤﺎﻧﻨﺪ ﺗﻮ ﺩﺭ آﻔﺮﻳﻨﺶ. ﺍگﺮ گﻨﺎﻫﻲ ﺍﺯ آﻨﺎﻥ ﺳﺮ ﻣﻲ ﺯﻧﺪ ﻳﺎ ﻋﻠﺖ ﻫﺎﻳﻲ ﺑﺮ آﻨﺎﻥ ﻋﺎﺭﺽ ﻣﻲ ﺷﻮﺩ، ﻳﺎ ﺧﻮﺍﺳﺘﻪ ﻭ ﻧﺎﺧﻮﺍﺳﺘﻪ ﺍﺷﺘﺒﺎﻫﻲ ﻣﺮﺗﻜﺐ ﻣﻲ گﺮﺩﻧﺪ آﻨﺎﻥ ﺭﺍ ﺑﺒﺨﺸﺎﻱ ﻭ ﺑﺮ آﻨﺎﻥ آﺴﺎﻥ گﻴﺮ. آﻦ گﻮﻧﻪ ﻛﻪ ﺩﻭﺳﺖ ﺩﺍﺭﻱ ﺧﺪﺍ ﺗﻮ ﺭﺍ ﺑﺒﺨﺸﺎﻳﺪ ﻭ ﺑﺮ ﺗﻮ آﺴﺎﻥ گﻴﺮﺩ. ﺍﻣﺎﻡ ﻋﻠی)ﻉ(

Maternal & Newborn Effects of Prenatal Substance Abuse Noori-Shadkam M(MD) Maternal & Newborn Effects of Prenatal Substance Abuse Noori-Shadkam M(MD)

Objectives Substance use and pregnancy ¡ Maternal & fetal effects during pregnancy ¡ Withdrawal Objectives Substance use and pregnancy ¡ Maternal & fetal effects during pregnancy ¡ Withdrawal syndrome ¡ treatment ¡

Behavior during pregnancy ¡ Behaviors of drug-using pregnant women contribute to H. R pregnancy Behavior during pregnancy ¡ Behaviors of drug-using pregnant women contribute to H. R pregnancy l l l Unsafe sex with risk of violence Infection from injection Stimulant abuse may lead to early labor Poor nutrition Lack of prenatal care

Drug Classes ¡ Alcohol ¡ Opioids ¡ Stimulants ¡ Nicotine ¡ Marijuana Drug Classes ¡ Alcohol ¡ Opioids ¡ Stimulants ¡ Nicotine ¡ Marijuana

Opioids ¡ ¡ Morphine heroin Oxy. Contin methadone Opioids ¡ ¡ Morphine heroin Oxy. Contin methadone

Effects on mothers • Extrauterine pregnancies • Premature labor • PROM • Uterin irritability Effects on mothers • Extrauterine pregnancies • Premature labor • PROM • Uterin irritability • Breech presentation • Antepartum hemorrhage • Toxemia

Con… • Anemia • Infections • Stillbirth Con… • Anemia • Infections • Stillbirth

Opioids: Effects on fetus ¡ ¡ ¡ Hyperactivity Hypoxia Meconium passage No known fetal Opioids: Effects on fetus ¡ ¡ ¡ Hyperactivity Hypoxia Meconium passage No known fetal anomalies Utero demise

Effect on neonate • LBW • Thrombocytosis & increased circulating platelet aggregation • Abnormal Effect on neonate • LBW • Thrombocytosis & increased circulating platelet aggregation • Abnormal thyroid function • Decrease HMD • Decrease sever hyperbilirubinemia

Neonatal withdrawal syn. Neonatal withdrawal syn.

Follow-up reports • Neurobehavioral deficits • Decrease visual & auditory orientation • Decrease motor Follow-up reports • Neurobehavioral deficits • Decrease visual & auditory orientation • Decrease motor maturity • More jerkiness • Tremulousness • Hypertonicity

Con… • Irritability • Increase cry • Decrease PDI • Increase nystagmus; strabismus & Con… • Irritability • Increase cry • Decrease PDI • Increase nystagmus; strabismus & otitis media

Stimulants o o o Cocaine Crack Amphetamine Methamphetamine MDMA(Ecstasy) Caffeine Stimulants o o o Cocaine Crack Amphetamine Methamphetamine MDMA(Ecstasy) Caffeine

Cocaine Cocaine

Pharmacologic effects Norepinephrine effect tachycardia arrhythmias hypertension vasoconstriction diaphoresis mild tremors Pharmacologic effects Norepinephrine effect tachycardia arrhythmias hypertension vasoconstriction diaphoresis mild tremors

Pharmacologic effects Dopamin effects increased alertness enhanced sense of well-being & self-stem heightened energy Pharmacologic effects Dopamin effects increased alertness enhanced sense of well-being & self-stem heightened energy sexual excitement

Effects on mother • Spontaneous abortion • Abruptio placenta • PROM • STD Effects on mother • Spontaneous abortion • Abruptio placenta • PROM • STD

Effects on fetus & neonate ¡ ¡ ¡ Fetal hypoxia Fetal hypertention Cocaine-Induced ischemia Effects on fetus & neonate ¡ ¡ ¡ Fetal hypoxia Fetal hypertention Cocaine-Induced ischemia intestinal atresia infarction NEC

Con… • G. U malformation • STD • Prematurity • IUGR • SIDS • Con… • G. U malformation • STD • Prematurity • IUGR • SIDS • Diminished alertness • Poorer state regulation

Con… • Abnormal reflex; tone & motor maturity • Impaired autonomic control • Irritability Con… • Abnormal reflex; tone & motor maturity • Impaired autonomic control • Irritability • Poorer orientation • Decreased habituation

Amphetamine Amphetamine

Effects on mother • Miscarriage • Placental hemorrhage Effects on mother • Miscarriage • Placental hemorrhage

Effects on fetus • Prematurity • IUGR • Congenital anomaly cardiovascular musculoskeletal Effects on fetus • Prematurity • IUGR • Congenital anomaly cardiovascular musculoskeletal

Complication • Cardiac arrhythmia • ARF • DIC • Rhabdomyolysis • Learning & memory Complication • Cardiac arrhythmia • ARF • DIC • Rhabdomyolysis • Learning & memory damage

Con… • Loss of sexual pleasure • Effect on cognitive; sleep; appetite • death Con… • Loss of sexual pleasure • Effect on cognitive; sleep; appetite • death

Nicotine ¡ ¡ Cigarettes pipe Nicotine ¡ ¡ Cigarettes pipe

Nicotine release • Acetylcholine • Norepinephrine • GABA • Glutamine • Dopamine Nicotine release • Acetylcholine • Norepinephrine • GABA • Glutamine • Dopamine

Nicotine • Increase HR • Increase BP • Increase RR • Hyperglycemia • Decrease Nicotine • Increase HR • Increase BP • Increase RR • Hyperglycemia • Decrease appetite

Nicotine: Withdrawal symptom • Irritability • Headache • Nausea • Craving Nicotine: Withdrawal symptom • Irritability • Headache • Nausea • Craving

Smoking: Effects on fetus ¡ ¡ Prematurity IUGR SIDS Increased risk for oral cleft Smoking: Effects on fetus ¡ ¡ Prematurity IUGR SIDS Increased risk for oral cleft

Neurobehavioral & Developmental Effects In Infancy • Increase tremulousness • Increase autonomic excitability • Neurobehavioral & Developmental Effects In Infancy • Increase tremulousness • Increase autonomic excitability • Increase ADHD • Decrease auditory habituation • Decrease auditory responsiveness • Decrease verbal comprehension • Decrease verbal learning & memory

Marijuana & Hashish Marijuana & Hashish

Acute Effect • Euphoria & Relaxation • Increase HR • Increase BP in a Acute Effect • Euphoria & Relaxation • Increase HR • Increase BP in a seated or supine • Decrease BP in a standing • Dizziness • Decrease salivation • Increase appetit

Con… • Impaired coordination • Poor decision making • Delayed responding • Altered sense Con… • Impaired coordination • Poor decision making • Delayed responding • Altered sense of time • Impaired concentration & learning

Effects on fetus & neonate ¡ o o Brain abnormalities (in animal model) LBW(? Effects on fetus & neonate ¡ o o Brain abnormalities (in animal model) LBW(? ) Meconium passage

treatment ¡ Pregnancy ¡ Neonate treatment ¡ Pregnancy ¡ Neonate

Treatment in pregnancy ¡ Reduce disease & crime Counseling Social service ¡ Avoid withdrawal Treatment in pregnancy ¡ Reduce disease & crime Counseling Social service ¡ Avoid withdrawal & craving Maintenance vs. detoxification Long-acting medication for control o STD

Methadone Long-acting pure opioid agonist ¡ Available for opioid addiction treatment ¡ Requires daily Methadone Long-acting pure opioid agonist ¡ Available for opioid addiction treatment ¡ Requires daily clinic visits, but may get take-home dose privileges ¡ Also used for pain like other Schedule II opioids ¡

Methadone and Pregnancy ¡ ¡ Standard of care for opioiddependent pregnant women Stabilization of Methadone and Pregnancy ¡ ¡ Standard of care for opioiddependent pregnant women Stabilization of mother and fetus l l ¡ ¡ Medical and social Higher dose in 3 rd trimester Improves growth of fetus & newborn Decreases practice of high-risk behaviors

Buprenorphine ¡ ¡ ¡ Long-acting opioid agonist-antagonist Office-based opioid addiction treatment l Schedule III Buprenorphine ¡ ¡ ¡ Long-acting opioid agonist-antagonist Office-based opioid addiction treatment l Schedule III l Buy at local pharmacy (Subutex, Suboxone) Very low risk of overdose Combined with naloxone Used for acute pain treatment (Buprenex)

Buprenorphine and Pregnancy ¡ ¡ Pregnancy Category C Use Subutex instead of Suboxone to Buprenorphine and Pregnancy ¡ ¡ Pregnancy Category C Use Subutex instead of Suboxone to avoid naloxone NAS less intense than with methadone Studies ongoing, results encouraging

Treatment in neonate Treatment in neonate

The goal is an infant who • • • No irritable No vomitting No The goal is an infant who • • • No irritable No vomitting No diarrhea Can feed well Sleep between feeding

Symptomatic treatment • Tight swaddling • Holding • Rocking • Placing in a slightly Symptomatic treatment • Tight swaddling • Holding • Rocking • Placing in a slightly darkened quiet area • Hypercaloric formula • Never give naloxone

Medication • Neonatal morphine solution(NMS) • Phenobarbital • NMS+Pb Medication • Neonatal morphine solution(NMS) • Phenobarbital • NMS+Pb

NMS score 8 -10 11 -13 14 -16 17 or >17 NMS 0. 8 NMS score 8 -10 11 -13 14 -16 17 or >17 NMS 0. 8 ml/kg/day 1. 2 1. 6 2

Phenobarbital Loading 20 mg/kg 30 40 Maintenance 5 mg/kg/d 6. 5 8 Phenobarbital Loading 20 mg/kg 30 40 Maintenance 5 mg/kg/d 6. 5 8

NMS & pb NMS 0. 4 ml/kg/day Pb loading dose 10 mg/kg then 5 NMS & pb NMS 0. 4 ml/kg/day Pb loading dose 10 mg/kg then 5 mg/kg/day