DRUGS IN PREGNANCY
Obstetrical and Neonatal Outcomes of Methadone-Maintained Pregnant Women: A Canadian Multisite Cohort Study

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Abstract

Objective

To describe obstetrical and neonatal outcomes including neonatal abstinence syndrome (NAS) in a Canadian cohort of methadone-maintained pregnant women.

Methods

We conducted a retrospective chart review at three integrated care programs in Vancouver, Toronto, and Montreal. Pregnant women on methadone maintenance treatment (MMT) who attended for care between 1997 and 2009 were included in this multisite study. Maternal and neonatal outcomes in each of the three contributing centres were compared.

Results

A total of 94 pregnant methadone-maintained women were included in the final analysis: 36 from Toronto, 36 from Vancouver, and 22 from Montreal. Maternal demographics showed inter-site differences in ethnicity and marital status. Obstetrical complications were not frequent; the most frequent was antenatal hemorrhage, which occurred in 14% of the total cohort. The incidence of premature labour was significantly higher in Vancouver and Montreal than in Toronto. The mean gestational age at delivery for the entire cohort was 38 weeks; mean birth weight was 2856 grams. The average length of hospital stay for babies with NAS was 19 days, with 27% of neonates requiring pharmacological treatment for NAS. Approximately 60% of neonates were discharged from hospital to the care of their mother.

Conclusion

Integrated care programs resulted in satisfactory obstetrical and neonatal outcomes for pregnant women on MMT. Policies promoting maternal–newborn contact, rooming-in, and breastfeeding may help to decrease the severity of NAS and the need for pharmacological treatment of NAS. We strongly recommend the development of similar programs across Canada to address gaps in services.

Résumé

Objectif

Décrire les issues obstétricales et néonatales, y compris le syndrome d’abstinence néonatal (SAN), au sein d’une cohorte canadienne de femmes enceintes recevant un traitement de substitution à la méthadone.

Méthodes

Nous avons mené une analyse de dossiers rétrospective au sein de trois programmes de soins intégrés à Vancouver, à Toronto et à Montréal. Les femmes enceintes recevant un traitement de substitution à la méthadone (TSM) qui ont sollicité les services de ces programmes entre 1997 et 2009 ont été admises à cette étude multisite. Les issues maternelles et néonatales constatées au sein de chacun des centres participants ont été comparées.

Résultats

En tout, 94 femmes enceintes recevant un traitement de substitution à la méthadone ont été admises à l’analyse finale : 36 de Toronto, 36 de Vancouver et 22 de Montréal. Les caractéristiques démographiques maternelles ont révélé la présence de différences entre les programmes en matière d’ethnicité et d’état matrimonial. Les complications obstétricales n’ont pas été fréquentes : la plus fréquente a été l’hémorragie prénatale, laquelle a été constatée chez 14 % des femmes de la cohorte entière. L’incidence du travail prématuré était considérablement plus élevée à Vancouver et à Montréal qu’à Toronto. Pour l’ensemble de la cohorte, l’âge gestationnel moyen au moment de l’accouchement a été de 38 semaines; le poids de naissance moyen a été de 2 856 grammes. La durée moyenne de l’hospitalisation des nouveau-nés présentant un SAN a été de 19 jours, 27 % d’entre eux ayant nécessité une pharmacothérapie pour contrer le SAN. Environ 60 % des nouveau-nés ont été remis à leur mère à la suite de l’obtention de leur congé de l’hôpital.

Conclusion

Les programmes de soins intégrés ont permis l’obtention d’issues obstétricales et néonatales satisfaisantes chez les femmes enceintes recevant un TSM. Les politiques favorisant les contacts entre la mère et le nouveau-né, le partage de la même chambre d’hôpital et l’allaitement pourraient contribuer à atténuer la gravité du SAN et la nécessité d’avoir recours à une pharmacothérapie pour contrer le SAN. Nous recommandons fortement la mise sur pied de programmes similaires partout au Canada afin de combler les écarts en matière de services.

Section snippets

INTRODUCTION

The prevalence of perinatal opioid use has been increasing over the past decade.1., 2., 3. Opioid use during pregnancy can lead to adverse obstetrical and neonatal outcomes, including an increased risk of intrauterine growth restriction, prematurity, and neonatal abstinence syndrome.4 Data from the Canadian Institute for Health Information have demonstrated that the incidence of NAS in Ontario increased from 1.3 to 3.2 cases per 1000 deliveries over the five-year period from 2004 to 2009.3

METHODS

We conducted a multisite retrospective review of the medical records of methadone-maintained pregnant women attending integrated care programs from 1997 to 2009 in three cities (Vancouver, Toronto, and Montreal). The programs were the Sheway clinic in Vancouver, the Toronto Centre for Substance Use in Pregnancy, and the Herzl Family Practice Centre in Montreal. T-CUP and the Herzl Clinic are both hospital-based centres, whereas Sheway is a community-based clinic. These programs reduce barriers

RESULTS

A total of 94 women were included in this study: 36 from Toronto, 36 from Vancouver, and 22 from Montreal. We excluded eight women who attended the Toronto program but for whom documentation relating to delivery and neonatal outcome was not available for review because they delivered at an external hospital.

Maternal demographic data are presented in Table 1. Significant inter-site differences were found in ethnicity and marital status. Women in Montreal were more likely to have partners than

DISCUSSION

These data provide an overview of obstetrical and neonatal outcomes for a national cohort of pregnant women on MMT. Differences in obstetrical outcomes are mostly related to maternal demographics and rates of maternal substance use. As previously reported,6 this sample of pregnant women used multiple substances including heroin, prescription opioids, nicotine, cocaine, marijuana, and benzodiazepines during pregnancy. This pattern of substance use is common among opioid-dependent women.5 The

CONCLUSION

In this Canadian cohort of pregnant methadone-maintained women, opioid maintenance therapy as part of an integrated care program provided satisfactory maternal, obstetrical, and neonatal outcomes. Obstetrical complications were infrequent with most infants born at term. NAS is the most significant adverse consequence of MMT during pregnancy only because of the need for prolonged hospital stay and the potential need for pharmacological treatment. Policies promoting maternal–newborn contact,

ACKNOWLEDGEMENTS

Grant support was received from the Lawson Foundation to assist with data collection. The authors wish to thank Talar Boyajian and Hee Yung Lim for assistance with data entry and Dr Rahim Moineddin for advice with data analysis.

REFERENCES (19)

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Competing Interests: None declared.

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