Universal screening for substance abuse at the time of parturition

doi:10.1016/j.ajog.2007.10.780

American Journal of Obstetrics and Gynecology

Volume 198, Issue 5, May 2008, Pages e30-e32

https://doi.org/10.1016/j.ajog.2007.10.780 Get rights and content

Objective

The purpose of this study was to determine the prevalence of substance abuse in an inner city population at delivery admission by universal urine toxicology screening.

Study Design

This was a retrospective analysis of universal urine toxicology screening at admission for delivery on the LSU obstetric service at University Hospital in New Orleans.

Results

Four hundred sixty-two women delivered during the first 4 months of 2005. Four hundred and sixteen (90%) had a urine screen performed and 79 (19%) screened positive for 1 or more substances. Rates of a positive test by substance were: cocaine (3.1%), amphetamines (2.4%), barbiturates (2.1%), opiates (2.6%), THC (17.2%), benzodiazepine (5.7%), and phencyclidine (0%).

Conclusion

Nineteen percent of the tested population screened positive for at least 1 of 7 substances at admission for delivery. Women who used illicit substances were older and of higher parity. Low birthweight and HIV were particularly prevalent in those who screened positive for cocaine and/or amphetamines.

Section snippets

Materials and Methods

The Institutional Review Board at Louisiana State University (LSU) Health Sciences Center approved this study. This is a retrospective study, with maternal and neonatal clinical information derived from the LSU obstetric database of patients that delivered at University Hospital in New Orleans in the first 4 months of year 2005. Pregnant women were screened for substance abuse at their initial visit. Based on the results and risk factors, some had repeat screening. At labor admission, we

Results

Of the 462 women who delivered during the first 4 months of 2005 on the LSU obstetric service at University Hospital in New Orleans, 416 (90%) had a urine toxicology screen performed and 79 (19%) screened positive for at least 1 of the 7 substances at the time of admission for delivery. Rates of a positive test by substance were: cocaine (3.1%), amphetamines (2.4%), barbiturates (2.1%), opiates (2.6%), THC (17.2%), benzodiazepine (5.7%), and phencyclidine (0%).

Women who used illicit substances

Comment

Illicit substance abuse is common among pregnant patients.17, 18, 19 Our study shows that 19% of laboring patients were positive for at least 1 illicit substance at the time of admission for delivery. Recognizing that substance abuse requires intervention (such as social service consult), and the fact that pregnant patients usually respond very well to intervention by cessation of illicit drugs, underscores the importance of detection of substance abuse.

Previous studies have shown that maternal

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Concordance and discordance between maternal and newborn drug test results
2021, American Journal of Obstetrics and Gynecology MFM
Citation Excerpt :
The American College of Obstetricians and Gynecologists does not recommend laboratory testing, in large part owing to the potential legal and ethical pitfalls.5,6 However, many practitioners continue to rely on urine drug testing of the mother, newborn, or both in place of validated questionnaires, often citing concerns regarding underreporting and potential late recognition of neonatal withdrawal.7–13 Despite widespread use, laboratory testing has shortcomings.
Screening for substance use is recommended during pregnancy, and many clinicians rely on urine drug screening to identify newborns at potential risk for withdrawal.
This study aimed to determine the concordance and discordance rates between maternal and neonatal drug testing at or near the time of delivery.
This retrospective chart review was performed at a single institution that employs universal testing for those who consent. Results of maternal and neonatal urine drug testing via immunoassay at delivery were compared.
Of 1573 singleton pregnancies, 233 mothers (14.8%) had a positive test result for any substance and 102 of their newborns (43.8%) had concordant positive test results. Of the 285 positive maternal test results for individual substances, 133 (46.7%) were concordant with newborn test results. After removing iatrogenic positives, there were 84 truly discordant pairs representing 5.9% of the total cohort of test pairs, but 29.5% of the pairs with maternal positive test results. When considering the outcome of a newborn positive test result, the overall sensitivity and specificity for the maternal test were 21.1% and 85.8%, respectively. The positive and negative predictive values were 46.7% and 96.4%, respectively. After excluding iatrogenic positive test results, the sensitivity and specificity for maternal testing were 97.8% and 99.4%, respectively, and the negative predictive value of maternal testing for all substances approached 100%. A total of 11 pairs of twins had at least 1 twin with a positive drug test result, and of these, 6 twin pairs (54.5%) had drug test results that were discordant from each other.
There is a high rate of iatrogenic discrepancy in maternal and neonatal drug testing. After adjusting for iatrogenic positive test results, the negative predictive value of maternal testing is high. Many discrepancies, such as those in twins, remained unexplained by medication administration, and potential reasons for these discrepancies warrant further investigation.
Prevalence of benzodiazepines and benzodiazepine-related drugs exposure before, during and after pregnancy: A systematic review and meta-analysis
2020, Journal of Affective Disorders
Citation Excerpt :
For example, Bergman et al. only included women who had Medicaid insurance (Bergman et al., 1992). Various studies, such as the study by Azadi et al. (Azadi and Dildy, 2008), Bosio et al. (1997), Chaves et al. (2009), Lendoiro et al. (2013) and Potchoo et al. (2009), included women who delivered at one specific hospital. Other studies, such as the study by Radojcic et al. (2017) and Calderon-Margalit et al. (2009) only included women who participated in a study.
Maternal use of benzodiazepines during pregnancy is common and has increased over the last decades. In this systematic review and meta-analysis, we studied the literature to estimate the worldwide use of benzodiazepines before, during and after pregnancy, which could help to estimate benzodiazepine exposure and to prioritize and guide future investigations.
We systematically searched Embase, Medline Ovid, Web of Science and Cochrane Central up until July 2019 for studies reporting on benzodiazepine use before (12 months), during and after pregnancy (12 months). Random effects meta-analysis was conducted to calculate pooled prevalence estimates, as well as stratified according to substantive variables.
We identified 32 studies reporting on 28 countries, together reporting on 7,343,571 pregnancies. The worldwide prevalence of benzodiazepine use/prescriptions during pregnancy was 1.9% (95%CI 1.6%-2.2%; I² 97.48%). Highest prevalence was found in the third trimester (3.1%; 95%CI 1.8%-4.5%; I² 99.83%). Lorazepam was the most frequently used/prescribed benzodiazepine (1.5%; 95%CI 0.5%-2.5%; I² 99.87%). Highest prevalence was found in Eastern Europe (14.0%; 95%CI 12.1%-15.9%; I² 0.00%).
All analyses revealed considerable heterogeneity.
Our meta-analysis confirmed that benzodiazepine use before, during and after pregnancy is prevalent. The relatively common use of benzodiazepines with possible risks for both mother and (unborn) child is worrying and calls for prescription guidelines for women, starting in the preconception period. Given the substantial proportion of children exposed to benzodiazepines in utero, future research should continue to study the short- and long-term safety of maternal benzodiazepine use during pregnancy and to explore non-pharmacological alternative treatments.
Child abuse: Types and emergent issues
2019, Child Abuse and Neglect: Forensic Issues in Evidence, Impact and Management
The identification of child abuse as an individual, social, health, educational, and forensic concern is very ‘present-orientated’, having moved well beyond the 1962 ‘discovery’ by Kempe and associates of the child battering syndrome. Since that time, a burgeoning literature examining child abuse has expanded our understanding of types, onset and desistance, outcomes and management strategies, and a vast array of forensic issues and considerations. The current chapter acts as a foundation of sorts, for characterising overarching classifications of child abuse; provides estimations of rates; and presents contemporaneous issues facing modern scholarship.
Prenatal substance exposure diagnosed at birth and infant involvement with child protective services
2018, Child Abuse and Neglect
Citation Excerpt :
Retrospective evaluations using CPS records alone provide a crude measure of population-level incidence rates of prenatal substance exposure. Research on prenatal substance use based on self-reports (Ebrahim & Gfroerer 2003; O’Donnell et al., 2009; Substance Abuse and Mental Health Administration, 2012), toxicology screens (Azadi and Diggy, 2008), and medical billing records (Kelly et al., 2002; O’Donnell et al., 2009) have produced widely varying prevalence rates. Very few studies have examined the rate of prenatal substance exposure among infants reported to CPS (Burns et al., 2006; O’Donnell et al., 2009; Smith & Testa, 2002).
Infants have the highest rates of maltreatment reporting and entries to foster care. Prenatal substance exposure is thought to contribute to early involvement with child protective services (CPS), yet there have been limited data with which to examine this relationship or variations by substance type. Using linked birth, hospital discharge, and CPS records from California, we estimated the population prevalence of medically diagnosed substance exposure and neonatal withdrawal disorders at birth. We then explored the corresponding rates of CPS involvement during the first year of life by substance type after adjusting for sociodemographic and health factors. Among 551,232 infants born alive in 2006, 1.45% (n = 7994) were diagnosed with prenatal substance exposure at birth; 61.2% of those diagnosed were reported to CPS before age 1 and nearly one third (29.9%) were placed in foster care. Medically diagnosed prenatal substance exposure was strongly associated with an infant’s likelihood of being reported to CPS, yet significant variation in the likelihood and level of CPS involvement was observed by substance type. Although these data undoubtedly understate the prevalence of prenatal illicit drug and alcohol use, this study provides a population-based characterization of a common pathway to CPS involvement during infancy. Future research is needed to explicate the longer-term trajectories of infants diagnosed with prenatal substance exposure, including the role of CPS.
Neurobehavior of Neonates Born to Mothers Receiving Opioid Maintenance Treatment: Methadone and Buprenorphine
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Methadone maintenance treatment (MMT) has been the recommended opioid substitution therapy during pregnancy for over 30 years. Recent evidence has shown that treatment with buprenorphine has similar clinical outcomes as methadone for the neonate, with no differences between the peak severity and occurrence of neonatal abstinence syndrome (NAS). However, buprenorphine maintenance treatment (BMT) has been shown to have some advantages over MMT for the neonate, including the need for less medication to treat NAS, a shorter duration of treatment, and a shorter stay in hospital. Studies investigating the neurobehavioral function of neonates exposed to both drugs have shown dysregulated behavior common to both, but buprenorphine neonates in one study exhibited lower arousal, excitability, and hypertonia and fewer signs of stress abstinence than methadone-exposed infants. In addition, buprenorphine-exposed infants required less handling and exhibited better self-regulatory behavior than the methadone-exposed infants. Future studies are needed to replicate these findings and determine the long-term effects of both BMT and MMT.
At the tip of an iceberg: Prenatal marijuana and its possible relation to neuropsychiatric outcome in the offspring
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Endocannabinoids regulate brain development via modulating neural proliferation, migration, and the differentiation of lineage-committed cells. In the fetal nervous system, (endo)cannabinoid-sensing receptors and the enzymatic machinery of endocannabinoid metabolism exhibit a cellular distribution map different from that in the adult, implying distinct functions. Notably, cannabinoid receptors serve as molecular targets for the psychotropic plant-derived cannabis constituent Δ⁹-tetrahydrocannainol, as well as synthetic derivatives (designer drugs). Over 180 million people use cannabis for recreational or medical purposes globally. Recreational cannabis is recognized as a niche drug for adolescents and young adults. This review combines data from human and experimental studies to show that long-term and heavy cannabis use during pregnancy can impair brain maturation and predispose the offspring to neurodevelopmental disorders. By discussing the mechanisms of cannabinoid receptor-mediated signaling events at critical stages of fetal brain development, we organize histopathologic, biochemical, molecular, and behavioral findings into a logical hypothesis predicting neuronal vulnerability to and attenuated adaptation toward environmental challenges (stress, drug exposure, medication) in children affected by in utero cannabinoid exposure. Conversely, we suggest that endocannabinoid signaling can be an appealing druggable target to dampen neuronal activity if pre-existing pathologies associate with circuit hyperexcitability. Yet, we warn that the lack of critical data from longitudinal follow-up studies precludes valid conclusions on possible delayed and adverse side effects. Overall, our conclusion weighs in on the ongoing public debate on cannabis legalization, particularly in medical contexts.

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Residents' paperUniversal screening for substance abuse at the time of parturition

Objective

Study Design

Results

Conclusion

Section snippets

Materials and Methods

Results

Comment

Brain Res Dev Brain Res

Am J Obstet Gynecol

Obstet Gynecol

Drug Alcohol Depend

Am J Obstet Gynecol

Prenatal toxicology screening

J Perinatol

Marijuana use in pregnancy and pregnancy outcome

Am J Perinatol

Pregnancy and drug use trends

Growth of infants prenatally exposed to cocaine/crack: comparison of a prenatal care and a no prenatal care sample

Pediatrics

Impact of cocaine exposure on intrauterine growth of full-term infants: impact of prenatal cocaine exposure

Pediatrics

Residents' paper
Universal screening for substance abuse at the time of parturition