ACOG Practice Bulletin Diagnosis and Management of Preeclampsia and Eclampsia:  This bulletin provides guidelines for the diagnosis and management of hypertensive disorders unique to pregnancy, as well as the various associated complications.  Note: No link as ACOG has specifically asked that this information NOT be shared.

Recommendations for Blood Pressure Measurement in Humans and Experimental Animals:  Accurate measurement of blood pressure is essential to classify individuals, to ascertain blood pressure–related risk, and to guide management.  This article provides recommendations from the American Heart Association on correct blood pressure monitoring.

Alternative magnesium sulphate regimens for women with preeclampsia and eclampsia:  Cochran review  to assess the comparative effects of alternative regimens for the administration of magnesium sulphate when used for the care of women with pre-eclampsia or eclampsia, or both.

Antihypertensive drug therapy for mild to moderate hypertension during pregnancy:  Cochran review to assess the effects of antihypertensive drug treatments for women with mild to moderate hypertension during pregnancy

ACOG Practice Bulletin - Chronic Hypertension in Pregnancy:  The purpose of this document is to review the effects of chronic hypertension on pregnancy, to clarify the terminology and criteria used to define and diagnose it during pregnancy, and to review the available evidence for management options. Note: No link as ACOG has specifically asked that this information NOT be shared.

Diagnosis and Management of Gestational Hypertension and Preeclampsia:  This article provides diagnosis criteria and classifications of hypertension in pregnancy and management strategies.

Magnesium sulfate prophylaxis in preeclampsia:  Lessons learned from recent trials:  Article that discusses recent trials using magnesium sulfate in preeclampsia

Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial:  a randomized placebo controlled trial:  The Magpie Trial (MAGnesium sulphate for Prevention of Eclampsia) was a large international trial designed to evaluate the effects of magnesium sulphate on women and their babies. The aim was to find out if, overall, women with pre-eclampsia or their children, or both, do better if they are given magnesium sulphate rather than placebo, regardless of whether treatment is started before or after delivery and irrespective of any previous anticonvulsant therapy

Evaluation and management of severe preeclampsia before 34 weeks’ gestation:  Objective was to review the risks and benefits of expectant management of severe preeclampsia remote from term, and to provide recommendations for expectant management, maternal and fetal evaluation, treatment, and indications for delivery.

Management of Late Preterm and Early-Term Pregnancies Complicated by Mild Gestational Hypertension/Pre-Eclampsia:  Provides summaries of studies and treatment recommendations

Magnesium Sulfate in Women With Mild Preeclampsia:  A Randomized Controlled Trial:  A randomized control trial with the objective to determine whether magnesium sulfate prevents disease progression in women with mild preeclampsia.

Management of hypertensive disorders during pregnancy:  summary of NICE guidance:  A summary of guidelines in the treatment of hypertension

Oral beta-blockers for mild to moderate hypertension during pregnancy:   Cochran review to assess whether oral beta-blockers are better than placebo, or no beta-blocker, and have advantages over other antihypertensives, for women with mild to moderate pregnancy hypertension.

How to manage hypertension in pregnancy effectively:  Article discusses management of hypertension and other aspects of care for the hypertensive pregnant patient

Prediction of adverse maternal outcomes in pre-eclampsia development and validation of the fullPIERS model:  The fullPIERS model identifi es women at increased risk of adverse outcomes up to 7 days before complications arise and can thereby modify direct patient care (eg, timing of delivery, place of care), improve the design of clinical trials, and inform biomedical investigations related to pre-eclampsia.

Instituting Surveillance Guidelines and Adverse Outcomes in Preeclampsia:  A study to assess the incidence of combined adverse maternal and perinatal outcomes in women with preeclampsia before and after introducing standardized assessment and surveillance.

WHO recommendations for Prevention and treatment of pre-eclampsia and eclampsia:  Recommendations from the World Health Organization on prevention and treatment of preeclampsia and eclampsia

Pregnancy Medical Home Program Care Pathway:  Management of women with hypertensive disorders of pregnancy.  This pathway provides definitions of the disorders to better standardize the language used with hypertension and details management of each stage of hypertension.

Improving Health Care Response to Preeclampsia: A California Quality Improvement Toolkit - The toolkit provides a series of articles on best practices for hypertensive disorders that range in topic from diagnostic challenges to appropriate implementation of accepted medical therapy and recognition of institutional limitations in providing care for these complex maternal patients. Of particular interest, the toolkit addresses the management of severe preeclampsia < 34 weeks, the importance of recognition and treatment of delayed postpartum preeclampsia/eclampsia in the emergency department and early postpartum follow-up upon discharge. In addition, the toolkit provides care guideline summaries (in checklist, flowchart and table chart formats)

NAS Outcome Measures:

The overall aims statement for the NAS initiative was developed by the expert team along with outcome measures to ensure a standardized approach to the care of the NAS infant and family.

nas outcome image 

Outcome Measures

Examples of NAS Management Algorithms

The expert team is using the following examples to create Care Management Algorithms to standardize the treatment of NAS:

Phase I:  To Treat of not to treat algorithm is used to determine whether the patient will be treated with non-pharmacologic methods or whether they will receive pharmacologic treatment

NAS Treatment Algorithm

 Phase I algorithm 

Phase II:  Stabilization on Morphine algorithm is used to begin treatment and to increase dosing if needed.

NAS Stabilization Algorithm

Phase II Stabilization algorith


 Phase III: Weaning

weaning algorithm image

Phase III Weaning Algorithm

Phase III  Backsliding 

backsliding algorithm image

Phase III  Backsliding algorithm


Carolinas Healthcare System:  Management of Pain in the Neonate

Guidelines to ensure the assessment and management of neonatal pain and potential opioid withdrawal

Catawba Valley Medical Center:  Drug Withdrawal

Guidelines on care needed by infants of mothers that used methadone/opiates or other substances while pregnant.  

Forsyth Medical Center:  Neonatal Abstinence Management

Guidelines for the management and cohorting of infants experiencing withdrawal symptoms.  

Forsyth Medical Center:  Best Practice Neonatal Abstinence Syndrome 

Collection of best practices for the treatment of NAS - part 1

Forsyth Medical Center:   Neonatal Abstinence Assessment

Collection of best practices for the treatment of NAS - part 2

UNC:  Urine Toxicology Screening on Labor and Delivery Clinical Guidelines

Guidelines of who should be screened and a description of toxicology testing available at UNC

UNC:  UNC Newborn Nursery Clinical Guidelines

Guidelines for the treatment of Neonatal Abstinence Syndrome

UNC:  Can my baby withdraw?

Brochure for parents on what to expect with NAS

Vidant: NAS Policy and Procedure

Policy for assessment and care of NAS infant

Vidant: Procedure for management of NAS using Clonidine with Morphine

Details the dosing for pharmacologic treatment of NAS

Vidant: Guide to NAS - What to expect for your baby

Parent education booklet

Presby: NAS Initiation

Initiation order set for NAS

Presby: NAS Symptom-Based Protocol

Protocol for symptom-based morphine administration

Neonatal Abstinence Syndrome: How States Can Help Advance the Knowledge Base for Primary Prevention and Best Practices of Care
This report by the Association of State Health and Territorial Officials discusses prevention and intervention opportunities to avert or ameliorate the outcome of NAS along a continuum of care spanning time frames in the mother’s life and that of her child.
In this article, (from Pediatrics, February 2013), the authors review the data regarding the prevalence of exposure and available technologies for identifying exposure as well as current information regarding short- and long-term outcomes of exposed infants, with the aim of facilitating pediatricians in fulfilling their role in the promotion and maintenance of infant and child health.
This article (from Pediatrics, August 2013) reviews the current literature on prevention, recognition, and management of withdrawal syndromes in infants and children.
This documents details the NAS clinical practice guidelines that provide the framework to inform and support a coordinated strategy to address NAS in Ontario.
This article (from JAMA, May 2013) describes the national incidence of NAS and antepartum maternal opiate use and characterizes trends in national health care expenditures associated with NAS from 2000-2009 (all of which increased substantially during this time).
This document describes the guidelines for management of opioid-exposed newborns at Vermont Children’s Hospital at Fletcher Allen Health Care.  It includes treatment, screening, and breastfeeding guidelines, and the guidelines for special cases such as the management of infants born to Hepatitis C positive women.
These NAS clinical practice guidelines were produced by the Provincial Council for Maternal and Child Health in Canada.  They are primarily organized by tables, listing the recommendation, rationale, quality of evidence and classification of recommendations, and implementation considerations.
This article (from Pediatrics, March 2013) updates information about the clinical presentation of infants exposed to intrauterine drugs and the therapeutic options for treatment of withdrawal.  It also includes evidence-based approaches to the management of the hospitalized infant who requires weaning from analgesics or sedatives.
This brief PowerPoint presentation describes the important of attaining reliability with clinical screening tools, defines the items that make up the Finnegan NAS Scoring Tool, and describes how to determine inter-observer reliability with this tool.
This is a lengthy PowerPoint presentation by the Medical Director of QI Services at Nationwide Children’s Hospital in Ohio that describes a clinical convention for determining when LOS is prolonged in a regional neonatal referral center, describes how local data from VON can be used with the Model of Improvement to reduce LOS in a regional neonatal referral center, and lists three interventions (PDSA) associated with decreased LOS for NAS patients.
This statement (from Pediatrics, March 2013) presents current information about the clinical presentation, differential diagnoses, therapeutic options and outcome for the offspring associated with intrauterine drug exposure.
This article (from Addiction, 2010) assesses the variability of the Finnegan scores in newborns not exposed to opiates, showing that scores increased from days 1-3 to weeks 4-6 and show day-night cycles with 5-6 weeks.
This article (from Advances in Neonatal Care, 2012) describes the development, implementation, and outcomes of a NAS management program and utilization of the Finnegan NAS Scoring Tool.  A non-experimental study evaluated change in nursing knowledge about NAS and the use of the scoring tool after implementation of evidence-based clinical practice guidelines and an educational project.  The authors conclude that all nurses showed some level of improvement in knowledge.
This article (Clinical Obstetrics and Gynecology, March 2013) discusses the short- and long-term developmental outcomes associated with prenatal opiate exposure, maternal and infant risk factors, and the importance of characterizing corollary environmental risk factors.
This article (from Journal of Perinatology, 2006) consists of the results of a questionnaire distributed to the chiefs of neonatology divisions with accredited fellowship programs in Neonatal-perinatal medicine in the US.   The authors conclude that the management of neonatal psychomotor behavior consistent with withdrawal varies widely, with inconsistent policies to determine its presence or treatment.  The authors found that only about half of NICUs had written guidelines for the management of NAS at that time.
This article (from New England Journal of Medicine, 2010) describes the results of a double blind, randomized, controlled, international study comparing buprenorphine and methadone treatment for 175 pregnant women with opioid dependency.  Overall, the results were consistent with the use of buprenorphine as an acceptable treatment for opioid dependence in pregnant women.
This article, by a nurse practitioner with clinical NAS experience, provides an overview of the possible risks, benefits, and outcomes of pharmacologic and complementary therapies in the neonatal population, and illustrates the gaps in knowledge related to their use for neonatal withdrawal.
This is a Cochrane Review of opiate treatment for opiate withdrawal in newborn infants.  Selection criteria for this review included trials enrolling infants with NAS born to mothers with an opiate dependence, with >80% follow up and using random or quasi-random allocation to opiate or control.  Controls could include an opiate, sedative, or non-pharmacological treatment.  Because of methodological limitations, the authors advise to treat the conclusions from this review with caution.