Transcript Meconium - Tarrant County, Texas

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
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
Infant Development, Environment, and Lifestyle (IDEAL)
Study conducted 2004-2005
National Pregnancy and Health Survey (NPHS)
conducted in 1992–1993.
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”
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
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.
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.”
“a human being who
has been born and is
alive”
“a human being who is
alive, including an
unborn child at every
stage of gestation,
from fertilization until
birth.”
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.
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
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.
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.
Transitional Stool - Stage Two
• Stool is lighter in color
and slightly less thick
than meconium.
Transitional Stool - Stage Three
• Much lighter and
thinner than
meconium.
• Occurs just before
regular stooling
begins
Breastfed Stool
• Yellow
• Runny
• Small seed like
objects in the stool
• Often called baby
poop mustard
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
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
Survey of studies pertaining to fetal
exposure to methamphetamine
• There are no adequate and well-controlled
studies in pregnant women.
Some studies addressing fetal
exposure to methamphetamine
•
•
•
•
•
Cleft palate
Heart anomalies
Fetal growth retardation,
Behavioral problems
Cranial abnormalities
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.
The problem
• Approximately 5% of pregnant women use
methamphetamine at some point during
pregnancy
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.