Saundra Ehrlich

Cocaine abuse in pregnancy: effects on the fetus and newborn.

The outcome of infants born to cocaine-using drug dependent women was compared to that of infants of non-cocaine using drug dependent and non-drug dependent women. The study population included 150 pregnant women: 50 women used heroin and methadone plus cocaine, 50 used heroin and methadone minus cocaine, and 50 were non-drug dependent women. Significant differences were found between the cocaine and drug-free groups in infant birth weight, length, head circumference and Apgar scores, with the cocaine group having lower values for each variable. Average gestational age did not vary between the 3 groups. The cocaine group included 1 spontaneous abortion and 4 fetal deaths; non-cocaine drug dependent women had 2 fetal deaths, with none in the control group. Mean abstinence scores for 19 of the physiological and behavioral parameters were lower in the cocaine group than in the non-cocaine drug dependent women with the exception of vomiting and convulsions. These data suggest that: (1) infants born to drug dependent women have a poorer general outcome than those born to non-drug dependent women; (2) maternal cocaine use does not appear to increase the incidence of severe neonatal abstinence symptomatology; (3) pregnancies complicated by cocaine abuse have a greater chance for fetal loss resulting from both spontaneous abortions and fetal death; (4) infants born to cocaine abusing women had infants with decreased birth weight, head circumference, length and Apgar scores.

Infants of drug addicts: at risk for child abuse, neglect, and placement in foster care

In a methadone maintenance program for pregnant, drug dependent women, an investigation was undertaken (1) to study the occurrence of violence experienced by the women as children and as adults and (2) to lean whether those who report past violence/abuse are more likely to neglect and/or abandon their children to the care of others. Subjects included 178 drug dependent women who completed a Violence Questionnaire and 70 comparable, but drug-free women. Results revealed that a history of violence or abuse is related to drug abuse and also to the placement of ones child(ren) in foster care.

Prospective comparison of external sphincter balloon dilatation and prosthesis placement with external sphincterotomy in spinal cord injured men

The purpose of our investigation was to compare external sphincterotomy, the traditional method of treatment of detrusor-external sphincter dyssynergia (DESD), with two newer methods, balloon dilatation or internal stenting of the external sphincter. Sixty-one spinal cord injured (SCI) men were prospectively evaluated. The indications for treatment were DESD and voiding pressure greater than 60 cmH2O demonstrated during video-urodynamic study. Twenty patients were treated with balloon dilatation of the external sphincter, 26 with an internal stent prosthesis, and 15 with traditional external sphincterotomy. Age and duration of SCI were similar among the three treatment groups. A significant decrease in both voiding pressure and residual urine from presurgery levels persisted during the follow-up period of 3 to 26 months (mean, 15 months) in all three groups. Bladder capacity remained constant, renal function improved or stabilized, and autonomic dysreflexia (AD) improved in all three groups. Balloon dilatation and prosthesis placement are associated with a significantly shorter length of surgery (p = 0.045), length of hospitalization (p = 0.005), decrease in hospitalization cost (p = 0.01), and decrease in hemoglobin postoperatively (p = 0.046) when compared to external sphincterotomy. Complications of stent insertion included device migration (three patients) and secondary bladder neck obstruction (two patients). In the balloon dilatation group, three recurrent sphincter obstructions, one case of bleeding requiring transfusion, and one case of bulbous urethral stricture occurred. After external sphincterotomy, two patients developed recurrent obstruction, two required blood transfusion, and 1 patient noted erectile dysfunction. Balloon dilatation and prosthesis placement both proved to be as effective as external sphincterotomy in the treatment of DESD.(ABSTRACT TRUNCATED AT 250 WORDS)

Pelvic marrow in adults

The appearance of hematopoietic marrow in magnetic resonance (MR) imaging is variable and differences between normal and pathologic marrow may be subtle. To aid in the evaluation of this problem, we reviewed 82 consecutive pelvic MR examinations in men with no evidence of osseous metastases. Images were evaluated with regard to the overall fraction of residual hematopoietic marrow present and the characteristics of this marrow. The patient population in our study was older (mean age 66 years) than the patient populations in previous papers documenting normal marrow patterns. The overall amount of hematopoietic marrow present was less in this older patient population, with 80% of patients having less then 40% residual hematopoietic marrow. A consistent pattern of morphologic change was noted as hematopoietic marrow converted to fatty marrow with increasing age. Initially, hematopoietic marrow tended to appear diffuse, heterogeneous, and with poorly defined margins on MR imaging. As conversion to fatty marrow continued, hematopoietic marrow became more focal and sharply defined, usually in the form of islands of residual hematopoietic marrow. Periarticular hematopoietic marrow predominated in the sacroiliac region (72% of patients) with little residual hematopoietic marrow noted in the symphysis pubis (5%) and hip joints (30%). Hematopoietic marrow persisted longer in juxtacortical locations (87%), was always symmetric (100%), remained less intense than fat on T2-weighted images (100%), and usually had a central focus of fat (98%). These morphologic criteria may be of value in establishing the MR appearance and patterns of marrow in the pelvis, and in the recognition and confident diagnosis of foci of hematopoietic marrow.

COCAINE AND PREGNANCY: MATERNAL AND INFANT OUTCOME

The number of infants born to women who abuse cocaine is rapidly increasing. Subjects of this study, conducted within a drug treatment program providing pre and postnatal services to drug dependent women(DDW), included 237 pregnant women: 91 cocaine using DDW, 83 non-cocaine using DDW, and 63 non-DDW. The groups were similar for maternal age, socioeconomic status, nicotine use and parity, but differed in race. Abruptio placentae occurred in 8% of the cocaine DDW, 4% of the non-cocaine DDW and in 2% of the non-DDW. Spontaneous abortions, emergency C-sections and meconium staining occurred more often in the cocaine DDW than in either of the other 2 groups. Birth weight and length, head circumference, gestational age, and 1 min. Apgar scores were significantly lower in the infants of cocaine DDW. No differences existed in the occurrence of congenital anomalities and intracranial hemorrhage. There were more premature deliveries in the cocaine (21%) than in the non-cocaine (11%) and comparison (4%) groups. Mean neonatal abstinence scores, which incorporated 21 physiological and behavioral parameters to quantify symptoms, were lower for the cocaine exposed infants. Differences were significant with respect to cry, disturbed tremors, increased muscle tone, excoriations, fever, mottling, and loose stools. The results of this study suggest that: 1)cocaine use in pregnancy adversely effects maternal and infant outcome, 2)exposure to cocaine in-utero does not appear to increase the incidence of neonatal abstinence symptomatology.

Cocaine and Pregnancy: Maternal and Infant Outcome

The number of pregnant women using cocaine has grown with the drug’s increasing availability, its highly addictive quality, and its persistent image as a socially acceptable and harmless agent. Although the destructive effects of cocaine on the adult user are well known, little has been reported regarding maternal cocaine use and its affect on the perinatal period and the neonate.’-’ With these concerns in mind, the present study was conducted within Family Center, a treatment program providing preand postnatal services for drug-dependent women and their infants! Maternal and infant outcomes for women using cocaine with other drugs were compared to those of drugdependent women not using cocaine and a group of drug-free women. Subjects included 239 women: 93 cocaine-using, drug-dependent women, 83 noncocaine-using, drugdependent women, and 63 nondrug-dependent comparison women. The groups were similar in maternal age, socioeconomic status, nicotine use and parity, but differed in race. Emergency cesarean sections, meconium staining and small for gestational age infants occurred more often in the cocaine group. Birth weight, length, head circumference, gestational age, one minute Apgar scores, mean neonatal abstinence scores and incidence of nuchal cords were significantly lower in the infants of the cocaineusing, drug-dependent women. No differences were found in the incidence of intracranial hemorrhage or congenital anomalies. The occurrence of Sudden Infant Death Syndrome and the need for cardiorespiratory monitors was similar for cocaineand noncocaine-exposed infants of drug-dependent women, but greater than the figures reported in the general population. Abruptio placentae occurred in 9% of cocaine drug-dependent women, 4% of noncocaine drug-dependent women and 2% of drugfree women. More premature deliveries were seen in the cocaine group (20%) than in the noncocaine (1 1%) and drug-free (3%) groups. The results of this study suggest that maternal and infant outcome are generally poorer when women are drug dependent and use cocaine. A consistent trend is seen in the parameters that define fetal/ neonatal and maternal outcome. Drug-free women and their infants have the best outcome, drug-dependent women and their infants a less favorable outcome, and cocaine-abusing women and their infants the least favorable. The life style of drugdependent women is erratic and hardly conducive to achieving an optimal outcome in pregnancy. The use of cocaine appears to adversely effect this already poor situation. Cocaine has been found to effectively suppress appetite, and it decreases the user’s interests in fulfilling bodily needs.’ Because of the drug’s highly addictive quality the search for and use of the drug becomes the most important goal in the user’s life.

MATERNAL DRUG ABUSE DURING PREGNANCY AND PHARMACOTHERAPY FOR NEONATAL ABSTINENCE SYNDROME (NAS)

Newborns exposed in-utero to opiates and/or nonopiates frequently undergo NAS. This study evaluated:1)the relationship between the type of maternal drug use and the incidence of NAS and 2)which of 3 treatment drugs was most effective-- paregoric, phenobarbitol, or diazepam. NAS was assessed by a scoring system related to drug dose. Successful treatment was considered when one drug controlled the NAS. Of the 300 infants, 176(59%) were treated for NAS and 124(41%) required no treatment. Maternal drug use consisted of opiates(33%), non-opiates(14%)and varying combinations of both(53%). Infants exposed to non-opiates in-utero were less likely to undergo abstinence(36%) than those exposed to opiates(58%) or both(70%). The mean number of days to control symptoms of NAS was 7.6, and duration of treatment averaged 38,6 days, The efficacy of treatment drug for NAS depended upon the type of drug exposure in-utero. If maternal drug use included opiates alone, paregoric was the drug most successful in controlling NAS (87% of infants). In maternal non-opiate use, phenobarbital was most effective(100%). In maternal opiate and non-opiate use, paregoric was most effective(88%). Treating an infant with diazepam indicated the need for a second treatment drug in 70% of cases, regardless of maternal drug use (p=.001). These data suggest that:1)effective NAS treatment is related to the type of maternal drug use, 2)there is a higher incidence of NAS in infants prenatally exposed to opiates alone or in combinnation with non-opiates, and 3)diazepam is Ineffective as a treatment agent for NAS.

57 SEXUAL VIOLENCE AND PLACEMENT OF CHILDREN

Family Center is a comprehensive program which provides obstetrical and psychosocial services and methadone maintenance for pregnant drug-dependent women and their infants. Between 1979 and 1983, 171 women on enrollment to the program completed our Violence Questionnaire. Objectives of the questionnaire were: 1) to ascertain episodes and degrees of violence experienced by the women, including acts of physical and sexual abuse occurring in childhood or as an adult. 2) to learn if women reporting a history of violence/abuse were more likely to have had children in foster care. Individual item responses on the questionnaire, reported in percentages, were:Of the 171 women studied, 40% had children in voluntary or involuntary foster placement. Women with a reported history of sexual trauma, particularly if occuring in childhood or repeatedly, were significantly more likely to have children in foster care (p= <.01). Women who were physically abused (without sexual trauma) as children and/or adults were less likely to have their children in placement. This study suggests that failure to resolve childhood sexual trauma or coping with the trauma by use of illicit drugs, disrupts the ability of women to parent their own children. The effects of violence toward women, particularly when they themselves were children, may have untoward effects upon their own children.

THE USE OF TRI-CYCLIC ANTI-DEPRESSANTS (TCA) IN METHADONE MAINTAINED (MM) PREGNANT WOMEN AND INFANT OUTCOME

Little is known about TCA use in pregnancy and infant outcome. This study evaluated Infants born to MM women who were concurrently prescribed TCAs for the treatment of depression. Subjects included:1)18 infants born to MM women also exposed in-utero to imipramine(N=3) or doxepin(N=15) in doses ranging from 25mg, to 100mg. and 2)18 infants born to MM women not exposed to TCAs in-utero. The women were similar with regard to age, race, gravidity, parity, methadone dose, number of prenatal visits and socioeconomic status. Although types of illicit drug use in pregnancy differed between groups, these differences were taken into account in the analysis. The infant variables compared in the 2 groups were: gestational age, birth weight, head circumference, intrauterine growth, 1 and 5 min. Apgar scores, length of hospital stay, infant complications and neonatal abstinence. Infants in the TCA group were born earlier than controls(37.1 wks. VB, 38,7wka., p<.05), other differences between groups included lower birth weight, smaller head circumferences and lower Apgar scores, and were attributable to gestational age differences. The groups were found similar on other variables. Within the TCA group, when comparisons were made according to trimester prescribed, infants exposed during the 3rd trimester were found to be born earlier and somewhat smaller than infants with 1st and/or 2nd trimester exposure. These results suggest continued caution in prescribing TCAs in MM pregnant women. Their use can only be jxistified when the benefits outweigh the potential risks.

1300 THE INCIDENCE OF CONGENITAL ANOMALIES AMDNG INFANTS OF DEPENDENT PREGNNANT MEN

There is concern about infants born to drug-dependent women with regard to whether illicit drug use during pregnancy adversely affects structural fetal development. To assess the risk of fetal exposure to psychoactive drugs in-utero, a study of infants born to drug-dependent women enrolled in Family Center, a program providing prenatal care, counseling and methadone maintenance for these women, was conducted. From 1979 through 1983, 201 infants were examined for evidence of congenital anomalies. One-hundred and twelve of the infants (56%) were treated for neonatal abstinence; 89 infants (44%) required no treatment. Overall, the incidence of congenital anomalies in both groups fell within that of the general population (2-3%), suggesting that methadone maintenance, with or without accompanying illicit drug use during pregnancy, does not place the fetus at higher risk for anatomic defects. Of the anomalies seen, the cardiovascular system was most frequently affected. Structural congenital heart disease was found in 3.4% of the infants, (four times the incidence reported in the general population-.6%-.8%). Septal defects and pulmonic stenosis were the lesions identified. No explanation is available at present for these findings; however, the following should be considered: 1) Cardiac development occurs between weeks 2 and 8 of gestation, 2) The drug seeking behaviors of the addicted pregnant woman place her at risk for early intrauterine infection, 3) Exposure to viral teratogens (primarily coxsackie and rubella) has been implicated in abnormal cardiac development. These data suggest that, although the drug-dependent women may experience greater exposure to environmental teratogens early in pregnancy, the incidence of congenital malformations are not increased over that expected in the general population. However, the fetal cardiovascular system does appear more sensitive to environmental stressors in a pregnancy complicated by drug-dependency.