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BMJ Case Rep. 2010; 2010: bcr09.2009.2246.
Published online Feb 11, 2010. doi:  10.1136/bcr.09.2009.2246
PMCID: PMC3029977
Reminder of important clinical lesson
Pregnant heroin addict: what about the baby?
Vasudevan Namboodiri, Sanju George, Sylvie Boulay, and Mandy Fair
Birmingham and Solihull Mental Health NHS Trust, Addiction Psychiatry, The Bridge, 15 Larch Croft, Birmingham B37 7UR, UK
Correspondence to Sanju George, sanju.george/at/bsmhft.nhs.uk
Heroin misuse in pregnancy is a significant health and social problem, and it can have an adverse effect on the mother and the baby. Although heroin and methadone have no specific teratogenic potential, 48–94% of children exposed in utero will have neonatal abstinence syndrome (NAS). The primary aim of this case report is to raise awareness of NAS among clinicians and to remind them that although very common, it is not inevitable. The risk of NAS can be further minimised by offering comprehensive and co-ordinated antenatal care that addresses the various biopsychosocial needs of the pregnant woman. Further, a brief description of NAS and a review of evidence in the field of management of opioid misuse in pregnancy, as relevant to this case, are provided. We have also included the patient’s own reflections on her pregnancy and treatment.
Heroin addiction is a major health and social problem that has wide ranging adverse consequences for the individual, family and the wider community. This is more so the case when the heroin addict is a pregnant woman. The prevalence of heroin addiction in pregnancy is difficult to estimate because of feelings of shame and guilt experienced by the woman, denial due to fear of social services involvement, and lack of awareness among professionals in antenatal services.1 Hence it follows that reported prevalence figures are very likely to be underestimates due to under-reporting and inadequate capture. However, it is known that around one third of heroin addicts in treatment are female and nearly 90% of them are of childbearing age.
Heroin misuse in pregnancy can have an adverse impact on the woman (obstetric and non-obstetric effects) and, because heroin easily crosses the placental barrier, the baby as well. Non-obstetric adverse effects include physical (malnutrition, poor dental hygiene, infections, etc), psychological (feelings of blame and guilt, self harm, depression, etc) and social (relationship difficulties, domestic violence, involvement in crime, etc).2 Specific obstetric complications include antepartum haemorrhage, low birth weight, and higher neonatal mortality3; and non-specific complications include premature rupture of membranes, premature birth, and intrauterine growth retardation.4 Ongoing heroin use during pregnancy has also been shown to be associated with use of other illicit drugs, poor engagement with antenatal services, frequent use of emergency care facilities, and social adversity.5 Although heroin and other opioids have no specific teratogenic potential, 48–94% of children exposed in utero will have opioid withdrawals at birth or neonatal abstinence syndrome6 (NAS). A brief description of its characteristics and treatment is given in the discussion section.
In this report we present the case of a pregnant heroin addict who was treated with methadone during her pregnancy, with very good outcomes for her and the baby. The primary aim of this case report is to raise awareness of NAS among clinicians and to remind them that, although very common in children born to opioid dependent mothers, NAS is not inevitable. Although by no means unique, this case will hopefully serve as a reminder of this important clinical lesson. We also demonstrate that comprehensive and coordinated antenatal care addressing the biopsychosocial needs of the pregnant addict can minimise the risk of NAS and other adverse outcomes for the mother and the baby—this has also previously been reported in literature7 but we feel is important for clinicians to bear in mind.
The case involves is a 27-year-old white British woman, who lives with her three children (aged 7, 6 and 1) in a council tenancy. She is unemployed and receives state benefits. She was first seen at our drug service in 2004, following a self referral. At initial assessment, she reported a 5 year history of heroin dependence and a 3 year history of cocaine misuse. She was smoking between 2–3 bags (0.4–0.6 g) of heroin and 1–2 ‘shots’ of cocaine a day, but denied ever injecting drugs. She also denied ever misusing any other illicit psychoactive substance or alcohol. Assessment revealed nothing suggestive of underlying psychiatric comorbidity or other medical disorders. At that time she had two children aged 2 and 1. She reported having stayed off drugs (heroin and cocaine) all through her two pregnancies, but relapsed into regular heroin and cocaine use 6 weeks after the birth of her first child and 16 weeks after her second child, respectively. She appeared highly motivated to address her drug problems.
The patient derives from a family of three, with no history of substance dependence in the family. Her parents separated when she was a child, but she maintains excellent relationship with both of them. Her sister is extremely supportive to her; her younger brother is autistic. She was born and raised locally, attended normal mainstream schools, and was average academically. She has no formal educational qualifications and has never been in structured employment. She has committed numerous acquisitive offences (shoplifting) to finance her drug use. Until recently, she was in an abusive relationship with a drug using partner, but is now separated and lives with her three children.
Following the initial assessment, the patient was started on methadone 40 ml daily (1mg/1ml, oral solution). In addition, her treatment package consisted of one-to-one psychological input from her keyworker and further support to address her social needs. She started making progress in treatment and reduced her heroin and cocaine use significantly. Three years into treatment, she was pregnant for a third time, but this went unrecognised until she was 16 weeks pregnant. Soon her care was transferred to our specialist mother and baby nurse. This nurse remained the patient’s keyworker throughout her further treatment and she coordinated her care with other professionals such as antenatal staff, maternity services, general practitioner, and social services. There were regular multidisciplinary reviews of her care and progress in treatment. A comprehensive care plan was drawn up, with the patient’s active participation, with extensive input from all professionals involved in her treatment. She was also informed and educated about the rationale and benefits of methadone treatment and the risk of NAS. Adequate opportunities were provided for her to understand the risk of NAS, its symptoms, and how it could be treated. During the second trimester, at her request, the dose of methadone was gradually reduced to 17 ml daily. At this dose, she remained clean of heroin and denied any craving or withdrawal symptoms. She was receiving regular antenatal care and her pregnancy was uneventful.
At 37 weeks gestation, the patient gave birth normally to a healthy baby. He weighed 8 lbs (3.6 kg) and showed no signs of NAS. They were kept in hospital for 3 days to monitor the baby for NAS, after which they were discharged.
Patient perspective
Given below is the patient’s reflections on her pregnancy, drug use and treatment in general:
“When I first found out I was pregnant, it was at 3 months I think, I was still using heroin but soon after I found out I was pregnant I stopped straightaway. I am probably one of the rare ones who can actually stop using heroin quite quickly, if you know what I mean. With me it was more about the people that I was around that were using that tempted me to use. If it wasn’t there in front of my face then it wouldn’t bother me at all. I would not sit there thinking I would love to smoke now. It was when it was there in front of me that was the temptation for me, so once I got rid of it being there in my face I didn’t really have a problem with it. I never have had a problem with it when I’ve been on my own, it’s just people around me.
“I felt guilty about being on methadone and being pregnant so while I was pregnant I was just trying to drop it as much as I could, but do it at a safe level as well because it can harm the baby if you drop too much too quick. I did not want to drop it too much, because then I would have had to smoke heroin. My keyworker explained about dropping methadone as much as we could but slowly and steadily and then we kept it at 17 ml for the last few months so that it was a steady balance. So when he was actually born I was on 17 ml of methadone a day which is not a lot, but he could still have had withdrawal symptoms from that. I was worried about it. I mean, people that I spoke to at the clinic and people who I spoke to at the hospital said you know there is a lot we can do. I was worried because I didn’t want him going through that because knowing how it feels to withdraw myself, I didn’t want my newborn baby to feel that, so I felt bad but I was very relieved when he was born. We were kept in for 3 days because he was monitored closely to make sure he did not show any symptoms which he didn’t, but it was a worry all the way through. I didn’t want him feeling what I felt with withdrawing. It’s not nice is it?
“The clinic was great—definitely. My keyworker was great. I have always got on with her. When I had my hospital (antenatal) appointments, not that anybody said anything or done anything but you know, when they read your notes and they read that you are on methadone, I don’t know, you just feel that they think oh, it is bad to be on methadone or to be smoking heroin when you are pregnant. Just the way they sit there filling out forms and don’t really talk to you like a normal person, do you know what I mean? Just like that. So it did make me feel like people looked down their noses a bit at the fact that I was pregnant and on methadone.
“But it helped my keyworker telling me about NAS, she told me a lot about it. In fact, we did speak a lot about what happens if the baby shows signs and that the baby could be given medication to come out of it. She explained all that to me and how it works and stuff. I mean there have been people that I know that their babies have been born and they have had to be in hospital for 2 to 3 weeks being weaned off it, and I was just glad that after 3 days I was able to take him home and he was OK. I was as happy as I could have been.”
Investigations
Urine and saliva tests at various points in her treatment have corroborated her history of illicit (heroin and cocaine) and prescribed (methadone) psychoactive substance use.
Treatment
The patient is currently drug-free and has been discharged from our treatment service. During her time with us, she was treated with maintenance doses of methadone ranging from 17 ml (1 mg/1 ml) to 45 ml of methadone a day. Eventually, this was reduced very gradually (by 2 ml every 2 weeks) and stopped.
After the birth of her third child, she continued in treatment with our service. She was still on methadone 17 ml daily and was also in receipt of 1:1 psychosocial input from her keyworker. A few months after her delivery, she relapsed into regular heroin and cocaine use, and hence the dose of her methadone was increased to 40 ml daily. This helped her eliminate heroin use and she was maintained on that dose. Her motivation improved significantly and she started making appropriate psychosocial changes in her life, and started working towards a drug-free life. She split up with her drug using partner, who she considered a major impediment to her own journey to recovery. She sought and received support to work through her separation from her partner and also regarding domestic violence. She also mobilised extensive support from her mother and sister. Simultaneously, it was also agreed to gradually reduce and stop methadone, and over the next few months she was methadone free. She was also clean of heroin and cocaine. Social services, who continued to support her during and after her pregnancy, soon decided to ‘close her case’ as she had made significant progress and there were no concerns about her child care or parenting. She was offered naltrexone treatment which she declined. Hence a relapse prevention plan was put in place and she was discharged from our service.
In this section, we will first briefly describe NAS, its features and treatment. Then we will highlight aspects of the patient’s treatment that we believe helped achieve a successful outcome for her and her baby. This will be discussed within the context of and with reference to existing research findings and evidence base in the field of pregnancy and opioid dependence.
NAS is a set of behavioural and physiological signs and symptoms in the newborn that is a result of abrupt psychoactive substance withdrawal at birth. It occurs in the majority of infants exposed to opioids in utero and estimates vary from 48–94%.6 NAS can vary in its onset, duration and severity depending on the severity of maternal dependence and fetal metabolism. Although symptoms of NAS are usually apparent within 24–72 hours after birth, occasionally this could be as late as 10 days. Typical characteristics of opioid NAS are irritability, high pitched cry, vomiting, diarrhoea, hypertonicity, tremor, tachypnoea and, in severe case, seizures. Some have noted methadone to cause NAS that is delayed in onset, of longer duration, and of greater severity.8 Most cases of NAS only require supportive treatment measures, but severe cases will need pharmacological treatment. Drugs such as morphine, tincture of opium, barbiturates and benzodiazepines have been used with good success. If adequately treated, NAS causes no long term damage to the child.
In drug using women, pregnancy often presents a window of opportunity for change: motivation levels tend to be high; they are more amenable to treatment; and hence it is an ideal time to intervene. In our case, she was already engaged in treatment (and was on methadone) when she found out that she was pregnant. Her engagement with treatment services continued to be very good. Furthermore, her care and keyworking was taken over by our specialist mother and baby nurse, who also coordinated her care with other agencies and professionals. This included ongoing liaison and regular meetings with all professionals involved in her care: the midwife, obstetrician, GP and social services. Such a comprehensive and coordinated multidisciplinary treatment package also gave the opportunity to address her psychosocial needs. The benefits of such treatment programmes have been reported previously in literature by Day et al9 who showed that they result in high levels of engagement and pronounced reduction of illicit drug use.
Another important aspect of our patient’s care was the gradual reduction and eventual successful maintenance on 17 ml of methadone daily during her last trimester. She was also informed of the risk of NAS and was adequately prepared for the same. She was told that methadone was a safe drug to be on during pregnancy and when she requested a detoxification, the risks of it during the last trimester (premature labour, low birth weight, neonatal morbidity, etc) were mentioned, and on balance she chose to be on a low maintenance dose of methadone. Given that the rates of NAS among those on methadone are as high as 90%, it is perhaps surprising that our patient’s child did not have NAS. But evidence suggests that specialised multidisciplinary management of drug use during pregnancy can reduce the risk of NAS to as low as 26%.10 In fact, a good outcome for the mother and baby in this case is perhaps not all that surprising: better antenatal care, healthier pregnancies and healthier babies were outcomes reported in outpatient methadone programmes for pregnant women.11
We acknowledge that this is only one case and hence has obvious generalisability limitations. We also acknowledge, given that addiction can be a chronic disorder and given her past history, we cannot yet comment on her long term prognosis. Nevertheless, it seems reasonable to draw some valid conclusions. First, pregnancy is a window of opportunity for change. Second, methadone substitution treatment is safe and results in good outcomes for the mother and the baby. Thirdly, although NAS is very common it is not inevitable and measures can be put in place to minimise the risk of NAS. Finally, clinicians need to be aware of this syndrome, its presentation, its impact on the mother, and measures that can be put in place to minimise the risk.
Learning points
  • Heroin misuse in pregnancy is a significant health and social problem, and it can adversely effect the mother and the baby.
  • In drug using women, pregnancy often presents a window of opportunity for change; they are more amenable to treatment and hence this is an ideal time to intervene.
  • Methadone substitution treatment is safe in pregnant women, with good outcomes for the mother and the baby.
  • 48–94% of children exposed to opioids in utero will have opioid withdrawals at birth or neonatal abstinence syndrome (NAS).
  • The risk of NAS can be minimised by offering comprehensive and coordinated antenatal care that addresses the various biopsychosocial needs of the pregnant woman.
Footnotes
Competing interests: None.
Patient consent: Patient/guardian consent was obtained for publication.
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2. Fapohunda M, George S. Opioid misuse in the pregnant woman. MIMS Women’s Health 2008; 3: 24–6.
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11. Giles W, Patterson T, Sanders F, et al. Outpatient methadone programs for pregnant heroin using women. Austr NZ J Obstetr Gynaecol 1989; 29: 225–9. [PubMed]
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