Newborn Drug Screening - Meconium and Umbilical Cord

Dx
Background
Lab Tests

Diagnosis

Indications for Testing

Suspected or known maternal drug abuse; obstetrical complications associated with drug abuse (eg, fetal distress)

Laboratory Testing

Meconium drug testing
- For more information, refer to Drug Analytes Detected in Meconium and Umbilical Cord
- Routine analysis includes a qualitative screen for nine drug classes; specimens testing positive for one or more drugs are reflexed to confirmatory testing
- Directed (confirmation only) tests are available when only one drug class is of clinical interest or when quantity of meconium available for testing is very small (eg, <1g)
Umbilical cord tissue testing – may also confirm drug abuse in mother
Maternal drug testing may detect very recent use; urine is the preferred specimen

Differential Diagnosis

Metabolic disorder
In utero exposure to other toxicants
- Alcohol
- Nicotine
- Heavy metals
  - Lead
  - Arsenic
- Prescription drugs

Clinical Background

Exposure to maternal drug use during gestation may adversely affect neonatal development and may lead to acute adverse events including neonatal abstinence syndrome and infant mortality and may contribute to long-term behavioral and developmental deficits.

Epidemiology

Prevalence – approximately 30% of the drug-abuse population is female, and most are of childbearing age

Pathophysiology

Meconium (dark, tarry material passed from the neonate’s rectum in the first days after birth until milk or formula-based stool appears) is the best specimen for assessing in utero exposure of the neonate to maternal drug use
- Meconium begins to form during the 12th–16th week of gestation and is usually passed within first 3 days of birth
  - Passage may be delayed when the baby is exposed to opioids or with premature birth
  - May also be expelled in utero or during birth
- Meconium is preferred over urine for testing of neonates
  - Urine testing indicates drug use only over the last 1–10 days, depending on the drug
  - Meconium documents drug use over an extended period of time, covering at least the last trimester of pregnancy
  - Meconium is easier to obtain than urine (combining all meconium voids can be helpful if sample size is small)
- Umbilical cord tissue is the preferred specimen for assessing in utero exposure of the neonate to maternal drug use when meconium is not available
  - Deposition of drugs in umbilical cord tissue is not well studied, but window of detection appears similar to meconium

Clinical Presentation

Stimulants
- Cocaine
  - Infant
    - Irritability and withdrawal at birth
    - Subarachnoid and intracerebral hemorrhage
    - Small neonatal head size
    - Reduced birth weight
    - Fetal death
    - Childhood behavioral disorders (eg, attention deficit hyperactivity disorder – ADHD)
  - Mother
    - Premature labor
    - Ruptured uterus, abruptio placentae
    - Adult behavioral disorders (eg, ADHD)
- Amphetamines (particularly methamphetamine)
  - Infant
    - Effects are similar to cocaine
    - Medical problems in early life
  - Mother
    - Effects are similar to cocaine
    - Complications during pregnancy – reduced fetal growth, stillbirth, congenital anomalies
    - Increased rates of premature birth
Cannabinoid (marijuana)
- Infant
  - Negative effect on attentional behavior and on visual analysis/hypothesis testing
  - No effect on global IQ
Opiates, barbiturates, benzodiazepines
- Infant and mother – withdrawal symptoms
  - Irritability
  - Tremors
  - Hyperactivity
  - Seizures

Indications for Laboratory Testing

Tests generally appear in the order most useful for common clinical situations
Click on number for test-specific information in the ARUP Laboratory Test Directory

Test Name and Number	Recommended Use	Limitations	Follow Up
Drugs of Abuse Panel, Meconium - Screen with Reflex to Confirmation/Quantitation 0092516 Method: Qualitative Enzyme-Linked Immunosorbent Assay/Quantitative Gas Chromatography-Mass Spectrometry/Quantitative Liquid Chromatography-Tandem Mass Spectrometry	Verify and document maternal drug abuse during the last trimester of pregnancy If specimen screens positive, Confirmation/Quantitation by GC/MS and/or LC-MS/MS will be added to confirm result	Result verifies drug use only Cannot determine date of maternal drug use, what specific drug was taken, or amount taken Detects only drugs and toxicants listed	See the pediatric peer-reviewed literature for neonate treatment recommendations
Drug Detection Panel by High-Resolution Time-of-Flight Mass Spectrometry, Umbilical Cord Tissue 2006621 Method: Qualitative Liquid Chromatography-Time of Flight Mass Spectrometry	Test for maternal drug abuse Panel includes amphetamines, cocaine, opioids, PCP, methadone, barbiturates, benzodiazepines, propoxyphene, tramadol and meperidine Marijuana (ELISA – Available August 2013)	Result verifies drug use only Cannot determine date of maternal drug use, what specific drug was taken, or amount taken Detects only drugs and toxicants listed	See the pediatric peer-reviewed literature for neonate treatment recommendations

Test Name and Number

Recommended Use

Limitations

Follow Up

Drugs of Abuse Panel, Meconium - Screen with Reflex to Confirmation/Quantitation 0092516

Method: Qualitative Enzyme-Linked Immunosorbent Assay/Quantitative Gas Chromatography-Mass Spectrometry/Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Verify and document maternal drug abuse during the last trimester of pregnancy

If specimen screens positive, Confirmation/Quantitation by GC/MS and/or LC-MS/MS will be added to confirm result

Result verifies drug use only

Cannot determine date of maternal drug use, what specific drug was taken, or amount taken

Detects only drugs and toxicants listed

See the pediatric peer-reviewed literature for neonate treatment recommendations

Drug Detection Panel by High-Resolution Time-of-Flight Mass Spectrometry, Umbilical Cord Tissue 2006621

Method: Qualitative Liquid Chromatography-Time of Flight Mass Spectrometry

Test for maternal drug abuse

Panel includes amphetamines, cocaine, opioids, PCP, methadone, barbiturates, benzodiazepines, propoxyphene, tramadol and meperidine

Marijuana (ELISA – Available August 2013)

Result verifies drug use only

Cannot determine date of maternal drug use, what specific drug was taken, or amount taken

Detects only drugs and toxicants listed

See the pediatric peer-reviewed literature for neonate treatment recommendations

Additional Tests Available

Click the plus sign to expand the table of additional tests.

Test Name and Number	Comments
Drugs of Abuse Confirmation/Quantitation - Amphetamines (Amphetamine & Methamphetamine) - Meconium 0092310 Method: Quantitative High Performance Liquid Chromatography-Tandem Mass Spectrometry	Neonatal testing
Barbiturates - Confirmation - Meconium 0092311 Method: Quantitative Gas Chromatography-Mass Spectrometry/Qualitative Liquid Chromatography /Time of Flight Mass Spectrometry	Neonatal testing
Drugs of Abuse Confirmation/Quantitation - Cannabinoids (Marijuana) - Meconium 0092316 Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry	Neonatal testing
Drugs of Abuse Confirmation/Quantitation - Methadone & Metabolite - Meconium 0092313 Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry	Neonatal testing
Drugs of Abuse Confirmation/Quantitation - Opiates - Meconium 0092314 Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry	Neonatal testing
Drugs of Abuse Confirmation/Quantitation - Propoxyphene & Metabolite - Meconium 0092524 Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry	Neonatal testing
Cocaine and Metabolites - Confirmation/Quantitation - Meconium 0092312 Method: Quantitative Gas Chromatography-Mass Spectrometry/Liquid Chromatography-Tandem Mass Spectrometry	Neonatal testing
Phencyclidine (PCP) - Confirmation/Quantitation - Meconium 0092315 Method: Quantitative Gas Chromatography-Mass Spectrometry/Liquid Chromatography-Tandem Mass Spectrometry	Neonatal testing
Drugs of Abuse Confirmation/Quantitation - Benzodiazepines - Meconium 0092520 Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry	Neonatal testing
Drugs of Abuse Confirmation/Quantitation - Barbiturates - Serum or Plasma 0093308 Method: Quantitative Gas Chromatography-Mass Spectrometry	Maternal testing Not recommended for drug screening; urine is preferred specimen
Drugs of Abuse Confirmation/Quantitation - Benzodiazepines - Serum or Plasma 0093300 Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry	Maternal testing Not recommended for drug screening; urine is preferred specimen
Drugs of Abuse Confirmation/Quantitation - Cannabinoids (9-carboxy-THC) - Serum or Plasma 0090676 Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry	Maternal testing Not recommended for drug screening; urine is preferred specimen
Drugs of Abuse Confirmation/Quantitation - Cocaine & Metabolites - Serum or Plasma 0090684 Method: Quantitative Gas Chromatography-Mass Spectrometry	Maternal testing Not recommended for drug screening; urine is preferred specimen
Methadone and Metabolite - Confirmation/Quantitation - Serum or Plasma 0090699 Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry	Maternal testing Not recommended for drug screening; urine is preferred specimen
Opiates - Confirmation/Quantitation - Serum or Plasma 0092354 Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry	Maternal testing Not recommended for drug screening; urine is preferred specimen
Drugs of Abuse Confirmation/Quantitation - Phencyclidine - Serum or Plasma 0091571 Method: Quantitative Gas Chromatography-Mass Spectrometry	Maternal testing Not recommended for drug screening; urine is preferred specimen
Drugs of Abuse Confirmation/Quantitation - Amphetamines - Urine 0090439 Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry	Maternal testing
Drugs of Abuse Confirmation/Quantitation - Barbiturates - Urine 0090357 Method: Quantitative Gas Chromatography-Mass Spectrometry	Maternal testing
Benzodiazepines - Confirmation/Quantitation - Urine 2008291 Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry
Drugs of Abuse Confirmation/Quantitation - Cannabinoids (9-carboxy-THC) - Urine 0090369 Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry	Maternal testing
Drugs of Abuse Confirmation/Quantitation - Cocaine Metabolite (Benzoylecgonine) - Urine 0090359 Method: Quantitative Gas Chromatography-Mass Spectrometry	Maternal testing
Drugs of Abuse Confirmation/Quantitation - Phencyclidine (PCP) - Urine 0090366 Method: Quantitative Gas Chromatography-Mass Spectrometry	Maternal testing
Drugs of Abuse Confirmation/Quantitation - Propoxyphene & Metabolite - Urine 0090368 Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry	Maternal testing
Drugs of Abuse Screen - Stimulant Amines - Urine 0090302 Method: Enzyme Immunoassay	Maternal testing
Drugs of Abuse Screen - Cocaine and Metabolites - Urine 0090306 Method: Enzyme Immunoassay	Maternal testing
Hairstat 5 Reflexive Panel 0092068 Method: Qualitative Enzyme-Linked Immunosorbent Assay/Quantitative Gas Chromatography-Mass Spectrometry	May detect drug use or exposure over several months previous to specimen collection; each cm length of hair represents approximately 1 month Note that drug use or exposure must have occurred at least one month prior to specimen collection If screen is positive, confirmation will be added
Synthetic Cannabinoid Metabolites, Screen with Reflex to Confirmation, Urine 2008091 Method: Qualitative Enzyme-Linked Immunosorbent Assay/High Performance Liquid Chromatography-Tandem Mass Spectrometry