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Narcotic withdrawal in pregnancy: Stillbirth incidence with a case report
Narcotic withdrawal
in pregnancy: Stillbirth
incidence with a case report JOSfi
LUIS
REMENTERfA,
NEMESIO Bronx,
N. New
M.D
NUNAG,
M.D.
York
A stillborn infant was born to a drug-addicted mother who had withdrawal symptoms shortly before delivery. Mechanisms are presented to help explain the possible relationship between the maternal withdrawal and the fetal death. Statistics are also presented to show an increased stillborn and neonatal mortality rate in the over-all pregnant drug-addicted population
1 N KIIC E ~1‘ Y EAR s, pregnant drugaddicted women have been treated in either methadone maintenance’s ” or methadone detoxification programs.” Reports from both types of programs would seem to indicate that there is no apparent harm to the fetus. There are, hokvever, many women who may enroll in a methadone detoxification program during their pregnancy only to revert to the use of heroin at some time before delivery. Blinick and associates” reported that up to 40 per cent of the women treated in the methadone detoxification program were found to be using heroin at the time of delivery. However. there are many pregnant drug addicts \vho may enroll in a detoxification program but remain on heroin and/or other drugs for some part of their pregnancy. Heroin addicts, including pregnant women can experience withdrawal symptoms if they cannot obtain the heroin dose sufficient for their addicted state. From the Departments Pathology, Fordham Hospitals. Received 197.3.
for publication
Accepted
March
of Pediatrics and Misericordia
There has been a paucity of reports to date about events which occur in the fetus when a pregnant drug addict experiences withdrawal symptoms. In their review of the drug effects on the fetus, Sutherland and Light’ stated that narcotic withdrawal may result in an increase in fetal movements and occasional fetal death. Chappel” reported two episodes of neonatal death (in the third trimester of pregnancy) caused by meconium aspiration following opiate withdrawal prior to labor. The following is a case report of a pregnant heroin addict who experienced withdrawal symptoms during the thirty-ninth week of pregnancy and was delivered of a stillborn infant. Case
search Laboratory test positive, whose last menstrual period was estimated to be sometime in
and
June, February
report
M. R. was admitted in labor on March 11, 1972, to the Fordham Hospital Obstetrical Service. She was a 23-year-old Puerto Rican primigravid nonclinic patient, Venereal Disease Re-
9,
1971,
and
whose
expected
ment was given as March, heroin addict for 7 years had experimented with marihuana, amphetamines,
26, 197.7.
Reprint requests: Dr. lose’ Luis Rementeria, Department of Pediatrics, Fordham Hospital, Bronx, New York 10458
During was 152
admitted
her sixteenth
date
of confine-
1972. She had been a and, at various times, cocaine, barbiturates, and other drugs.
week of pregnancy,
to a methadone
treatment
she
center,
Volume Number
116 8
withdrawn from heroin within a 7 day period, and discharged. She managed to stay drug free for one month but then reverted to the use of heroin, taking an average of 3 “bags” a day intravenously and continuing this dose until the thirty-first week of pregnancy. Seeking help, she was admitted to another methadone treatment center, where she remained for a period of 3 weeks. Leaving the treatment center in the thirtyfourth week of pregnancy, she returned to her previous environment and soon began to take the usual dose of 3 “bags” of heroin per day, gradually increasing the dosage to 6 “bags” a day. Because of the increasing cost of the habit and apprehension concerning the effects of the fetus, she obtained illicit methadone and decreased the heroin intake. Although she preferred to be maintained on methadone during this stage of pregnancy, she frequently had to resort to substituting heroin because illicit methadone was difficult to obtain. On the night before delivery, she took 3 “bags” of heroin and, on awakening in the early hours of the morning, she experienced symptoms such as sweating, restlessness, a feeling of desperation, nausea, and a runny nose. It was apparent to her that the bags she used the previous night contained little heroin and that she was experiencing withdrawal symptoms. She reported that she had spent several stressful hours locating a “pusher,” who finally sold her heroin. Labor contractions started shortly after the withdrawal symptoms began, and, after she gave herself an injection of heroin, she went to the hospital. Until arrival at the hospital, she felt fetal movements, but, when the admitting physician examined her, he could not detect fetal heart sounds. Labor pains continued, and, after several hours, a stillborn female infant was delivered vaginally. The amniotic fluid was heavily stained with meconium and large quantities of meconium were removed from the nose and mouth of the stillborn infant. Postmortem examination of the infant revealed a nonmacerated female, weighing 2,720 grams (6 pounds 0 ounces). There were large quantities of meconium in the mouth and nasal passages. The head circumference was 33.5 cm., chest 31.0 cm., and length 48.5 cm. Gestational age was estimated to be 39 weeks. There was bilateral pulmonary atelectasis and the presence of meconium in the trachea and bronchi.
Narcotic
withdrawal
in pregnancy
1153
Microscopic examination of the lungs revealed collapsed alveoli containing meconium. There was a moderate number of anucleated squame cells and many more mononuclear phagocytes laden with brownish pigment interpreted as meconium. In addition, there were focal hemorrhages and congestion in the visceral organs, spleen; kidney, ovaries, liver, and adrenal glands. Comment Blinick and associates3 reported meconium in amniotic fluid in 33 per cent of heroin addict pregnancies. This meconium was described as “old meconium,” passed by the fetus during stressful periods, possibly during the time when the maternal narcotic intake may have been increased or decreased. In the addict’s environment, it may be difficult to obtain a steady heroin supply of a reliable concentration; this may result in a variable serum level of the drug. Louria and colleaguesG demonstrated that of 122 heroin “bags” confiscated and analyzed 12 contained no heroin and, in the remaining 110 bags, the content of heroin ranged from 1 to 77 per cent. In the study of Blinick and associates,3 it would appear that most of the fetuses exenvironment posed in this “old meconium” apparently do well. Of the 102 infants delivered by his group, there was one stillborn infant (908 grams) and 2 neonatal deaths; one weighed 936 grams and the other weighed 1,816 grams and died from respiratory distress syndrome. From this study and that of Statzer and Wardell,l it would seem that the stillborn rate in pregnant heroinaddicted women will not differ from that of the general population (stillborn rate of 12 to 16 per 1,000 live births72 “). Stone and co-workers8 and SussmanlO do not mention any stillbirths associated with pregnant drug addicts. However Stern’sI report (5 stillbirths of 70 infant’s delivered) would indicate that the incidence of stillbirth could be much higher, 71 per 1,000 live births. At Fordham Hospital, during an 18 month period, 47 infants were delivered of 46 drug-
i 154
Rementeria
Table I. Mortality between
January
and
Nunag
Am.
data from 47 drug-addicted 15, 1971, and July 15, 1972
infants
born at Fordham
Total Perinatal
Fetus W.
Weight (grams) Gestational age (weeks)
1,928 34
1,076 32
time of fetal death before delivery Postnatal time of infant’s death Maternal age (yr.1 Length of time of maternal addiction Maternal withdrawal symptoms during pregnancy Prenatal clinic visits VDRL (maternal) .4mniotic fluid
1 wk.
12-24
Estimated
Prenatal complications Cause of death Was mother on methadone program at time of delivery Had mother ever been in a methadone program
Fetus R. 2,720 39
hr.
2-4
Hospital
deaths Neonatal
Fetus A.
15, 1973 Gynccol.
deaths
Stillbirths Data
August J. Obstet
deaths Infant C.
Infant Sl
Infant S:
Infant F.*
594 24
1,104 32
880 ‘7
2,836 40
hr.
-
-
6 hr.
8 days
3 days
5 wk.
“4
17
23
17
19
21
22
Not
Not
known
7 yr.
Not
known
1 yr.
Not known
3 % yr.
Not known
Not
known
Yes
Not
known
Not
Not known
NO
None
None
None
None
None
None
None
Neg. Meconium stain None known -
Neg. Bloody
Neg. Clear
Neg. Clear
Neg Clear
Neg. Clear
Abruptio placentae -
Pos. Meconium stain Withdrawal symptoms -
Vaginal bleeding RDS
Vaginal bleeding RDS
None known SIDS
No
No
No
No
Twins, PRM 48 hr. Necro. enter. Yes
No
Yes
Not
Not
Yes
Not
-
Not known
-
known
known
known
known
known
Abbreviations: PRhl. premature rupture of membranes; RDS, respiratory distress syndrome; Necro. colitis; SIDS, sudden infant death syndrome. VDRL, Venereal Disease Research Laboratory test. *Infant F.. born to a methadone-treated drug addict, had a sudden, unexpected death at 5 weeks
addicted mothers (one set of twins) . There were 3 stillbirths and 3 neonatal deaths. Table I summarizes the clinical findings in the 6 perinatal deaths, and Table II compares our experience with other reports. The stillborn rate in our series was 64 per 1,000 live births, vvhich is romparable to the rate recorded hv .Stern.” In contrast to the mothers supervised by Hlinick and associates and Statzer and Wardell. most of the mothers in our ‘group were not on methadone lnaintenance at the time of delivery. Actually. only 14 of the 46 mother< in our sarirs were in a methadone
enter.,
necrotizing
entero-
of age.??
program or had sampled methadone during their pregnancy. This may account for the higher stillborn and neonatal death rates in our group. It is felt that when a heroin-addicted mother undergoes withdrawal symptoms, the fetus is also experiencing them. The mother usually recalls that fetal movements are significantly increased when she notes her own signs and symptoms of withdrawal. As a result of this stressful episode, the fetus would pass meconium and, at the same time, initiate strong respiratory movements.“~ “’ These events could account for the presence of me-
Volume Number
116 8
Narcotic
Table II. Stillborn infants
and neonatal mortality of drug-addicted mothers Total
Blinick and associates3 Statzer and Ward&l Stone and colleagues9 SussmanI” Stern’l Wallach and co-workers” Reddy and associates20 Nathenson and colleague9 Rementeria and co-workers
in various
addicted infants 102 100 384 18 70 13 40 18 47
“During the same 18 month period, the stillborn (43 stillbirths and 2,766 live births). The stillbirth obstetric population.
No. of stillbirths infants 1 2 5 1 3 rate among rate among
conium in the amniotic fluid reported by Blinick and associates” and in the trachea, bronchi, and alveoli of the infant in our report. The autopsy findings of focal hemorrhages and congestion in the organs would be those expected in anoxia. In the absence of any obvious cord compression, the mechanism of intrauterine anoxia remains obscure. During normal pregnancy, there is a progressive rise in oxygen consumption as indicated by the increase in the maternal metabolic rate of as much as 25 per cent.14 In the average pregnant woman, the metabolic rate of the fetus is believed to be much higher than that of the mother on a weightfor-weight basis. I5 When the pregnant heroin addict undergoes severe withdrawal, muscular activity increases, which probably increases the metabolic rate and oxygen consumption. Since it has been noted that fetal activity during maternal withdrawal also increases, the oxygen needs of the fetus could also be assumed to be increased. The oxygen reserve in the intervillous space of the placenta may or may not be able to supply the extra oxygen needed by the fetus. This oxygen reserve would be completely exhausted in 2 to 2!,4 minutes if blood flow through the intervillous space was tolabor, contractions tally arrested. I6 During the blood flow through the compromise uterus and consequently have an effect on
No. of neonatal deaths 2 2 14 2 0 2 3
in pregnancy
1155
studies involving
Incidence
No.
of drug-
Study
rates reported
withdrawal
per
in drug-addicted 1,000 live births
infants
Stillborn
Neonatal deaths
Perinatal deaths
9.8 20 -
19.6 20 36.4
29.4 40 127.8
71.4 79.9
111-
63.9’
the entire obstetric population our drug-addicted population
50 63.9 was
was 15.5 4 times
per 1,ooO live births that of the general
of the intervillous the oxygen reserve space. 17+I8 The longer and stronger the contractions, the more compromised the circulation through the uterus.l’ If labor should coincide with withdrawal symptoms in the mother, the increased oxygen needed by the withdrawing fetus would occur at a period of variable uterine blood flow. If the fetus were exposed to an environment of insufficient oxygen for any length of time, we might expect the fetus to suffer hypoxia and possibly death. Another factor which might have mitigated against the survival of the fetus in our report was the onset of withdrawal symptoms by the mother in the thirty-ninth week of pregnancy. The older the fetus, the greater the metabolic rateI and oxygen consumption. It is likely that a pregnant woman undergoing severe withdrawal symptoms during the latter part of pregnancy would be less likely to supply the withdrawing fetus with its required oxygen needs than would an addict in the first trimester of pregnancy. These may have been some of the factors that had compromised the fetus and resulted in a stillbirth. The effects of withdrawal on the fetus during pregnancy require clarification in certain areas : ( 1) While we presume that the increased intrauterine activity of the fetus is because of muscular activity, we have to consider the possibility that this may be evidence of intrauterine
1156
Rementeria
and
August
Nunag
convulsions caused by hypoxia; (2) we need to know the short- and long-term sequelae on the fetus surviving severe intrauterine withdrawal symptoms; (3) we require more knowledge of the placental circulation and oxygen consumption in the mother and fetus during withdrawal. VVith
the
knowledge
that
a high
of mothers who are detoxified heroin (thereby predisposing greater
risk
to encourage
of withdrawal),
methadone
15, 1973
Am. J. Obstet. Gy~wcol.
percentage
revert them would
programs
back to to
a
it be wiser
tain”j
rather
during
pregnancy?
than
“withdraw”
the
addict
The authors would like to express their thanks to Dr. Sophie Pierog (Neonatologist, Jewish Medical Center, Brooklyn, New York), Dr. Abraham Mizrahi (Consultant Neonatologist, Fordham Hospital, Bronx, New York), and Dr. Melvin Hollander (Director, Department of Pediatrics, Misericordia-Fordham Hospitals, Bronx, New York) for their aid in the prepara-
tion of this manuscript.
to “main-
REFERENCES
D. E., and Wardell, J. N.: AM. J. 1. Statzer, OBSTET. GYNECOL. 113: 273, 1972. 2. Wallach, R. C., Jerez, E., and Blinick, G.: AM. J. ORSTET. GYNECOL. 105: 1226, 1969. 3. Blinick, G., Wallach, R. C., and Jerez, E.: AM. J. OBSTET. GYNECOL. 105: 997, 1969. 4. Sutherland, J. M., and Light, I. J.: Pediatr. Clin. North Am. 12: 781, 1965. 5. Chappel, J. N.: J. A. M. A. 221: 1516, 1972. 6. Louria, D. B., Hensle, T., and Rose, J.: Ann. Intern. Med. 67: 1, 1967. C.: Report of the Perinatal Mortality 7. Carrier, Committee of the Province of Quebec covering Perinatal Mortality in 1968, p. 9. H. M.: Clin. Obstet. Gynecol. 13: 8. Wallace, 13, 1970. 9. Stone, M. L., Salerno, L. J., Green, M., and Zelson, C.: AM. J. OBSTET. GYNECOL. 109: 716, 1971. IO. Sussman, S.: Am. J. Dis. Child. 106: 325, 1963. 11. Stern, R.: AM. J. OBSTET. GYNECOL.~~: 253, 1966. 12. Pierog, S. H., and Ferrara, A.: Approach to the Medical Care of the Sick Newborn, St.
13.
14. 15.
16. 17.
18. 19.
20. 21. 22.
Louis, 1971, The C. V. Mosby Company, p. 173. Babson, S. G., and Benson, R. C.: Management of High-Risk Pregnancy and Intensive Care of the Neonate, St. Louis, 1971, The C. V. Mosby Company, p. 241. Greenhill, J. P.: Obstetrics, ed. 13, Philadelphia, 1965, W. B. Saunders Company, p. 243. Abrams, R., Caton, D., Clapp, J., and Barron, D. H.: Clin. Obstet. Gynecol. 13: 549, 1970. Towell, M. E.: Pediatr. Clin. North Am. 13: 575, 1966. Dawes, G. S.: Foetal and Neonatal Physiology, Chicago, 1968, Year Book Medical Publishers, Inc., p. 119. Caldeyro-Barcia, R.: Hosp. Pratt. 5: 33, 1970. Ramsey, E. M.: Circulation of the Placenta, Birth Defects Original Article Series, April, 1965, vol. 1, no. 1. Reddy, A. M., Harper, R. G., and Stern, G.: Pediatrics 48: 353, 1971. Nathenson, G., Golden, G. S., and Litt, I. F.: Pediatrics 48: 523, 1971 . Pierson, P. S., Howard, P., and Kleber, H. D.: J. A. M. A. 220: 1733, 1972.
in pregnancy: Stillbirth
incidence with a case report JOSfi
LUIS
REMENTERfA,
NEMESIO Bronx,
N. New
M.D
NUNAG,
M.D.
York
A stillborn infant was born to a drug-addicted mother who had withdrawal symptoms shortly before delivery. Mechanisms are presented to help explain the possible relationship between the maternal withdrawal and the fetal death. Statistics are also presented to show an increased stillborn and neonatal mortality rate in the over-all pregnant drug-addicted population
1 N KIIC E ~1‘ Y EAR s, pregnant drugaddicted women have been treated in either methadone maintenance’s ” or methadone detoxification programs.” Reports from both types of programs would seem to indicate that there is no apparent harm to the fetus. There are, hokvever, many women who may enroll in a methadone detoxification program during their pregnancy only to revert to the use of heroin at some time before delivery. Blinick and associates” reported that up to 40 per cent of the women treated in the methadone detoxification program were found to be using heroin at the time of delivery. However. there are many pregnant drug addicts \vho may enroll in a detoxification program but remain on heroin and/or other drugs for some part of their pregnancy. Heroin addicts, including pregnant women can experience withdrawal symptoms if they cannot obtain the heroin dose sufficient for their addicted state. From the Departments Pathology, Fordham Hospitals. Received 197.3.
for publication
Accepted
March
of Pediatrics and Misericordia
There has been a paucity of reports to date about events which occur in the fetus when a pregnant drug addict experiences withdrawal symptoms. In their review of the drug effects on the fetus, Sutherland and Light’ stated that narcotic withdrawal may result in an increase in fetal movements and occasional fetal death. Chappel” reported two episodes of neonatal death (in the third trimester of pregnancy) caused by meconium aspiration following opiate withdrawal prior to labor. The following is a case report of a pregnant heroin addict who experienced withdrawal symptoms during the thirty-ninth week of pregnancy and was delivered of a stillborn infant. Case
search Laboratory test positive, whose last menstrual period was estimated to be sometime in
and
June, February
report
M. R. was admitted in labor on March 11, 1972, to the Fordham Hospital Obstetrical Service. She was a 23-year-old Puerto Rican primigravid nonclinic patient, Venereal Disease Re-
9,
1971,
and
whose
expected
ment was given as March, heroin addict for 7 years had experimented with marihuana, amphetamines,
26, 197.7.
Reprint requests: Dr. lose’ Luis Rementeria, Department of Pediatrics, Fordham Hospital, Bronx, New York 10458
During was 152
admitted
her sixteenth
date
of confine-
1972. She had been a and, at various times, cocaine, barbiturates, and other drugs.
week of pregnancy,
to a methadone
treatment
she
center,
Volume Number
116 8
withdrawn from heroin within a 7 day period, and discharged. She managed to stay drug free for one month but then reverted to the use of heroin, taking an average of 3 “bags” a day intravenously and continuing this dose until the thirty-first week of pregnancy. Seeking help, she was admitted to another methadone treatment center, where she remained for a period of 3 weeks. Leaving the treatment center in the thirtyfourth week of pregnancy, she returned to her previous environment and soon began to take the usual dose of 3 “bags” of heroin per day, gradually increasing the dosage to 6 “bags” a day. Because of the increasing cost of the habit and apprehension concerning the effects of the fetus, she obtained illicit methadone and decreased the heroin intake. Although she preferred to be maintained on methadone during this stage of pregnancy, she frequently had to resort to substituting heroin because illicit methadone was difficult to obtain. On the night before delivery, she took 3 “bags” of heroin and, on awakening in the early hours of the morning, she experienced symptoms such as sweating, restlessness, a feeling of desperation, nausea, and a runny nose. It was apparent to her that the bags she used the previous night contained little heroin and that she was experiencing withdrawal symptoms. She reported that she had spent several stressful hours locating a “pusher,” who finally sold her heroin. Labor contractions started shortly after the withdrawal symptoms began, and, after she gave herself an injection of heroin, she went to the hospital. Until arrival at the hospital, she felt fetal movements, but, when the admitting physician examined her, he could not detect fetal heart sounds. Labor pains continued, and, after several hours, a stillborn female infant was delivered vaginally. The amniotic fluid was heavily stained with meconium and large quantities of meconium were removed from the nose and mouth of the stillborn infant. Postmortem examination of the infant revealed a nonmacerated female, weighing 2,720 grams (6 pounds 0 ounces). There were large quantities of meconium in the mouth and nasal passages. The head circumference was 33.5 cm., chest 31.0 cm., and length 48.5 cm. Gestational age was estimated to be 39 weeks. There was bilateral pulmonary atelectasis and the presence of meconium in the trachea and bronchi.
Narcotic
withdrawal
in pregnancy
1153
Microscopic examination of the lungs revealed collapsed alveoli containing meconium. There was a moderate number of anucleated squame cells and many more mononuclear phagocytes laden with brownish pigment interpreted as meconium. In addition, there were focal hemorrhages and congestion in the visceral organs, spleen; kidney, ovaries, liver, and adrenal glands. Comment Blinick and associates3 reported meconium in amniotic fluid in 33 per cent of heroin addict pregnancies. This meconium was described as “old meconium,” passed by the fetus during stressful periods, possibly during the time when the maternal narcotic intake may have been increased or decreased. In the addict’s environment, it may be difficult to obtain a steady heroin supply of a reliable concentration; this may result in a variable serum level of the drug. Louria and colleaguesG demonstrated that of 122 heroin “bags” confiscated and analyzed 12 contained no heroin and, in the remaining 110 bags, the content of heroin ranged from 1 to 77 per cent. In the study of Blinick and associates,3 it would appear that most of the fetuses exenvironment posed in this “old meconium” apparently do well. Of the 102 infants delivered by his group, there was one stillborn infant (908 grams) and 2 neonatal deaths; one weighed 936 grams and the other weighed 1,816 grams and died from respiratory distress syndrome. From this study and that of Statzer and Wardell,l it would seem that the stillborn rate in pregnant heroinaddicted women will not differ from that of the general population (stillborn rate of 12 to 16 per 1,000 live births72 “). Stone and co-workers8 and SussmanlO do not mention any stillbirths associated with pregnant drug addicts. However Stern’sI report (5 stillbirths of 70 infant’s delivered) would indicate that the incidence of stillbirth could be much higher, 71 per 1,000 live births. At Fordham Hospital, during an 18 month period, 47 infants were delivered of 46 drug-
i 154
Rementeria
Table I. Mortality between
January
and
Nunag
Am.
data from 47 drug-addicted 15, 1971, and July 15, 1972
infants
born at Fordham
Total Perinatal
Fetus W.
Weight (grams) Gestational age (weeks)
1,928 34
1,076 32
time of fetal death before delivery Postnatal time of infant’s death Maternal age (yr.1 Length of time of maternal addiction Maternal withdrawal symptoms during pregnancy Prenatal clinic visits VDRL (maternal) .4mniotic fluid
1 wk.
12-24
Estimated
Prenatal complications Cause of death Was mother on methadone program at time of delivery Had mother ever been in a methadone program
Fetus R. 2,720 39
hr.
2-4
Hospital
deaths Neonatal
Fetus A.
15, 1973 Gynccol.
deaths
Stillbirths Data
August J. Obstet
deaths Infant C.
Infant Sl
Infant S:
Infant F.*
594 24
1,104 32
880 ‘7
2,836 40
hr.
-
-
6 hr.
8 days
3 days
5 wk.
“4
17
23
17
19
21
22
Not
Not
known
7 yr.
Not
known
1 yr.
Not known
3 % yr.
Not known
Not
known
Yes
Not
known
Not
Not known
NO
None
None
None
None
None
None
None
Neg. Meconium stain None known -
Neg. Bloody
Neg. Clear
Neg. Clear
Neg Clear
Neg. Clear
Abruptio placentae -
Pos. Meconium stain Withdrawal symptoms -
Vaginal bleeding RDS
Vaginal bleeding RDS
None known SIDS
No
No
No
No
Twins, PRM 48 hr. Necro. enter. Yes
No
Yes
Not
Not
Yes
Not
-
Not known
-
known
known
known
known
known
Abbreviations: PRhl. premature rupture of membranes; RDS, respiratory distress syndrome; Necro. colitis; SIDS, sudden infant death syndrome. VDRL, Venereal Disease Research Laboratory test. *Infant F.. born to a methadone-treated drug addict, had a sudden, unexpected death at 5 weeks
addicted mothers (one set of twins) . There were 3 stillbirths and 3 neonatal deaths. Table I summarizes the clinical findings in the 6 perinatal deaths, and Table II compares our experience with other reports. The stillborn rate in our series was 64 per 1,000 live births, vvhich is romparable to the rate recorded hv .Stern.” In contrast to the mothers supervised by Hlinick and associates and Statzer and Wardell. most of the mothers in our ‘group were not on methadone lnaintenance at the time of delivery. Actually. only 14 of the 46 mother< in our sarirs were in a methadone
enter.,
necrotizing
entero-
of age.??
program or had sampled methadone during their pregnancy. This may account for the higher stillborn and neonatal death rates in our group. It is felt that when a heroin-addicted mother undergoes withdrawal symptoms, the fetus is also experiencing them. The mother usually recalls that fetal movements are significantly increased when she notes her own signs and symptoms of withdrawal. As a result of this stressful episode, the fetus would pass meconium and, at the same time, initiate strong respiratory movements.“~ “’ These events could account for the presence of me-
Volume Number
116 8
Narcotic
Table II. Stillborn infants
and neonatal mortality of drug-addicted mothers Total
Blinick and associates3 Statzer and Ward&l Stone and colleagues9 SussmanI” Stern’l Wallach and co-workers” Reddy and associates20 Nathenson and colleague9 Rementeria and co-workers
in various
addicted infants 102 100 384 18 70 13 40 18 47
“During the same 18 month period, the stillborn (43 stillbirths and 2,766 live births). The stillbirth obstetric population.
No. of stillbirths infants 1 2 5 1 3 rate among rate among
conium in the amniotic fluid reported by Blinick and associates” and in the trachea, bronchi, and alveoli of the infant in our report. The autopsy findings of focal hemorrhages and congestion in the organs would be those expected in anoxia. In the absence of any obvious cord compression, the mechanism of intrauterine anoxia remains obscure. During normal pregnancy, there is a progressive rise in oxygen consumption as indicated by the increase in the maternal metabolic rate of as much as 25 per cent.14 In the average pregnant woman, the metabolic rate of the fetus is believed to be much higher than that of the mother on a weightfor-weight basis. I5 When the pregnant heroin addict undergoes severe withdrawal, muscular activity increases, which probably increases the metabolic rate and oxygen consumption. Since it has been noted that fetal activity during maternal withdrawal also increases, the oxygen needs of the fetus could also be assumed to be increased. The oxygen reserve in the intervillous space of the placenta may or may not be able to supply the extra oxygen needed by the fetus. This oxygen reserve would be completely exhausted in 2 to 2!,4 minutes if blood flow through the intervillous space was tolabor, contractions tally arrested. I6 During the blood flow through the compromise uterus and consequently have an effect on
No. of neonatal deaths 2 2 14 2 0 2 3
in pregnancy
1155
studies involving
Incidence
No.
of drug-
Study
rates reported
withdrawal
per
in drug-addicted 1,000 live births
infants
Stillborn
Neonatal deaths
Perinatal deaths
9.8 20 -
19.6 20 36.4
29.4 40 127.8
71.4 79.9
111-
63.9’
the entire obstetric population our drug-addicted population
50 63.9 was
was 15.5 4 times
per 1,ooO live births that of the general
of the intervillous the oxygen reserve space. 17+I8 The longer and stronger the contractions, the more compromised the circulation through the uterus.l’ If labor should coincide with withdrawal symptoms in the mother, the increased oxygen needed by the withdrawing fetus would occur at a period of variable uterine blood flow. If the fetus were exposed to an environment of insufficient oxygen for any length of time, we might expect the fetus to suffer hypoxia and possibly death. Another factor which might have mitigated against the survival of the fetus in our report was the onset of withdrawal symptoms by the mother in the thirty-ninth week of pregnancy. The older the fetus, the greater the metabolic rateI and oxygen consumption. It is likely that a pregnant woman undergoing severe withdrawal symptoms during the latter part of pregnancy would be less likely to supply the withdrawing fetus with its required oxygen needs than would an addict in the first trimester of pregnancy. These may have been some of the factors that had compromised the fetus and resulted in a stillbirth. The effects of withdrawal on the fetus during pregnancy require clarification in certain areas : ( 1) While we presume that the increased intrauterine activity of the fetus is because of muscular activity, we have to consider the possibility that this may be evidence of intrauterine
1156
Rementeria
and
August
Nunag
convulsions caused by hypoxia; (2) we need to know the short- and long-term sequelae on the fetus surviving severe intrauterine withdrawal symptoms; (3) we require more knowledge of the placental circulation and oxygen consumption in the mother and fetus during withdrawal. VVith
the
knowledge
that
a high
of mothers who are detoxified heroin (thereby predisposing greater
risk
to encourage
of withdrawal),
methadone
15, 1973
Am. J. Obstet. Gy~wcol.
percentage
revert them would
programs
back to to
a
it be wiser
tain”j
rather
during
pregnancy?
than
“withdraw”
the
addict
The authors would like to express their thanks to Dr. Sophie Pierog (Neonatologist, Jewish Medical Center, Brooklyn, New York), Dr. Abraham Mizrahi (Consultant Neonatologist, Fordham Hospital, Bronx, New York), and Dr. Melvin Hollander (Director, Department of Pediatrics, Misericordia-Fordham Hospitals, Bronx, New York) for their aid in the prepara-
tion of this manuscript.
to “main-
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