Maternal Drug Abuse, Exposure, and Withdrawal
Katherine W. Altshul
This is a revision of the chapter by Sylvia Schechner in the 6th edition.
I. MATERNAL DRUG AND SUBSTANCE USE AND ABUSE.
There are many drugs, exposures, and medications that, when taken in pregnancy, can have an adverse impact on the developing fetus and the infant postnatally. These include both illicit drugs as well as prescription medication. The concerns with these prenatal exposures is not only the effect they have on an infant’s health and comfort, but also the impact they have on the child’s growth, development, and behavior. The most recent National Survey on Drug Use and Health (Substance Abuse and Mental Health Services Administration, www.samhsa.gov), which compares data on drug use among pregnant and nonpregnant women, showed that 4% of pregnant women reported using illicit drugs in a given month compared to 10% of nonpregnant women. However, with the growing drug epidemic in this country, it is important that health care providers have an understanding of how these exposures can affect fetuses and infants.
The most common illicit drugs abused in the United States are cannabinoids, cocaine, heroin, and methamphetamine. There is also a growing epidemic of narcotic abuse and methadone treatment that is having profound impacts on neonates throughout the country. Alcohol and tobacco are also common exposures during pregnancy, despite their known teratogenic effects and the widespread education against their use. Intrauterine exposure to alcohol occurs more often than all the illicit substances listed in the preceding text combined. It is also difficult to tease out the effects of any one of the drugs, as many of them are taken in conjunction with others. Another increasing trend is the use of psychotropic medications taken during pregnancy, most commonly for treatment of maternal depression, anxiety, and bipolar disorder. Many of the medications used to treat these disorders are not recommended in pregnancy, and others, including some of the selective serotonin reuptake inhibitors (SSRIs), are still being studied.
II. DIAGNOSIS OF ILLICIT DRUG USE
Take a comprehensive medical and psychosocial history including a specific inquiry about maternal drug use as part of every prenatal and newborn evaluation. Accurate information regarding illicit drug use during pregnancy is sometimes difficult to obtain.
Maternal associations with drug abuse
Poor or no prenatal care
Preterm labor
Placental rupture
Precipitous delivery
Frequent demands or requests for large doses of pain medication
Signs of maternal drug abuse in the infant
Small for gestational age (SGA)
Microcephaly
Neonatal stroke or any arterial infarction
Any of the symptoms listed in Table 12.1
Diagnostic tests. Screen urine if drug withdrawal is a possibility. Urine testing is a quick, noninvasive way to test for drug exposure in the neonate; however, it will only show drug use that occurred within days of delivery. For example, cocaine will remain in the urine up to 3 days after the most recent use, marijuana 7 to 30 days, methamphetamine 3 to 5 days, and opiates (including methadone) 3 to 5 days. Drugs administered during labor may cause difficulty in interpreting urine results.
Meconium analysis by radioimmunoassay affords a longer view into the drug-use pattern but is an expensive test and results take longer to obtain. Hair analysis of the infant can reveal maternal drug use during the previous 3 months, but hair grows slowly and recent drug use may not be detected. Any negative test does not rule out the possibility of drug exposure, so clinical status is the most important evaluation. Drug screening is also not appropriate in certain situations, and it is important to consider the implications of a positive test result. The following is our statement for testing:
Physician Guidelines for Testing, Reporting, and Care of Neonates Who May Have Been Exposed Prenatally to Controlled Substances
Brigham and Women’s Hospital, Boston, MA
Testing
Purpose. A positive urine test for controlled substances can serve several purposes: (i) It may help complete a diagnostic workup for an infant with symptoms of drug dependency or withdrawal (e.g., seizures or jitteriness), (ii) it may serve as a marker for an infant at risk for developmental delay, and (iii) it may indicate an at-risk family in need of social services. (A negative test result, however, cannot rule out any of the purposes mentioned earlier.)
Symptomatic infants
Performance of a toxicology screen is strongly recommended for infants with any of the following symptoms: (i) severe intrauterine growth restriction (IUGR), which is defined as a birth weight below the third percentile; (ii) symptoms consistent with neonatal drug dependency; (iii) withdrawal and/or central nervous system (CNS) irritability; and (iv) symptoms consistent with intracranial hemorrhage (ICH) such as focal seizures or paresis. These criteria are intended to serve as guidelines only. The attending physician must decide on a case-by-case basis whether a toxicology screen is indicated, and he or she must order it.
It is hospital policy not to require a separate specific consent from the parents for a toxicology screen on a symptomatic infant. As testing of symptomatic infants is done to assist in the medical diagnosis and/or treatment of the infant, the general parental consent obtained in the initial admission consent form is sufficient. Parents must be informed by the responsible pediatrician (prior to the test if possible) of the purpose of the toxicology screen. This discussion should be documented in the medical record, indicating that the discussion was held and that the parent (mother) assents to the testing. In the event that the parents, when informed, object to the performance of the toxicology screen, the legal office should be contacted for consultation. The results of the test and any follow-up or treatment should also be discussed with the parents. The obstetrician should also be notified of all positive test results.
Table 12.1 Reported Withdrawal Syndromes in Newborns after Maternal Drug Ingestion
Lethargy
Poor state control
Fever
Diaphoresis
Tachycardia
Tachypnea or respiratory distress
Cyanosis
High-pitched or abnormal cry
Altered sleeping
Tremors
Hypotonicity
Hypertonicity
Hyperreflexia
Increased suck
Ineffective suck
Irritability
Jitteriness
Seizures
Nasal congestion
Sneezing/yawning
Ravenous appetite
Vomiting
Excessive regurgitation
Diarrhea
Weight loss
Abdominal distention
Onset
Duration
Narcotics
Codeine
X
X
X
X
X
X
X
X
X
0.5-30 h
4-17 d
Heroin
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
1-144 h
7-20 d
Methadone
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
1-14 d
20-45 d
Morphine/oxycodone
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
1 h-7 d
1-2 wk
Propoxyphene
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
±
3-20 h
56 h-6 d
Pentazocine plus tripelennamine
X
X
X
X
X
X
X
X
X
X
X
X
X
X
(“T’s and Blues”)
X
X
X
X
X
X
Sedatives
Barbiturates
X
±
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
0.5 h-14 d
11 d-6 mo
Butalbital (Fiorinal, Esgic)
X
X
X
?
X
2 d
24 d
Chlordiazepoxide
X
X
2 d
37 d
Diazepam
X
X
X
X
X
X
X
X
X
2-6 h
10 d-6 wk
Diphenhydramine
X
X
5 d
10 d-5 wk
Ethanol
X
X
X
X
X
X
±
±
X
6-12 d
Ethchlorvynol (Placidyl) (plus propoxyphene plus diazepam)
X
X
X
X
X
X
X
24 h
9-10 d
Glutethimide (plus heroin)
X
X
X
X
X
X
X
X
8 h
45 d
Hydroxyzine (Vistaril) (600 mg/d plus Pb)
X
X
X
X
X
X
X
15 min
156 h
Stimulants
Methamphetamine
X
X
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