A 27-year-old woman at 8 weeks gestation comes to the office for her first prenatal visit. This is her first pregnancy; it was unplanned. The patient lives alone and works part-time as a restaurant server. She has a 5-year history of intravenous heroin use and says, "I've tried to quit before, but it was so hard. I know drugs are bad for the baby, so I want to try again." The patient uses heroin daily. Her last injection was 6 hours ago. She has no other chronic medical conditions and no known drug allergies. Temperature is 37.2 C (99 F), blood pressure is 126/80 mm Hg, and pulse is 88/min. Physical examination is notable only for needle marks on the patient's extremities. Transvaginal ultrasonography reveals an intrauterine gestation and a heart rate of 150/min. Which of the following is the best next step in management of this patient?

Question

A 27-year-old woman at 8 weeks gestation comes to the office for her first prenatal visit.  This is her first pregnancy; it was unplanned.  The patient lives alone and works part-time as a restaurant server.  She has a 5-year history of intravenous heroin use and says, "I've tried to quit before, but it was so hard.  I know drugs are bad for the baby, so I want to try again."  The patient uses heroin daily.  Her last injection was 6 hours ago.  She has no other chronic medical conditions and no known drug allergies.  Temperature is 37.2 C (99 F), blood pressure is 126/80 mm Hg, and pulse is 88/min.  Physical examination is notable only for needle marks on the patient's extremities.  Transvaginal ultrasonography reveals an intrauterine gestation and a heart rate of 150/min.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient's continued heroin use puts her and the fetus at high risk for adverse outcomes, including overdose, effects of needle sharing, poor nutrition, and lifestyle choices that threaten maternal health and fetal growth. Opioid substitution therapy with methadone or buprenorphine is recommended as first-line treatment for opioid-dependent pregnant patients. Methadone, a long-acting opioid agonist, prevents withdrawal symptoms, decreases cravings, and reduces the euphoric effects of subsequent nonprescription opioid use. It can be used throughout pregnancy, ideally as part of a comprehensive multidisciplinary program that includes prenatal care, social work services, and counseling. Dosage increases typically are required due to increased metabolism related to pregnancy. Neonatal abstinence syndrome is expected but manageable. Compared to medication-assisted withdrawal (ie, detoxification), opioid substitution therapy is safer and associated with lower risk of relapse. Recommending medication-assisted detoxification or abstinence without pharmacologic intervention for this patient who has been unable to quit would put her at high risk for relapse, resulting in fetal stress from erratic intoxication and withdrawal episodes (Choice A). Compared with abstinence, opioid substitution therapy for opioid-dependent mothers has demonstrated improved maternal and neonatal outcomes. (Choice B) Naltrexone is an opioid antagonist used for maintenance treatment to prevent relapse, but it requires complete detoxification and an opioid-free period. Beginning naltrexone in this patient who is actively using would precipitate immediate withdrawal. In addition, there is limited evidence for the use of naltrexone in pregnancy, making methadone or buprenorphine the better choice. (Choice D) Clonidine is an alpha-2 adrenergic agonist used to relieve autonomic symptoms of opioid withdrawal, often as an adjunct to methadone and buprenorphine. Clonidine does not prevent withdrawal and craving and would put this patient at high risk of relapse. (Choice E) Reviewing the maternal and fetal health risks of continued opioid use with this patient is important. However, suggesting termination to a patient who wants to do well for her baby and has not requested it is inappropriate. Educational objective: Opioid substitution therapy with methadone or buprenorphine is the first-line treatment for opioid-dependent pregnant patients. Compared with abstinence, it is safer and associated with improved maternal and neonatal outcomes and lower risk of relapse. References: Methadone, buprenorphine, and naltrexone for the treatment of opioid use disorder in pregnant women. (http://www.ncbi.nlm.nih.gov/pubmed/28543191) Treating women who are pregnant and parenting for opioid use disorder and the concurrent care of their infants and children: literature review to support national guidance. (http://www.ncbi.nlm.nih.gov/pubmed/28406856)

A 27-Year-Old Woman at 8 Weeks Gestation Comes to the Office