neonatal death associated with maternal methamphetamine abuse susan r. howe, phd joyce y. ho, bs...

Neonatal Death Associated with Maternal Methamphetamine Abuse

Susan R. Howe, PhDJoyce Y. Ho, BSCarl Wigren, MD

December, 2006

Topics for Today

• Two cases of neonatal death– History of maternal methamphetamine use

• Children and methamphetamine

• Methamphetamine analysis in the lab

• Pathology of neonatal death with maternal methamphetamine use

What is Methamphetamine?

• CNS Stimulant

• Extremely addictive

• 6-8 hr high (or longer)

• Easy to produce

• Inexpensive

Pleasurable Effects

• Nearly immediate “flash” or “rush”

• Euphoria, alertness

• Increased energy

• Increased libido

Undesirable Effects• Used in “binge and crash” pattern• Leads to tolerance and abuse• Users forego food and sleep• Significant toxicity

– Increased heart rate – High blood pressure– Increase body temperature– Convulsions– Stroke– Death

Long Term Meth Use

• Violent behavior

• Psychotic symptoms

– Auditory hallucinations

– Mood disturbances

– Delusions and paranoia

• Changes to the brain

Current Perspective

National Drug Intelligence Center, 2005

Current Perspective

• 2005: 4.3% of US population > 12 has used methamphetamine

2005 National Survey on Drug Use and Health

• 2005: 4.5% of high school seniors have used methamphetamine

2005 Monitoring the Future Study, NIDA

Women and Meth

• 2003 Arrestee Drug Abuse Monitoring Program

– 4.7% of adult male arrestees test positive for meth at the time of arrest

– 8.8% of adult female arrestees test positive for meth at the time of arrest

Meth and Pregnancy• Infant Development, Environment, and

Lifestyle Study, 2006 (IDEAL)

– 5.2% of women have used meth at some time in their pregnancy

– Meth use during pregnancy associated with small birth weight babies

Meth and Pregnancy

• Fetal growth restriction– Long term effects?

• Ruptured placenta

• Preterm labor

• Disease (HIV, hepatitis)

• Poor prenatal care, nutrition

“Prenatal exposure to drugs of abuse is

the single largest preventable cause of

developmental compromise of American children today.”

Malanga and Kosofsky, Developmental Brain Research 147(1-2): 47-57, 2003

Compromised Parenting

• Neglect• Diverted resources• Physical/mental health problems• Lack of supervision• Access to meth and paraphernalia• Exposure to high risk population• Poor nutrition/living conditions• Poor preventive care/disease management

Meth Manufacture

• An excerpt from the Betty Cranker Cookbook:

“Take a pinch of red phosphorous, a smidgen of ephedrine, a dash of iodine and a skosh of lye. Add some distilled water and simmer for a few hours and hope it doesn’t explode and kill you.”

Number of Children Affected by Methamphetamine Labs

2002–2005

  2002 2003 2004 2005

Child injured 11 25 13 11

Child killed 2 1 3 2

Children affected

3,660 3,682 3,088 1,647

Total injured/killed/affected

3,673 3,708 3,104 1,660

Meth Lab Hazards to Children

• Accidental methamphetamine ingestion

• Chemical and physical hazards

• Neglect and abuse

• Increased risk of accidents

Medical Examiner’s Case 1

• Hispanic Female admitted to hospital for

vaginal bleeding

• Emergency hysterectomy performed

after delivery

• Later pronounced at the hospital

Toxicology Report Case 1

• Aorta Blood Amphetamine TDX Positive

• Hospital Blood Amphetamine 33.7 ng/ml• Hospital Urine Amphetamine Positive• Hospital Blood Methamphetamine 109.0 ng/ml• Hospital Urine Methamphetamine Positive

Case 2Companion Case to Case No.1

• Full term fetal demise pronounced upon delivery

• Mother tested positive for Amphetamine Screen at the hospital

Toxicology Report Case 2

• Urine Amphetamine TDX Positive

• Aorta Blood Amphetamine 104.5 ng/ml• Urine Amphetamine Positive• Meconium Amphetamine 422.0 ng/ml• Aorta Blood Methamphetamine 299.2 ng/ml• Urine Methamphetamine Positive• Meconium Methamphetamine 1468.4 ng/ml

Case 3

• Full term stillborn infant delivered by cesarean section

• Mother had normal pregnancy

• Mother denied drug usage

• Urine drug screen on mother tested positive

Toxicology Report Case 3

• Urine Amphetamine TDX Positive• Aorta Blood Amphetamine 45.1 ng/ml• Urine Amphetamine Positive• Meconium Amphetamine 266.0 ng/ml• Aorta Blood Methamphetamine 235.5 ng/ml• Urine Methamphetamine Positive• Meconium Methamphetamine 1816.0 ng/ml

Chief Medical Examiner

Crime Lab Toxicology Human ID

DNA

Firearms

TraceEvidence

ForensicToxicology

Drug Chemistry

ForensicDentistry

Fingerprints

Anthropology/Radiology

Toxicology Laboratory Goals:

– assist the medical examiner in evaluating the role of toxicants as a determinant or contributory factor in the cause and manner of death

– aid law enforcement agencies in the investigation of criminal activities

TSQ

AMPHETAMINE/METHAMPHETAMINE CHROMATOGRAM

C:\Xcalibur\Data\AMPQCMIXOCT12 10/12/2006 1:20:37 PM

RT: 0.00 - 8.01

0 1 2 3 4 5 6 7 8Time (min)

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RT: 4.494.487AA: 13185356SN: 2922

RT: 4.444.444AA: 3113532SN: 3269

RT: 5.115.113AA: 18874303SN: 4607

RT: 5.105.099AA: 6151323SN: 9271

RT: 3.723.721AA: 18380772SN: 4931

RT: 5.155.149AA: 1990057SN: 1947

RT: 5.615.606AA: 7288093SN: 1526

RT: 3.463.464AA: 241049SN: 22

RT: 6.536.533AA: 32367SN: 9

NL: 9.23E5TIC F: + c ESI SRM ms2 136.084@-10.00 [ 91.121-91.123, 119.125-119.127] MS ICIS AMPQCMIXOCT12

NL: 2.19E5TIC F: + c ESI SRM ms2 141.200@-10.00 [ 96.099-96.101] MS ICIS AMPQCMIXOCT12

NL: 1.46E6TIC F: + c ESI SRM ms2 150.132@-19.00 [ 91.120-91.122, 119.126-119.128, 133.140-133.142] MS ICIS AMPQCMIXOCT12

NL: 4.79E5TIC F: + c ESI SRM ms2 155.132@-13.00 [ 92.119-92.121] MS ICIS AMPQCMIXOCT12

NL: 1.13E6TIC F: + c ESI SRM ms2 166.131@-12.00 [ 148.157-148.159] MS ICIS AMPQCMIXOCT12

NL: 1.68E5TIC F: + c ESI SRM ms2 180.067@-19.00 [ 135.061-135.063] MS ICIS AMPQCMIXOCT12

NL: 6.48E5TIC F: + c ESI SRM ms2 194.073@-22.00 [ 135.061-135.063] MS ICIS AMPQCMIXOCT12

AMPHETAMINE/METHAMPHETAMINE SPECTRAC:\Xcalibur\Data\AMPQCMIXOCT12 10/12/2006 1:20:37 PM

RT: 0.00 - 8.01

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Time (min)

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RT: 4.494.487AA: 13185356SN: 2922

NL: 9.23E5

TIC F: + c ESI SRM ms2 136.084@-10.00 [ 91.121-91.123, 119.125-119.127] MS ICIS AMPQCMIXOCT12

AMPQCMIXOCT12 #1505 RT: 4.49 AV: 1 NL: 5.69E5F: + c ESI SRM ms2 136.084@-10.00 [ 91.121-91.123, 119.125-119.127]

91.122 91.123

m/z

119.125 119.126

m/z

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91.12

119.13

RT: 0.00 - 8.01

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Time (min)

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me

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RT: 5.115.113AA: 18874303SN: 4607

NL: 1.46E6

TIC F: + c ESI SRM ms2 150.132@-19.00 [ 91.120-91.122, 119.126-119.128, 133.140-133.142] MS ICIS AMPQCMIXOCT12

AMPQCMIXOCT12 #1707 RT: 5.09 AV: 1 NL: 1.35E6F: + c ESI SRM ms2 150.132@-19.00 [ 91.120-91.122, 119.126-119.128, 133.140-133.142]

91.122

m/z

119.126

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133.140

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91.12

119.13

133.14