1. Antenatal Case Study Serah Mungai & Hywel Mackey

2. 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

3. 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 Decision on Midwife or Obstetric led care

4. 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)

5. Investigations Full Blood Count Check for anaemia Serum antibodies Check anti-D status Rubella immunity HIV blood test Glucose tolerance testing (GTT) In at risk women

6. 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 Avoidance of infection (avoid soft cheese etc.)

7. Case Presentation Miss W 30 year old lady Primigravida 39 + 0 gestation Well lady Under consultant led care

8. 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 Hep C and tox screen -ve

9. 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: Heroin Crack cocaine Valium Stopped using at 35 weeks gestation Has also been on Methadone for 15 years, currently 50ml Lost her job due to her addiction Currently under Public Law Outline (PLO) with Social Services Snowballing

10. 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 Alternatives are Buprenorphine

11. 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]

12. 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 Encouraged to breastfeed regardless

13. 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 disturbance, autonomic dysfunction Presents around 48-72 hours after birth

14. Questions?

15. References UpToDate: Methadone Maintenance Therapy during Pregnancy Neonatal Abstinence Syndrome Obstetrics & Gynaecology, Impey