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FeedbackExposure to maternal drug use during gestation may adversely affect neonatal development and may lead to acute adverse events, including neonatal abstinence syndrome (NAS) and infant mortality. Prenatal drug exposure may also contribute to long-term behavioral effects and developmental deficits.
Timely detection of in utero drug exposure is critical for effective identification and management of intoxication, withdrawal syndrome, and long-term needs (social and medical) of exposed neonates.
Detection of drugs depends on the extent of maternal drug use, drug stability, drug analyte deposition in meconium and umbilical cord tissue, and performance of the analytical method.
Quick Answers for Clinicians
Newborn drug testing should be considered in infants born to mothers with high-risk behaviors (eg, a history of drug misuse and/or addiction), minimal or no prenatal care, or unexplained obstetric events. Infants with unexplained neurologic complications, intrauterine growth retardation, or drug withdrawal symptoms should also be considered for testing. Refer to the Newborn Drug Testing algorithm for more information.
ARUP offers testing of umbilical cord tissue and meconium. Urine and blood tests are generally not recommended for newborn drug testing. Refer to Available Specimen Types for more information.
Umbilical cord tissue is easy to collect at birth, drugs deposit evenly across the length of the cord, and the cord grows with the fetus throughout development. Concentrations of some drug analytes are lower in cord tissue than in meconium, but can still be detected with the appropriate methodology. Meconium is the traditional newborn drug testing specimen and usually passes within 48 hours of birth. Collection of meconium requires coordinated efforts, and the detection of drugs in meconium depends on many factors, including the quality and completeness of collection. Refer to the ARUP Drug Test Table – Meconium and Umbilical Cord for more information.
Prenatal coexposure to gabapentin and drugs of abuse, particularly opioids, is becoming increasingly common as individuals with substance use disorder use gabapentin to enhance the euphoric effects of other drugs. Coexposure to opioids and gabapentin during pregnancy may cause infants to experience more severe, prolonged neonatal abstinence syndrome than exposure to opioids alone. Therefore, it is important to identify such coexposure for timely, appropriate monitoring and intervention. Gabapentin coexposure can be detected using a multidrug assay on an umbilical cord specimen. For a detailed discussion of the detection of gabapentin coexposure, see Okoye and McMillin, 2020.
Indications for Testing
Newborn drug testing is recommended in infants born to mothers with high-risk behaviors (eg, history of drug use/abuse, prostitution, nicotine use), minimal or no prenatal care, or unexplained obstetric events (eg, placental abruption, premature labor).
Additionally, infants with unexplained neurologic complications, unexpected intrauterine growth retardation, or drug withdrawal symptoms (eg, NAS) should be tested for drug exposure.
Available Specimen Types
ARUP offers newborn drug testing for two specimen types: umbilical cord tissue and meconium. Urine as a specimen type for neonatal drug testing has limited success; the first void is often missed because it may occur during or immediately after delivery. Urine tests generally detect only recent maternal drug use in the days before delivery.
| Meconium | Umbilical Cord Tissue |
|---|---|
|
First stool of the newborn Begins to form at ~12-16 wks gestation Accumulates over remainder of pregnancy (nonlinear process) Usually passes within 48 hrs of birth Used for drug testing for ~25 yrs Collection requires coordinated efforts and may not be available Drug detection in meconium depends on many factors (eg, quality and completeness of collection, drug use patterns) |
Forms ~5th wk of gestation Grows with fetus throughout pregnancy (nonlinear process) Easy to collect at time of birth Drugs appear to deposit consistently across length of cord Concentrations of drug analytes are lower in cord than in meconium, but can be detected with appropriate methodology Drug detection in cord tissue depends on many factors (eg, quality and completeness of collection, drug use patterns) |
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NOTE: Umbilical cord tissue and meconium drug tests are performed to support clinical and social management decisions and do not usually require chain of custody. ARUP offers a specimen tracking form for documentation of the collection, handling, and shipping of specimens. Contact ARUP Client Services for more information. |
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There are several factors to consider when deciding whether to use umbilical cord tissue or meconium for drug testing.
| Factors to Consider | Umbilical Cord Tissue | Meconium |
|---|---|---|
|
Preferred process for collection is at birth, for all infants; test immediately for high-risk births, store for low-risk births |
X |
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Collection based on need (eg, history of drug exposure, maternal urine screen results, NAS symptoms/diagnosis) |
X |
X |
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Tracking of specimen collection and handling process required |
X |
X |
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Fastest available time to result when positive results are expected |
X |
|
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Traditional testing approach (screen with reflex to confirmation testing) preferred |
|
X |
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Most sensitive and definitive testing for cannabis use |
|
X |
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Most sensitive and definitive testing for heroin use |
X |
|
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Preferred for the detection of gabapentin, fentanyl, meperidine, propoxyphene, tramadol, tapentadol, phentermine, and/or zolpidem |
X |
|
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Meconium specimen is limited or unavailable |
X |
|
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Cord tissue specimen is limited or unavailable |
|
X |
ARUP Umbilical Cord Tissue Testing
Routine analysis by the ARUP drug detection panel includes qualitative detection by mass spectrometric methods for all compounds (eg, opioids, stimulants, sedative-hypnotics). The presence of metabolites improves confidence in results and lengthens the detection window. Umbilical cord testing is thought to reflect maternal drug use during approximately the last trimester of a full-term birth. Tests to detect marijuana metabolite and ethyl glucuronide (alcohol metabolite) are available separately from the panel.
Further Resources
- Umbilical cord tissue collection instructions
- Umbilical cord tissue collection video
- Test Fact Sheets: ARUP Drug Detection Panel, Umbilical Cord Tissue (Qualitative) and Ethyl Glucuronide, Umbilical Cord Tissue, Qualitative
ARUP Meconium Testing
Routine analysis by the ARUP panel test includes a qualitative screen for nine drug classes; specimens that test positive for one or more drugs are reflexed to confirmatory testing by highly sensitive and specific mass spectrometric methods. Directed (confirmation only) tests are available when only one drug class is of clinical interest or when the quantity of meconium available for testing is very small (ie, <1 g).
The panel is the preferred meconium test to detect and document maternal drug use during pregnancy (approximately the last trimester of a full-term birth). Targeted single drug-class testing is appropriate if only a particular drug class or classes are of clinical interest, or when the quantity of meconium available for testing is very small (ie, <1 g).
Evaluation and Interpretation of Results
Drugs administered to the mother during labor and delivery may be detected in meconium or umbilical cord tissue. Drugs administered to the newborn after birth may be detected in meconium if the meconium is collected after drug administration.
Negative results do not exclude the possibility that the mother used drugs during pregnancy; only the drugs targeted by the testing can be detected. Maternal history and urine testing may also identify a possible infant drug exposure and should be used in combination with other laboratory results and the infant’s clinical presentation to diagnose a drug exposure.
Specimen variations can contribute to false-negative results. When definitive analytical methods (eg, liquid chromatography-tandem mass spectrometry [LC-MS/MS], gas chromatography-mass spectrometry [GC-MS]) are used, false-positive results are extremely unlikely.
Refer to the Drug Testing topic for test result interpretation organized by drug class.
Further Resources
Opioid Metabolic Pathway
Benzodiazepine Metabolic Pathway
ARUP Drug Cut-Off Limits for Meconium and Umbilical Cord Tissue (includes drug classes/metabolites, common trade/street names, and lowest concentration reported)
ARUP Laboratory Tests
Use to detect and document maternal drug use during approximately the last trimester of a full-term pregnancy
For additional test information, refer to the Drug Detection Panel, Umbilical Cord Tissue (Qualitative) Test Fact Sheet
Qualitative Liquid Chromatography/Tandem Mass Spectrometry
Use to detect in utero exposure to cannabis (marijuana) in neonates consistent with maternal use during approximately the last trimester of a full-term pregnancy
Qualitative Liquid Chromatography-Tandem Mass Spectrometry
Detects cannabinoid (THC)
Use to detect and document maternal use of ethanol during approximately the last trimester of a full-time pregnancy
For additional test information, refer to the Ethyl Glucuronide, Umbilical Cord Tissue, Qualitative Test Fact Sheet
Qualitative Liquid Chromatography-Tandem Mass Spectrometry
Preferred meconium test to detect and document maternal drug use during approximately the last trimester of a full-term pregnancy
Qualitative Enzyme-Linked Immunosorbent Assay/Quantitative Liquid Chromatography-Tandem Mass Spectrometry
Panel detects opioids, stimulants, sedative-hypnotics, PCP, cannabinoids (11-nor-9-carboxy-THC)
Several drug metabolites are also included to increase likelihood of detection and increase confidence in results
See targeted drug class testing below for all components
Use for infant drug testing when specific drug exposure is of clinical interest or when the quantity of meconium available for testing is very small (ie, <1 g).
Quantitative High Performance Liquid Chromatography-Tandem Mass Spectrometry
Test detects amphetamine, methamphetamine, MDMA-Ecstasy, methylenedioxyethylamphetamine (MDEA-Eve), methylenedioxyamphetamine (MDA)
Quantitative Liquid Chromatography-Tandem Mass Spectrometry
Test detects alprazolam, alpha-hydroxyalprazolam, clonazepam, 7-aminoclonazepam, diazepam, chlordiazepoxide, lorazepam, midazolam, alpha-hydroxymidazolam, nordiazepam, oxazepam, temazepam
Quantitative Gas Chromatography-Mass Spectrometry/Quantitative Liquid Chromatography-Tandem Mass Spectrometry/Qualitative Liquid Chromatography/Time of Flight Mass Spectrometry
Test detects butalbital, phenobarbital
Quantitative Liquid Chromatography-Tandem Mass Spectrometry
Test detects buprenorphine, norbuprenorphine
Quantitative Liquid Chromatography-Tandem Mass Spectrometry
Test detects 9-carboxy-THC
Quantitative Gas Chromatography-Mass Spectrometry/Liquid Chromatography-Tandem Mass Spectrometry
Test detects cocaine, benzoylecgonine, M-hydroxybenzoylecgonine (qualitative only), cocaethylene
Quantitative Liquid Chromatography-Tandem Mass Spectrometry
Test detects methadone and metabolite (EDDP)
Quantitative Liquid Chromatography-Tandem Mass Spectrometry
Test detects codeine, morphine, 6-acetylmorphine, hydrocodone, hydromorphone, oxycodone, oxymorphone
Quantitative Gas Chromatography-Mass Spectrometry/Liquid Chromatography-Tandem Mass Spectrometry
Test detects PCP
Medical Experts
McMillin
References
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29419722
Wabuyele SL, Colby JM, McMillin GA. Detection of Drug-Exposed Newborns. Ther Drug Monit. 2018;40(2):166-185.
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32860706
Okoye NC, McMillin GA. Patterns of neonatal co-exposure to gabapentin and commonly abused drugs observed in umbilical cord tissue. J Anal Toxicol. 2020:bkaa118. [Published online ahead of print Aug 2020]
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28977394
Wu F, Scroggin TL, Metz TD, et al. Development of a Liquid Chromatography-Tandem Mass Spectrometry Method for the Simultaneous Determination of Four Cannabinoids in Umbilical Cord Tissue. J Anal Toxicol. 2018;42(1):42-48.
Primary drugs detected: