Drug and Alcohol Dependence, 2 (1977) 131 0 Elsevier Sequoia S.A., Lausanne - Printed
THE EFFECTS OF MATERNAL MORTALITY *
LORETTA
P. FINNEGAN,
DIAN
131
- 140 in the Netherlands
DRUG DEPENDENCE
S. REESER
and JAMES
ON NEONATAL
F. CONNAUGHTON,
Departments of Pediatrics and Obstetrics and Gynecology, Philadelphia General and the University of Pennsylvania School of Medicine, Philadelphia (U.S.A.)** (Received
December
Jr. Hospital
12, 1976)
Summary Addiction in pregnancy has become an important health problem owing to the tendency of drug-dependent women to neglect general health care and to avoid seeking prenatal care. In addition, continued heroin administration during pregnancy carries additional risks for the maternal-fetal unit. Thus, there is an increased incidence of obstetrical and medical complications in these mothers, resulting in high incidences of prematurity, low birth weight and mortality in their infants. Therefore, there is a high neonatal mortality rate due to clinical conditions most commonly seen among premature infants. Data from three groups of drug-dependent women and their infants and one control group demonstrate that the high mortality rate, as well as the incidence of low birth weight, can be reduced to a rate similar to the control group in infants of mothers who receive comprehensive services that include prenatal care in conjunction with methadone maintenance.
Introduction Although the exact magnitude of narcotic dependency in pregnancy has been difficult to determine, estimates over the past decade show that increasing numbers of pregnant addicts have presented themselves to medical facilities. These estimates have generally been based on women who are seen at hospitals for delivery. However, it is suspected that a considerable number of pregnant drug-dependent women may self-deliver without a physician in attendance. Moreover, many hospitals do not identify drug-dependent *Read at the Thirty-Eighth Scientific Meeting of the Committee on Problems of Drug Dependence, Div. of Med. Sciences, National Research Council, Richmond Virginia (U.S.A.) 1976. **New address: Department of Pediatrics, Jefferson Medical College, Philadelphia, Pa. (U.S.A.)
132
women, nor do they record data on deliveries of known drug abusers, so that they are unable to report such cases in their annual statistics. Despite the increase of pregnant drug-dependent women who present themselves to hospitals, in general they do not seek medical assistance until the onset of labor. Consequently, addiction in pregnancy has become an important health problem owing to an increased incidence of obstetrical and medical complications in these women and, moreover, the extremely high rate of prematurity and other untoward sequelae in their infants. The clinical management of these patients is difficult because of complications which usually result from their tendency to neglect general health care and to avoid seeking prenatal care throughout pregnancy. Social and emotional problems, such as poor housing, inadequate income, lack of education and feelings of worthlessness and depression, add to the overall difficulties presented to the pregnant addict. The lack of prenatal care is consistent with the lifestyle of a woman abusing drugs, for she fears calling attention to her drug habit and does not wish to risk confrontation with legal authorities. In general, pregnant drug-dependent women have a low standard of self-care and it has been estimated that 75% have never seen a physician during pregnancy. The use of heroin carries the high risk of repeated infections, foreign body reactions, continued illegal activity, fatal overdose, inadequate nutrition, obstetrical problems such as premature labor, potential or serious neonatal narcotic withdrawal and other sequelae, and difficulty in learning adequate mothering practices [ 11. In the past, neonatal mortality in the infants of heroin-dependent women has been reported to be extremely high. In 1956, Goodfriend et al. reported a mortality rate of 94% in untreated infants [2]. For those infants in whom withdrawal symptoms were recognized and treated, the mortality rate was reported as 34% [ 21. By 1963, subsequent reports revealed that treated infants have an incidence of mortality between 0 and 25%. The latter reflects the improved methods of care for the high risk newborn. Only a few reports in the literature describe the pathological findings in the infants who had died and in whom there was maternal drug abuse. Generally, the causes of death include hyaline membrane disease, resorptive atelectasis, congenital anomalies, pneumonia and intracranial hemorrhage - all conditions which are most commonly seen among premature infants. Recent studies have shown a mortality rate between 3 and 4.5% [3] . By the 1970’s, methods for decreasing the incidence of prematurity and the treatment of seriously ill low birth weight infants had markedly improved, thereby contributing to the decrease in neonatal mortality rates in infants born to drug-dependent women. For those who do not get involved in medical care, fetal wastage continues to be far above the average expected figures in the U.S. This study presents the available data on 278 infants born to drugdependent women and 1586 control infants from the general population of the Philadelphia General Hospital (PGH), in regard to the incidence of low birth weight, neonatal mortality and pathological findings.
133
Materials and methods The data were tabulated from 278 infants born to drug-dependent mothers at the Philadelphia General Hospital between 1969 and 1974. These infants were categorized into three groups according to maternal prenatal care. The first group A, (N = 63), included women whose primary drug of dependence was heroin. These women had no prenatal care and were admitted only for delivery. The second group, B (N = 80), included women who had minimal prenatal care, having been to the prenatal clinic an average of 1.8 visits. These women had been maintained on a low-dose methadone maintenance program which also had intensive psychosocial counseling available. Unfortunately, these women did not attend either the prenatal clinic or their counseling sessions on a regular basis. The third group, C (N = 135), included women who had an average of 9.2 prenatal visits. These women were also being maintained on a low-dose methadone maintenance program (the same program as was available to group B), which had available intensive psychosocial counseling. These women did attend regular prenatal visits as well as their counseling sessions. In addition, they were provided with the overall services in Family Center, a special comprehensive program at PGH for pregnant women and their newborns. In addition to the obstetrical, psychosocial and addictive care, these women were involved in the outreach aspects of the program. These included regular visits to the clients’ homes by public health nurses in order to identify medical and social problems that may need immediate attention. Since the majority of the infants were born during 1972 - 1974, a group of control infants were chosen, from the general population at PGH, who were born within that time period. The mothers of this group of infants were provided with prenatal care in the same setting as the pregnant drug-dependent women (in the outpatient clinic of PGH). They all delivered in this institution and were provided with the same nursery services as the infants of the drug-dependent women. Data were collected on the incidence of overall low birth weight, mortality and the causes of mortality.
Results Eighty-six of the 278 infants in groups A, B and C had low birth weight, which is an incidence of 30.9%. On separating the drug-dependent population into groups A, B and C (as described), there were 30, 31 and 25 low birth weight infants, respectively, an incidence of 47.6%, 38.8% and 18.5% (Table 1). There were 241 low birth weight infants from the control population of 1586 live births, which is an incidence of 15.2%. The total number of deaths in groups A, B and C was 15, an incidence of 5.4%. In groups A, B and C, there were 3, 8 and 4 deaths, respectively, an incidence of 4.8%, 10.0% and 3.0%. In the 1586 total live births at PGH during this time, there were 26 deaths, an incidence of 1.6%. The incidence
134 TABLE
1
Low birth weight (LBW) in 278 infants infants, 1969-1974 __
Total live. births LBW infants (< 2500 g) Incidence of LBW (%)
of drug-dependent
women
and 1586 control
PGH controls
Groups A, B, C
Group A
Group B
Group C
1586 241 15.2
278 86 30.9
63 30 47.6
80 31 38.8
135 25 18.5
of death in low birth weight infants in groups A, B and C combined was 13.3%, and in groups A, B and C individually, it was lO.O%, 25.8% and 4.0%, respectively. In the 1586 controls, the incidence of death in low birth weight infants was 10%. The incidence of overall mortality in the three addicted groups is three times that of the general population at PGH. When separating the drugdependent population into the three groups, the most striking rate is in group B, where both overall mortality and low birth weight mortality is affected, suggesting that methadone given in an uncontrolled manner to pregnant women may be more harmful than illicit heroin. In contrast, the methadone-maintained mothers with adequate prenatal and addictive care had a somewhat increased overall mortality but a decreased mortality in the low birth weight infants in comparison with that of the control population (Table 2). TABLE 2 Neontal deaths 1969-1974
in 278 infants
of drug-dependent
Total live births
women
and 1586 control
infants,
PGH controls
Groups A, B, C
Group A
Group B
Group C
1586
278
63
80
135 _
-. Total deaths Incidence (%)
26 1.6
15 5.4
3 4.8
8 10.0
4 3.0
Incidence of death in low birth weight infants (%)
10.0
13.3
10.0
25.8
4.0
Birth weight, gestational age, clinical diagnosis and maternal drug usage are tabulated in Tables 3, 4 and 5 for groups A, B and C. In group A, the three infants who died had an average birth weight of 1197 g and an average gestational age of 29 weeks. The average amount of heroin used by the mothers in group A was 3.75 bags per day for an average of 7 years. In group B the average birth weight was 1455 g, with an average gestational age of 28 weeks. In addition to the eight neonatal deaths, there
wt.
27 32 27
age
diagnosis
Gestational (weeks)
age, infant
disease.
907 1 650 980
1-M 2-F 3-M
membrane
Birth
(9)
Infant case No. and sex
*Hyaline
gestational
3
weight,
Birth
TABLE
diagnosis
drug histories
Immaturity Asphyxia neonatorum HMD*
Clinical
and maternal
in group
Unknown 7 Unknown
(wars)
5- 10 3-5 4
Duration
Amount
(bags/day)
Heroin
A (N = 63)
None None None
(mg/day)
Dose
Methadone Duration
None None None
(months)
Birth
Infant case No. and sex
1980
11-M
wt.
36
34 36 34 28 26
33
36
age
diagnosis
Gestational (weeks)
age, infant
disease.
1899 2268 1814 1050 795
6-F 7-F 8-IM 9-F 10-F
membrane
1420
5-F
*Hyaline
1780
4-F
(g)
gestational
4
weight,
Birth
TABLE
hemorrhage.
Trisomy 18, ICH** pneumonia
Asphyxia neonatorum HMD*, pneumothorax Asphyxia neonatorum Prematurity Immaturity
HMD*, sepsis, asphyxia neonatorum
**Intracranial
in group
heart disease failure
diagnosis
drug histories
Congenital with heart
Clinical
and maternal
24 mg/day (Dilaudid)
8 7 4 12 6
6
4
12 2 8 18 2
Unknown
4
(years)
(bags/day) 25
Duration
Amount
Heroin
B (N = 80)
30
50 50 50 25 65
10
80
Dose (mglday)
Methadone
1
6 1 Unknown % Unknown
Unknown
9
Duration (months)
3 650
2 260
2 730
3 500
12-M
13-M
14-F
15-F
*Hyaline membrane disease.
Birth wt. (g)
Infant case No. and sex
40
37
39
40
Gestational age (weeks)
Precipitous delivery, meconium aspiration, asphyxia neonatorum
HMD*, anemia, erythroblastosis fetalis
Gastroschisis
Meconium aspiration syndrome
Clinical diagnosis
10
25
4
14
Amount (bags/day)
Heroin
Birth weight, gestational age, infant diagnosis and maternal drug histories in group C (N = 135)
TABLE 5
3
6
10
5
Duration (years)
25
47
60
120
Dose (mg/day )
Methadone
11
31
4
Unknown
Duration (months)
138
was one intrauterine fetal death and one spontaneous abortion in group B. The latter weighed 410 g and the former, 1134 g. In group B, the average amount of heroin was 12 bags per day for an average of 5.6 years. These mothers were on an average 44.5 mg of methadone for 3.2 months. In group C, in addition to the four neonatal deaths, there was one intrauterine fetal death and one spontaneous abortion. The average birth weight of these infants was 2416 g with an average gestational age of 34 weeks. The average amount of heroin was 13 bags per day for an average duration of 5.2 years. These mothers were maintained on an average methadone dose of 57 mg per day for an average duration of 14.6 months prior to delivery. Data on pathological findings are listed in Table 6, along with the average age of death of the 15 infants born to drug-dependent mothers. In both groups A and B, the infants generally died from the effects of prematurity, including hyaline membrane disease, asphyxia neonatorum, intracranial hemorrhage, pulmonary hemorrhage, pneumothorax and pneumonia. In group C, one infant died subsequent to attempts at surgical repair of a congenital anomaly (gastroschisis). Another infant was born to a mother who had severe Rh hemolytic disease. The infant was prematurely born and had hydrops fetalis and hyaline membrane disease. The other two infants both succumbed to meconium aspiration and subarachnoid hemorrhage. One of these mothers, seen very early in our program (1972), was on an extremely high dose of methadone (120 mg). Attempts to decrease her dosage had never been successful. The infant was born covered with extremely thick meconium and suffered a massive aspiration syndrome to which it succumbed within a few hours after birth. The other infant’s mother was on a low dose of methadone (25 mg) but she delivered precipitously at home, during which time her infant underwent extremes in asphyxia and traumatic birth with subsequent aspiration of meconium. TABLE
6
Significant Infant case No.
pathological Group
findings in infants of drug-dependent
Birth wt. (g)
Age at death lh
Pathological
mothers
diagnosis
No post-mortem
1
A
907
2
A
1 650
47 h
Immature brain with anoxic encephalopathy, GPH*; hemorrhage: kidney, adrenals, lungs; liver necrosis and hemorrhage
3
A
980
26 h
HMD**; GPH; IVHt ; immature brain; atelectasis of lungs; spleen and liver congestion
4
B
1 780
38 h
Immature brain; GPH; IVH; hemorrhage cerebral white matter; acute necrosis of thalamus; atelectasis of lungs; single umbilical artery (continued
into
on facing page)
139
TABLE
6 (continued) Group
Birth wt. (g) -
Age at death
Pathological diagnosis
5
B
1 420
22 days
Subarachnoid hemorrhage; GPH (organized); multiloculated cysts periventricularly; severe diffuse white matter gliosis; atelectasis of lungs with interstitial fibrosis; acute broncho-pneumonia.
6
B
1 899
THE EFFECTS OF MATERNAL MORTALITY *
LORETTA
P. FINNEGAN,
DIAN
131
- 140 in the Netherlands
DRUG DEPENDENCE
S. REESER
and JAMES
ON NEONATAL
F. CONNAUGHTON,
Departments of Pediatrics and Obstetrics and Gynecology, Philadelphia General and the University of Pennsylvania School of Medicine, Philadelphia (U.S.A.)** (Received
December
Jr. Hospital
12, 1976)
Summary Addiction in pregnancy has become an important health problem owing to the tendency of drug-dependent women to neglect general health care and to avoid seeking prenatal care. In addition, continued heroin administration during pregnancy carries additional risks for the maternal-fetal unit. Thus, there is an increased incidence of obstetrical and medical complications in these mothers, resulting in high incidences of prematurity, low birth weight and mortality in their infants. Therefore, there is a high neonatal mortality rate due to clinical conditions most commonly seen among premature infants. Data from three groups of drug-dependent women and their infants and one control group demonstrate that the high mortality rate, as well as the incidence of low birth weight, can be reduced to a rate similar to the control group in infants of mothers who receive comprehensive services that include prenatal care in conjunction with methadone maintenance.
Introduction Although the exact magnitude of narcotic dependency in pregnancy has been difficult to determine, estimates over the past decade show that increasing numbers of pregnant addicts have presented themselves to medical facilities. These estimates have generally been based on women who are seen at hospitals for delivery. However, it is suspected that a considerable number of pregnant drug-dependent women may self-deliver without a physician in attendance. Moreover, many hospitals do not identify drug-dependent *Read at the Thirty-Eighth Scientific Meeting of the Committee on Problems of Drug Dependence, Div. of Med. Sciences, National Research Council, Richmond Virginia (U.S.A.) 1976. **New address: Department of Pediatrics, Jefferson Medical College, Philadelphia, Pa. (U.S.A.)
132
women, nor do they record data on deliveries of known drug abusers, so that they are unable to report such cases in their annual statistics. Despite the increase of pregnant drug-dependent women who present themselves to hospitals, in general they do not seek medical assistance until the onset of labor. Consequently, addiction in pregnancy has become an important health problem owing to an increased incidence of obstetrical and medical complications in these women and, moreover, the extremely high rate of prematurity and other untoward sequelae in their infants. The clinical management of these patients is difficult because of complications which usually result from their tendency to neglect general health care and to avoid seeking prenatal care throughout pregnancy. Social and emotional problems, such as poor housing, inadequate income, lack of education and feelings of worthlessness and depression, add to the overall difficulties presented to the pregnant addict. The lack of prenatal care is consistent with the lifestyle of a woman abusing drugs, for she fears calling attention to her drug habit and does not wish to risk confrontation with legal authorities. In general, pregnant drug-dependent women have a low standard of self-care and it has been estimated that 75% have never seen a physician during pregnancy. The use of heroin carries the high risk of repeated infections, foreign body reactions, continued illegal activity, fatal overdose, inadequate nutrition, obstetrical problems such as premature labor, potential or serious neonatal narcotic withdrawal and other sequelae, and difficulty in learning adequate mothering practices [ 11. In the past, neonatal mortality in the infants of heroin-dependent women has been reported to be extremely high. In 1956, Goodfriend et al. reported a mortality rate of 94% in untreated infants [2]. For those infants in whom withdrawal symptoms were recognized and treated, the mortality rate was reported as 34% [ 21. By 1963, subsequent reports revealed that treated infants have an incidence of mortality between 0 and 25%. The latter reflects the improved methods of care for the high risk newborn. Only a few reports in the literature describe the pathological findings in the infants who had died and in whom there was maternal drug abuse. Generally, the causes of death include hyaline membrane disease, resorptive atelectasis, congenital anomalies, pneumonia and intracranial hemorrhage - all conditions which are most commonly seen among premature infants. Recent studies have shown a mortality rate between 3 and 4.5% [3] . By the 1970’s, methods for decreasing the incidence of prematurity and the treatment of seriously ill low birth weight infants had markedly improved, thereby contributing to the decrease in neonatal mortality rates in infants born to drug-dependent women. For those who do not get involved in medical care, fetal wastage continues to be far above the average expected figures in the U.S. This study presents the available data on 278 infants born to drugdependent women and 1586 control infants from the general population of the Philadelphia General Hospital (PGH), in regard to the incidence of low birth weight, neonatal mortality and pathological findings.
133
Materials and methods The data were tabulated from 278 infants born to drug-dependent mothers at the Philadelphia General Hospital between 1969 and 1974. These infants were categorized into three groups according to maternal prenatal care. The first group A, (N = 63), included women whose primary drug of dependence was heroin. These women had no prenatal care and were admitted only for delivery. The second group, B (N = 80), included women who had minimal prenatal care, having been to the prenatal clinic an average of 1.8 visits. These women had been maintained on a low-dose methadone maintenance program which also had intensive psychosocial counseling available. Unfortunately, these women did not attend either the prenatal clinic or their counseling sessions on a regular basis. The third group, C (N = 135), included women who had an average of 9.2 prenatal visits. These women were also being maintained on a low-dose methadone maintenance program (the same program as was available to group B), which had available intensive psychosocial counseling. These women did attend regular prenatal visits as well as their counseling sessions. In addition, they were provided with the overall services in Family Center, a special comprehensive program at PGH for pregnant women and their newborns. In addition to the obstetrical, psychosocial and addictive care, these women were involved in the outreach aspects of the program. These included regular visits to the clients’ homes by public health nurses in order to identify medical and social problems that may need immediate attention. Since the majority of the infants were born during 1972 - 1974, a group of control infants were chosen, from the general population at PGH, who were born within that time period. The mothers of this group of infants were provided with prenatal care in the same setting as the pregnant drug-dependent women (in the outpatient clinic of PGH). They all delivered in this institution and were provided with the same nursery services as the infants of the drug-dependent women. Data were collected on the incidence of overall low birth weight, mortality and the causes of mortality.
Results Eighty-six of the 278 infants in groups A, B and C had low birth weight, which is an incidence of 30.9%. On separating the drug-dependent population into groups A, B and C (as described), there were 30, 31 and 25 low birth weight infants, respectively, an incidence of 47.6%, 38.8% and 18.5% (Table 1). There were 241 low birth weight infants from the control population of 1586 live births, which is an incidence of 15.2%. The total number of deaths in groups A, B and C was 15, an incidence of 5.4%. In groups A, B and C, there were 3, 8 and 4 deaths, respectively, an incidence of 4.8%, 10.0% and 3.0%. In the 1586 total live births at PGH during this time, there were 26 deaths, an incidence of 1.6%. The incidence
134 TABLE
1
Low birth weight (LBW) in 278 infants infants, 1969-1974 __
Total live. births LBW infants (< 2500 g) Incidence of LBW (%)
of drug-dependent
women
and 1586 control
PGH controls
Groups A, B, C
Group A
Group B
Group C
1586 241 15.2
278 86 30.9
63 30 47.6
80 31 38.8
135 25 18.5
of death in low birth weight infants in groups A, B and C combined was 13.3%, and in groups A, B and C individually, it was lO.O%, 25.8% and 4.0%, respectively. In the 1586 controls, the incidence of death in low birth weight infants was 10%. The incidence of overall mortality in the three addicted groups is three times that of the general population at PGH. When separating the drugdependent population into the three groups, the most striking rate is in group B, where both overall mortality and low birth weight mortality is affected, suggesting that methadone given in an uncontrolled manner to pregnant women may be more harmful than illicit heroin. In contrast, the methadone-maintained mothers with adequate prenatal and addictive care had a somewhat increased overall mortality but a decreased mortality in the low birth weight infants in comparison with that of the control population (Table 2). TABLE 2 Neontal deaths 1969-1974
in 278 infants
of drug-dependent
Total live births
women
and 1586 control
infants,
PGH controls
Groups A, B, C
Group A
Group B
Group C
1586
278
63
80
135 _
-. Total deaths Incidence (%)
26 1.6
15 5.4
3 4.8
8 10.0
4 3.0
Incidence of death in low birth weight infants (%)
10.0
13.3
10.0
25.8
4.0
Birth weight, gestational age, clinical diagnosis and maternal drug usage are tabulated in Tables 3, 4 and 5 for groups A, B and C. In group A, the three infants who died had an average birth weight of 1197 g and an average gestational age of 29 weeks. The average amount of heroin used by the mothers in group A was 3.75 bags per day for an average of 7 years. In group B the average birth weight was 1455 g, with an average gestational age of 28 weeks. In addition to the eight neonatal deaths, there
wt.
27 32 27
age
diagnosis
Gestational (weeks)
age, infant
disease.
907 1 650 980
1-M 2-F 3-M
membrane
Birth
(9)
Infant case No. and sex
*Hyaline
gestational
3
weight,
Birth
TABLE
diagnosis
drug histories
Immaturity Asphyxia neonatorum HMD*
Clinical
and maternal
in group
Unknown 7 Unknown
(wars)
5- 10 3-5 4
Duration
Amount
(bags/day)
Heroin
A (N = 63)
None None None
(mg/day)
Dose
Methadone Duration
None None None
(months)
Birth
Infant case No. and sex
1980
11-M
wt.
36
34 36 34 28 26
33
36
age
diagnosis
Gestational (weeks)
age, infant
disease.
1899 2268 1814 1050 795
6-F 7-F 8-IM 9-F 10-F
membrane
1420
5-F
*Hyaline
1780
4-F
(g)
gestational
4
weight,
Birth
TABLE
hemorrhage.
Trisomy 18, ICH** pneumonia
Asphyxia neonatorum HMD*, pneumothorax Asphyxia neonatorum Prematurity Immaturity
HMD*, sepsis, asphyxia neonatorum
**Intracranial
in group
heart disease failure
diagnosis
drug histories
Congenital with heart
Clinical
and maternal
24 mg/day (Dilaudid)
8 7 4 12 6
6
4
12 2 8 18 2
Unknown
4
(years)
(bags/day) 25
Duration
Amount
Heroin
B (N = 80)
30
50 50 50 25 65
10
80
Dose (mglday)
Methadone
1
6 1 Unknown % Unknown
Unknown
9
Duration (months)
3 650
2 260
2 730
3 500
12-M
13-M
14-F
15-F
*Hyaline membrane disease.
Birth wt. (g)
Infant case No. and sex
40
37
39
40
Gestational age (weeks)
Precipitous delivery, meconium aspiration, asphyxia neonatorum
HMD*, anemia, erythroblastosis fetalis
Gastroschisis
Meconium aspiration syndrome
Clinical diagnosis
10
25
4
14
Amount (bags/day)
Heroin
Birth weight, gestational age, infant diagnosis and maternal drug histories in group C (N = 135)
TABLE 5
3
6
10
5
Duration (years)
25
47
60
120
Dose (mg/day )
Methadone
11
31
4
Unknown
Duration (months)
138
was one intrauterine fetal death and one spontaneous abortion in group B. The latter weighed 410 g and the former, 1134 g. In group B, the average amount of heroin was 12 bags per day for an average of 5.6 years. These mothers were on an average 44.5 mg of methadone for 3.2 months. In group C, in addition to the four neonatal deaths, there was one intrauterine fetal death and one spontaneous abortion. The average birth weight of these infants was 2416 g with an average gestational age of 34 weeks. The average amount of heroin was 13 bags per day for an average duration of 5.2 years. These mothers were maintained on an average methadone dose of 57 mg per day for an average duration of 14.6 months prior to delivery. Data on pathological findings are listed in Table 6, along with the average age of death of the 15 infants born to drug-dependent mothers. In both groups A and B, the infants generally died from the effects of prematurity, including hyaline membrane disease, asphyxia neonatorum, intracranial hemorrhage, pulmonary hemorrhage, pneumothorax and pneumonia. In group C, one infant died subsequent to attempts at surgical repair of a congenital anomaly (gastroschisis). Another infant was born to a mother who had severe Rh hemolytic disease. The infant was prematurely born and had hydrops fetalis and hyaline membrane disease. The other two infants both succumbed to meconium aspiration and subarachnoid hemorrhage. One of these mothers, seen very early in our program (1972), was on an extremely high dose of methadone (120 mg). Attempts to decrease her dosage had never been successful. The infant was born covered with extremely thick meconium and suffered a massive aspiration syndrome to which it succumbed within a few hours after birth. The other infant’s mother was on a low dose of methadone (25 mg) but she delivered precipitously at home, during which time her infant underwent extremes in asphyxia and traumatic birth with subsequent aspiration of meconium. TABLE
6
Significant Infant case No.
pathological Group
findings in infants of drug-dependent
Birth wt. (g)
Age at death lh
Pathological
mothers
diagnosis
No post-mortem
1
A
907
2
A
1 650
47 h
Immature brain with anoxic encephalopathy, GPH*; hemorrhage: kidney, adrenals, lungs; liver necrosis and hemorrhage
3
A
980
26 h
HMD**; GPH; IVHt ; immature brain; atelectasis of lungs; spleen and liver congestion
4
B
1 780
38 h
Immature brain; GPH; IVH; hemorrhage cerebral white matter; acute necrosis of thalamus; atelectasis of lungs; single umbilical artery (continued
into
on facing page)
139
TABLE
6 (continued) Group
Birth wt. (g) -
Age at death
Pathological diagnosis
5
B
1 420
22 days
Subarachnoid hemorrhage; GPH (organized); multiloculated cysts periventricularly; severe diffuse white matter gliosis; atelectasis of lungs with interstitial fibrosis; acute broncho-pneumonia.
6
B
1 899
