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September 19, 2004
Cocaine and Intrauterine Death:(
She was a G4P1, 24 weeks of gestation, 28-year-old with a history of two previous medical abortions. When she came in on a scheduled prenatal visit I was surprised to know that she was not sure whether she was 5 or 6 months pregnant. (even though in the chart it stated it clearly). Also, she noticed as a matter of fact that the baby did not move for a week and that her stomach kind of sank down a little. She did not complain of vaginal bleeding or abdominal pain. When asked why she did not go to the hospital right away after the first day of absent fetal movement, this mother-to be answered that she thought the baby was sleeping. The previous pregnancy was significant for third trimester hypertension, but not preeclampsia. On this day’s exam BP was 140/100. The fundal height was at 23 cm. On Doppler test there was no fetal heart beat and sonography did not show fetal movement. The doctor called an ambulance and the lady was rushed to L&D (labor and delivery). She delivered a stillborn male without cord abnormalities. Maternal blood showed marijuana and cocaine.
? Can maternal use of cocaine cause intrauterine fetal death?
The article called Cocaine, Pregnancy and Risk of Intrauterine Death, at www.wisc.edu/wissp/wisspers/dec97001.htm, stated that besides alcohol and tobacco, cocaine now is the most widely used drug during pregnancy. The article reviewed several studies on this topic and concluded that currently perhaps as many as one in every ten intrauterine deaths in the United States results from use of cocaine. It said also that there is a marked excess risk of stillbirth in cocaine users (4-25% according to a study by Burkett et al.). This study showed that there was a higher risk in erratic users than in consistent users because erratic users were more likely to use the most drug at any one time.
According to this article and the other one called In Utero Exposure to Cocaine: A Review, www.drugpolicy.org/library/ellis.cfm, cocaine easily diffuses across the placenta and fetal levels are virtually identical to the maternal ones. Due to this property, harmful effects can happen either through effects on mother and placenta, or on fetus directly. The pathophysiologic effect of cocaine is believed to be through its action of vasoconstriction in the mother, placenta, and the fetus. This action causes decreased oxygen and nutrient supply to the placenta and the baby. In a study by Woods et al., acute administration of cocaine to an animal caused a significant, dose-dependent increase in maternal MAP with an almost 50% decarese in placental blood flow. One of the ways by which cocaine causes intrauterine death is through the placental abruption. Various studies have placed the risk as high as 10-19%, or 5 to 20 fold over risks of control groups. There are instances of placental abruption immediately after cocaine use. Again, vasoconstriction thought to be responsible for the disruption of placental adherence to the uterus.
Vasoconstriction also entails creating hypertension in a mother, which may trigger abruptio placentae. Other effects of cocaine are: blocking of the fast Na+ channels and inhibition of the neural and cardiac action potentials, leading to development of arrhythmias; increasing tissue metabolism and myocardial oxygen demand with concurrent ischemia due to vasoconstriction; and direct harmful effects on developing fetal nervous and system and other tissues.
Importance: It is possible that in this patient fetal death was caused by an acute cocaine use. The patient has a history of hypertension during pregnancy which might have contributed to the fetal demise. Cocaine could have potentiated maternal hypertension further decreasing oxygen supply to the fetus. Another article, www.journalsip.astm.org/jofs/PAGES/1478.htm, had a case of intrauterine death of a 35-week-old fetus after a single acute cocaine use. Thus, we have to realize and explain to our patients, that even one time can kill their baby. In the inner city community, where drug use and unplanned pregnancies are not rare occurrences, this information could be of high relevance to the patients.        
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