The use of amphetamine-type stimulants (ATSs) has been increasing among women worldwide [
ATS is a family of potent central nervous system stimulants composed of amphetamine sulfate and methamphetamine. Amphetamine was first synthesized in 1887. Cases of amphetamine usage in pregnant mothers in Thailand were reported by Thaithumyanon [
Sample of methamphetamine in Thailand.
In our antenatal care and delivery room at Bhumibol Adulyadej Hospital (BAH), there was an increase in maternal-fetal complications in recent years with pregnant mothers who showed symptoms of methamphetamine withdrawal. Other previous studies in Thailand came from the descriptive retrospective data only, while the current form of methamphetamine was different from the old formulation in the previous data.
The aim of this study was to determine obstetric and neonatal outcomes among methamphetamine-abusing parturient who currently used MA.
This retrospective cohort study was conducted at BAH, Bangkok, Thailand, between January 2017 and December 2019. This research protocol was approved by the BAH ethics committee (No. 40/63).
Data were collected from medical records and birth reports from the medical database of the Department of Obstetrics and Gynecology, BAH, during the period of study. Pregnant women who attended the BAH labor room during the period of study with a history of illicit drug (MA, cannabis, cocaine, and opioid) usage during pregnancy or displaying signs and symptoms of MA withdrawal were asked for a urine amphetamine test. MA withdrawal signs and symptoms included agitation, dysphoria, anhedonia, fatigue, and drug craving [
Spot urine samples were obtained for MA detection after consent was granted. Urine MA detection was performed using commercial rapid urine tests (Bioline®, Pacific Biotech, BKK, Thailand). Bioline methamphetamine cards are a one-step immunochromatographic assay in which a chemically labeled drug (methamphetamine-protein conjugate) built into the test device competes with methamphetamine. It is used for the qualitative detection of methamphetamine in human urine at a cutoff of 1,000 ng/ml. Singleton pregnant women with positive MA urine tests during the period of study were recruited.
Exclusion criteria were participants with twin pregnancies, fetal anomalies, and underlying health conditions such as pregestational diabetic mellitus and thyroid disease.
Patients with urine MA positive were classified as a study group. The control group was healthy participants who had matching characteristics, namely, age, ethnic group, and mode of delivery during the study period. Data included age, parity, body mass index (BMI), underlying diseases, number of antenatal care visits, and history of drug abuse. The outcomes of pregnancy such as preterm birth, birth weight, Apgar score, and intrapartum complications were also recorded.
Statistical analysis was computerized using Statistical Package for the Social Science software (SPSS Inc., Chicago, IL, USA). Continuous variables were analyzed by Student’s
During the period of study, 206 cases were recruited. Participants were divided into the study and control groups equally as shown in Figure
Flow chart of the study and control group.
Comparison of characteristic features between the study group and control group.
Characteristic | Study ( | Control ( | OR | 95% CI | |
---|---|---|---|---|---|
Age (years) | 29.2 ± 6.1 | 27.7 ± 6.4 | — | — | 0.104 |
<20 | 4 (3.9) | 9 (8.7) | 0.42 | 0.12–1.41 | 0.251 |
20–34 | 81 (78.6) | 78 (75.7) | 1.18 | 0.61–2.26 | 0.739 |
≥35 | 18 (17.5) | 16 (15.5) | 1.15 | 0.55–2.40 | 0.851 |
Thai ethnicity | 101 (98) | 95 (92.2) | 4.25 | 0.08–20.53 | 0.52 |
Multiparity | 85 (82.5) | 51 (49.5) | 4.81 | 2.54–9.11 | <0.001 |
PPW (kg) | 53.8 ± 11.3 | 56.1 ± 13.5 | — | — | 0.191 |
BMI (kg/m2) | 21.2 ± 3.9 | 22.3 ± 4.9 | — | — | 0.097 |
ANC visit | 2.1 ± 2.8 | 7.7 ± 3.6 | — | — | <0.001 |
No ANC | 48 (46.6) | 5 (4.7) | 17.10 | 6.42–45.50 | <0.001 |
Alcohol | 13 (12.6) | 0 (0) | 2.14 | 1.84–2.49 | <0.001 |
Smoker | 40 (38.8) | 1 (1.0) | 2.55 | 2.09–3.12 | <0.001 |
STD | |||||
Syphilis | 1 (0.97) | 0 (0) | — | — | 1.000 |
Hepatitis B | 0 (0) | 0 (0) | — | — | — |
HIV | 5 (4.9) | 0 (0) | — | — | 0.059 |
∗n (%), PPW: prepregnancy weight, BMI: body mass index, ANC: antenatal care, No ANC: unattended antenatal care, Alcohol: alcoholic drinker, STD: sexually transmitted disease, HIV: human immunodeficiency virus.
Maternal outcomes of parturient in both groups are summarized and presented in Table
Comparison of pregnancy outcomes between the study and control group.
Study ( | Control ( | Crude OR | 95%CI | ||
---|---|---|---|---|---|
GA (weeks) | 37.0 ± 2.6 | 38.1 ± 1.7 | — | — | <0.001 |
Preterm birth rate | 34 (33.3) | 12 (11.7) | 3.73 | 1.80–7.74 | <0.001 |
Late preterm | 26 (25.2) | 11 (10.7) | 2.82 | 1.33–6.08 | 0.253 |
PIH∗ | |||||
GHT | 15 (14.6) | 1 (1.0) | 17.43 | 2.51–134.38 | <0.001 |
PE | 5 (4.9) | 4 (3.9) | 1.26 | 0.32–4.84 | 0.749 |
SPE | 7 (6.8) | 1 (1.0) | 7.43 | 0.89–61.57 | 0.065 |
Vaginal delivery | 83 (80.6) | 72 (69.9) | 1.78 | 0.93–3.40 | 0.075 |
Low APGAR | 2 (1.9) | 1 (1) | 2.01 | 0.18–22.62 | 0.560 |
BW (g) | 2779.1 ± 486.6 | 3049.5 ± 510 | — | — | <0.001 |
<2500 | 28 (27.2) | 11 (10.7) | 3.12 | 1.45–6.68 | 0.004 |
2500–4000 | 73 (70.9) | 89 (86.4) | 0.38 | 0.18–0.77 | 0.011 |
>4000 | 2 (1.9) | 3 (2) | 0.66 | 0.10–4.03 | 1 |
GA: gestational age at delivery, PIH: pregnancy-induced hypertension, GHT: gestational hypertension, PE: preeclampsia with nonsevere feature, SPE: preeclampsia with severe feature, Low APGAR: APGAR score equal to and less than 7 at 5 minutes, BW: average birth weight.
Among complications for pregnancy-induced hypertension, only gestational hypertension was found to be significantly increased in the study group compared to the control group at 14.6 vs. 1.0%, respectively (
Neonatal outcomes are shown in Table
Exposure to ATS during pregnancy was reported to cause both obstetric and neonatal complications [
Previous studies among methamphetamine abused during pregnancy are summarized and represented in Table
The comparison studies in patients’ characteristic and pregnancy outcomes.
Homsup [ | Good [ | Wright [ | Gorman [ | Thamkhantho [ | Thaithumyanon [ | Present | |
---|---|---|---|---|---|---|---|
Case | 197 | 276 | 60 | 8542 | 77 | 178 | 103 |
Year | 2017 | 2010 | 2015 | 2014 | 2018 | 2005 | 2020 |
Country | Thailand | US (CA) | US (HI) | US (LA) | Thailand | Thailand | Thailand |
GA (weeks) | 37.0 ± 2.3 | 38 ± 2.1 | 36.9 ± 2.1 | 38.1 ± 2.3 | 37.0 ± 2.6 | ||
Age | 28.4 ± 6.7 | 24.3 ± 5.8 | 23.4 ± 5.2 | 29.2 ± 6.1 | |||
ANC | 7.5 ± 4.4 | 2.1 ± 2.8 | |||||
No ANC | 2,178 (25.5) | 61 (79.2) | 141 (79.2) | 48 (46.6) | |||
Preterm | 64 (32.5) | 133 (50) | 8 (13) | 1,999 (23.4) | 46 (59.7) | 55 (30.9) | 34 (33.3) |
PIH | 48 (17) | ||||||
GHT | 4 (5.2) | 15 (14.6) | |||||
PE | 10 (5.1) | 4 (6.6) | 580 (6.8) | 11 (6.2) | 5 (4.9) | ||
SPE | 213 (2.5) | 7 (6.8) | |||||
Eclampsia | 25 (0.3) | 5 (6.49) | 0 (0) | ||||
Vaginal delivery | 174 (88.3) | 195 (71) | 48 (80.3) | 65 (84.4) | 146 (82.0) | 83 (80.6) | |
Low APGAR | 4 (2) | 16 (6) | 2 (1.9) | ||||
BW (kg) | 2.8 ± 0.5 | 3.1 ± 0.5 | 2.7 ± 0.4 | 2.7 ± 0.5 | 2.8 ± 0.5 |
GA: gestational age at delivery, ANC: antenatal care, PIH: pregnancy-induced hypertension, GHT: gestational hypertension, PE: preeclampsia with nonsevere feature, SPE: preeclampsia with severe feature, Low APGAR: APGAR score equal to and less than 7 at 5 minutes, BW: average birth weight.
MA subjects had higher incidences of smoking and alcohol consumption than those in the control group. Alcohol and tobacco were associated with pregnancy outcomes, especially low birth weight [
The 2018 annual report from the tobacco control research and knowledge management center (TRC) in Thailand stated that the prevalence of smoking in Thai women was 1.7 percent [
Another report from the National Statistical Office (NSO) in 2017 reported that 10.6 percent of Thai females consumed alcohol products. In the current study, the percentage of women with MA abuse was similar to that number (10.6 vs. 12.6%) [
The current study revealed smoking and alcohol consumption in pregnant women with MA at 38.8 and 12.6 percent compared to one and zero percent in the control group, respectively. Data from Thamkhantho’s work reported smoking and alcohol drinking at 27.3 and 16.9 percent, respectively [
Preterm delivery had multifactorial causes either from maternal or fetal underlying conditions. Vasoconstrictive property of MA during intrautero exposure caused increased risk of preterm birth, low birth weight, and small stature of a gestational-age infant [
Preterm labor could be prevented by cessation of MA and other addictive-substance usage. We recommend the use of a promotion campaign to reach out to MA pregnant women encouraging them to attend ANC clinic. MA-addicted pregnant women should be informed about the complications from MA consumption during the ANC visit and encouraged to stop using it with help from experienced healthcare providers.
MA is one of the sympathomimetic amines. It is not categorized as a major teratogen. MA consumption increases dopamine release and decreases dopamine reuptake. Heart rate and blood pressure increase as a consequence of sympathomimetic effects of MA [
Hypertensive disorder during pregnancy (PIH) is a catastrophic event in modern obstetrics. MA enhanced PIH incidence [
In the current study, there were no eclampsia cases among MA participants. However, data from Talkathon’s report showed that 17 percent of amphetamine-addicted pregnant women came to the labor room with convulsions (eclampsia). The high percentage of eclampsia (17%) in Thamkhantho’s study might be the result of a high percentage of amphetamine participants’ failure to attend ANC service (79%) [
Vaginal delivery in MA users from our study when compared to the studies of Homsup’s group in Thailand and Good’s in the US was of similar percentage, ranging from 70 to 88% [
MA can be collected in the urine in case of repeat usage [
Limitations of this study included its methodology as a retrospective self-report questionnaire. Urine tests for MA were performed in all pregnant women with history or suspicion of MA consumption. BAH had no policy to perform this urine test in all pregnant women as a routine screening. As a result, the current number of parturient with MA consumption might have been underreported. Other concomitant substance abuse such as opioids which may affect pregnancy outcomes were not routinely investigated because of high cost of consumption for Thai people.
The author recommended a prospective study in illicit-drug-infested areas to collect all necessary data, along with universal MA screening tests in pregnant mothers. It will allow a true understanding of the size of the MA problem in the pregnant population. An MA urine screening test is also recommended in preterm labor or clinical of pregnancy-induced hypertension cases in such an area.
In conclusion, the present retrospective cohort study confirmed that the use of MA during pregnancy significantly increased both maternal and fetal complication, namely, preterm birth delivery and gestational hypertension. The knowledge can be used to help healthcare staff create a plan for MA parturient in anticipation of a high-risk delivery and postdelivery maternal-fetal treatment. Moreover, the results from this study can be used to inform pregnant women during antenatal care to promote substance-free pregnancy.
Data are under supervision by the board of ethical committee.
The authors report no conflicts of interest.