Effective Tuesday, August 27, 2013, the University of Iowa Hospitals and Clinics will offer umbilical cord testing for newborn drug testing.  The Epic orderable is “DRUG OF ABUSE – UMBILICAL CORD” (LAB7758).
The umbilical cord drug testing is sent out to ARUP Laboratories and includes confirmatory level testing for amphetamines/amphetamine-like drugs, benzodiazepines and other sedative-hypnotics, cannabis/marijuana, cocaine, opioids, and phencyclidine.  The analysis is on the umbilical cord tissue not the cord blood.  Comparison studies of umbilical cord with meconium drug testing show similar rates of drug and drug metabolite detection encompassing exposures during 2^nd and 3^rd trimester.  There are two main advantages of umbilical cord testing:

1. Specimens can be collected on all newborns.  Meconium collection is missed in at least 10-15% of cases where newborn drug testing is ordered.
2. Umbilical cord testing avoids detection of medications administered to infant after birth but prior to meconium passage.  A retrospective analysis of 4 years of newborn drug testing at University of Iowa Hospitals and Clinics showed that detection of infant medications in meconium comprised the majority of drugs found in meconium.  This is particularly an issue in premature infants that have delayed meconium passage and frequent use of medications such as lorazepam, morphine, and phenobarbital.

The following will be the procedure:

1. Umbilical cord will be collected on all infants born at University of Iowa Hospitals and Clinics.  The preferred specimen is 8 inches of umbilical cord that is drained of blood.  Small sections of coagulated blood are acceptable and are removed by reference laboratory prior to analysis.  The exterior of the cord is rinsed with normal saline or equivalent.  The specimen is then patted dry and placed in container for transport.  Collection of cord blood gases does not impact the detection of drugs in umbilical cord tissue.
2. Cords will be held refrigerated for 7 days, allowing for drug testing orders to be made within this time window.  This will allow for newborn drug testing in cases where risk factors for maternal substance abuse are only recognized days after birth.
3. The “DRUG OF ABUSE – MECONIUM” (LAB4840) order will still be available for cases (e.g., transfers from outside hospitals) in which umbilical cord is not available at University of Iowa Hospitals and Clinics, but newborn drug testing is clinically warranted.  A warning prompt in Epic will advise that meconium is no longer the preferred newborn drug testing procedure except when umbilical cord is not available.  There is no clinical justification for ordering both meconium and umbilical cord drug testing.
4. The Epic orders for “DRUG OF ABUSE – UMBILICAL CORD” (LAB7758) and “DRUG OF ABUSE – MECONIUM” (LAB4840) will include questions that allow LIP to document that newborn meets criteria for drug testing in the University of Iowa Hospitals and Clinics Perinatal Illicit Drug/Exposure Risk Assessment Tool.

The complete list of drugs and drug metabolites detectable in umbilical cord are as follows:

1. Amphetamines and related drugs: amphetamine, methamphetamine, MDA, MDEA, MDMA/Ecstasy, phentermine
2. Benzodiazepines, barbiturates, and other sedative-hypnotics: alprazolam, amobarbital, butalbital, clonazepam, diazepam, flunitrazepam, flurazepam, lorazepam, midazolam, nitrazepam, nordiazepam, phenobarbital, secobarbital, temazepam, triazolam, zolpidem
3. Cannabinoids:  THC (cannabis)
4. Cocaine
5. Opioids: buprenorphine, codeine, dihydrocodeine, fentanyl, heroin, hydrocodone, hydromorphone, meperidine, methadone, morphine, naloxone, naltrexone, oxycodone, oxymorphone, propoxyphene, tapentadol, tramadol
6. Phencyclidine (PCP)

Questions should be directed to Matthew Krasowski, MD, PhD, medical director of the Clinical Chemistry Laboratory (384-9380, matthew-krasowski@uiowa.edu).