Opioid misuse in pregnancy

M R C O G PA R T 2 · S O S P O C K E T C A R D · K N O W L E D G E A R E A 5 – A N T E N ATA L C A R E

Opioid Misuse in Pregnancy Thomson S et al. Opioid misuse in pregnancy. TOG 2022;24:101–108. doi:10.1111/tog.12779

55–95% 60–120 mg 12–16 mg INFANTS SHOWING SIGNS OF NAS METHADONE MAINTENANCE DOSE/DAY BUPRENORPHINE MAINTENANCE DOSE

DO N' T-M IS S FA C TS

  1. NAS occurs in 55–95% of opioid-exposed infants; substitution therapy reduces but does not eliminate this risk

  2. Methadone 60–120 mg/day; buprenorphine 12–16 mg (up to 32 mg) maintenance – buprenorphine not first-line to initiate in pregnancy

  3. Never give naloxone to the neonate for respiratory depression – precipitates withdrawal crisis

  4. No sudden cessation in pregnancy; gradual 2nd-trimester detox = 2–3 mg methadone every 3–5 days

  5. Continue methadone/buprenorphine through labour – not sufficient analgesia alone; wait 2–8h after opioid analgesia before buprenorphine dosing

  6. Continuous CTG in labour – opioid effect (↓variability, low baseline, no accelerations) can mimic/mask hypoxia

  7. Promote LARC before discharge (failure rate <1%); avoid oxycodone/codeine postnatally (relapse/respiratory depression risk)

  8. Urinary opioid clearance 48–72h; infants monitored ≥72h with NAS scoring from 2h, 4-hourly

SUBSTITUTION AT A GLANCE

Methadone: better retention, closer supervision for severe dependence

Buprenorphine: lower early overdose risk, milder withdrawal, less severe NAS – not first-line to initiate

ABBREVIATION KEY

NAS — neonatal abstinence syndrome IV — intravenous

CNS — central nervous system IAPT — Improving Access to Psychological Therapies

DSM V — Diagnostic and Statistical Manual of Mental Disorders, 5th SSRI — selective serotonin reuptake inhibitor edition LARC — long-acting reversible contraception NICE — National Institute for Health and Care Excellence IUD — intrauterine device CTG — cardiotocograph/cardiotocography SCBU — special care baby unit BBV — blood-borne virus SIDS — sudden infant death syndrome STI — sexually transmitted infection

Source: The Obstetrician & Gynaecologist (TOG), RCOG journal — Thomson S et al. Opioid misuse in pregnancy. TOG 2022;24:101–108. doi:10.1111/tog.12779

Clinically reviewed by NHS obstetricians and gynaecologists

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