Bioanalytical procedures for monitoring in utero drug exposure

Racism in Drug Testing

Racial disparities in drug testing for substance-use disorders underscore systemic inequalities. Studies reveal that minority groups, particularly Black and Hispanic Americans, are disproportionately targeted for drug testing despite similar rates of drug use across racial lines. Such bias impacts employment opportunities, legal outcomes, and access to treatment. The overrepresentation of minorities in drug testing reflects broader societal prejudices, leading to a cycle of discrimination and marginalization. Addressing these disparities requires a multifaceted approach, including policy reform, increased awareness of implicit biases, and equitable health care practices to ensure fair treatment of all individuals struggling with substance-use disorders.

Development of a dispersive liquid-liquid microextraction method for the evaluation of maternal-fetal exposure to cocaine employing human umbilical cord tissue

Illicit drug use is a serious and complex public health problem, not only due to the severity of the health damage but also to the social implications, such as marginalization and drug trafficking. Currently, cocaine (COC) is among the most abused drugs worldwide with about 22 million users. Drug abuse has also been found in women during the pregnancy period, which has shed light on a new group for epidemiology. The diagnosis of COC use in these cases usually depends largely on the mother's reports, which in several cases omit or deny consumption. Therefore, considering physical-chemical methods of sample preparation and exposure biomarkers, the development of analytic toxicological methods can help to confirm drug use during pregnancy. Thus, the objective of the present work was to develop an analytical method based on dispersive liquid-liquid microextraction for the determination of COC analytes, using umbilical cord tissue as an alternative biological matrix, and detection by gas chromatography coupled to mass spectrometry. Therefore, after optimization, the dispersive liquid-liquid microextraction method was fully validated for quantification of COC, benzoylecgonine, cocaethylene, ecgonine, ecgonine methyl ester and norcocaine. The limits of detection were between 15 and 25 ng/g, the limits of quantification were 30 ng/g for ecgonine and 25 ng/g for the other analytes. Linearity ranged from the limits of quantification to 1,000 ng/g. Coefficients of variation for intra-assay precision were <18.5%, inter-assay was <8.75% and bias was <16.4% for all controls. The developed method was applied in 10 suspected positive samples, based on the mother's report and maternal urine screening and confirmation. COC, benzoylecgonine, ecgonine and ecgonine methyl ester were quantified in four umbilical cords with concentrations that ranged from 39.6 to 420.5 ng/g.

Can umbilical cord testing add to maternal urine drug screen for evaluation of infants at risk of neonatal opioid withdrawal syndrome?

OBJECTIVE

This study evaluated maternal urine drug screen (UDS) at delivery and umbilical cord drug testing and its association with neonatal opioid withdrawal syndrome (NOWS) diagnosis and severity following opioid exposed pregnancy.

METHODS

A retrospective chart review of 770 mother-infant dyads at five birthing hospitals in the United States Appalachian region for a five-year period was performed. Variables of interest included dyad demographics, results of maternal UDS at delivery and umbilical cord drug testing, and three neonatal outcomes: NOWS diagnosis, pharmacologic treatment administered for NOWS, and length of hospital stay (LOS) of the newborn.

RESULTS

Opioid-positivity was between 8.5% and 66.3% based on maternal UDS at delivery or umbilical cord testing. Odds of NOWS diagnosis and increased infant LOS was best associated with opioid detection in maternal UDS alone (OR = 5.62, 95% CI [3.06, 10.33] and OR = 8.33, 95% CI [3.67, 18.89], respectively). However, odds of pharmacologic treatment for NOWS was best associated with opioid detection in both maternal UDS and umbilical cord testing on the same dyad (OR = 3.22, 95% CI [1.14, 9.09]).

CONCLUSION

Maternal UDS is a better option compared to umbilical cord testing for evaluation of opioid-exposed infants and risk of NOWS diagnosis and increased infant LOS.

Drug exposure during pregnancy: Current understanding and approaches to measure maternal-fetal drug exposure

Prescription drug use is prevalent during pregnancy, yet there is limited knowledge about maternal-fetal safety and efficacy of this drug use because pregnant individuals have historically been excluded from clinical trials. Underrepresentation has resulted in a lack of data available to estimate or predict fetal drug exposure. Approaches to study fetal drug pharmacology are limited and must be evaluated for feasibility and accuracy. Anatomic and physiological changes throughout pregnancy fluctuate based on gestational age and can affect drug pharmacokinetics (PK) for both mother and fetus. Drug concentrations have been studied throughout different stages of gestation and at or following delivery in tissue and fluid biospecimens. Sampling amniotic fluid, umbilical cord blood, placental tissue, meconium, umbilical cord tissue, and neonatal hair present surrogate options to quantify and characterize fetal drug exposure. These sampling methods can be applied to all therapeutics including small molecule drugs, large molecule drugs, conjugated nanoparticles, and chemical exposures. Alternative approaches to determine PK have been explored, including physiologically based PK modeling, in vitro methods, and traditional animal models. These alternative approaches along with convenience sampling of tissue or fluid biospecimens can address challenges in studying maternal-fetal pharmacology. In this narrative review, we 1) present an overview of the current understanding of maternal-fetal drug exposure; 2) discuss biospecimen-guided sampling design and methods for measuring fetal drug concentrations throughout gestation; and 3) propose methods for advancing pharmacology research in the maternal-fetal population.

A Text Messaging-Based Support Intervention to Enhance Pre-exposure Prophylaxis for HIV Prevention Adherence During Pregnancy and Breastfeeding: Protocol for a Randomized Controlled Trial

BACKGROUND

Cisgender women in Kenya are at elevated risk of HIV acquisition during pregnancy and post partum. Acute HIV infection during pregnancy and breastfeeding accounts for approximately one-third of all vertical HIV transmissions. The World Health Organization recommends offering oral tenofovir-based pre-exposure prophylaxis (PrEP) to pregnant and postpartum women who are HIV negative but at substantial and ongoing risk for HIV acquisition. PrEP delivery for pregnant and postpartum women is expanding within routine maternal child health clinics in Kenya. However, approximately half of pregnant women discontinue PrEP within 30 days of initiation. Therefore, it is crucial to develop PrEP adherence strategies that enhance support for adherence when peripartum events and health issues pose challenges to sustaining PrEP adherence.

OBJECTIVE

We are conducting a randomized controlled trial to determine the effect of a bidirectional communication platform named Mobile Solutions for Women's and Children's Health (mWACh), which utilizes two-way SMS text messaging between patients and remote nurses to support PrEP adherence and address maternal health concerns in real time during the peripartum period.

METHODS

The mWACh-PrEP study is a randomized trial designed to support PrEP adherence during the peripartum period by comparing mWACh-PrEP to the standard of care (ie, in-clinic adherence counseling) among women who are HIV negative and initiating PrEP. Purposive sampling was used to select 5 facilities offering PrEP in antenatal clinics in Kisumu and Siaya Counties, and block randomization will be used to divide participants into groups. Participants in the intervention arm will receive a customized messaging curriculum via SMS text messages targeted toward their particular perinatal stage. The primary outcome, PrEP adherence at 6 months post partum, will be evaluated using a log-binomial regression model, adjusting for imbalanced baseline characteristics. Based on a previous study of directly observed dosing conditions, we will use a hair tenofovir concentration cutoff of 0.038 ng/mg (corresponding to 7 doses/week) as the primary adherence outcome measured at 6 months post partum (binary outcome). Qualitative interviews and cost-effective analyses will be conducted to understand the feasibility, acceptability, and economic impact of the intervention.

RESULTS

Enrollment began in March 2022 and is projected to continue until July 2023, with follow-up through March 2024. The study results are expected to be reported in 2025.

CONCLUSIONS

This trial will provide insights into using mobile health to enhance PrEP adherence among pregnant and postpartum mothers. Additionally, the findings will have implications for the use of mobile health technology to improve adherence to other daily medications during the peripartum period.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04472884; https://clinicaltrials.gov/ct2/show/NCT04472884.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/41170.

Intrauterine and Neonatal Exposure to Opioids: Toxicological, Clinical, and Medico-Legal Issues

Opioids have a rapid transplacental passage (i.e., less than 60 min); furthermore, symptoms characterize the maternal and fetal withdrawal syndrome. Opioid withdrawal significantly impacts the fetus, inducing worse outcomes and a risk of mortality. Moreover, neonatal abstinence syndrome (NAS) follows the delivery, lasts up to 10 weeks, and requires intensive management. Therefore, the prevention and adequate management of NAS are relevant public health issues. This review aims to summarize the most updated evidence in the literature regarding toxicological, clinical, and forensic issues of intrauterine exposure to opioids to provide a multidisciplinary, evidence-based approach for managing such issues. Further research is required to standardize testing and to better understand the distribution of opioid derivatives in each specimen type, as well as the clinically relevant cutoff concentrations in quantitative testing results. A multidisciplinary approach is required, with obstetricians, pediatricians, nurses, forensic doctors and toxicologists, social workers, addiction specialists, and politicians all working together to implement social welfare and social services for the baby when needed. The healthcare system should encourage multidisciplinary activity in this field and direct suspected maternal and neonatal opioid intoxication cases to local referral centers.

Drug testing in support of the diagnosis of neonatal abstinence syndrome: The current situation

Illicit drug use during pregnancy is a concern worldwide, with many international studies describing attempted strategies to mitigate this problem. Drug misuse during pregnancy is associated with significant maternal as well as perinatal complications, which include a high incidence of stillbirths, fetal distress, neonatal abstinence syndrome (NAS) and increased neonatal mortality. Unfortunately, the identification of a drug-exposed mother or neonate is challenging. Maternal disclosure of drug use is often inaccurate, principally due to psychosocial factors including behavioral denial or the fear of the consequences resulting from such admissions. Likewise, many infants who have been exposed to drugs in utero may appear normal at birth and initially show no overt manifestations of drug effects. Thus, the identification of the drug-exposed infant requires a high index of clinical suspicion. Conversely, analytical testing is an objective means of determining drug exposure when it may be necessary to document proof of the infant's exposure to illicit drugs. The review will discuss the different matrices that are most commonly used for testing (e.g., maternal urine, neonatal urine, meconium, and umbilical cord), the strengths and limitations for each matrix, which drugs and metabolites are appropriate for testing, the various testing methods, and the advantages and disadvantages of each method.

Cannabis Use in Pregnancy and Downstream effects on maternal and infant health (CUPiD): a protocol for a birth cohort pilot study

INTRODUCTION

Cannabis use in pregnancy and post partum is increasing. Accessibility to cannabis has expanded due to the legalisation of cannabis in Canada. Therefore, there is a critical need to monitor the impact of cannabis on pregnancy outcomes and infant neurodevelopment. This pilot study will assess the feasibility of modern recruitment and data collection strategies adapted to the current cannabis environment and inform the design of a multicentre prospective birth cohort.

METHODS AND ANALYSIS

We will establish a pregnancy and birth cohort of 50 cannabis users and 50 non-users recruited before delivery. We will follow the participants at regular visits from recruitment to 12 weeks post partum. Participants will provide demographic and socioeconomic data, report their cannabis use patterns, and provide biological samples. Biological samples include maternal and infant urine and blood, breastmilk/chestmilk, cord blood, cord tissue, placenta and meconium. All samples will be processed and stored at -80°C until analysis by immunoassay or liquid chromatography-tandem mass spectrometry to determine the presence of cannabis metabolites. In addition, partners will be invited to provide additional socioeconomic and substance use data.

ETHICS AND DISSEMINATION

Ethics was obtained from Ottawa Health Science Network Research Ethics Board through Clinical Trials Ontario (3791). Our findings will be published in peer-reviewed journals, presented at scientific conferences and shared broadly with patients, healthcare decision-makers, and project partners online and through social media.

TRIAL REGISTRATION NUMBER

NCT05309226.Cite Now.

Determination of Prenatal Substance Exposure Using Meconium and Orbitrap Mass Spectrometry

The aim of this study was to develop and to validate a toxicological untargeted screening relying on LC-HRMS in meconium including the detection of the four main classes of drugs of abuse (DoA; amphetamines, cannabinoids, opioids and cocaine). The method was then applied to 29 real samples. Analyses were performed with a liquid chromatography system coupled to a benchtop Orbitrap operating in a data-dependent analysis. The sample amount was 300 mg of meconium extracted twice by solid phase extraction following two distinct procedures. Raw data were processed using the Compound Discoverer 3.2 software (Thermo). The method was evaluated and validated on 15 compounds (6-MAM, morphine, buprenorphine, norbuprenorphine, methadone, EDDP, amphetamine, MDA, MDMA, methamphetamine, cocaine, benzoylecgonine, THC, 11-OH-THC, THC-COOH). Limits of detection were between 0.5 and 5 pg/mg and limits of identification between 5 and 50 pg/mg. Mean matrix effect was between −79 and −19% (n = 6) and mean overall recovery between 18 and 73% (n = 6) at 100 pg/mg. The application allows the detection of 88 substances, including 47 pharmaceuticals and 15 pharmaceutical metabolites, cocaine and its metabolites, THC and its metabolites, and natural (morphine, codeine) and synthetic (methadone, buprenorphine, tramadol, norfentanyl) opioids. This method is now used routinely for toxicological screening in high-risk pregnancies

Toxicology as a diagnostic tool to identify the misuse of drugs in the perinatal period

The use, misuse, and abuse of substances are a continued public health concern in this country and around the world. Perinatal exposure to substances of abuse is associated with several long-term negative consequences for the neonate. Limited resources exist to assist perinatal health professionals on this very complex subject. The purpose of this document is to provide additional information about selecting monitoring protocols, the specifics of appropriate testing methodologies, and the interpretation of toxicological findings. Understanding these concepts better allows perinatal healthcare professionals to be a voice for the voiceless in order to protect and enrich lives during this unprecedented opioid epidemic.

Quantitation of phosphatidylethanols in dried blood spots to determine rates of prenatal alcohol exposure in Ontario

BACKGROUND

Estimating rates of prenatal alcohol exposure (PAE) in a population is necessary to ensure that proper medical and social supports and interventions are in place. This study sought to estimate PAE in Ontario, Canada by quantifying phosphatidylethanol (PEth) homologues in over 2000 residual neonatal dried blood spots (DBS).

METHODS

A random selection of 2011 residual DBS collected over a 1-week time period were anonymized and extracted. A targeted liquid chromatography-mass spectrometry method was used to quantify 1-palmitoyl-2-oleoyl-sn-glycero-3-phosphoethanol (PEth (16:0/18:1) or POPEth), the clinically accepted biomarker, and six additional PEth homologues. A POPEth level above the United States Drug Testing Laboratories (USDTL) cutoff up to 4 weeks predelivery was indicative of PAE. All PEth homologues were correlated to one another and logistic regression was used to determine the association between PAE status and infant characteristics.

RESULTS

The estimated rate of PAE in Ontario, up to the last 4 weeks of gestation, was 15.5% (POPEth >28.5 nM). Most PEth homologues were moderately to strongly correlated to one another. A low birth weight and preterm birth were both associated with PAE, while being small for gestational age had lower odds of PAE.

CONCLUSIONS

The results of this study suggest that PAE may be more prevalent in Ontario than previous estimates by self-report or meconium testing. These findings support the need to consider the effectiveness of current interventions and the design of new interventions to address this significant public health issue.

The GNE-KLH anti-cocaine vaccine protects dams and offspring from cocaine-induced effects during the prenatal and lactating periods

Protecting children from prenatal cocaine exposure is a significant challenge for physicians and childbearing women with cocaine use disorder. Cocaine use is highly prevalent among reproductive-aged women and prenatal cocaine exposure produces obstetric, foetal neurodevelopmental and long-term behavioural impairments. Cocaine crosses the maternal and foetal blood-brain barrier and the placenta by diffusion. The best approach to prevent prenatal cocaine exposure is to stop cocaine use. However, only 25% of cocaine users can discontinue their use during pregnancy. Anti-cocaine vaccination decreases cocaine passage through the blood-brain barrier. This study describes an innovative approach for preventing prenatal cocaine exposure using the GNE-KLH anti-cocaine vaccine, a novel use for the named anti-drug vaccines. Here, we show that anti-cocaine vaccination with GNE-KLH produced and maintained anti-cocaine IgG antibody titres and avidity during pregnancy. These antibodies protected the pregnant rats and their pups against prenatal cocaine damage during pregnancy until weaning. The present work is the first preclinical evidence of the efficacy of an innovative mechanism to prevent prenatal cocaine exposure damage, a worldwide public health care issue. In the future, this mechanism may be useful in pregnant women with cocaine use disorder. Further studies to understand the mechanisms of how anti-cocaine antibodies exert their protective effects in pregnancy are warranted.

The Effects of Cannabis on Female Reproductive Health Across the Life Course

Introduction: Cannabis is commonly used for its medicinal and therapeutic benefits and is also widely used as a recreational drug. Cannabis use has been increasing in Canada, including among Canadian women of reproductive age. Post-legalization, further increases in cannabis use are expected due to increased availability and lowered perceptions of harm. Although cannabinoids are well known for their effects on the central and peripheral nervous systems, endocannabinoid receptors have also been characterized throughout the female reproductive tract. Cannabinoids may affect many aspects of female reproductive health, including fertility, pregnancy outcomes with neonatal implications, and menopause. Purpose: To provide a comprehensive review of trends in cannabis use among women and review the impact of cannabis across the female reproductive lifespan. Methods: We searched PubMed and Cochrane Library databases using keywords and MeSH terms. Included studies reported the potential impact of cannabinoids on female fertility, pregnancy, transmission to breast milk, neonatal outcomes, and menopause. Results: The existing literature is primarily concentrated on the effect of cannabis use in pregnancy and breastfeeding, with little exploration of its impact on fertility and in later life. Studies are limited in number, with small sample sizes, and are hampered by methodological challenges related to confounding and other potential biases. Conclusions: There remain critical gaps in the literature about the potential risks of cannabis use, particularly in vulnerable populations, including pregnant women, women who are breastfeeding, and their infants. Given the rise in the prevalence of cannabis use, new, robust investigations into the consequences of cannabis exposure on female reproductive health are needed.

A Case of False-positive Amphetamine Results on Urine Toxicology Testing Secondary to Imatinib

In this case report, we describe a case of imatinib leading to a false-positive amphetamine result on urine drug testing. A 21-year-old female with chronic myelocytic leukemia and in recovery from opioid use disorder reinitiated imatinib maintenance therapy in her third trimester, after previous discontinuation at the beginning of pregnancy. Subsequently, she had multiple presumptive immunoassay-based urine drug tests that resulted positive for amphetamines. The infant's meconium testing was negative for amphetamines, as was maternal definitive testing using urine gas chromatography-mass spectrometry. She had no history of stimulant use and denied any substance use during her pregnancy. Imatinib and/or its metabolites may be responsible for cross-reactivity with urine drug immunoassays leading to a false-positive result for amphetamine.

Neonatal Exposure to Tramadol through Mother's Breast Milk

Tramadol is an opioid used in the treatment of moderate to moderately severe pain. Tramadol's use during pregnancy is generally avoided and may cause some reversible withdrawal effects in neonates and its use during lactation is not licensed by the manufacturer. A small clinical trial reported infants were exposed to < 3% of a mother's tramadol dose though breast milk with no evidence of harmful effects. Presented is a case study of breast milk, neonatal urine, and neonatal oral fluid for the analysis of tramadol and its metabolites, along with the validation of a method for the analysis of tramadol, O-desmethyltramadol, and N-desmethyltramadol in breast milk. Tramadol and its metabolites were extracted by solid-phase extraction (SPE) after saponification of breast milk to remove lipids. Samples were analyzed by ultra-pressure liquid chromatography-tandem mass spectrometry (UPLC-MS/MS). To the author's knowledge, this is the first report of tramadol and its metabolites in neonatal oral fluid. The breast milk concentrations were 63, 22, and 76 ng/mL tramadol, O-desmethyltramadol and N-desmethyltramadol, respectively on day of life 12. On day of life 20, the breast milk concentrations were 1,254, 388, and 937 ng/mL tramadol, O-desmethyltramadol and N-desmethyltramadol, respectively. Oral fluid concentrations were 1,011, 1,499, and 406 ng/mL tramadol, O-desmethyltramadol and N-desmethyltramadol, respectively on day of life 20. Oral fluid concentrations were similar to breast milk for tramadol, almost four times higher for O-desmethyltramadol, and less than half for N-desmethyltramadol. The absolute infant dose was calculated to be 10 μg/kg/day and 294 μg/kg/day tramadol on day of life 12 and 20, respectively.

Analysis of cannabinoids in conventional and alternative biological matrices by liquid chromatography: Applications and challenges

Cannabis is by far the most widely abused illicit drug globe wide. The analysis of its main psychoactive components in conventional and non-conventional biological matrices has recently gained a great attention in forensic toxicology. Literature states that its abuse causes neurocognitive impairment in the domains of attention and memory, possible macrostructural brain alterations and abnormalities of neural functioning. This suggests the necessity for the development of a sensitive and a reliable analytical method for the detection and quantification of cannabinoids in human biological specimens. In this review, we focus on a number of analytical methods that have, so far, been developed and validated, with particular attention to the new "golden standard" method of forensic analysis, liquid chromatography mass spectrometry or tandem mass spectrometry. In addition, this review provides an overview of the effective and selective methods used for the extraction and isolation of cannabinoids from (i) conventional matrices, such as blood, urine and oral fluid and (ii) alternative biological matrices, such as hair, cerumen and meconium.

Findings of illicit drugs in hair of children at different ages

Hair is a preferred material to detect exposure or use of illegal drugs in children. In the present study, we investigated a total of 387 hair samples for commonly applied illegal drugs of children up to 16 years. Analysis was by liquid chromatography/mass spectrometry with LOQs of 0.01 ng/mg hair for all analytes except tetrahydrocannabinol carboxylic acid with an LOQ of 0.1 pg/mg hair. Results were firstly compared with our in-house statics on results from adults' hair, and secondly to literature data. We started from the assumption that drug concentrations decrease with increasing age.Results were assigned to 4 different age groups (< 1 year, 1-< 6 years, 6-< 14 years, 14-16 years). As expected, higher results were obtained in age groups 1 and 2. The lowest concentrations were present in age group 3, whereas an increase could be observed in group 4 except heroin. In babies, positive results may be due to in utero exposure, breast milk feeding, and a close physical contact. All drugs under investigation such as cannabinoids, cocaine, amphetamines, and opiates have been detected in breast milk as well as in skin excretions such as sebum, sweat and cutaneous cells. For most drugs, average concentrations in children hair were lower than in adult hair when compared with our in-house statistics. Interestingly, the increase of cannabinoids, cocaine, and amphetamines concentrations in adolescents' hair points to a deliberate use of these drugs possibly in addition to passive exposure. This observation shows that age groups 1 and 4 are most vulnerable if caregivers or parents are drug users, even if the sources of positive drug findings differ.

Application of microextraction techniques in alternative biological matrices with focus on forensic toxicology: a review

The interest in alternative biological matrices (e.g., hair and saliva) for forensic toxicology analysis has increased, and recent developments in sample preparation have targeted rapid, cheap, efficient and eco-friendly methods, including microextraction techniques. For this review, we have gathered information about these two hot topics. We discuss the composition, incorporation of analytes and advantages and disadvantages of different biological matrices, and also present the operation principles of the most reported microextraction procedures and their application in forensic toxicology. The outcome of this review may encourage future forensic researches into alternative samples and microextraction techniques.

Neonatal Opioid Withdrawal Syndrome

The opioid crisis has grown to affect pregnant women and infants across the United States, as evidenced by rising rates of opioid use disorder among pregnant women and neonatal opioid withdrawal syndrome among infants. Across the country, pregnant women lack access to evidence-based therapies, including medications for opioid use disorder, and infants with opioid exposure frequently receive variable care. In addition, public systems, such as child welfare and early intervention, are increasingly stretched by increasing numbers of children affected by the crisis. Systematic, enduring, coordinated, and holistic approaches are needed to improve care for the mother-infant dyad. In this statement, we provide an overview of the effect of the opioid crisis on the mother-infant dyad and provide recommendations for management of the infant with opioid exposure, including clinical presentation, assessment, treatment, and discharge.

A Case Study Evaluating the Efficacy of an Ad Hoc Hospital Collection Device for Fentanyl in Infant Oral Fluid

Neonatal drug exposure is currently assessed using meconium, urine, blood, hair, or umbilical cord tissue/blood. Due to the invasiveness, challenges, and limitations of collection, and/or analytical difficulties of these matrices, oral fluid may be a more desirable matrix in diagnosing opioid exposure and risk for opioid withdrawal in neonatal abstinence syndrome. Traditional oral fluid collection devices are not viable options as they are too large for neonates' mouths and may contain chemicals on the collection pad. Unstimulated and stimulated infant oral fluid samples have been used for therapeutic drug monitoring as an alternative matrix to blood. The objective of this study was to assess the viability of a simple oral fluid collection system using a sterile foam-tipped swab rinsed in phosphate-buffered saline. Two infants were administered fentanyl for post-operative pain relief while hospitalized in the Neonatal Intensive Care Units at the Children's Hospital of Richmond of Virginia Commonwealth University. Oral fluid samples were collected at 16 h, 2 days, and/or 7 days following the start of intravenous infusion of fentanyl. Samples were analyzed by ultra-high-pressure liquid chromatography-tandem mass spectrometry for fentanyl and norfentanyl after solid-phase extraction. In one of the three samples tested, fentanyl and norfentanyl were detected at concentrations of 28 and 78 ng/mL, respectively. Based on the infusion rate, the theoretical oral fluid fentanyl concentration at steady state was calculated to be 33 ng/mL.

Drug testing in biological samples vs. maternal surveys for the detection of substance use during whole pregnancy

BACKGROUND

Early diagnosis of nicotine, ethanol and drug use during pregnancy is critical in order to provide adequate care. Current screening procedures show limitations in terms of reliability and short windows of detection.

OBJECTIVES

To investigate the prevalence and identify biomarkers of substance use and changes in substance use during pregnancy. To compare drug testing results in different types of biological samples (maternal hair, meconium, placenta, umbilical-cord) with self-reported data.

PARTICIPANTS AND SETTING

Prospective cohort study using data from pregnant women and their newborns.

METHODS

Biological matrices were collected at birth and analyzed by liquid chromatography tandem mass spectrometry. A paper survey was provided to determine substance use habits.

RESULTS

867 mother-newborn pairs were included. According to the analysis of biological samples, 29.1% cases were positive for one or more substances (13.6% nicotine, 8.4% ethanol, 8.3% cocaine, 6.4% cannabis, 5.7% opioids). The profile of the substance-using mother was a single woman, <28 years-old, with no higher education and unemployed. Segmental maternal hair analysis showed a decrease in tobacco, cannabis and cocaine use throughout pregnancy (p < 0.001). The level of concordance between results from interviews and from biological analyses was weak for opioids, cocaine, and cannabis (kappa coefficient < 0.40). Maternal hair detected the highest number of cases, followed by meconium and by placenta and/or umbilical-cord.

CONCLUSIONS

Maternal survey was not a reliable screening technique. Analysis of maternal hair detected the highest number of cases with the broadest detection window (whole pregnancy).

LC-MS-MS Method for the Determination of Antidepressants and Benzodiazepines in Meconium

An LC-MS-MS method for the determination of 14 benzodiazepines (BZDs) (alprazolam, α-hydroxyalprazolam, clonazepam, bromazepam, diazepam, nordiazepam, lorazepam, lormetazepam, oxazepam, flunitrazepam, 7-aminoflunitrazepam, triazolam, midazolam and zolpidem) and 15 antidepressants (ADs) (amitriptyline, nortriptyline, imipramine, desipramine, clomipramine, norclomipramine, fluoxetine, norfluoxetine, sertraline, norsertraline, paroxetine, venlafaxine, desmethylvenlafaxine, citalopram and desmethylcitalopram) in meconium was developed and validated. Meconium samples (0.25 ± 0.02 g) were homogenized in methanol and subjected to mixed-mode cation exchange solid-phase extraction. Chromatographic separation was performed in reversed phase, with a gradient of 0.1% formic acid in 2 mM ammonium formate and acetonitrile. Two different chromatographic gradient methods were employed, one for the separation of ADs and another for BZDs. Analytes were monitored by tandem mass spectrometry employing electrospray positive mode in MRM mode (2 transitions per compound). Method validation included: linearity [n = 5, limit of quantification (LOQ) to 400 ng/g], limits of detection (n = 6, 1-20 ng/g), LOQ (n = 9, 5-20 ng/g), selectivity (no endogenous or exogenous interferences), accuracy (n = 15, 90.6-111.5%), imprecision (n = 15, 0-14.6%), matrix effect (n = 10, -73 to 194.9%), extraction efficiency (n = 6, 35.9-91.2%), process efficiency (n = 6, 20.1-188.2%), stability 72 h in the autosampler (n = 3, -8.5 to 9%) and freeze/thaw stability (n = 3, -1.2 to -47%). The method was applied to four meconium specimens, which were analyzed with and without hydrolysis (enzymatic and alkaline). The authentic meconium samples tested positive for alprazolam, α-hydroxyalprazolam, clonazepam, diazepam, nordiazepam, fluoxetine, norfluoxetine, clomipramine and norclomipramine. Therefore, the present LC-MS-MS method allows a high throughput determination of the most common BZDs and ADs in meconium, which could be useful in clinical and forensic settings.

Assessment of prenatal stress-related cortisol exposure: focus on cortisol accumulation in hair and nails

Prenatal stress adversely affects offspring development. Although cortisol is hypothesized to be a key mediator of stress-induced developmental deficits, determining the amount of fetal cortisol exposure produced by maternal stress has proved challenging. Current approaches, such as measuring cortisol concentrations in maternal plasma, saliva, or urine, amniotic fluid, fetal plasma, or cord blood, all have significant limitations for assessing cumulative fetal cortisol exposure over time. A recently emerging approach is to measure cortisol concentrations in maternal hair and/or newborn hair or nail samples. Maternal hair cortisol potentially shows long-term production across each trimester of pregnancy, whereas neonatal hair or nail cortisol is thought to reflect mainly third trimester hormone accumulation. This review first describes fetal adrenocortical development, placental cortisol metabolism, and the various sources of fetal cortisol exposure across pregnancy. We then summarize the results obtained from "classical" methods of assessing prenatal cortisol exposure prior to the advent of hair and nail cortisol measurement. Lastly, we discuss the initial development and validation of the hair cortisol methodology, its subsequent application to studies of chronic stress, and recent findings regarding maternal and neonatal hair or nail cortisol concentrations in relation to prenatal stress and other variables of interest.

Screening for Opioid and Stimulant Exposure In Utero Through Targeted and Untargeted Metabolomics Analysis of Umbilical Cords

BACKGROUND

Neonatal abstinence syndrome is an array of signs and symptoms experienced by a newborn due to abrupt discontinuation of intrauterine exposure to certain drugs, primarily opioids. In the United States, the incidence of neonatal abstinence syndrome has tripled over the past decade. The current standard of care for drug testing includes the analysis of infant urine and meconium. Sample collection is associated with several limitations, including diaper media interferences, limited sample amount, sample heterogeneity, and the need for professional staff for collection. Umbilical cord tissue has emerged as a convenient sample matrix for testing owing to its universal availability. The purpose of this study was to examine umbilical cords using an untargeted metabolomics approach to determine the detected drugs and validate an analytical method to confirm and quantify the identified drugs.

METHODS

A metabolomics analysis was performed with 21 umbilical cords to screen for drugs and drug metabolites by liquid chromatography-mass spectrometry. Drugs were identified using the National Institute of Standards and Technology database, and an analytical method was developed and validated using secondary liquid chromatography-mass spectrometry instrument for positive confirmation and quantitative analysis.

RESULTS

Twenty-one random umbilical cords from women were tested: 4 were positive for cocaine and the primary and secondary metabolites; one was positive for methadone, the primary metabolite; 3 were positive for cotinine, the metabolite of nicotine; and 5 were positive for acetyl norfentanyl.

CONCLUSIONS

Our research is a prospective method development study using untargeted and targeted approaches to characterize steady-state drug metabolite levels in the umbilical cord matrix at the time of delivery. By characterizing drug type and concentration, this methodology can be used to develop a reliable complementary testing method for meconium toxicology screens.

Dysregulation of inflammatory cytokines and inhibition of VEGFA in the human umbilical cord are associated with negative pregnancy outcomes

INTRODUCTION

Cytokines and vascular endothelial growth factors (VEGF) are involved in all aspects of pregnancy: from placentation, through fetal development, parturition and neonatal well-being. Umbilical cord inflammatory cytokines and/or VEGF have not been well studied with respect to dysregulation associated with disorders of pregnancy or maternal/neonatal outcomes.

METHODS

Here we have used multiplex ELISA to screen umbilical cord lysates (comprising cord blood, endothelia and Wharton's jelly, n = 380), for levels of IFN-γ, IL1-β, IL-6, IL-8, IL-10, TNF-α and VEGFs A, C and D and associations with 46 ICD9/10 codes encompassing obstetric, maternal and neonatal variables.

RESULTS

No significant differences were observed for IFNγ, VEGFC or VEGFD with any clinical outcomes. The cytokines IL1-β, IL-6, IL-8, IL-10, and TNF-α showed varying levels of induction and suppression with primarily fetal-placental and neonatal complications. The largest number of significant differences between umbilical cytokines and clinical outcomes were observed for chorioamnionitis (IL1-β, IL-6, IL-8, TNF-α), and meconium passage during birth (IL1-β, IL-6, IL-8) where significant pro-inflammatory responses occurred and sex differences in IL-8 expression were noted. In contrast, gonococcal infection showed suppressed immune response significantly lowering IL1-β, IL-6, IL-8, IL-10 and TNF-α. For 12/46 negative pregnancy outcomes, strong suppression of VEGFA occurred.

DISCUSSION

Angiogenic and inflammatory changes in the umbilical cord could be detrimental by increasing vascular permeability in the umbilical artery or vein and/or altering vascular tone, either of which would alter blood flow affecting delivery and removal of compounds. Further elucidation of inflammatory responses in the umbilical cord may provide mechanistic understanding of adverse pregnancy outcomes.

The Association Between Antenatal Maternal Self-reported Substance Use, Maternal Characteristics, and Obstetrical Variables

BACKGROUND

Substance use disorders during pregnancy are a concern both to the public and medical community, because the negative consequences can be detrimental to both mother and the fetus. The accurate identification of prenatal drug exposure is necessary to determine appropriate medical and psychosocial intervention, and to identify risk factors that may affect outcomes for the mother and her newborn. The prevalence of prenatal drug exposure is very difficult to estimate because of flaws in all methods of identification.

OBJECTIVE

The study is designed to identify risk factors and demographic variables that contribute to nondisclosure of illicit and nonillicit substance use. In addition, this study aims to determine if nondisclosure leads to adverse neonatal outcomes.

STUDY DESIGN

Newborns delivered with a positive meconium or urine toxicology, and/or known maternal exposure to illicit and nonillicit substances, were identified. Maternal records were reviewed for disclosure of substance use during pregnancy at admission for delivery along with other medical and demographic variables. Women with antenatal prescription drug use that may alter toxicology screens were excluded from analysis. Pediatric records were also reviewed to obtain neonatal variables.

RESULTS

One hundred sixty-eight newborns were identified as having prenatal exposure to an illicit or nonillicit substance over the 4-year period. Eighty-six per cent (145/168) of women tested positive or their newborn tested positive for at least 1 illicit substance, and 49% (82/168) tested positive for multiple illicit substances. Fifty-four per cent (91/168) of women did not disclose using at least one illicit drug for which she or her newborn tested positive.With regards to maternal characteristics, there was no statistically significant difference between age (P = 0.958), parity (P = 0.300), or race (P = 0.531), and disclosure or failure to disclose about illicit drug use. However, patients who did not report prenatal illicit drug use (33/82 = 40%) were less likely (P = 0.049) to receive complete prenatal care (defined as 3 or more visits) compared with those who acknowledged their substance use (40/70 = 57%).

CONCLUSION

Substance use disorders during pregnancy are an often underestimated cause of maternal, fetal, and neonatal complications. Limited studies have examined the relationship between maternal characteristics and associated illicit or nonillicit drug use. The absence of correlation between maternal demographics and disclosure of illicit substance use demonstrates the fact that all antepartum patients are at risk for these behaviors. Furthermore, the fact that women who did not disclose their illicit drug use were less likely to seek complete prenatal care reflects the need for physicians to provide a destigmatized healthcare environment, encouraging pregnant women to disclose their substance use so they can be provided with appropriate counseling and treatment.

Maternal and neonatal wellbeing during elective C-section induced with a combination of propofol and dexmedetomidine: How effective is the placental barrier in dogs?

Anaesthetics administered during C-section (CS) can cross the placenta and the foetal blood-brain barrier contributing to distress up to neonatal mortality. Therefore, to prevent neonatal risks, sedatives and analgesics are not commonly administered to the bitch until all pups are delivered. This study aims to evaluate the effect of a new anaesthetic and analgesic protocol for elective CS in dogs, focused on both maternal and neonatal wellbeing. General anaesthesia was induced by a combination of propofol (PPF) and dexmedetomidine (DEX) and maintained with isoflurane. DEX was added to PPF in order to provide analgesia and to reduce PPF dose. Propofol and DEX concentrations in maternal blood, amniotic fluid, and placenta were correlated to maternal and neonatal parameters. Maternal pain score was assessed with Glasgow Composite Measure Pain Scale short-form. Nine healthy purebred dogs scheduled for elective CS delivered 54 pups. The 77.8% of pups were vigorous at birth and assigned to the highest Apgar score (AS). The lowest AS was recorded in pups from mothers receiving additional doses of PPF (p < 0.001). Apgar scores improved with the increase in time between induction and pups' extraction, starting from 30 min after induction (p < 0.01). This study could contribute to clarify the controversy about the optimal extraction's time of pups after induction i.e. the best time between PPF administration and birth. No bitch showed post-operative pain or required additional analgesic doses based on their pain score. Maternal blood PPF and DEX, as well as placental PPF concentrations, decreased over time (p < 0.01). Conversely, placental DEX was fair uniformly detected in littermate pups. Both PPF and DEX were not detectable in amniotic fluid. Placenta resulted an effective barrier against foetal DEX exposure, making this protocol safe, analgesic and advisable for elective CS in dogs.

Opioid Use in Pregnant Women and Neonatal Abstinence Syndrome-A Review of the Literature

Opiate use during pregnancy has been an increasing problem over the last two decades, making it an important social and health concern. The use of such substances may have serious negative outcomes in the newborn, and clinical and cognitive conditions have been reported, including neonatal abstinence syndrome, developmental problems, and lower cognitive performance. These conditions are common when opiates are used during pregnancy, making the prescription of these kinds of drugs problematic. Moreover, the mother may develop opiate addiction, thus, increasing the likelihood of the infant being born with any of those conditions. This paper reviews the use of opiates during pregnancy and focuses mainly on the neonatal abstinence syndrome. First, the commonly prescribed opiates will be identified, namely those usually involved in cases of addiction and/or neonatal abstinence syndrome. Second, published approaches to deal with those problems will be presented and discussed, including the treatment of both the mother and the infant. Finally, we will outline the treatments that are safest and most efficient, and will define future goals, approaches, and research directions for the scientific community regarding this problem.

Umbilical Cord Tissue and Meconium May Not Be Equivalent for Confirming in Utero Substance Exposure

In a retrospective study of 501 neonates with potential in utero substance exposure, the drug detection performance of a commercially available umbilical cord tissue toxicology test was evaluated against a commercially available gold standard meconium toxicology test. Drugs detected in paired meconium and umbilical cord tissue samples were often discordant.

Green sample preparations for the bioanalysis of drugs of abuse in complex matrices

The sample preparation is the most critical step involved in the bioanalytical process. When dealing with green analytical chemistry, sample preparation can be even more challenging. To fit the green analytical chemistry principles, efforts should be made toward the elimination or reduction of the use of toxic reagents and solvents, minimization of energy consumption and increased operator safety. The simplest sample preparations are more appropriate for liquid biological matrices with little interfering compounds such as urine, plasma and oral fluid. The same does not usually occur with complex matrices that require more laborious procedures. The present review discusses green analytical approaches for the analyses of drugs of abuse in complex biological matrices, such as whole blood, breast milk, meconium and hair.

Assessment of medication use during pregnancy by Web-based questionnaires, pharmacy records and serum screening

OBJECTIVE

To compare assessment of early pregnancy medication exposure using three methods of data collection.

METHODS

Serum samples were obtained from 752 women participating in the PRegnancy and Infant DEvelopment (PRIDE) Study before gestational week 17. For 52 women using medication at the date of blood sampling according to Web-based questionnaires or pharmacy records, we analysed serum samples using untargeted liquid chromatography time-of-flight spectrometry.

RESULTS

Medication was detected in 18 serum samples (35%). Medications taken orally for chronic conditions reported in the questionnaire were detected in serum and vice versa. Pharmacy records did not identify additional exposed women, but missed exposure in 5 women mainly due to unavailability. We observed substantial discordance between the three methods for inhaled medication, dermatological preparations, and medications for short-term use, which went often undetected in serum.

CONCLUSIONS

It remains challenging to assess medication use in large-scale studies as no 'gold standard' is currently available.

Detection of In Utero Cannabis Exposure in Umbilical Cord Tissue by a Sensitive Liquid Chromatography-Tandem Mass Spectrometry Method

In utero exposure to cannabis may cause various short- and long-term health problems in newborns, such as low birth weight and neonatal withdrawal syndrome. Drug testing with umbilical cord tissue can be used to identify in utero exposure to cannabis. Here, we described a liquid chromatography-tandem mass spectrometry (LC-MS/MS) method that simultaneously quantifies four cannabinoids in umbilical cord tissue, including tetrahydrocannabinol (THC), 11-nor-Δ9-carboxy-THC (THC-COOH), cannabinol (CBN), and 11-hydroxy-THC (11-OH-THC). Umbilical cord specimens are weighed and homogenized, and cannabinoids are extracted using anion exchange solid-phase extraction columns (AX-SPE). Liquid chromatography separation is performed, and quantitative results are obtained using LC-MS/MS.

Comparison of Biological Screening and Diagnostic Indicators to Detect In Utero Opiate and Cocaine Exposure Among Mother-Infant Dyads

BACKGROUND

Opioid and cocaine antenatal substance use can result in significant obstetric and pediatric health implications. Accurate detection of in utero-exposed neonates can improve patient care and health outcomes. Therefore, the effectiveness of mother-infant biological and diagnostic indicators collected at labor and delivery to provide accurate detection of in utero opiate and cocaine exposure was assessed.

METHODS

A retrospective medical chart review included 335 mother-infant dyads exposed to antenatal substances who were delivered between January 2009 and March 2014. Mother-infant dyads were a subset of a larger retrospective cohort of 560 substance-using mothers, who had a valid meconium drug screen (MDS) and anesthesia before delivery. Alternative biological and diagnostic indicators of maternal urine drug screens (UDS), maternal substance use International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes, and neonatal exposure diagnostic ICD-9-CM codes were compared against MDS. Data were analyzed using classification accuracy measures.

RESULTS

Compared with MDS, maternal UDS had the highest sensitivity [0.52, 95% confidence interval (CI), 0.39-0.65] and specificity (0.88, 95% CI, 0.79-0.97) to detect intrauterine opiate exposure. Maternal substance use diagnosis had the highest sensitivity (0.39, 95% CI, 0.16-0.61) and maternal UDS had the highest specificity (1.00, 95% CI, 0.99-1.00) to detect intrauterine cocaine exposure. Cocaine exposure had significantly higher accuracy scores across detection methods compared with opiate exposure.

CONCLUSIONS

Alternative indicators collected at delivery were ineffective at identifying in utero substance exposure, especially neonatal-exposed ICD-9-CM codes. Low sensitivity scores indicate that many exposed neonates could be misdiagnosed or left untreated. Accurate antenatal exposure identification at delivery is an important form of tertiary assessment that warrants the development of improved screening methodology and standardization of hospital biological drug testing.

Drug exposure during pregnancy: analytical methods and toxicological findings

Drug use during pregnancy constitutes a major preventable worldwide public health issue. Birth defects, growth retardation and neurodevelopmental disorders are associated with tobacco, alcohol or drugs of abuse exposure during pregnancy. Besides these adverse health effects, drug use during pregnancy also raises legal and social concerns. Identification and quantification of drug markers in maternal and newborn biological samples offers objective evidence of exposure and complements maternal questionnaires. We reviewed the most recent analytical methods for quantifying drugs of abuse, tobacco, alcohol and psychotropic drugs in maternal, newborn and maternal-fetal unit biological samples by gas and liquid chromatography coupled to mass spectrometry. In addition, manuscripts comparing the usefulness of different biological samples to detect drug exposure during pregnancy were reviewed.

Prenatal substance exposure diagnosed at birth and infant involvement with child protective services

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.

Ethical Considerations for Perinatal Toxicology Screening

Neonatal nurses frequently care for babies who have been exposed in utero to potentially harmful substances, both licit and illicit. The risks to the fetus from nicotine, marijuana, alcohol, and opiates are significant. Adverse effects from environmental factors may confound pharmacologic effects of substances. Nurses are called to shift the perception of substance use disorder from that of willful harm to the fetus to that of an opportunity to provide treatment assistance that can positively affect child health and development. Concerns for unethical practices in the toxicology screening of pregnant women and their babies by risk factors that are unproven or disproven are discussed, and three goals of toxicology screening based on the ethical principles of justice and beneficence are proposed. This article will help equip neonatal nurses to fulfill their professional responsibility to advocate for just screening and referral practices in their institutions and communities.

Assessment of tobacco, alcohol and cannabinoid metabolites in 645 meconium samples of newborns compared to maternal self-reports

Prenatal psychoactive substance exposure has significant impact on neonatal health and child development and the development of reliable biomarkers is critical. Meconium presents several advantages for detecting prenatal exposure to psychoactive substances, as it is easy to collect and provides a broad time frame of exposure (third trimester). The aim of our study was to compare the prevalence of alcohol, tobacco and/or cannabis use during the third trimester of pregnancy (using maternal self-reports) with the results of meconium testing of their metabolites in newborns (cotinine, ethyl-glucuronide (EtG) and cannabinoid metabolites). Among all deliveries (993) that occurred in all maternities in Rouen (Normandy) during a defined time period (5 consecutive weeks in August, 2010 and August, 2011), 724 mothers were included and 645 meconium samples were collected. Maternal self-reports, using the Addiction Severity Index (5th edition), and meconium samples were collected within 72 h of delivery. Cotinine detection appears highly correlated to maternal self-reports (Kappa value: 0.79; [95%CI: 0.73-0.85]). Moreover, detection in meconium seems more accurate in the prediction of neonatal consequences of prenatal tobacco exposure as compared to maternal self-reports. In contrast, we have found a lower concordance between maternal self-reports and meconium testing for EtG and cannabinoid metabolites (Kappa value: 0.13; [95%CI: 0.04-0.22] and: 0.30; [95%CI: -0.03-0.63], respectively); however the total number of EtG- and cannabinoid-positive meconium samples was small. Interestingly, meconium samples with the highest levels of EtG mainly corresponded to negative maternal self-reports. Fetal exposure to alcohol, tobacco or cannabis may also considerably differ as displayed in our pairs of dizygotic twins. Finally, a polyconsumption of these psychoactive substances was not frequently observed according to meconium testing. In conclusion, cotinine detection appears as a valuable meconium biomarker. EtG measurement in meconium samples seems interesting if there is any risk of high fetal exposure, whereas assessment of prenatal cannabis exposure, using meconium testing, needs to be improved.

Comparison of umbilical cord tissue and meconium for the confirmation of in utero drug exposure

OBJECTIVES

Drug screening in neonates is traditionally performed using meconium, but cord tissue has been proposed as an alternative specimen. This study compares the detection of drugs in a large number of paired meconium and umbilical cord tissue samples from subjects at risk of in utero drug exposure.

DESIGN AND METHODS

Physician-ordered toxicology results and clinical information were collected in a retrospective review of subject medical records. All toxicology testing was performed by a national reference laboratory using a combination of immunoassays and chromatography-mass spectrometry. The comparison was limited to drugs present in both cord and meconium panels.

RESULTS

Overall agreement between cord and meconium ranged from 76% (cannabinoids) to 100% (barbiturates), but Cohen's kappa was <65% for 5 of the 6 drug classes we studied. Considering meconium as the gold standard, cord was less sensitive for the detection of 5 of the 6 drug classes, and for the detection of all 5 individual opioids. For 3 of the 5 individual opioids, the concentration of drug measured in meconium did not correlate well with qualitative detection in cord.

CONCLUSIONS

This study reveals different sensitivities of drug detection in umbilical cord tissue and meconium. For the drugs studied here, meconium provides greater sensitivity, and is likely to remain the specimen of choice when sensitivity is of greatest importance. These results can help clinicians, laboratorians, and epidemiologists to (1) select the most appropriate test to confirm a suspected drug exposure and (2) interpret discordant results when testing is performed in multiple matrices.

Bioanalysis for cocaine, opiates, methadone, and amphetamines exposure detection during pregnancy

Drug exposure during pregnancy constitutes a major legal issue and a public health concern. Drug and metabolite determination in biological matrices from mother and newborn is an objective indication of prenatal drug exposure. However, limited data are available regarding the interpretation of these analytical results in terms of window of detection and degree of exposure. We collected paired maternal hair, meconium, placenta, and umbilical cord from 727 mother-newborn dyads. We analyzed these specimens by liquid chromatography-tandem mass spectrometry for the determination of cocaine, opioids, methadone, and amphetamines, and compared the analytical results from the four different matrices. The cases were divided in non-exposure, low, and frequent exposure, based on maternal hair concentrations and segmental analysis by trimesters. For cocaine, 62 cases tested positive in hair, 9 in meconium, 6 in placenta and 7 in umbilical cord. In the case of opioids, 14 maternal hair cases were positive, 11 meconium and umbilical cord and 9 placenta samples. For methadone, 11 cases were positive in hair, 9 in meconium and 6 in placenta and umbilical cord. For amphetamines, 18 cases were positive according to maternal hair, but all meconium, placenta, and umbilical cord tested negative. Maternal hair was the most sensitive specimen to detect drug exposure during pregnancy. Meconium, placenta, and umbilical cord tested positive if hair concentrations showed frequent drug use during the whole pregnancy, especially during the third trimester. Meconium, placenta, and umbilical cord also tested positive for morphine and metabolites, if this drug was administered during labour and delivery. Copyright © 2016 John Wiley & Sons, Ltd.

OBJECTIVE TESTING – URINE AND OTHER DRUG TESTS

Drug testing, when carefully collected and thoughtfully interpreted, offers a critical adjunct to clinical care and substance use treatment. However, because test results can be misleading if not interpreted in the correct clinical context, clinicians should always conduct a careful interview with adolescent patients to understand what testing is likely to show and then use testing to validate or refute their expectations. Because of the ease with which samples can be tampered, providers should also carefully reflect on their own collection protocols and sample validation procedures to ensure optimal accuracy."

Predictors of neonatal abstinence syndrome in buprenorphine exposed newborn: can cord blood buprenorphine metabolite levels help?

BACKGROUND

Buprenorphine is a semi-synthetic opioid used for the treatment of opioid dependence. Opioid use, including buprenorphine, has been increasing in recent years, in the general population and in pregnant women. Consequently, there has been a rise in frequency of neonatal abstinence syndrome (NAS), associated with buprenorphine use during pregnancy. The purpose of this study was to investigate correlations between buprenorphine and buprenorphine-metabolite concentrations in cord blood and onset of NAS in buprenorphine exposed newborns.

METHODS

Nineteen (19) newborns who met inclusion criteria were followed after birth until discharge in a double-blind non-intervention study, after maternal consent. Cord blood and tissue samples were collected and analyzed by liquid chromatography-mass spectrometry (LC-MS) for buprenorphine and metabolites. Simple and multiple logistic regressions were used to examine relationships between buprenorphine and buprenorphine metabolite concentrations in cord blood and onset of NAS, need for morphine therapy, and length of stay.

RESULTS

Each increase in 5 ng/ml level of norbuprenorphine in cord blood increases odds of requiring treatment by morphine 2.5 times. Each increase in 5 ng/ml of buprenorphine-glucuronide decreases odds of receiving morphine by 57.7 %. Along with concentration of buprenorphine metabolites, birth weight and gestational age also play important roles, but not maternal buprenorphine dose.

CONCLUSIONS

LC-MS analysis of cord blood concentrations of buprenorphine and metabolites is an effective way to examine drug and metabolite levels in the infant at birth. Cord blood concentrations of the active norbuprenorphine metabolite and the inactive buprenorphine-glucuronide metabolite show promise in predicting necessity of treatment of NAS. These finding have implications in improving patient care and reducing healthcare costs if confirmed in a larger sample.

Drug Screening in Neonates

Gestational substance exposure continues to be a significant problem. Neonates may be exposed to various substances including illicit drugs, prescription drugs, and other legal substances that are best not used during pregnancy because of their potential deleterious effects as possible teratogens or their potential to create dependence and thus withdrawal in the neonate. Screening the newborn for gestational substance exposure is important for both acute care and early intervention to promote the best possible long-term outcomes. This column provides insight into what is known about the extent of substance use by pregnant women, an overview of neonatal biologic matrices for drug testing, and a discussion of the legal implications of neonatal substance screening.