Heroin

 Risk Factor: B*
 Class: CENTRAL NERVOUS SYSTEM DRUGS / Narcotic Agonist Analgesics

Contents of this page:

Fetal Risk Summary
Breast Feeding Summary
References
Questions and Answers

Fetal Risk Summary

In the United States, heroin exposure during pregnancy is confined to illicit use as opposed to other countries, such as Great Britain, where the drug is commercially available. The documented fetal toxicity of heroin derives from the illicit use and resulting maternal-fetal addiction. In the form available to the addict, heroin is adulterated with various substances (such as lactose, glucose, mannitol, starch, quinine, amphetamines, strychnine, procaine, or lidocaine) or contaminated with bacteria, viruses, or fungi (1,2). Maternal use of other drugs, abuse and nonabuse, is likely. It is, therefore, difficult to separate entirely the effects of heroin on the fetus from the possible effects of other chemical agents, multiple diseases with addiction, and lifestyle.

Heroin rapidly crosses the placenta, entering fetal tissues within 1 hour of administration. Withdrawal of the drug from the mother causes the fetus to undergo simultaneous withdrawal. Intrauterine death may occur from meconium aspiration (3,4).

Assessment of fetal maturity and status is often difficult because of uncertain dates and an accelerated appearance of mature lecithin:sphingomyelin ratios (5).

Until recently, the incidence of congenital anomalies was not thought to be increased (6,7 and 8). Current data, however, suggest that a significant increase in major anomalies can occur (9). In a group of 830 heroin-addicted mothers, the incidence of infants with congenital abnormalities was significantly greater than in a group of 400 controls (9). Higher rates of jaundice, respiratory distress syndrome, and low Apgar scores were also found. Malformations reported with heroin are multiple and varied with no discernible patterns of defects (6,7,8,9,10,11,12 and 13). In addition, all of the mothers in the studies reporting malformed infants were consuming numerous other drugs, including drugs of abuse.

Characteristics of the infant delivered from a heroin-addicted mother may be (14): Accelerated liver maturity with a lower incidence of jaundice (8,15) Lower incidence of hyaline membrane disease after 32 weeks' gestation (5,16) Normal Apgar scores (6) (Note: The findings of Ostrea and Chavez (9) are in disagreement with the above statements.) Low birth weight; up to 50% weigh less than 2500 g Small size for gestational age Narcotic withdrawal in about 85% (58%91%): symptoms apparent usually within the first 48 hours with some delaying up to 6 days; incidence is directly related to daily dose and length of maternal addiction; hyperactivity, respira tory distress, fever, diarrhea, mucus secretion, sweating, convulsions, yawning, and face scratching (7,8) Meconium staining of amniotic fluid Elevated serum magnesium levels when withdrawal signs are present (up to twice normal) Increased perinatal mortality; rates up to 37% in some series (13) Random chromosomal damage was significantly higher when Apgar scores were 6 or less (12,17). However, only one case has appeared relating chromosomal abnormalities to congenital anomalies (12). The clinical significance of this is doubtful. The lower incidence of hyaline membrane disease may be caused by elevated prolactin blood levels in fetuses of addicted mothers (18).

Long-term effects on growth and behavior have been reported (19). As compared with controls, children aged 36 years delivered from addicted mothers were found to have lower weights, lower heights, and impaired behavioral, perceptual, and organizational abilities.

[*Risk Factor D if used for prolonged periods or in high doses at term.]

Breast Feeding Summary

Heroin crosses into breast milk in sufficient quantities to cause addiction in the infant (20). A milk:plasma ratio has not been reported. Previous investigators have considered nursing as one method for treating the addicted newborn (21). The American Academy of Pediatrics classifies heroin abuse as a contraindication to breast feeding (22).

References

1. Anonymous. Diagnosis and management of reactions to drug abuse. Med Lett Drugs Ther 1980;22:74.
2. Thomas L. Notes of a biology-watcher. N Engl J Med 1972;286:5313.
3. Chappel JN. Treatment of morphine-type dependence. JAMA 1972;221:1516.
4. Rementeria JL, Nunag NN. Narcotic withdrawal in pregnancy: stillbirth incidence with a case report. Am J Obstet Gynecol 1973;116:11526.
5. Gluck L, Kulovich MV. Lecithin/sphingomyelin ratios in amniotic fluid in normal and abnormal pregnancy. Am J Obstet Gynecol 1973;115:53946.
6. Reddy AM, Harper RG, Stern G. Observations on heroin and methadone withdrawal in the newborn. Pediatrics 1971;48:3538.
7. Stone ML, Salerno LJ, Green M, Zelson C. Narcotic addiction in pregnancy. Am J Obstet Gynecol 1971;109:71623.
8. Zelson C, Rubio E, Wasserman E. Neonatal narcotic addiction: 10 year observation. Pediatrics 1971;48:17889.
9. Ostrea EM, Chavez CJ. Perinatal problems (excluding neonatal withdrawal) in maternal drug addiction: a study of 830 cases. J Pediatr 1979;94:2925.
10. Perlmutter JF. Drug addiction in pregnant women. Am J Obstet Gynecol 1967;99:56972.
11. Krause SO, Murray PM, Holmes JB, Burch RE. Heroin addiction among pregnant women and their newborn babies. Am J Obstet Gynecol 1958;75:7548.
12. Kushnick T, Robinson M, Tsao C. 45,X chromosome abnormality in the offspring of a narcotic addict. Am J Dis Child 1972;124:7723.
13. Naeye RL, Blanc W, Leblanc W, Khatamee MA. Fetal complications of maternal heroin addiction: abnormal growth, infections and episodes of stress. J Pediatr 1973;83:105561.
14. Perlmutter JF. Heroin addiction and pregnancy. Obstet Gynecol Surv 1974;29:43946.
15. Nathenson G, Cohen MI, Liff IF, McNamara H. The effect of maternal heroin addiction on neonatal jaundice. J Pediatr 1972;81:899903.
16. Glass L, Rajegowda BK, Evans HE. Absence of respiratory distress syndrome in premature infants of heroin-addicted mothers. Lancet 1971;2:6856.
17. Amarose AP, Norusis MJ. Cytogenetics of methadone-managed and heroin-addicted pregnant women and their newborn infants. Am J Obstet Gynecol 1976;124:63540.
18. Parekh A, Mukherjee TK, Jhaveri R, Rosenfeld W, Glass L. Intrauterine exposure to narcotics and cord blood prolactin concentrations. Obstet Gynecol 1981;57:4479.
19. Wilson GS, McCreary R, Kean J, Baxter JC. The development of preschool children of heroin-addicted mothers: a controlled study. Pediatrics 1979;63:13541.
20. Lichtenstein PM. Infant drug addiction. NY Med J 1915;102:905. As reported by Cobrinik RW, et al, in Pediatrics 1959;24:288304.
21. Cobrinik RW, Hood RT Jr, Chusid E. The effect of maternal narcotic addiction on the newborn infant. Pediatrics 1959;24:288304.
22. Committee on Drugs, American Academy of Pediatrics. The transfer of drugs and other chemicals into human milk. Pediatrics 1994;93:13750.