Opioid addiction

/ Antenatal Care, MRCOG Part 3, Special Situations / By

Opioid addiction

This is a patient simulated task. The task assesses:

  • Information gathering
  • Communication with patient
  • Applied clinical knowledge
  • Patient safety

You are about to see, Mary Williams, a 25-year-old lady, in her 1st pregnancy. She is here for a booking visit at 16 weeks.Your task is to:

  • Take relevant history
  • Address her concerns
  • Formulate a management plan

Discussion & Questions

History

General Questions:

  • Is this your first pregnancy? Any previous pregnancies?
  • Duration of pregnancy?
  • When did you find out you were pregnant?
  • Any previous antenatal care or visits so far?
  • Do you know your blood group? (Important for Rh-negative)
  • Any past medical or surgical history?
  • Any allergies?
  • Any current medications, including methadone or buprenorphine?
  • Any concerns about fetal movements yet?

Obstetric History:

  • Any past pregnancies, miscarriages, or terminations?
  • Mode of delivery?
  • Any complications like preterm birth, growth restriction, or stillbirth?

Drug Use History:

  • How long have you been using heroin?
  • Route of use (smoking, snorting, injecting)?
  • Frequency and last use?
  • Desire or attempts to stop? Any previous detox or rehab?
  • Have you increased your dose recently?
  • Time or effort spent on procuring the drug?
  • Interference with quality of life or relationships?
  • Involvement of violence or coercion?
  • Are you on any substitution therapy (methadone, buprenorphine)?

Systemic History:

  • Psychiatric: Mood, depression, anxiety (screen for co-existing mental health issues)
  • Sexual Health: STIs, contraception use, partner status
  • Social: Support at home? Financial situation? Stable housing?
  • Smoking/Alcohol/Other drugs?
  • Domestic abuse screening
  • FGM screening (routine in booking)

Examination

With consent and chaperone:

  • General: BP, HR, temperature
  • BMI and nutritional status
  • Skin signs: needle marks, abscesses, poor dentition
  • Venous access assessment
  • Urinalysis
  • Fundal height (later gestation)
  • Doppler for fetal heart (if applicable)

Addressing Concerns (Reassurance & Education)

  • “You’ve done the right thing by attending today. We’re here to support you and your baby.”
  • “I know this can be difficult to talk about—everything you say is confidential unless there are safety concerns.”
  • “We’ll work together with a team to make your pregnancy as healthy as possible.”

Possible Effects of Heroin Use

On the Mother:

  • Irregular periods, increased risk of miscarriage, infection, thrombosis
  • Malnutrition, infections (HIV, Hepatitis B/C)
  • Mental health issues, poor dental health
  • Increased risk of DVT, pulmonary embolism, anaemia, and cardiac infection (endocarditis)

On the Baby:

  • Premature birth, growth restriction, low birth weight
  • Neonatal Abstinence Syndrome (withdrawal symptoms after birth)
  • Sudden infant death syndrome (SIDS), neurodevelopmental problems
  • NOT linked to congenital anomalies

Management

Antenatal Care:

  • Refer to a specialist multidisciplinary team: obstetrician, drug and alcohol services, mental health, safeguarding, social worker
  • Urine toxicology at booking (with consent)
  • HIV, Hepatitis B & C, syphilis, STI screening
  • High-dose folic acid, vitamin D
  • Serial growth scans for fetal monitoring
  • Dental referral due to increased risk of decay
  • Mental health support – IAPT or perinatal mental health services

Opioid Substitution Therapy:

  • Continue current stable dose of methadone or buprenorphine (1st line)
  • Avoid sudden withdrawal (“cold turkey”)
  • Monitor for compliance and illicit use

Intrapartum Care:

  • Birth at a consultant-led unit
  • Early IV cannula due to poor veins
  • Continue opioid therapy in labour
  • Avoid naloxone at birth unless essential (can trigger severe withdrawal in baby)
  • Continuous fetal monitoring in labour
  • Consider paediatric input at delivery

Postnatal Care:

  • Observe baby for signs of NAS (Neonatal Abstinence Syndrome)
  • Provide more analgesia than routine (opioid tolerance)
  • Avoid drugs with high relapse potential (oxycodone)
  • Involve safeguarding team if needed
  • Support with breastfeeding, contraception, social and financial help

Closure

  • Offer written information (PIL) on heroin use and pregnancy
  • Arrange MDT follow-up and consultant review
  • Discuss contraception postnatally
  • Reinforce that care is supportive, not judgmental

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