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Prevalence of drug use in pregnant West Virginia patients.


Substance abuse in pregnancy is known to have deleterious effects on neonates. These effects differ with respect to the substance ingested and can include neonatal abstinence syndrome (NAS (1) See network access server.

(2) (Network Attached Storage) A specialized file server that connects to the network. A NAS device contains a slimmed-down operating system and a file system and processes only I/O requests by supporting the popular
), low birth weight, intrauterine intrauterine /in·tra·uter·ine/ (-u´ter-in) within the uterus.

Within the uterus.

Situated or occuring in the uterus.
 fetal demise, and structural abnormalities such as gastroschisis.

The substance abuse rates have been estimated to be between 2.8-19% (1,2,3) These reported rates vary based upon the population screened and the method of screening used.

The lowest number reported in the study by Ebrahim and Gfroerer utilized a population survey of the entire United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area.  (1) while the highest rates reported (19%) by Azadi and Dildy utilized urine toxicology testing. (3) Chasnoff et al developed a screening tool that estimated that 15% of the population studied continued to use substances of abuse after becoming aware of the pregnancy. (2)

Recent work published by Montgomery et al compared the performance of meconium meconium /me·co·ni·um/ (mi-ko´ne-um) dark green mucilaginous material in the intestine of the full-term fetus.

 samples versus the testing of umbilical cord umbilical cord (ŭmbĭl`ĭkəl), cordlike structure about 22 in. (56 cm) long in the pregnant human female, extending from the abdominal wall of the fetus to the placenta.  tissue. (4) This study showed concordance of the testing methods that correlated at or above 90% for all substances analyzed. Follow-up work included a study in which umbilical cord samples were collected and tested if high risk criteria for substance abuse were identified. Out of this cohort, 157 of 498 (32%) cords tested positive for substances of abuse. (5)

The number of newborns treated for neonatal abstinence syndrome (NAS) has increased dramatically in West Virginia West Virginia, E central state of the United States. It is bordered by Pennsylvania and Maryland (N), Virginia (E and S), and Kentucky and, across the Ohio R., Ohio (W). Facts and Figures

Area, 24,181 sq mi (62,629 sq km). Pop.
. In data collected from the Cabell Huntington Hospital in Huntington, WV, the number of neonates treated for NAS increased from 25 in 2003 to 70 in 2007. (6) The cost difference in the care of an otherwise healthy neonate neonate /neo·nate/ (ne´o-nat) newborn infant.

A neonatal infant.


a newborn animal.
 with NAS compared to a normal full-term healthy neonate was estimated to be $3,934 in the Cabell-Huntington cohort. Because of the added costs associated with the increased risk of prematurity, the average cost of all infants with NAS was $36,000 compared to $2,000 for a normal neonate. (6) Obviously any significant reduction in the number of neonates being treated for NAS can save significant amounts of money for the healthcare system.

In order to formulate public policy and to ensure that the proper maternal and neonatal medical services are available in West Virginia to prevent and to care for pregnancies complicated by substance abuse, an accurate determination of the rate of substance abuse during pregnancy as well as the substances involved is required. The objective of our study was to accurately determine the rate of substance abuse affecting pregnancy in West Virginia.

Materials and Methods

This study was conceived as an anonymous (no patient information collected) survey of normally discarded tissue (umbilical cord). As such, consent was waived and the study was approved by the institutional review boards at each of the eight participating hospitals. Hospitals were recruited with the goal having broad geographic distribution and collection of 1000 samples in one month.

Delivery staff in each hospital was instructed to collect a 6 to 9 inch segment of umbilical cord from as many deliveries as possible for the month of August (2009). Each sample was stripped of intravascular intravascular /in·tra·vas·cu·lar/ (in?trah-vas´ku-lar) within a vessel.

Within one or more blood vessels.
 blood, rinsed in sterile saline, put in a separate sterile plastic specimen container and frozen for subsequent shipment to United States Drug Testing Laboratories (USDTL, Des Plaines, IL).

Eight drugs were selected for testing (Table 1). Commercially available enzyme linked immunoabsorbent (ELISA ELISA (e-li´sah) Enzyme-Linked Immuno-Sorbent Assay; any enzyme immunoassay using an enzyme-labeled immunoreactant and an immunosorbent.

) kits, with confirmatory testing by gas chromatography/mass spectometry were used for 6 of the drugs. Buprenorphine was tested using liquid chromatography/ mass spectrometry mass spectrometry
 or mass spectroscopy

Analytic technique by which chemical substances are identified by sorting gaseous ions by mass using electric and magnetic fields.
 (LCMSMS LCMSMS Liquid Chromatography Tandem Mass Spectrometry (biochemical analysis) ). Phosphatidylethanol (a metabolite of ethanol) testing was based on high pressure liquid chromatography/ mass spectrometry (HPLCMS).

Self reporting was assessed determining the prevalence of drug and alcohol use reported on birth certificate data as well as a nursing assessment tool used in West Virginia called the WV Birth Score as provided by the Office of Maternal Child and Family Health of the State of West Virginia.


Seven hundred fifty nine (759) samples were collected in one month and analyzed in batch form by USDTL. The participation by hospital is shown in Table 2. There were 142 (19.2%) cord specimens positive for drugs and/or alcohol (Table 3). Polypharmacy was common (Table 4), especially among those patients using benzodiazapines and methadone methadone (mĕth`ədōn', –dŏn'), synthetic narcotic similar in effect to morphine. Synthesized in Germany, it came into clinical use after World War II. It is sometimes used as an analgesic and to suppress the cough reflex. . There was also significant regional variation in drug and alcohol use (Table 5). Self reporting prevalence rates of drug and alcohol rates are compared to actual umbilical cord prevalence in Table 6.


This anonymous sampling of umbilical cords involving 8 medical centers in West Virginia identified an overall prevalence of drug and alcohol use of almost 1 in 5 deliveries. There was a 10-19% prevalence of substance and 1-15% incidence of alcohol use in patients delivering during August 2009 with marked underreporting with standard data collection tools. There was a wide geographic variability in the prevalence of individual drugs and alcohol with one hospital reporting a 1 in 4 rate of drug and alcohol use! The lack of significant cocaine and methamphetamine use was surprising. Buprenorphine diversion has also been noted elsewhere but was not a significant contributor to the drug problem among these pregnancies.

Some limitations of this study should be noted. The hospitals were not selected at random. Rather they were selected to optimize the possibility of obtaining a large enough sample size (approximately 1000 deliveries) to be relevant and where possible to geographically cover the state of West Virginia. It includes the three tertiary care tertiary care Managed care The most specialized health care, administered to Pts with complex diseases who may require high-risk pharmacologic regimens, surgical procedures, or high-cost high-tech resources; TC is provided in 'tertiary care centers', often  centers located in the state which could result in an overestimation of the prevalence as some out of state referrals may be included. However, the prevalence of drug exposure at these hospitals was comparable to the other hospitals in the study. Due to the anonymous nature of the sampling, it is impossible to analyze reasons for the wide geographic variations. While factors such as poverty, unemployment, and location of drug rehabilitation centers may play a role, definitive answers await a more comprehensive exploration of the problem. Finally, while there are some well known cross-reactivities on the ELISA screening tests used, each positive sample was confirmed using gas chromatography/mass spectroscopy which virtually rules out false positive results.

As noted earlier in the paper, the cost of drug addicted infants averages $36,000 per infant compared to $2,000 for non-affected infants (6), with multiple fetal effects contributing to this cost (Table 7). These findings sparked interest in possible detoxification Detoxification Definition

Detoxification is one of the more widely used treatments and concepts in alternative medicine. It is based on the principle that illnesses can be caused by the accumulation of toxic substances (toxins) in the body.
 or rehabilitation for patients who are using either illegal or non-prescribed substances or alcohol. The literature previously described the avoidance of detoxification during the second and third trimesters of pregnancy due to concerns about harms to the fetus. (7,8) Recent literature, however, does not substantiate these claims. (9,10,11) Luty studied 101 opiate opiate /opi·ate/ (o´pe-it)
1. any drug derived from opium.

2. hypnotic (2).

 dependent women who underwent a 21 day opiate withdrawal with no adverse effects found. (11) Opioid dependence, including methadone maintenance, has been linked to fetal death, growth restriction, pre-term birth, meconium aspiration meconium aspiration
Aspiration of amniotic fluid contaminated with meconium by a fetus in hypoxic distress.
, and neonatal abstinence syndrome. (7,12) Neonatal abstinence syndrome may be present in 60-90% of neonates exposed in-utero with up to 70% of affected neonates with central nervous system irritability that may progress to seizures. (13) Up to 50% may experience respiratory issues, feeding problems, and failure to thrive Failure to Thrive Definition

Failure to thrive (FTT) is used to describe a delay in a child's growth or development. It is usually applied to infants and children up to two years of age who do not gain or maintain weight as they should.
. (14) These issues are present as well in those infants whose mothers' are on methadone maintenance. (15) However, with methadone the onset of neonatal abstinence syndrome may be delayed for several weeks. (15) Some authors recommend 5-8 days of maternal hospitalization while their neonates' undergo observation for neonatal abstinence syndrome. (16) However, most insurance plans will not reimburse for the prolonged uncomplicated maternal stay.

The incidence of opioid relapse in pregnant opioid abusing women is very high with 41-96% relapsing. This mirrors the relapse rate of the general population at 1 month of 65-80%. (17,18) Over 90% of patients will relapse at 6 months after medication-assisted withdrawal. (19) Buprenorphine (Subutex[TM]) appears to have no difference in outcomes with regard to treatment of opiate addicted women. The same neonatal abstinence syndrome and neonatal effects are present. (20) Treatment of amphetamine amphetamine (ămfĕt`əmēn), any one of a group of drugs that are powerful central nervous system stimulants. Amphetamines have stimulating effects opposite to the effects of depressants such as alcohol, narcotics, and barbiturates.  abuse with fluoxetine fluoxetine /flu·ox·e·tine/ (floo-ok´se-ten) a selective serotonin reuptake inhibitor used as the hydrochloride salt in the treatment of depression, obsessive-compulsive disorder, bulimia nervosa, and premenstrual dysphoric disorder.  and imipramine imipramine /imip·ra·mine/ (i-mip´rah-men) a tricyclic antidepressant of the dibenzazepine class, used as i. hydrochloride or i. pamoate.  may be useful but is not a panacea for treatment. A recent review by the Cochrane Collaboration in 2001 (reissued in 2009) noted that medications are of limited use in treatment of amphetamine abuse. (21) They note that there are very limited trials at this time to be able to suggest what is the best way to treat amphetamine abuse. Benzodiazepine benzodiazepine (bĕn'zōdīăz`əpēn'), any of a class of drugs prescribed for their tranquilizing, antianxiety, sedative, and muscle-relaxing effects. Benzodiazepines are also prescribed for epilepsy and alcohol withdrawal.  dependence and detoxification must be done gradually to reduce symptoms. Little has been written about benzodiazepine detoxification in pregnancy. Alcohol rehabilitation has had little written and until recently (as found in our paper) no ability to verify chronic use of alcohol due to its volatile nature and inability to test for its presence.

Co-morbidities with multiple psychiatric issues in the patients with substance abuse issues must be considered. Many patients with substance dependence have affective disorders including: depression, mania, schizoaffective schizoaffective /schizo·af·fec·tive/ (skiz?o-uh-fek´tiv) pertaining to or exhibiting features of both schizophrenic and mood disorders.

 disorders, schizophrenia, borderline personality, and bipolar disorders. Therefore, many authors recently note that detoxification must be linked with a combination of behavioral therapy with contingency management therapy. (16,22,23) Behavioral therapy consists of the use of addictions counselors and counseling to assist substance and alcohol abusers to remain drug and alcohol free. A pilot program at Charleston Area Medical Center Charleston Area Medical Center (CAMC) is the name of a complex of hospitals in Charleston, West Virginia, formed via a merger of previously independent facilities. It is the state's largest hospital.  (CAMC CAMC Canadian Association of Management Consultants
CAMC Canadian Aviation Maintenance Council
CAMC Conservation Authorities Moraine Coalition
CAMC Conditional Access Management Center (DirecTV) 
) uses this approach with both individual and group therapy. Contingency management therapies are a type of psychosocial intervention psychosocial intervention Psychology A nonpharmacologic maneuver intended to alter a Pt's environment or reaction to lessen the impact of a mental disorder. See Attention-deficit-hyperactivity syndrome.  where the clients receive rewards in the form of vouchers or prizes if they demonstrate changed behaviors. There seems to be data to support its use in cocaine and opioid abuse. (24,25) Due to the large number of patients affected in the State of West Virginia by both substance abuse and alcohol abuse, we suggest a programmatic approach with the use of both inpatient and outpatient therapy be used. Detoxification seems a reasonable approach with treatment of the psychological co-morbidities associated with substance use. Multidisciplinary clinics would appear the ideal solution with the combination of medical, psychiatric, counseling, and social support necessary to return healthy mothers with healthy drug-free neonates.


After completing this program, the reader will be able to quantify the rate of substance abuse during pregnancy in West Virginia and describe the maternal, fetal, neonatal and societal consequences of substance abuse during pregnancy.


(1.) Ebrahim SH, Gfroerer J. Pregnancy-related substance use in the United States during 1996-1998. Obstet Gynecol. 2003;101(2):374-9.

(2.) Chasnoff IJ, McGourty RF, Bailey GW, Hutchins E, Lightfoot SO, Pawson LL, Fahey C, May B, Brodie P, McCulley L, Campbell J. The 4P's Plus screen for substance use in pregnancy: clinical application and outcomes. J Perinatol. 2005;25(6):368-74.

(3.) Azadi A, Dildy GA 3rd. Universal screening for substance abuse at the time of parturition parturition
 or birth or childbirth or labour or delivery

Process of bringing forth a child from the uterus, ending pregnancy. It has three stages.
. Am J Obstet Gynecol. 2008;198(5):e30-2. Epub 2008 Feb 14.

(4.) Montgomery D, Plate C, Alder SC, Jones M, Jones J, Christensen RD. Testing for fetal exposure to illicit drugs using umbilical cord tissue vs meconium. J Perinatol. 2006;26(1):11-4.

(5.) Montgomery DP, Plate CA, Jones M, Jones J, Rios R, Lambert DK, Schumtz N, Wiedmeier SE, Burnett J, Ail S, Brandel D, Maichuck G, Durham CA, Henry E, Christensen RD. Using umbilical cord tissue to detect fetal exposure to illicit drugs: a multicentered study in Utah and New Jersey. J Perinatol. 2008;28(11):750-3. Epub 2008 Jul 3.

(6.) Baxter FR, Nerhood R, Chaffin D. Characterization of babies discharged from Cabell Huntington Hospital during the calendar year 2005 with the diagnoses of neonatal abstinence syndrome. WV Med J. 2009;105(2):16-21.

(7.) Rementeria JL, Nunag NN. Narcotic narcotic, any of a number of substances that have a depressant effect on the nervous system. The chief narcotic drugs are opium, its constituents morphine and codeine, and the morphine derivative heroin.

See also drug addiction and drug abuse.
 withdrawal in pregnancy. Am J Obstet Gynecol 1973;116:1152-1156.

(8.) Finnegan JP. Treatment issues for opioid dependent women during the perinatal period. J Psychoactive Drugs 1991;23:191-202

(9.) Jarvis MAE (1) (Metropolitan Area Exchange) Originally known as Metropolitan Area Ethernets, MAEs are junction points on the Internet where data is exchanged between carriers. See IXP and NAP. , Schnoll SH. Methadone maintenance and withdrawal in pregnant opioid addicts. In CN Chiang & LP Finnegan (eds). Medication development for the treatment of pregnant addicts and their infants. (pp 58-77). Washington, D.C.: US Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979
Health and Human Services, HHS
 (NIDA NIDA National Institute on Drug Abuse
NIDA National Institute of Dramatic Arts (Australia)
NIDA Northern Ireland Development Agency (UK)
NIDA Northern Ireland Dairy Association
 Monograph 149).

(10.) Dashe JS, Jackson GL, Olscher DA, Zane EH, Wendel GD. Opioid detoxification in pregnancy. Obstet Gynecol 1998;92:854-58.

(11.) Luty J, Nikolaou V, Bearn J. Is opiate detoxification unsafe in pregnancy? J of Substance Abuse Treatment 2003;24:363-367.

(12.) Hoegerman G, Schnoll SH. Methadone maintenance and withdrawal in pregnant opioid addicts. Clinical Perinat 1991;18:51-76.

(13.) Briggs GG, Freeman RK, Yaffee SJ. Drugs in pregnancy and lactation lactation

Production of milk by female mammals after giving birth. The milk is discharged by the mammary glands in the breasts. Hormones triggered by delivery of the placenta and by nursing stimulate milk production.
. Williams and Wilkins, Baltimore, MD, 1994, pp 557-558,

(14.) Cooper JR, Altman F, Brown BS, Czechowicz D. (Eds1983). Research on the treatment of narcotic addiction: State of the art. (NIDA Research Monograph 83-1201). Rockville, MD: US Department of Health and Human Services.

(15.) Andres RL, Jones KL. Social and illicit drug illicit drug Street drug, see there  use in pregnancy. In RK Creasy & R Resnick (eds). Maternal-Fetal Medicine (pp 191-192), 1994, Philadelphia, PA: Saunders.

(16.) Winklbaur B, Kopf N, Ebner N, Jung E, Thau K, Fischer G. Treating pregnant women dependent on opioids is not the same as treating pregnancy and opioid dependence: a knowledge synthesis for better treatment for women and neonates. Addiction 2008;103:1429-1440.

(17.) Chutuape MA, Jasinski DR, Fingerhood MI, Stitzer ML. One, three, and six month outcomes following brief inpatient opioid detoxification. Am J Drug Alcohol Abuse 2001;27:19-44.


See: Chicago Mercantile Exchange


See Chicago Mercantile Exchange (CME).

19. Which of the following substances is associated with fetal growth abnormalities when ingested during pregnancy?

a. Cocaine

b. Marijuana

c. Amphetamines

d. Opiates

e. all the above

20. In the study population, the detection of alcohol ingestion ingestion /in·ges·tion/ (-chun) the taking of food, drugs, etc., into the body by mouth.

1. The act of taking food and drink into the body by the mouth.

 was similar at all eight of the participating hospitals. True or False?

21. According to the study results, the most frequently abused substance (excluding tobacco) during pregnancy in West Virginia is:

a. Benzodiazepines Benzodiazepines Definition

Benzodiazepines are medicines that help relieve nervousness, tension, and other symptoms by slowing the central nervous system.

Benzodiazepines are a type of antianxiety drugs.

b. Methadone/opiates

c. Alcohol

d. Cannabinoids/marijuana

e. Methamphetamine

Support provided by the West Virginia Department of Health and Human Resources, Bureau for Public Health, Office of Maternal, Child and Family Health with federal Maternal and Child Health Block Grant funds.

Michael L. Stitely, MD

Department of Obstetrics and Gynecology, West

Virginia University School of Medicine

Byron Calhoun, MD

Department of Obstetrics and Gynecology, West

Virginia University--Charleston Division

Stefan Maxwell, MD

Department of Neonatology neonatology /neo·na·tol·o·gy/ (ne?o-na-tol´ah-je) the diagnosis and treatment of disorders of the newborn.

, Charleston Area

Medical Center

Robert Nerhood, MD

Department of Obstetrics and Gynecology, Joan C.

Edwards School of Medicine at Marshall University

David Chaffin, MD

Department of Obstetrics and Gynecology, Joan C.

Edwards School of Medicine at Marshall University
Table 1. Umbilical cord drug profile.

Drug               Initial Test    Cutoff

Amphetamines       ELISA           5.0ng/ml
Cocaine            ELISA           2.0ng/ml
Opiates            ELISA           2.0ng/ml
Cannabinoids       ELISA           100pg/ml
Benzodiazapines    ELISA           2.0ng/ml
Methadone          ELISA           2.0ng/ml
Buprenorphine      LCMSMS          2.0ng/ml
Ethanol            HPLCMS          20ng/ml

Table 2. Distribution of sample collection by hospital.

Hospital                                  Number   % of Total

Bluefield Regional Medical Center BRMC       50          6.6
Raleigh General Hospital RGH                 83         10.9
Thomas Memorial Hospital TMH                 59          7.8
Charleston Area Medical Center CAMC         133         17.5
Cabell Huntington Hospital CHH              245         32.2
Ruby Memorial Hospital RMH                   52          6.9
Wheeling Hospital WH                         65          8.6
City Hospital CH                             72          9.5

Table 3. Prevalence and distribution of drug use in umbilical cords.

                                 % of               % of
Drug Class         Number   Positives (146)   population (759)

Amphetamines         1            <l                <<1
Cocaine              0             0                 0
Opiates              41           28                5.4
Cannabinoids         58           40                7.6
Benzodiazapines      17           12                2.2
Methadone            14           10                1.8
Buprenorphine        0             0                 0
Alcohol              39           27                5.1

Table 4. Polypharmacy in pregnant drug users.

Of patients                          % also using:
               Opiates   Cannabinoids   Benzos   Methadone   Alcohol

Opiates                       12          12         7          7
Cannabinoids      8                       5          3          7
Benzos           29           17                    11          6
Methadone        21           14          14                   14
Alcohol           7           10          2          5

Table 5. Regional variation in drug and alcohol use.

Hospital    Drugs %    Alcohol %

BRMC          14           4
RGH           19           2
TMH           10           8
CAMC          16           8
CHH           17           1
RMH           13           4
WH            12          15
CH            10           5

Table 6. Comparison of self-reporting tools and umbilical
cord screening.

                     Birth certificate/Birth Score reporting

Hospital                 Total       Reported Drug   Reported alcohol
(Total deliveries    deliveries in    Use in Aug     use in Aug 2009
in Aug 2009)           Aug 2009        2009 N(%)           N(%)

Bluefield Regional        56             5(9)              1(2)
Raleigh General           142            5(4)              2(1)
Thomas Memorial           68             3(4)              1(1)
CAMC                      283            15(5)            2(<1)
Cabell Huntington         251            7(3)              3(1)
Ruby Memorial             119            4(3)              1(1)
Wheeling Hospital         84             3(4)              1(1)
City Hospital             71             3(4)              2(3)
Total (1074)             1074            45(4)            13(1)

                     Umbilical cord screening

Hospital               Cords     Cords positive   Cords positive
(Total deliveries    collected     for drugs       for alcohol
in Aug 2009)             N            N(%)             N(%)

Bluefield Regional      50           7(14)             2(4)
Raleigh General         83           16(19)            2(2)
Thomas Memorial         59           6(10)             5(8)
CAMC                    133          21(15)           11(8)
Cabell Huntington       245          43(18)            3(1)
Ruby Memorial           52           7(13}             2(4)
Wheeling Hospital       65           8(12}            10(15)
City Hospital           72           7(10)             4(6)
Total (1074)            759         115(15)           39(5)

Table 7. Prenatal and neonatal effects of drugs of abuse.

            Marijuana                      Cocaine

Possible    Alters neurobehavioral         Lower head circumference
Physical      performance                    IUGR
Symptoms    Lower gestational age at       Abnormal fetal monitoring
              delivery                       and circulatory issues
            Increased risk of              Higher heart rates
              prematurity                  Higher incidence of
            Reduction in the heart rate      hypertension
              of the fetus                 Higher incidence of
            Growth Reduction                 respiratory distress
                                           Meconium staining
                                           Mai formations

Possible    Neurological symptoms          Tremors and jitters
Postnatal   Hypertonicity                  High pitched cry
Symptoms    Irritability                   Excessive sucking
            Jitteriness                    Seizures

Issues at   Late prenatal care             Placental abruption
delivery    More often required NICU       Premature ROM
              admission                    Pre term labor
                                           Less/late prenatal Premature
                                           High risk of maternal death
                                             from intracerebral
                                           High risk of perinatal HIV
                                           Higher risk of syphilis

Long Term   First trimester exposure       Higher infection rates
Impacts       affects child's depression   Negative behavioral outcomes
              and anxiety symptoms           at 3, 5 and 7 year
            Second trimester affects         follow-up
              reading comprehension        Lower IQ scores
            Speech and thought             Higher risk of SLDS

            Amphetamines                   Opiates/Methadone

Possible    SGA                            More feeding problems
Physical    Prematurity                    More likely tn require
Symptoms    IUGR                             resuscitation
            Smaller head circumference     More feeding problems
            Lower birthweight              Higher rates of prematurity,
            Transient bradycardia and        SGAh, Methadone treatment
              tachycardia                    can cause bradycardia,
            Higher incidence of cleft        tachycardia or an
              palate and cleft lip           irregular heart rate
            Congenital detects,
              including limb anomalies
              and cardiac septal defects

Possible    Same as cocaine                Symptoms of Neonatal
Postnatal   Tremors and jitters              Abstinence Syndrome (NAS)
Symptoms    High-pitched cry                 Central nervous system
            Excessive sucking                  dysfunction
            Possible seizures                  Irritability
            Tachycardia                        Excessive crying
            Tachypnea                          Hyperactive reflexes
            Apnea                              Increased tone
            Hyperirritabilily                  Sleep disturbance
                                             Autonomic dysfunction
                                             Respiratory symptoms

Issues at   Higher incidence of            Late prenatal care
delivery      stillbirth                   More often require NICU
            Poor prenatal care               admission
            Sexually transmitted           Antepartum hemorrhage
              diseases                     Increased risk of 1IIV
            Abruptio Placenta              More likely to require
            Postpartum hemorrhage            resuscitation
                                           Higher incidence of
                                             placental abruption
                                           Higher incidence of
                                             premature delivery
                                           Higher incidence of
                                           Higher rates of meconium

Long Term   Hyperactivity                  Higher incidence of SIDS
Impacts     Sleep disturbances
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Title Annotation:Scientific Article: Special Issue
Author:Stitely, Michael L.; Calhoun, Byron; Maxwell, Stefan; Nerhood, Robert; Chaffin, David
Publication:West Virginia Medical Journal
Article Type:Report
Geographic Code:1U5WV
Date:Jul 1, 2010
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