[CG] Benzodiazepines in pregnancy – guideline for obstetric management

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Applicable Unit policies

BENZODIAZEPINES

Many patients of all ages and backgrounds are long term users of oral prescribed benzodiazepines or users of oral or injected illicit benzodiazepines. Sudden withdrawal of benzodiazepine therapy leads to marked agitation, insomnia and even seizures and it is important to take action to avoid these consequences.

Long term users of prescribed benzodiazepines can continue at the prescribed dose while in hospital.

Pregnant women using illicit benzodiazepines should undergo detoxification (see below).

Benzodiazepine de-tox. In-patient

  1. For in-patient benzodiazepine de-tox, regardless of level, pattern or type of benzodiazepine used, commence at maximum total daily dose of diazepam 30mg administered in 3 divided doses. If using <30mg/day commence at actual level of use.
  2. Reduce daily dose of diazepam by 5mg daily, reducing 3 doses in rotation with evening dose last as shown below:

     

    Diazepam dose and time of administration

     

    09.00

    14.00

    22.00

    Day 1

    10mg

    10mg

    10mg

    Day 2

    10mg

    5mg

    10mg

    Day 3

    5mg

    5mg

    10mg

    Day 4

    5mg

    5mg

    5mg

    Day 5

    5mg

    0

    5mg

    Day 6

    0

    0

    5mg

  3. If difficulty in tolerating this regime manage as follows:
    1. If admission solely for benzodiazepine de-tox (i.e. no obstetric indication for admission) and SNIPS staff not available (e.g. out-with normal working hours) do not prescribe supplementary doses of diazepam. In such situations discharge woman with SNIPS follow up appointment to discuss option of formal benzodiazepine de-tox in residential rehab.
    2. If admission primarily for obstetric indication, (i.e. in-patient care deemed advisable) and SNIPS staff not available (e.g. out-with normal working hours) the prescribed dose of diazepam can be maintained at a max of 30mg/day or less (see 1 above) until reviewed by SNIPS staff.
  4. Ensure adequate Nicotine Replacement Therapy (NRT) (any combination of 24 hour patches, chewing gum, inhalator and nasal spray as required) is prescribed when necessary ((see SNIPS guideline)) and do not allow woman to leave ward. If she has to attend for care elsewhere ensure she is accompanied at all times by a member of staff.
  5. For all women using illicit benzodiazepines and women on significant doses of prescribed benzodiazepine (> 20mg diazepam daily or equivalent) transfer to SNIPS is advisable. If not transferred refer directly to addiction services and / or Hospital Addiction Liaison Nurse (see Therapeutics Handbook for contact details) and refer to Social Work for assessment.

Additional Obstetric Care

  1. Record problem alcohol and / or drug use (illicit and / or prescribed) on yellow alert sheet (maternal and neonatal sections) in maternal case notes.
  2. Women on regular benzodiazepines prescribed or illicit should be informed of the increased risk of cleft lip and/or palate at the time of the routine FAS scan is offered.
  3. Any woman with problem drug use (including women on prescribed opiate substitutes) should have AC measurements carried out at 28 – 30 and 32 – 34 weeks gestation at least 2 weeks apart.
  4. Opiates and / or benzodiazepines can cause reduced variability on CTG. Other explanations must be considered and excluded before assuming a causal link in this group of patients. Particular attention should be given to any CTG with more than one abnormal parameter.

Important notes

  1. Uncontrolled use of illicit opiates constitutes an obstetric emergency. Women reporting such use should be admitted immediately for stabilisation on prescribed methadone. Prescription of substitute methadone can be initiated by mainstream staff in accordance with the SNIPS guideline.
  2. Transfer to SNIPS of existing maintenance methadone prescription must be authorized by a member of SNIPS staff. This must be arranged during normal working hours and with a minimum of one week’s notice.
  3. Uncontrolled use of benzodiazepines is a significant obstetric problem but does not invariably warrant emergency admission. Inpatient detoxification (see above) is advisable but management cannot be agreed if the woman is intoxicated in which case she should be invited to return the following day for review.
  4. SNIPS staff should be notified as soon as possible with regard to ongoing management.

Last reviewed: 01 April 2016

Next review: 20 March 2021

Author(s): Dr E Ellis, Associate Specialist Obstetrician PRM; Mrs J Grant, Lead Clinical Pharmacist, W&C, O&G, GGC

Co-Author(s): Other professionals consulted: Dr H Mactier, Consultant Paediatrician, PRM GG&C Obstetric Guideline Group

Approved By: Dr C Bain, Clinical Director, Obstetrics, GGC