Nanci Stewart Woods

Cocaine use during pregnancy: Maternal depressive symptoms and infant neurobehavior over the first month

Research on the effects of prenatal cocaine exposure has produced an inconsistent pattern of results. The goals of this project were (a) to improve upon the methodology of previous research by matching subjects one-to-one on important confounding maternal and infant variables, (b) to investigate a population of rural women not enrolled in an intensive prenatal intervention program, (c) to assess the impact of cocaine use on maternal depressive symptoms both immediately and 1-month postpartum, and (d) to provide longitudinal data regarding the effect of cocaine exposure and maternal affect on neurobehavioral development of neonates by assessing the infants in the hospital and at 1 month of age. Cocaine-using mothers had significantly fewer prenatal visits and reported more depressive symptoms following delivery thon did control mothers. Cocaine-exposed infants had significantly lower birthweights and shorter gestations. There were no significant differences in neonatal performance on the Brazelton scale at birth or 1 month of age. These findings demonstrate that not all cocaine-exposed infants exhibit neurobehavioral deficits in the neonatal period. Longitudinal research is needed to determine if problems will manifest themselves at later ages when greater developmental demands are placed upon these children.

Prenatal cocaine use: A comparison of neonates matched on maternal risk factors

This study was designed to overcome some of the methodological limitations of previous work and investigate the impact of prenatal cocaine use in an understudied population: women using rural county public health units who had minimal access to drug rehabilitation. Through maternal history, interviews, and urine screens, 172 cocaine users were identified. Using an independently collected perinatal data base, 168 nonusers were matched for six variables known to affect pregnancy outcome and chosen a priori: race, age, parity, prenatal care, alcohol, and nicotine use. To avoid chance findings, 10 adverse perinatal outcome variables were identified prospectively. Cocaine-exposed neonates experienced significantly more of the adverse events than the matched controls and were more likely to be preterm, low birthweight, resuscitated at birth, and to remain in the hospital after their mothers were discharged. We conclude that prenatal cocaine use can be a contributor to adverse perinatal outcome in this population. An understanding of the effects of prenatal cocaine use and the needs of these women and infants is important for designing appropriate prenatal care, treatment, and follow-up programs.

Newborn evaluations of toxicity and withdrawal related to prenatal cocaine exposure

The literature on prenatal cocaine exposure is unclear whether immediate postpartum effects on the infant are transient, related to either acute toxicity of cocaine, or to a withdrawal effect as cocaine is metabolized, or whether they might persist. This prospective, longitudinal study was designed to test the hypotheses that newborns urine-positive for cocaine metabolites, compared to those exposed but urine-negative, and to nonexposed controls would (1) have poorer neurobehavioral scores (toxicity effect) and (2) worsen or demonstrate less improvement over the first week (withdrawal effect). We approached over 2500 pregnant women designated to deliver at our referral hospital from public health clinics; 85% consented to participate in a longitudinal study. We excluded women <18 years old with major chronic illness and prenatal drug use except cocaine, marijuana, alcohol and tobacco. From positive urine toxicologies or admissions in private, thorough interviews, 154 were identified as prenatal cocaine users; 154 were selected from noncocaine users matched on socioeconomic status (SES), race, parity and location of prenatal care (that related to perinatal risk), for a total sample size of 308. Included in this article are the 155 surviving infants who were full-term, delivered vaginally and were well and available for testing over the first week postpartum. Infant urine specimens were collected, and neurobehavorial testing was performed by certified, blinded examiners using the Neonatal Behavioral Assessment Scale on days 1, 2-4 and 5-7 postpartum. In toxicity analyses, controlling for amount of prenatal drug exposures, only autonomic regulation demonstrated significant overall and cocaine drug group effects. Urine-positive newborns had the poorest scores (i.e., more startles, tremors). However, given that planned comparisons were not significant, these data provided little support for acute toxicity effects. In withdrawal analyses, only one significant change over time varied among exposure groups. Those infants exposed and positive for cocaine metabolites increased their scores on regulation of state on days 2-4 and decreased them on days 5-7 (when withdrawal might be evident). However, their scores on days 5-7 were not significantly lower than their initial scores, nor different from the days 5-7 scores of the exposed negatives or control infants, lending little support for withdrawal effects. Our data support those of other controlled studies in failing to demonstrate devastating early effects of prenatal cocaine exposure. They add to our understanding that effects observed do not appear to be related to acute toxicity nor to cocaine withdrawal. The uncertainty of persistent effects of cocaine exposure warrants long-term follow-up.

Incidence and description of structural brain abnormalities in newborns exposed to cocaine.

OBJECTIVE This study was undertaken to determine whether an increased incidence of structural brain abnormalities could be demonstrated in newborns exposed to cocaine. STUDY DESIGN This study was part of a prospective, longitudinal study of 154 cocaine users matched to 154 control subjects on prenatal risk level, race, parity, and socioeconomic status. Subjects were enrolled prenatally from a rural public health department population or at delivery. Drug exposure was determined by means of repeated, detailed histories and urine screening for drug metabolites. Ultrasonographic examinations were performed within 4 days of birth by experienced technologists and were read by one experienced radiologist, each blinded to drug use history. RESULTS Cranial ultrasonography results were available for 266 infants (134 cocaine-exposed; 132 control). Only 27 infants had ultrasonography results that were not considered normal, and there were no significant differences between groups (17 cocaine-exposed vs 10 control; p = 0.119). Identified abnormalities included choroid plexus cysts, subependymal cysts, mildly dilated ventricles, and a cyst of the third ventricle. CONCLUSIONS The incidence of abnormal cranial ultrasonography results in our cocaine-exposed group was lower than that previously reported in the literature and not significantly different from the control group. In addition, the identified lesions were less severe than previously reported, despite a wide range of cocaine use in our sample, including heavy use.

Rural Pregnant Cocaine Users: An in-Depth Sociodemographic Comparison:

As part of a prospective, longitudinal study of the effects of prenatal cocaine use on infant outcome, we enrolled 308 women when they first came in for prenatal care or at delivery, in the case of no prenatal care. The 154 women in the cocaine use group, identified by means of drug history and urine testing, were matched to 154 non-cocaine using controls on race, parity, socioeconomic status, and level of prenatal risk. This report presents a summary of the demographic and drug-use information collected at the time of delivery and the psychosocial data measured at delivery including standardized measures of depression, locus of control, self-esteem, concepts of development, life stress, and social support. Between group comparisons revealed that cocaine users were more likely than non-users to be older, to use other drugs, to begin their drug use at an earlier age, to have more depressive symptoms, to have an external locus of control, to have lower self-esteem, to have a more simplistic understanding of child development, and to have higher positive life event impact scores.

Multiple risk factors do not identify cocaine use in rural obstetrical patients

This nonconcurrent, cohort study of consecutive admissions to one of three hospital units: labor and delivery (n = 474), well-born nursery (n = 100), and the neonatal intensive care unit (n = 100), was designed to determine the prevalence of cocaine exposure in a rural obstetrical sample and to determine the relationship between exposure and perinatal variables. Urines were analyzed for benzoylecgonine, and the Obstetrical Complications Scale was completed for each mother-infant pair. Elementary comparisons were made using chi 2 analyses and Students t test. Stepwise discriminant and discriminant function analyses were performed. The prevalence of exposure in the three groups of subjects ranged from 5%-7%. No significant differences in perinatal variables were found between users and nonusers in either of the newborn samples. In the maternal sample the groups differed on twelve mother or infant factors. However, no single variable or set of variables predicted use versus nonuse in any of the groups.

Quantification of the Dubowitz neurological assessment of preterm neonates: Developmental outcome

Abstract The Dubowitz Neurological Assessment Scale can be used with preterm and term hospitalized neonates and is easily administered and scored. However, no numbers are given to responses, so multivariate analyses have not been possible. We assigned numerical values and reduced the 33 items into four clinically meaningful clusters validated by factor analysis. The Dubowitz was used to assess 575 preterm infants. Regression analyses showed that adjusted age and birth weight were independently related to most cluster scores. Predictive validity was measured by independent developmental assessment of infants returning between 6 ( n = 150) and 24 ( n = 118) months adjusted age. Regression analyses demonstrated that only motor clusters were independently related to the Bayley Scales, predicting mental scores at 12 and 18 months and mental and psychomotor scores at 24 months. However, beyond 6 months, only one test item was independently related to mental development; eight items related to psychomotor scores were significant at 18 but not at 12 and 24 months.

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Part of the problem in understanding the nature of early postpartum effects of fetal cocaine exposure has been the lack of separation of true effects of prenatal exposure from those associated with acute toxicity. Only a few studies have compared newborn behavior of infants exposed prenatally and positive for cocaine metabolites at birth to those exposed infants negative for cocaine at birth. Most failed to use blinded observers, drug-free controls, or prospective enrollment. None considered amount of exposure of positive vs. negative infants, thus possibly confounding the effects of amounts of exposure with acute toxicity. We prospectively enrolled 154 women who used cocaine during pregnancy and matched 154 controls on SES, race, parity and prenatal risk. Marijuana was the only other illicit drug allowed. Pregnant women were interviewed in a private setting by trained staff who collected details of past drug use at the end of each trimester. All subjects were required to provide urine specimens at enrollment and to consent to full toxicology testing of their newborns. Following delivery, certified, blinded examiners administrated the Neonatal Behavioral Assessment Scale (NBAS) under controlled conditions. Based on interviews, toxicology testing, and availability for NBAS testing, there were 81 who admitted use or were positive in pregnancy, but whose infants were negative at birth; 48 whose infants were positive at birth; and 148 controls. We determined that median amounts spent on cocaine per day during pregnancy differed for those positive (

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1.81) and those negative (

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0.66) at birth; therefore, to evaluate acute toxicity, the amount spent on cocaine was used as a covariate in all analyses along with adjustment for amount of tobacco, alcohol and marijuana use. Our results demonstrated that of the 7 NBAS cluster scores, only Autonomic Regulation was significantly different by group. Of the 9 supplementary scores qualifying NBAS performance, only Alert Responsiveness was significant for group; the infants who were positive at birth scored significantly lower than controls, with scores of those negative falling in between. Our earlier work with this cohort found behavioral effects related to the amount of prenatal cocaine exposure. In this study, after controlling for the amount of prenatal exposure, only 2 of 16 NBAS scores were significantly different between infants positive and negative for cocaine metabolites at birth. We conclude that newborn behavioral effects do not seem to be highly related to acute toxicity.