Background: The incidence of both prescription opioid and heroin abuse among pregnant women has risen dramatically in recent years, currently affecting 5.6 per 1000 live births. In fact, drug overdose now represents the leading cause of maternal death in Colorado. In addition to overdose, other serious risks associated with opioid use during pregnancy include infectious complications from intravenous use, as well as socioeconomic sequelae, such as inadequate prenatal care, poor nutrition, and increased rates of maternal mental illness and interpersonal violence. For the newborn, Neonatal Opioid Withdrawal Syndrome (NOWS) can lead to significant morbidity from a combination of central nervous system, autonomic, and gastrointestinal disturbances. This syndrome is associated with poor developmental outcomes and significantly higher healthcare costs. Despite the above risks for both the mother and baby, maternal “detoxification” is discouraged, as the stress of acute withdrawal can lead to intrauterine growth restriction, preterm labor, and fetal demise. Instead, opioid agonist treatment remains the standard of care during pregnancy, as discussed below.
Case description: We report a 30-year-old G1P0 female presenting for cesarean section for breech presentation. The patient’s history was notable for heavy heroine abuse extending into her first trimester, at which time she was transitioned to remarkably high-dose Methadone maintenance (190mg BID). Surgical delivery under combined spinal-epidural anesthesia was performed without issues. The neonate did well after delivery (APGARS of 7 and 8), and never developed signs of NOWS. However, postoperatively, the patient’s pain proved difficult to control despite patient-controlled epidural analgesia, an incisional pain catheter, high-dose oral oxycodone, scheduled Acetaminophen and Ketorolac, as well as continuation of her home Methadone. Eventually, remarkable improvements were achieved after simply dividing the Methadone dosage from 190mg BID to 95mg QID. She was discharged home on postoperative day 4, along with her healthy baby boy.
Discussion: In review, this patient was successfully managed on Methadone therapy during pregnancy to mitigate the risks associated with both heroine abuse and withdrawal. Consistent with available literature, this patient demonstrated relatively unremarkable intraoperative anesthetic requirements, but had very difficult to control postoperative pain. Indeed, Meyer et al. showed that mothers on Methadone maintenance during pregnancy have no significant increases in intrapartum pain scores or opioid requirements compared to controls, but significantly higher pain scores and opioid requirements after cesarean delivery. There remains ongoing debate regarding the efficacy of Methadone versus Buprenorphine in this setting. Methadone has historically remained the gold standard with decades of proven safety and efficacy. Furthermore, it does not carry the same risk of precipitating acute withdrawal during initiation of therapy, and is clearly more effective for mothers with particularly high opioid requirements. Meanwhile, Buprenorphine offers decreased risks of drug interactions and overdose, and results in less severe NOWS. Regardless of the regimen, it is important to continue the patient’s home medication perioperatively, as part of a multimodal analgesia approach which may require atypical dosing as described above.
