Meconium: A Sticky Situation

2. Meconium: A Sticky Situation • Scope of the problem • Why the medical examiner tests for drugs of abuse in the fetus. • Legal implications of fetal methamphetamine positives. • When and how is meconium formed? • Fetal complications due to maternal methamphetamine use. • The problem/The Answer

3. Scope of the Problem • Study: • Every other neonate delivered in a perinatal center from November 1988 to September 1989 had meconium analyzed (3010 mother’s babies meconium) • 44% (1324) meconium were positive for cocaine, morphine, or cannabinoid • 11% (335) mothers admitted to drug use Ostrea et al. Drug Screening of Newborns by Meconium Analysis: A Large-Scale, Prospective, Epidemiologic Study; Pediatrics 1992; 89: 107-113

4. Infant Development, Environment, and Lifestyle (IDEAL) Study conducted 2004-2005 National Pregnancy and Health Survey (NPHS) conducted in 1992–1993.

5. WHY DOES THE MEDICAL EXAMINER LOOK FOR DRUGS IN MECONIUM? • Requirement of our job. • Jurisdiction of fetal deaths with: • Evidence of maternal trauma • Evidence of maternal drug use (positive maternal urine toxicology at admit). • Record our findings in the fetal death certificate filed with vital statistics • “Intrauterine fetal demise with maternal methamphetamine use”

6. Medical Examiner as Sentinel of Epidemiological Trends in Public Health • Identify fetal deaths with evidence of maternal drug use • Identify trends in drug use and fetal deaths • Communicate trends to local health officials and epidemiologists • Advocate programs to intervene • Update and educate the public/local community leaders and health professionals to emerging trends

7. WHY SHOULD WE LOOK FOR DRUGS IN MECONIUM? • Identify moms for appropriate intervention and follow-up • Data for epidemiologic surveys • Identify women who will need postnatal support. • Monitor effectiveness of programs designed to reduce drug abuse among pregnant women.

8. Legal Implications • Definition of the “individual” in Texas: • Changed two years ago (SB319, May 2003): • “a human being who has been born and is alive” to • “a human being who is alive, including an unborn child at every stage of gestation, from fertilization until birth.”

9. “a human being who has been born and is alive”

10. “a human being who is alive, including an unborn child at every stage of gestation, from fertilization until birth.”

11. SB 319: PRENATAL PROTECTION ACT (May 2003) • Amends the Civil Practice and Remedies Code • Allow parents to sue for the wrongful death of their child who is killed before birth • Amends the Penal Code • Third party can be prosecuted for the homicide, assault, or intoxication manslaughter of the child of a pregnant woman.

12. Why the Reluctance to Self Report? • Some physicians are concerned the new law (SB319) will prompt some women to skip their prenatal care or seek an abortion out of fear of prosecution

13. Meconium: Baby’s first stool • First stool a baby will pass thick • Green, tar-like substance • Lines the intestines of the fetus • First bowel movement within a few hours after birth.

14. Transitional Stool - Stage One • Newborn slowly begins to pass the meconium after birth • Meconium will begin to change in consistency • Slightly lighter in color than meconium.

15. Transitional Stool - Stage Two • Stool is lighter in color and slightly less thick than meconium.

16. Transitional Stool - Stage Three • Much lighter and thinner than meconium. • Occurs just before regular stooling begins

17. Breastfed Stool • Yellow • Runny • Small seed like objects in the stool • Often called baby poop mustard

18. How is meconium formed? • Drugs metabolized by the fetal liver → excreted bile → meconium OR • Drugs metabolized by the fetal liver → excreted urine → amniotic fluid → swallowed by fetus → meconium

21. When is meconium formed? • Fetus does not normally excrete stools while in the womb • Meconium is a waste product • Accumulates beginning 12 to 16 weeks gestation until birth

22. Survey of studies pertaining to fetal exposure to methamphetamine • There are no adequate and well-controlled studies in pregnant women.

23. Some studies addressing fetal exposure to methamphetamine • Cleft palate • Heart anomalies • Fetal growth retardation, • Behavioral problems • Cranial abnormalities

24. Fetal Exposure to Methamphetamine • Body of literature suggests: • Children might be at risk for poor child outcome due not only to prenatal drug exposure but concomitant alcohol and tobacco use and factors related to the caregiving environment.

25. The problem • Approximately 5% of pregnant women use methamphetamine at some point during pregnancy

26. The Answers • Educate physicians to be aware of treatment options and community resources to enable access to treatment • Particularly important where methamphetamine is currently a problem and areas where it is emerging concern • Expand and enhance treatment services for substance abusing pregnant women. • Treatment for methamphetamine dependence is difficult, but has been shown to be effective.