Cocaine Use During Pregnancy: The Most Innocent Victims of Drugs

According to the National Association for Perinatal Addiction Research and Education (NAPARE), about 1 out of every 10 newborns in the U.S. is exposed in the womb to one or more illicit drugs. The most frequent ingredient in the mix is cocaine. In major cities of the USA such as New York, Los Angeles, Detroit and Washington many hospitals report that the percentage of newborns showing the effects of drugs is 20% or even higher. By the latest estimates, more than 1 million women use cocaine in the USA.

Anomalies associated with maternal cocaine use during pregnancy

Anomalies associated with maternal cocaine use during pregnancy can range from minor ones i.e., fetal cocaine syndrome: low birth weight, prematurity, irritability, microcephaly (baby’s head is abnormally small), large fontanelles (the spaces where bones of the skull come together, but are not completely joined), prominent glabella (protrusion of the area between the eyes), marked periorbital and eyelid edema, low nasal bridge (a flattening of the top part of the nose), short nose, and small toenails, to major ones, i.e., segmental intestinal atresia (narrowing or absence of a portion of the intestine), sirenomelia (the term comes from “siren” or “mermaid” because of the characteristic fusion of the lower extremities that results from a failure in the development of a normal vascular supply to lower extremities), limb-body wall complex (presence of an abdominal wall defect, a short umbilical cord, abnormal curvature of the spine, limb anomaly, and craniofacial defect) and limb reduction defects (which involve missing tissue or bone in any part of a limb or limbs and can range in severity from missing fingers and toes to the complete absence of one or both arms and/or legs), congenital anomalies of the genitourinary system in infants, prune belly anomaly (when the intestinal pattern is evident through the thin protruding abdominal wall in the infant), neonatal necrotizing enterocolitis, neonatal myocardial infarction and myocardial calcification). Let us focus one of the most rare but most horrific anomalies associated with maternal cocaine use during pregnancy, gastroschisis.

Gastroschisis

Gastroschisis is a congenital disorder in which a defect is present in the wall of the abdomen of the embryo. Typically there is a small abdominal cavity with herniated abdominal organs that usually appear on the right side of the abdomen. There is no membranous sac covering the organs. The intestines may be swollen and look shortened due to exposure to the liquid that surrounds the fetus during pregnancy. Since the 1970s noteworthy trends have been observed in gastroschisis prevail. Overall, gastroschisis rates have increased over time in several regions around the world. Prevalence of gastroschisis displays wide variation by geographic location, both within and between countries. One study indicated that gastroschisis was more likely to occur in rural areas than urban ones. Birth prevalence in the United States for gastroschisis ranges between 1.22 and 5.11 per 10,000 live births (National Birth Defects Prevention Network).

Risk factors

Most studies focusing on the maternal age have found much higher rates of gastroschisis for very young mothers. The gender of the infant is associated with the risk for gastroschisis. Males are more likely than females to have gastroschisis. Maternal alcohol use has been linked to higher rates of gastroschisis, as has recreational drug use (cocaine, amphetamine, or LSD). Nevertheless scientific evidence indicates that not all people are equally susceptible to birth defects. Genetic and nutritional factors may combine with other environmental factors to increase the risk. This combination of factors makes it extremely difficult to conduct epidemiologic studies in populations of people when the entire collection of risk factors is not well understood or identified.

Cocaine and gastroschisis

Cocaine causes blood vessels to constrict, reducing the vital flow of oxygen and other nutrients. Because fetal cells multiply fleetly in the first months of the pregnancy, the proper blood supply of the embryo is set back by the mother’s early and continuous use of cocaine. The heavy maternal cocaine use during the later months of pregnancy can lead to an embolism, or clot, that lodges in a fetal vessel and completely disrupts the blood supply to an organ or limb. The result: different kind of deformities (shriveled arm or leg, missing section of intestine or kidney etc. Fortunately such bold defects are very rare. Thus the link between maternal cocaine use and increased gastroschisis risk is of particular interest because cocaine is a vasoconstrictor. One hypothesis offered for the etiology of gastroschisis is that it is a vascular disruption defect.

Diagnosis

The possibility of prenatal diagnosis either through echosonogram or any other method available allows the mother to be referred to an adequate center where a caesarean section or induced natural birth can be performed before term (as natural birth is recommended and just as safe as with a normal baby), preferably within 2 weeks of term, and allow the immediate surgery to be performed on the newborn. The main cause for lengthy recovery periods in patients is the time taken for the infants’ bowel function to return to normal. The morbidity is closely related to the presence of other malformations and complications of the wound or the intestine. Patients frequently require more than one surgery. The fetal abdominal wall can be seen by ultrasound from 9 postmenstrual weeks although the defect cannot not been confidently diagnosed until after the 12th week of pregnancy.

Treatment and Prognosis

There is a small risk of a chromosomal abnormality and other defects cannot be always excluded either, women who have a fetus with a gastroschisis an amniocentesis, also referred to as amniotic fluid test or AFT have been offered to check the karyotype. AFT is a medical procedure used in prenatal diagnosis of chromosomal abnormalities and fetal infections, in which a small amount of amniotic fluid contains fetal tissues, is extracted from the amnion or amniotic sac surrounding the fetus, and the fetal DNA is examined for genetic abnormalities. Most women are to be subjected to additional surveillance with ultrasound biophysical tests and or cardiotocographs (CTG) during the third trimester. In spite of all best efforts taken by doctors about 30% of women will labor prematurely (before 37 weeks gestation). The good news is most women will not have another fetus with gastroschisis (although there is a 3 – 5% reported recurrence risk). For babies born with gastroschisis, the defect requires immediate surgery and intensive hospital care. Some babies with gastroschisis born to have strongly damaged bowel. Besides, they can have blockages in the bowel. If these blockages have been present for a long time, they can cause parts of the bowel to be greatly distended. Even when these blockages are relieved after birth it can sometimes take many months for the bowel to function normally. So it can take many months for the baby to tolerate milk. They have a long stay in hospital and require intravenous feeding. Fortunately most babies do not have these types of serious problems and feeding can be established within 7 – 21 days of age. Most babies with gastroschisis are discharged within 3-4 weeks of birth. Nowadays 90% of the neonates could survive due to the current advances in surgical techniques and intensive care management.

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