Newborn Drug Screening - Meconium and Umbilical Cord Testing

Diagnosis

Indications for Testing

  • Detect prenatal exposure to drugs in umbilical cord tissue for infants
    • Born to mothers with high risk (eg, history of drug use, prostitution, sexually transmitted disease)
    • Born to mothers with little or no prenatal care
    • Born to mothers with unexplained placental abruption or premature labor
    • Born with unexplained neurological complications
    • Born with unexpected intrauterine growth retardation
    • Born with evidence of intoxication and/or drug withdrawal symptoms

Laboratory Testing

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

Differential Diagnosis

Clinical Background

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

Epidemiology

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

Pathophysiology

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

Clinical Presentation

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

Detection

  • Timely detection of in-utero drug exposure is critical for effective detection and management of intoxications, withdrawal syndrome, and long-term needs (social and medical) for exposed neonates
    • Actual time window for detecting exposure is unknown but is thought to represent at least the last trimester
  • Detection of drugs depends on
    • Extent of maternal drug use
    • Drug stability
    • Deposition of drug analytes in umbilical cord tissue
    • Performance of the analytical method
  • Umbilical cord tissue testing may be preferable to meconium due to
    • Ease of collection of a larger volume of specimen
    • Relatively fast turnaround time
    • Reflex/confirmation testing typically not required

Indications for Laboratory Testing

  • Tests generally appear in the order most useful for common clinical situations
  • Click on number for test-specific information in the ARUP Laboratory Test Directory
Test Name and Number Recommended Use Limitations Follow Up
Drugs of Abuse Panel, Meconium - Screen with Reflex to Confirmation/Quantitation 0092516
Method: Qualitative Enzyme-Linked Immunosorbent Assay/Quantitative Gas Chromatography-Mass Spectrometry/Quantitative Liquid Chromatography-Tandem Mass Spectrometry

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

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

Result verifies drug use only

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

Detects only drugs and toxicants listed

See the pediatric peer-reviewed literature for neonate treatment recommendations

Drug Detection Panel by High-Resolution Time-of-Flight Mass Spectrometry, Umbilical Cord Tissue 2006621
Method: Qualitative Liquid Chromatography-Time of Flight Mass Spectrometry/Qualitative Enzyme-Linked Immunosorbent Assay

Qualitative detection of drugs and drug metabolites to assess prenatal drug exposure

Panel includes opioids (buprenorphine, codeine, fentanyl, heroin (6-acetylmorphine, dihydrocodeine, hydrocodone, hydromorphone, meperidine, methadone, morphine, naloxone, naltrexone, oxycodone, oxymorphone, propoxyphene, tapentadol, tramadol); stimulants (amphetamines, cocaine, methamphetamine, MDMA, MDEA, MDA, phentermine); sedative-hypnotics (amphetamines, cocaine, methamphetamine, MDMA, MDEA, MDA, phentermine); phencyclidine (PCP); and cannabinoids (11-nor-9-carboxy-THC)

Details regarding the specific formulation, amount/dose, or time and length of exposure cannot be established by this testing

Minimum reporting limits (ng/g, pg/g) are established for each compound, but quantitation of detected drugs is not performed

Deposition of drugs in umbilical cord is not identical to meconium; concentrations of drugs and metabolites in cord tissue are generally lower than those found in meconium

This test is qualitative and does not provide quantitative results

While testing may be performed with chain of custody, ARUP is not a forensic laboratory; this test is intended for clinical use

Confirmation testing usually not required due to specificity of technology employed (high resolution, accurate mass spectometry)

Additional Tests Available
 
Click the plus sign to expand the table of additional tests.
Test Name and NumberComments
Drugs of Abuse Confirmation/Quantitation - Amphetamines (Amphetamine and Methamphetamine) - Meconium 0092310
Method: Quantitative High Performance Liquid Chromatography-Tandem Mass Spectrometry

Neonatal testing

Barbiturates - Confirmation - Meconium 0092311
Method: Quantitative Gas Chromatography-Mass Spectrometry/Quantitative Liquid Chromatography-Tandem Mass Spectrometry/Qualitative Liquid Chromatography/Time of Flight Mass Spectrometry

Neonatal testing

Drugs of Abuse Confirmation/Quantitation - Cannabinoids (Marijuana) - Meconium 0092316
Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Neonatal testing

Drugs of Abuse Confirmation/Quantitation - Methadone and Metabolite - Meconium 0092313
Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Neonatal testing

Drugs of Abuse Confirmation/Quantitation - Opiates - Meconium 0092314
Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Neonatal testing

Drugs of Abuse Confirmation/Quantitation - Propoxyphene and Metabolite - Meconium 0092524
Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Neonatal testing

Cocaine and Metabolites - Confirmation/Quantitation - Meconium 0092312
Method: Quantitative Gas Chromatography-Mass Spectrometry/Liquid Chromatography-Tandem Mass Spectrometry

Neonatal testing

Phencyclidine (PCP) - Confirmation/Quantitation - Meconium 0092315
Method: Quantitative Gas Chromatography-Mass Spectrometry/Liquid Chromatography-Tandem Mass Spectrometry

Neonatal testing

Drugs of Abuse Confirmation/Quantitation - Benzodiazepines - Meconium 0092520
Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Neonatal testing

Drugs of Abuse Confirmation/Quantitation - Barbiturates - Serum or Plasma 0093308
Method: Quantitative Gas Chromatography-Mass Spectrometry

Maternal testing

Not recommended for drug screening; urine is preferred specimen

Drugs of Abuse Confirmation/Quantitation - Benzodiazepines - Serum or Plasma 0093300
Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Maternal testing

Not recommended for drug screening; urine is preferred specimen

Drugs of Abuse Confirmation/Quantitation - Cannabinoids (9-carboxy-THC) - Serum or Plasma 0090676
Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Maternal testing

Not recommended for drug screening; urine is preferred specimen

Drugs of Abuse Confirmation/Quantitation - Cocaine Metabolite (Benzoylecgonine) - Serum or Plasma 0090684
Method: Quantitative Gas Chromatography-Mass Spectrometry/Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Maternal testing

Not recommended for drug screening; urine is preferred specimen

Methadone and Metabolite - Confirmation/Quantitation - Serum or Plasma 0090699
Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Maternal testing

Not recommended for drug screening; urine is preferred specimen

Opiates - Confirmation/Quantitation - Serum or Plasma 0092354
Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Maternal testing

Not recommended for drug screening; urine is preferred specimen

Drugs of Abuse Confirmation/Quantitation - Phencyclidine (PCP) - Serum or Plasma 0091571
Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Maternal testing

Not recommended for drug screening; urine is preferred specimen

Drugs of Abuse Confirmation/Quantitation - Amphetamines - Urine 0090439
Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Maternal testing

Drugs of Abuse Confirmation/Quantitation - Barbiturates - Urine 0090357
Method: Quantitative Gas Chromatography-Mass Spectrometry

Maternal testing

Benzodiazepines - Confirmation/Quantitation - Urine 2008291
Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry
Drugs of Abuse Confirmation/Quantitation - Cannabinoids (9-carboxy-THC) - Urine 0090369
Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Maternal testing

Drugs of Abuse Confirmation/Quantitation - Cocaine Metabolite (Benzoylecgonine) - Urine 0090359
Method: Quantitative Gas Chromatography-Mass Spectrometry/Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Maternal testing

Drugs of Abuse Confirmation/Quantitation - Phencyclidine (PCP) - Urine 0090366
Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Maternal testing

Drugs of Abuse Confirmation/Quantitation - Propoxyphene and Metabolite - Urine 0090368
Method: Quantitative Liquid Chromatography-Tandem Mass Spectrometry

Maternal testing

Drugs of Abuse Screen - Stimulant Amines - Urine 0090302
Method: Enzyme Immunoassay

Maternal testing

Drugs of Abuse Screen - Cocaine and Metabolites - Urine 0090306
Method: Enzyme Immunoassay

Maternal testing

Hairstat 5 Reflexive Panel 0092068
Method: Qualitative Enzyme-Linked Immunosorbent Assay/Quantitative Gas Chromatography-Mass Spectrometry

May detect drug use or exposure over several months previous to specimen collection; each cm length of hair represents approximately 1 month

Note that drug use or exposure must have occurred at least one month prior to specimen collection

If screen is positive, confirmation will be added

Synthetic Cannabinoid Metabolites, Screen with Reflex to Confirmation, Urine 2008091
Method: Qualitative Enzyme-Linked Immunosorbent Assay/High Performance Liquid Chromatography-Tandem Mass Spectrometry