Acetaminophen and Acetylsalicylic Acid Exposure in a Preterm Infant after Maternal Overdose

Abstract

Here, we review the case of a 26 1/7 weeks' gestation premature female infant born to a mother who intentionally ingested a large quantity of Tylenol, aspirin, quetiapine, and prenatal vitamins. The neonate subsequently had markedly elevated levels of both Tylenol and aspirin when checked on the first day of life. While overall clinically stable, the neonate did demonstrate coagulopathy as evidenced by abnormal coagulation studies. Both poison control and a pediatric gastroenterologist/hepatologist were consulted. She successfully tolerated a course of N-acetylcysteine; her subsequent Tylenol level was markedly decreased and the neonate exhibited no further effects of toxicity. The salicylate level decreased on its own accord. To our knowledge, this is the first report of a neonate at 26 weeks' gestation that has been successfully managed for supratherapeutic concentrations of acetaminophen and acetylsalicylic acid secondary to maternal ingestion. While rare, this case may serve as a reference for the effectiveness of N-acetylcysteine in premature infants in such instances.

Keywords

acetaminophen - aspirin - neonate - premature - toxicity - N-acetylcysteine

Authors' Contributions

All authors listed have contributed to writing and reviewing the manuscript and confirm agreement with the full content of said manuscript. All authors have consented to publication.

• References

• 1 Mowry JB, Spyker DA, Brooks DE, Zimmerman A, Schauben JL. 2015 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 33rd Annual Report. Clin Toxicol (Phila) 2016; 54 (10) 924-1109
• 2 Lee WM. Acetaminophen and the U.S. Acute Liver Failure Study Group: lowering the risks of hepatic failure. Hepatology 2004; 40 (01) 6-9
• 3 Karimi K, Keßler T, Thiele K. , et al. Prenatal acetaminophen induces liver toxicity in dams, reduces fetal liver stem cells, and increases airway inflammation in adult offspring. J Hepatol 2015; 62 (05) 1085-1091
• 4 Levy G, Khanna NN, Soda DM, Tsuzuki O, Stern L. Pharmacokinetics of acetaminophen in the human neonate: formation of acetaminophen glucuronide and sulfate in relation to plasma bilirubin concentration and D-glucaric acid excretion. Pediatrics 1975; 55 (06) 818-825
• 5 Horowitz RS, Dart RC, Jarvie DR, Bearer CF, Gupta U. Placental transfer of N-acetylcysteine following human maternal acetaminophen toxicity. J Toxicol Clin Toxicol 1997; 35 (05) 447-451
• 6 Lee WM. Acetaminophen (APAP) hepatotoxicity-Isn't it time for APAP to go away?. J Hepatol 2017; 67 (06) 1324-1331
• 7 Yoon E, Babar A, Choudhary M, Kutner M, Pyrsopoulos N. Acetaminophen-induced hepatotoxicity: a comprehensive update. J Clin Transl Hepatol 2016; 4 (02) 131-142
• 8 Jones AL. Mechanism of action and value of N-acetylcysteine in the treatment of early and late acetaminophen poisoning: a critical review. J Toxicol Clin Toxicol 1998; 36 (04) 277-285
• 9 Lauterburg BH, Corcoran GB, Mitchell JR. Mechanism of action of N-acetylcysteine in the protection against the hepatotoxicity of acetaminophen in rats in vivo. J Clin Invest 1983; 71 (04) 980-991
• 10 Bucaretchi F, Fernandes CB, Branco MM. , et al. Acute liver failure in a term neonate after repeated paracetamol administration. Rev Paul Pediatr 2014; 32 (01) 144-148
• 11 Brener P, Ballardo M, Mariani G, Ceriani Cernadas JM. Medication error in an extremely low birth weight infant: paracetamol overdose. Arch Argent Pediatr 2013; 111 (01) 53-55
• 12 Walls L, Baker CF, Sarkar S. Acetaminophen-induced hepatic failure with encephalopathy in a newborn. J Perinatol 2007; 27 (02) 133-135
• 13 Isbister GK, Bucens IK, Whyte IM. Paracetamol overdose in a preterm neonate. Arch Dis Child Fetal Neonatal Ed 2001; 85 (01) F70-F72
• 14 Aw MM, Dhawan A, Baker AJ, Mieli-Vergani G. Neonatal paracetamol poisoning. Arch Dis Child Fetal Neonatal Ed 1999; 81 (01) F78
• 15 Sancewicz-Pach K, Chmiest W, Lichota E. Suicidal paracetamol poisoning of a pregnant woman just before a delivery. Przegl Lek 1999; 56 (06) 459-462
• 16 Devarbhavi H. An update on drug-induced liver injury. J Clin Exp Hepatol 2012; 2 (03) 247-259
• 17 Cook SF, Stockmann C, Samiee-Zafarghandy S. , et al. Neonatal maturation of paracetamol (acetaminophen) glucuronidation, sulfation, and oxidation based on a parent-metabolite population pharmacokinetic model. Clin Pharmacokinet 2016; 55 (11) 1395-1411
• 18 de Wildt SN. Profound changes in drug metabolism enzymes and possible effects on drug therapy in neonates and children. Expert Opin Drug Metab Toxicol 2011; 7 (08) 935-948
• 19 Sekine S, Lan BY, Bedolli M, Feng S, Hebrok M. Liver-specific loss of beta-catenin blocks glutamine synthesis pathway activity and cytochrome p450 expression in mice. Hepatology 2006; 43 (04) 817-825
• 20 Boullata JI, Gilbert K, Sacks G. , et al; American Society for Parenteral and Enteral Nutrition. A.S.P.E.N. clinical guidelines: parenteral nutrition ordering, order review, compounding, labeling, and dispensing. J Parenter Enteral Nutr 2014; 38 (03) 334-377
• 21 Temple AR. Pathophysiology of aspirin overdosage toxicity, with implications for management. Pediatrics 1978; 62 (5 Pt 2, Suppl) 873-876
• 22 American College of Medical Toxicology. Guidance document: management priorities in salicylate toxicity. J Med Toxicol 2015; 11 (01) 149-152
• 23 Hill JB. Experimental salicylate poisoning: observations on the effects of altering blood pH on tissue and plasma salicylate concentrations. Pediatrics 1971; 47 (04) 658-665
• 24 Zelner I, Matlow J, Hutson JR. , et al; Toxicology Investigators Consortium (ToxIC). Acute poisoning during pregnancy: observations from the Toxicology Investigators Consortium. J Med Toxicol 2015; 11 (03) 301-308
• 25 Stolbach AI, Hoffman RS, Nelson LS. Mechanical ventilation was associated with acidemia in a case series of salicylate-poisoned patients. Acad Emerg Med 2008; 15 (09) 866-869
• 26 Corby DG. Aspirin in pregnancy: maternal and fetal effects. Pediatrics 1978; 62 (5 Pt 2, Suppl) 930-937
• 27 Koren G. Medication Safety in Pregnancy and Breastfeeding. 1st ed. New York: McGraw Hill; 2007: 121-128