Hoell Imke, Havemann-Reinecke Ursula
Klinik für Psychiatrie und Psychotherapie, Universitätsmedizin Göttingen, Von-Siebold-Str. 5, 37075 Göttingen.
Med Monatsschr Pharm. 2011 Oct;34(10):363-74; quiz 375-6.
Opioid dependent patients often are dependent from the illegal consumption of heroin and, in addition, perform a polytoxicomanic way of consuming drugs. They suffer of various somatic and psychiatric diseases. Moreover, pregnancies of drug addicted women are classified as high-risk pregnancies. With respect to the particular consumed drug substances other than opioids during pregnancy variable forms of teratogenic and toxic effects can be assigned to the baby. Critical values of maternal substance abuse referring to fetal impairment do not exist. With regard to the possible teratogenic and toxic fetal effects of maternal consume of alcohol, tobacco, sedativa, cannabis, cocaine and amphetamines, withdrawal treatment of polytoxicomanic pregnant patients under inpatient medical supervision including medication if necessary represent the first-line-treatment. With respect to smoking, it is possible to detoxicate the patients also by an outpatient treatment. However, referring to heroin addiction, a maintenance therapy with L-methadone, D/L-methadone or buprenorphine should be preferred since fetal withdrawal symptoms of opioids otherwise can cause severe complications which even can lead to the loss of the fetus and also increase the risks for the mother. Increasing the dose of the opioid substitute may be necessary, for example, to avoid premature uterus contractions. It is to be pointed out that substitution treatment with methadone or buprenorphine also improve the medicinal compliance and psychosocial circumstances of the pregnant patients. Subsequent to delivery, the maintenance treatment should initially be pursued over a further period of time. In the follow up, the question of continuing with maintenance treatment or starting a withdrawal treatment of opioids should be discussed on an individual basis. To sum up, proceeded interdisciplinary care during pregnancy and afterwards by all the professions involved like general practioners as well as social workers, gynaecologists, paediatrists, pharmacists, psychologists and psychiatrists should be ensured. Futhermore, diagnosis and therapy of the comorbid psychiatric and infectious diseases like hepatitis A, B, C and HIV are necessary and described (see Part II. Comorbidity and their treatment).
阿片类药物依赖患者往往依赖非法吸食海洛因，此外，还存在多种药物混合滥用的情况。他们患有各种躯体和精神疾病。此外，吸毒成瘾女性的妊娠被归类为高危妊娠。孕期除阿片类药物外，特定摄入的其他药物物质会对胎儿产生各种形式的致畸和毒性作用。目前尚无关于母体药物滥用导致胎儿损害的临界值。考虑到母体饮酒、吸烟、使用镇静剂、大麻、可卡因和苯丙胺可能对胎儿产生致畸和毒性作用，在住院医疗监督下对多药滥用的孕妇进行戒断治疗（必要时包括药物治疗）是一线治疗方法。对于吸烟，也可以通过门诊治疗使患者戒毒。然而，对于海洛因成瘾，应优先采用左旋美沙酮、消旋美沙酮或丁丙诺啡维持治疗，因为否则阿片类药物的胎儿戒断症状可能会导致严重并发症，甚至可能导致胎儿丢失，同时也会增加母亲的风险。例如，为避免子宫过早收缩，可能需要增加阿片类替代药物的剂量。需要指出的是，美沙酮或丁丙诺啡替代治疗还可改善孕妇的药物依从性和社会心理状况。分娩后，维持治疗应在一段时间内继续进行。后续应根据个体情况讨论继续维持治疗或开始阿片类药物戒断治疗的问题。总之，应确保在孕期及产后由全科医生、社会工作者、妇科医生、儿科医生、药剂师、心理学家和精神科医生等所有相关专业人员提供跨学科护理。此外，对合并的精神疾病和传染病如甲型、乙型、丙型肝炎及艾滋病毒进行诊断和治疗是必要的，相关内容将在第二部分“合并症及其治疗”中描述。
